3300, Administrative Procedures

Revision 19-1; Effective June 3, 2019

Program Support Unit (PSU) staff operate in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. PSU staff provide support necessary for the coordination of long-term services and supports (LTSS), including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

• nursing facilities (NFs) to the community, and
• the Medically Dependent Children Program (MDCP) to the STAR+PLUS HCBS program.

Responsibilities of PSU staff include:

• acting as an intermediary in relaying communications between Community Care Services Eligibility (CCSE) staff and the managed care organization (MCO);
• receiving requests for services from CCSE staff performing intake tasks;
• coordinating the application process for the STAR+PLUS HCBS program for NF residents who wish to transition to the community;
• assisting applicants with enrollment through the enrollment broker to select an MCO and primary care provider (PCP), if necessary;
• coordinating with Medicaid for the Elderly and People with Disabilities (MEPD) specialists regarding Medicaid eligibility, as appropriate;
• sending service authorizations (Form H3676, Managed Care Pre-Enrollment Assessment Authorization) to the MCO to do STAR+PLUS HCBS program assessments for non-members;
• serving as the primary contact for transitions in and out of STAR+PLUS service areas;
• assisting CCSE case managers in processing applications for non-Medicaid services by verifying the MCO denied the equivalent service under STAR+PLUS (see 3510, Money Follows the Person and Managed Care);
• assisting MCO members requesting placement on an interest list for services excluded from managed care (see 3222, Excluded Groups);
• removing members in STAR+PLUS counties from the STAR+PLUS HCBS program interest list and processing their applications;
• assisting members who are aging out of MDCP and/or Texas Health Steps/Comprehensive Care Program in transferring to the STAR+PLUS HCBS program (see 3420, Individuals Aging Out of Children's Programs);
• coordinating continuity of care for members suspended or disenrolled from STAR+PLUS;
• approving the STAR+PLUS HCBS program based upon eligibility;
• making Service Authorization System Online (SASO) entries as required for actions involving STAR+PLUS HCBS program members;
• handling the administrative claims process;
• researching and requesting disenrollment when the member is enrolled inappropriately;
• denying eligibility for the STAR+PLUS HCBS program; and
• handling requests for Medicaid fair hearings for applicants or members who are denied STAR+PLUS HCBS program eligibility.

3310 Intake and Enrollment

Revision 23-2; Effective June 30, 2023

When Community Care Services Eligibility (CCSE) receives a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

• appropriate Texas Health and Human Services Commission (HHSC) unit;
• HHSC enrollment broker;
• Program Support Unit (PSU) staff; or
• appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS.

When CCSE intake staff determine a request for the STAR+PLUS HCBS program should be forwarded to PSU staff for processing, they must submit an email to HHSC Star Plus Waiver Interest List.

The email should contain the following data elements:

• Name;
• Social Security number (SSN);
• Address;
• Contact phone number;
• Date of birth;
• Medicaid identification (ID) number, if applicable; and
• County of residence.

If CCSE intake staff are unable to obtain all data elements from the applicant, the referral will still be processed by PSU staff so that access to the STAR+PLUS HCBS program interest list will not be denied. Although CCSE intake staff routinely provides the initial four demographic data, there may be times when an individual requesting services is unable to furnish the date of birth. If this information is not included in the referral, PSU staff must obtain it as the date of birth is required for entry to the Community Services Interest List (CSIL) system.

PSU state office staff will monitor the interest list mailbox and process the referrals within three business days by placing the individual on the STAR+PLUS HCBS program interest list, using the original date CCSE intake staff referred the request to PSU staff.

Because of member choice issues, MCOs are prohibited from contacting non-members without the authorization from PSU staff to complete required HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS program interest list, or MFP and MFP Demonstration initiative individuals, PSU staff:

• complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
• upload Form H3676 to MCOHub in the MCO's SPW folder, following the naming convention instructions in 5110, MCOHub Naming Convention and File Maintenance.

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake screeners must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the intake and referral process when the individual requesting services is determined to be age 55 years or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.

CCSE intake screeners must be aware of the PACE service areas and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 18-2; Effective September 3, 2018

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care for Aged and Disabled (CCAD) program. Referrals to CCAD must be made for all full Medicaid recipients. Case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

3311.1 Earliest Date for Adding a Member Back to the Interest List

Revision 19-1; Effective June 3, 2019

The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) database for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program (for applicants) or (for STAR+PLUS Home and Community Based Services (HCBS) program members), the first date the applicant or member is no longer eligible for the program denied.

