3400, Transferring Into STAR+PLUS

Revision 19-1; Effective June 3, 2019

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Community Care Services Eligibility (CCSE) Handbook2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to her or his MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to 3125, STAR+PLUS Home and Community Based Services Program Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants or members, the losing service area must inform the gaining service area of the GR status. The gaining service area must follow the GR process.

3410 Transfer Scenarios

Revision 18-2; Effective September 3, 2018

3411 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Area with Prior Knowledge

Revision 23-2; Effective June 30, 2023

When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS service area, within two business days, the losing PSU:

  • notify the gaining PSU staff a member is transferring to its service area and provides the member's:
    • name;
    • Social Security number;
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • send Form H1700-1, Individual Service Plan, to the gaining PSU staff;
  • send Form H1700-3, Individual Service Plan – Signature Page, to the gaining PSU staff;
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist using Form H1746-A, MEPD Referral Cover Sheet, on medical assistance only (MAO) individuals;
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address; and
  • upload Form H2067-MC to the managed care organization (MCO) SPW folder in MCOHub using the appropriate naming convention, and requests Form H1700-1 and all forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the medical necessity/level of care (MN/LOC);
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.

Once the gaining PSU receives Form H1700-1 and H1700-3, PSU staff follow the usual intake procedures. The process is abbreviated since the member already has a:

  • medical necessity;
  • Resource Utilization Group; and
  • financial eligibility determination by MEPD, if applicable.

The gaining PSU coordinates all appropriate activities between the losing PSU, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

The gaining PSU maintains contact with the member until the move is complete. Within five business days after the move, PSU staff:

  • send an email to ERS notifying ERS the member has moved;
  • manually close all Service Authorization System Online (SASO) records for the losing MCO effective the end of the month the member moves;
  • update SASO with the gaining MCO's information;
  • send Form H2065-D, Notification of Managed Care Program Services, to the member and include the begin and end dates of the individual service plan (ISP) in the Comments section; and
  • upload a copy of Form H2065-D to the appropriate MCO's SPW folder in MCOHub, using the appropriate naming convention.

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

Refer to Appendix XXXI, STAR+PLUS Members Transitions from a Nursing Facility in one Service Area to the Community in Another Service Area, for additional information.

3412 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Delivery Area Without Prior Knowledge

Revision 23-2; Effective June 30, 2023

When Program Support Unit (PSU) staff are notified a transfer from one STAR+PLUS service area to another STAR+PLUS area has already occurred, within one business day the losing PSU staff:

  • notify the gaining PSU staff a member has transferred to its service area and provides the member's:
    • name;
    • Social Security number;
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • upload Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) SPW folder in MCOHub, using the appropriate naming convention, and requests Form H1700-1, Individual Service Plan, and all the forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the medical necessity and level of care (MN/LOC);
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide; and
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals; and
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address.

Within two business days of notification from the losing PSU staff, the gaining PSU staff:

  • contact the member to select an MCO from the gaining service area;
  • send the packet containing the MCO comparison chart; and
  • upload Form H2067-MC to MCOHub in the MCO's SPW folder, using the appropriate naming convention, requesting the MCO to inform the gaining health plan of the move.

Upon receipt of Form H2067-MC, the gaining MCO must contact the member within one business day and begin services within two business days.

Once the gaining PSU staff receives Form H1700-1 and H1700-3, PSU staff follow the usual intake procedures. The process is abbreviated since the member already has a:

  • MN/LOC;
  • Resource Utilization Group (RUG); and
  • financial eligibility determination by the MEPD specialist, if applicable.

The gaining PSU staff coordinates all appropriate activities between the losing PSU, MCOs, the member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

Within two business days after completing the steps above, the gaining PSU:

  • send an email to ERS notifying ERS the member has moved;
  • manually close all service authorization records effective the end of the month the member moves;
  • manually update the Service Authorization System Online (SASO) with the gaining MCO's information effective the first of the following month in which the move occurred;
  • send Form H2065-D, Notification of Managed Care Program Services, to the member (with the begin and end date of the ISP in the Comments section); and
  • upload a copy of Form H2065-D to the appropriate SPW folder in MCOHub, using the appropriate naming convention.

Within two business days of notification of the move, ERS considers coordination of claims to limit provider impact.

Refer to Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area, for additional information.