Example 1: The applicant is released from the STAR+PLUS HCBS program CSIL on March 2, 2019. The case manager determines the applicant is not eligible for STAR+PLUS HCBS program on March 28, 2019, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2019.

Example 2: A STAR+PLUS HCBS program member is determined not eligible on March 28, 2019, and PSU staff send notification to the STAR+PLUS HCBS program member of termination of benefits. Termination is effective April 30. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2019.

If the applicant's or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL database interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program.

Example 3: A member's STAR+PLUS HCBS program services are denied due to medical necessity (MN) and end on March 30, 2019. The first date the member can be added back to the STAR+PLUS HCBS program interest list is April 1, 2019.

Example 4: A member's STAR+PLUS HCBS program services are denied and will end March 13, 2019. The first date the member can be added back to the STAR+PLUS HCBS program interest list is March 14, 2019. If the member is already on another interest list, the denial date for the STAR+PLUS HCBS program would not impact the member's original date on the other interest list.

3312 Enrollment

Revision 19-1; Effective June 3, 2019

The enrollment broker mails enrollment packets to all Medicaid recipients who are candidates for STAR+PLUS. This packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the recipient can choose. Recipients can return enrollment forms via mail, complete an enrollment form at an enrollment event or presentation, or call the enrollment broker and enroll via telephone at 1-800-964-2777.

Recipients have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the recipient will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Recipient assignments to an MCO or PCP are automatic, using a default process. Recipients assigned through the default process may still make a choice about their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, he or she must receive Medicaid services through the assigned MCO and PCP until they contact the MCO or the enrollment broker at 1-800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity (MN) determination is required.

3312.1 Enrollment Procedures Following Release from the Interest List

Revision 23-2; Effective June 30, 2023

Within 14 days of release from the interest list (see 3311.1, Interest List Procedures),  Program Support Unit (PSU) staff take the following steps to ensure candidates are successfully enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

PSU staff contact the applicant or authorized representative (AR) to:

• give a general description of STAR+PLUS HCBS program services;
• provide a list of managed care organizations (MCOs) and encourage the member to contact one for service information;
• discuss the importance of choosing an MCO so assessments and initial individual service plans (ISPs) can be completed timely in order to avoid a delay in eligibility determination for the STAR+PLUS HCBS program; and
• inform the individual the MCO in which he or she enrolls can be changed at any time after the first month of service.

The applicant chooses an MCO and notifies PSU staff verbally or in writing.

Within two business days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it on MCOHub in the MCO's SPW folder, following the naming convention instructions in 5110, MCOHub Naming Convention and File Maintenance.

The MCO completes:

• Section B of Form H3676;
• a Medical Necessity and Level of Care (MN/LOC) Assessment;
• Form H1700-1, Individual Service Plan; and
• Form H1700-3, Individual Service Plan – Signature Page.

Note: The Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. The MCO has 45 days per UMCC requirement to complete all assessments and submit the results via Form H3676, Part B, to PSU staff.

The MCO uploads the STAR+PLUS HCBS program ISP to MCOHub in the MCO's ISP folder, following the naming instructions in Section 5110. The MCO uploads Form H3676 to MCOHub in the MCO's SPW folder, following instructions in Section 5110.

If the MCO does not upload an ISP within 45 days after PSU staff uploaded Form H3676, Part A, PSU staff notify by email the Managed Care Compliance & Operations (MCCO) staff assigned to the MCO.

Within five business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff verify eligibility based on Medicaid eligibility, medical necessity and level of care (MN/LOC), and an ISP cost within the individual's assessed cost limit based on the established Resource Utilization Group value.

The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month following receipt of the latter of:

• MN/LOC;
• ISP; and
• Medicaid eligibility.

Example: MN/LOC is received at Texas Medicaid & Healthcare Partnership (TMHP) on May 15, the ISP is uploaded to MCOHub on June 2, and Medicaid eligibility is effective May 1. The SOC date is July 1.

The SOC date is the same as the ISP begin date, and will always be the first day of the month. Because individuals are not eligible for any STAR+PLUS HCBS program benefits between the notification form signature date and the ISP begin date, PSU staff must take care in recording the correct date on the notification to the member.

If eligibility is approved, PSU staff complete Form H2065-D, and:

• mail the original to the applicant;
• upload the form on MCOHub in the MCO's SPW folder, following the instructions in Section 5110;
• fax or mail a copy to the MEPD specialist; and
• notify Enrollment Resolution Services (ERS) by email

If eligibility is denied, PSU staff complete Form H2065-D and:

• mail the original to the applicant;
• upload it on MCOHub in the MCO's SPW folder, following the instructions in Section 5110; and
• fax or email a copy to the MEPD specialist.

PSU staff make Service Authorization System Online (SASO) entries following procedures in the SAS Help File within five business days of receipt of all required eligibility verification.

After the individual has been determined eligible for the STAR+PLUS HCBS program, ERS updates the member's TIERS record to indicate managed care enrollment.

3313 Termination of CCAD Services Upon STAR+PLUS Home and Community Based Services Program Enrollment

Revision 19-1; Effective June 3, 2019

Code of Federal Regulations (CFR) §431.213 Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a recipient;

(b) The agency receives a clear written statement signed by a recipient that —

(1) He no longer wishes services; or

(2) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c) The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d) The recipient's whereabouts are unknown and the post office returns agency mail directed to her or him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e) The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f) A change in the level of medical care is prescribed by the recipient's physician.

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the Community Care Services Eligibility (CCSE) case manager so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service. The STAR+PLUS Home and Community Based Services (HCBS) program member must be encouraged to contact the managed care organization (MCO) to request any services being denied that are not included in the STAR+PLUS HCBS program individual service plan (ISP).

The 10-day adverse action prior notice requirement does not apply to individuals transferring from CCAD or other waiver programs to the STAR+PLUS HCBS program.

3313.1 Procedure for STAR+PLUS Home and Community Based Services Program Applicants

Revision 19-1; Effective June 3, 2019

For individuals just entering the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the waiver or Community Care Services Eligibility (CCSE) case manager. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System Online (SASO).

CCAD services are terminated by the CCSE case manager no later than the day prior to STAR+PLUS HCBS program enrollment. This is crucial since no STAR+PLUS HCBS program individual may receive CCAD and STAR+PLUS HCBS program services on the same day. The CCSE case manager must send:

• Form 2065-A, Notification of Community Care Services, denying ongoing Texas Health and Human Services Commission (HHSC) services; and
• Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring to the STAR+PLUS HCBS program.

3313.2 Procedure for STAR+PLUS Home and Community Based Services Program Members

Revision 19-1; Effective June 3, 2019

If it is determined that an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care for the Aged and Disabled (CCAD) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If CCAD services are authorized in SASO, the Community Care Services Eligibility (CCSE) case manager must immediately send:

• Form 2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to the STAR+PLUS HCBS program; and
• Form 2101, Authorization for Community Care Services.

3314 Managed Care Organization Changes

Revision 18-2; Effective September 3, 2018

Members may change managed care organization (MCO) plans as often as monthly by contacting the enrollment broker at 1-800-964-2777. The enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of the month. Depending on which day of the month (before or after the enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834-daily enrollment file notifying the MCO of the new member. The Program Support Unit (PSU), when notified by the member, state or an MCO that a member has elected to change MCOs, will update the Service Authorization System Online (SASO) to change the previous MCO to the new MCO.

3315 STAR+PLUS Home and Community Based Services Program Individuals Requesting Non-Managed Care Services

Revision 18-2; Effective September 3, 2018

Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program member. STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

3315.1 Requests from Individuals Awaiting Managed Care Enrollment

Revision 18-2; Effective September 3, 2018

Individuals awaiting managed care enrollment may be assessed for interim Community Care for the Aged and Disabled (CCAD) services. Texas Health and Human Services Commission (HHSC) case managers may assess all individuals whose managed care enrollment is pending if it appears CCAD services can be approved and delivered prior to enrollment in managed care.

3315.2 Requests from STAR+PLUS Home and Community Based Services Program Members

Revision 18-2; Effective September 3, 2018

Requirements of the federal 1115 waiver dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCO's) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

3315.3 Requests from STAR+PLUS Services Members

Revision 23-2; Effective June 30, 2023

When a STAR+PLUS services managed care member requests non-Medicaid services, Texas Health and Human Services Commission (HHSC) staff must first determine if there is a slot available for the requested service. If not, the individual's name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Members are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.

When a slot is available, or before release from the interest list, HHSC staff consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is a STAR+PLUS member (see 5130, Managed Care Data in TIERS). If it is determined that the individual is a STAR+PLUS member, intake staff must contact Program Support Unit (PSU) staff before assignment to a case manager to determine if the managed care organization (MCO) is already delivering the managed care version of the requested service.

Within two business days of contact by intake staff, PSU staff:

• contact the appropriate MCO by uploading Form H2067-MC, Managed Care Programs Communication, to MCOhub in the MCO's SPW folder using the appropriate naming convention. Form H2067-MC must contain:
  • the individual's name;
  • Medicaid number identification (ID); and
  • a request to determine if service is already being delivered; and
• follow up by phone every five business days until a response is received from the MCO.

Within five business days of receiving uploaded Form H2067-MC, the MCO must respond to PSU staff by uploading Form H2067-MC to the MCO's SPW folder in MCOHub using the appropriate naming convention.

Within two business days of receipt of the MCO's response, PSU staff must notify the referring HHSC staff by email or with Form H2067-MC.

If PSU staff determine the requested service is not being delivered by the MCO, the intake must be assigned to a case manager. The case manager processes the application and authorizes services if all eligibility criteria are met.

The PSU staff's response must be included in materials forwarded to the case manager at the time of case assignment. How the case manager proceeds with the eligibility determination process depends on the PSU's documented response.

If PSU staff determine the requested service is already being delivered by the MCO, PSU staff inform the member of the MCO's response. The member is urged to consult the MCO if he or she disagrees or feels the services are not sufficient to meet her or his needs.

See 3310, Intake and Enrollment, for additional information on intake and referral procedures.

3316 Requests for STAR+PLUS Home and Community Based Services Program from Participants in 1915(c) Medicaid Waivers

Revision 23-2; Effective June 30, 2023

Participants in 1915(c) Medicaid waivers may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program at any time if they:

• have Supplemental Security Income (SSI) Medicaid or another full Medicaid program; or
• are medical assistance only (MAO).

When a 1915(c) Medicaid waiver recipient requests the STAR+PLUS HCBS program through the Texas Health and Human Services Commission (HHSC), a referral is made to Program Support Unit (PSU) staff.

PSU staff are responsible for completing the following activities within 14 days of the initial request for a STAR+PLUS HCBS program assessment. All attempted contacts with the member or encountered delays must be documented. PSU staff:

• move the individual to the top of the STAR+PLUS HCBS program interest list with an "assessment requested" notation;
• contact the STAR+PLUS HCBS program member and explain STAR+PLUS HCBS program services; and
• send a copy of the regional STAR+PLUS managed care organization (MCO) provider directories and comparison chart to the 1915(c) Waiver recipient.

Within two business days of notification of the MCO selection by the STAR+PLUS HCBS program applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and uploads it in the MCO's SPW folder on MCOHub, using the appropriate naming convention.

The MCO completes:

• Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, as appropriate;
• Form H2060-A, Addendum to Form H2060;
• Form H2060-B, Needs Assessment Addendum, as applicable;
• medical necessity and level of care (MC/LOC);
• Section B of Form H3676;
• Form H1700-1, Individual Service Plan;
• Form H1700-2, Individual Service Plan – Addendum; and
• Form H1700-3, Individual Service Plan – Signature Page.

The MCO uploads Form H1700-1, Form H1700-3, and Form H3676 in the MCO's SPW folder on MCOHub using the appropriate naming convention. If the packet from the MCO is not received within 45 days after the assessment is authorized, PSU staff email Managed Care Compliance & Operations (MCCO) as notification of the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff determine STAR+PLUS HCBS program eligibility based upon medical necessity, and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for the STAR+PLUS HCBS program is denied or the applicant decides not to accept the STAR+PLUS HCBS program, PSU staff complete Form H2065-D, Notification of Managed Care Program Services, and:

• mail the original to the 1915(c) Medicaid waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving; and
• notify the MCO by uploading a copy to MCOHub.

If eligibility is approved and the individual chooses to accept STAR+PLUS HCBS program services, the individual is enrolled in the STAR+PLUS HCBS program the first day of the next month.

Within two business days of determining the start of care date for the STAR+PLUS HCBS program, PSU staff complete Form H2065-D and:

• mail the original to the 1915(c) Medicaid waiver recipient;
• notify the MCO by uploading a copy to MCOHub; and
• notify Enrollment Resolution Services (ERS) by email.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) Medicaid waiver services end the day before enrollment in the STAR+PLUS HCBS program.

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 18-2; Effective September 3, 2018

3321 General Eligibility Issues

Revision 19-1; Effective June 3, 2019

At the initial contact, Program Support Unit (PSU) staff must inform the medical assistance only (MAO) applicant or member and/or authorized representative (AR) that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant or member and/or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform MEPD specialists of the request for STAR+PLUS Home and Community Based Services (HCBS).

3321.1 Disability Determinations

Revision 19-1; Effective June 3, 2019

The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have absolutely no role in this process.

If a STAR+PLUS Home and Community Based Services (HCBS) program applicant's or member's application for Supplemental Security Income (SSI) disability has been pending for over 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

• Form H3034, Disability Determination Socio-Economic Report;
• Form H3035, Medical Information Release/Disability Determination; and
• a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment.

3322 Actions Pending Past the Medicaid for the Elderly and People with Disabilities Due Date

Revision 19-1; Effective June 3, 2019

Because Program Support Unit (PSU) staff depend on Medicaid for the Elderly and People with Disabilities (MEPD) staff to determine eligibility for medical assistance only (MAO) applicants, there are times when PSU staff must check with MEPD staff regarding the status of an application or program change.

Before contacting the MEPD specialist, PSU staff must ensure the MEPD time frame has expired. MEPD specialists have 45 days to complete applications for individuals over age 65. For individuals under age 65 whose disability has not yet been determined by the Social Security Administration (SSA), MEPD specialists have 90 days.

3330 STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program

Revision 23-2; Effective June 30, 2023

Medicaid members enrolled in STAR+PLUS qualify for Medicaid eligibility through various program types. Some members who request the STAR+PLUS Home and Community Based Services (HCBS) program may be Medicaid eligible through one of the following Medicaid program types:

• Pickle (Type Program (TP)-03);
• Disabled Adult Child (TP-18);
• Disabled Widow(er) (TP-21);
• Early Aged Widow(er) (TP-22);
• Medicaid Buy-in (TP-87); or
• Medicaid for Breast and Cervical Cancer (TA-67).

Although these Medicaid programs represent full Medicaid eligibility, they do not consider transfer of assets and substantial home equity reviews required to establish financial eligibility for the STAR+PLUS HCBS program. Therefore, these Medicaid types are not eligible for an upgrade and enrollment in the STAR+PLUS HCBS program until Medicaid for the Elderly and People with Disabilities (MEPD) specialists test for the additional criteria.

Managed care organizations (MCOs) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub within three business days of an upgrade request for a member who has one of these Medicaid program types. PSU staff must contact the member within three business days of the uploading date of Form H2067-MC to advise the member Form H1200, Application for Assistance - Your Texas Benefits, must be completed and returned to PSU staff.

Once the member returns Form H1200, PSU staff send the signed and completed application form within two business days of receipt to the MEPD specialist, along with Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken.

The MCO service coordinator must, within 45 days of a STAR+PLUS member's request for the STAR+PLUS HCBS program:

• complete an assessment in order to prepare the individual service plan (ISP);
• complete the Medical Necessity and Level of Care (MN/LOC) Assessment and submit it to Texas Medicaid & Healthcare Partnership (TMHP) to request medical necessity (MN);
• upload Form H1700-1, Individual Service Plan, in the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal; and
• upload Form H1700-3, Individual Service Plan – Signature Page, to MCOHub in the MCO's ISP folder, using the appropriate naming convention.

Within five business days of receipt of Form H1700-1 and Form H1700-3 from the MCO, PSU staff review the form to determine if the member meets eligibility criteria for the STAR+PLUS HCBS program.

If MN for a pending upgrade is denied, the MCO must inform PSU staff within three business days by uploading Form H2067-MC to MCOHub. When this occurs, PSU staff must send Form 1746-A to the MEPD specialist notifying the denial within three business days after receiving it from the MCO.

PSU staff must apply STAR+PLUS Program Support Unit Operational Procedures Handbook policy regarding upgrades to determine if the member meets the eligibility criteria for the STAR+PLUS HCBS program. This will include not only review of the functional criteria evaluated by the MCO, but also a determination that the member's Medicaid type is eligible for the STAR+PLUS HCBS program. For SSI-denied Medicaid program types referenced in this section, the Medicaid program type verification includes the MEPD certification that the additional required financial criteria have been met.

If not eligible, PSU staff:

• follow actions in 3632, Program Support Unit (PSU)-Initiated Denials/Terminations, to deny the request;
• send Form H2065-D, Notification of Managed Care Program Services, within three business days to the member; and
• upload Form H2065-D to MCOHub to the MCO's SPW folder.

If the member is eligible, PSU staff will process the member upgrade by:

• completing Form H2065-D and send it to the member and (if applicable) the MEPD specialist;
• uploading Form H2065-D in MCOHub to the MCO's SPW folder; and
• confirming Service Authorization System (SAS) entries to authorize eligibility for the STAR+PLUS HCBS program.