3413 STAR+PLUS Home and Community Based Services Program Member Transferring from One MCO to Another Within the Same Service Area

Revision 23-2; Effective June 30, 2023

Once the initial enrollment period of one full month has passed, a member is eligible to change managed care organization (MCO) plans. A member may request a transfer to another MCO in the service area through the state-contracted enrollment broker at any time for any reason. Texas Health and Human Services Commission (HHSC) will make only one plan change per month. When a member wants to change from one MCO to another MCO in the same service area, the member or authorized representative (AR) must contact the enrollment broker via phone call to 1-800-964-2777.

If the member calls to change MCO on or before the monthly HHSC MCO enrollment cut-off date, the change will take place on the first day of the next month following the change request. If the member calls after the monthly HHSC MCO enrollment cut-off date, the change will take place the first day of the second month following the change request. The HHSC MCO enrollment cut-off date is not always on the same day of every month, but it is typically mid-month.

Examples:

  • If the member calls on April 9, the change will likely take place on May 1.
  • If the member calls on April 20, the change will likely take place on June 1.

HHSC Program Enrollment & Support prepares and sends a Monthly Plan Changes report to Program Support Unit (PSU) staff. The MCO can find the member-specific report located in the Monthly Enrollment (P34) File in MCOHub. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month.

Within five business days of receiving the list and determining any new members, the gaining MCO must request from the losing MCO all applicable forms and documentation related to the new member, including all H1700 forms; all H2060 forms; any 1500 forms; the Medical Necessity and Level of Care (MN/LOC) assessment; Form H6516, Community First Choice Assessment; and any prior authorizations, as well as any one-time/lifetime limits that have been met. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. If the gaining MCO experiences issues obtaining this information, the MCO must notify Managed Care Compliance and Operations (MCCO) staff.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 14 days of notification of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 30 days of notification of the new member, the gaining MCO must conduct a home visit to assess the member's needs. The gaining MCO must provide services and honor authorizations included in the prior individual service plan (ISP) until the new assessment is completed and the gaining MCO is able to complete a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, update the ISP and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider(s) and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs.

3420 Individuals Transitioning to Services for Adults

Revision 19-1; Effective June 3, 2019

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults. The following services end at the end of the month following the member’s 21st birthday.

  • Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
  • The Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

Members who receive MDCP and/or PDN/PPECC may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving Medically Dependent Children Program or Texas Health Steps Comprehensive Care Program/Private Duty Nursing or Prescribed Pediatric Extended Care Centers

Revision 18-2; Effective September 3, 2018

Members may receive a combination of the following services:

  • Medically Dependent Children Program (MDCP);
  • Private Duty Nursing (PDN); or
  • Prescribed Pediatric Extended Care Center (PPECC) services.

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 23-2; Effective June 30, 2023

Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit provides a copy of the MDCP PDN Transition Report, which lists members enrolled in STAR Kids/STAR Health and receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

  • Program Support Unit (PUS) supervisor; and
  • UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice.

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including her or his authorized representative (AR), if applicable, to initiate the transition process.

During the face-to-face visit with the member, her or his support person or AR, the MCO must present an overview of STAR+PLUS, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to STAR+PLUS. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids HandbookAppendix VI, STAR Kids Transition Activities, or for STAR Health, in the Uniform Managed Care Manual.

The STAR Kids MCO:

The STAR Health MCO notifies UR via email indicating the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program. The notification must include the number of PDN hours currently authorized.

The UR Transition/High Needs coordinator must:

  • monitor the MDCP PDN Transition Report and identify all STAR Health members turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); and
    • Texas Home Living (TxHmL).
  • coordinate with UR staff for the IDD waivers and PSU staff if it is determined the member has high needs and/or needs to be assessed for the STAR+PLUS HCBS program.

PSU staff:

  • monitor the MDCP PDN Transition Report and identifies all members receiving MDCP, PDN or PPECC services turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub in the MCO's SPW folder earlier than five months prior to the member’s 21st birthday. 

The following chart outlines the responsibilities for monitoring the MDCP PDN Transition Report and contacting members transitioning from STAR Kids/STAR Health who receive MDCP waiver and/or PDN/PPECC 12 months prior to the member’s 21st birthday.

Twelve Month Transition Chart

Under Age 21 MDCPUnder Age 21 Other Services ReceivedMonitors MDCP PDN Transition Report12-Month Contact
MDCPPDN-CCP or PPECC-CPPSU StaffMCO
MDCPNonePSU StaffMCO
Not ApplicablePDN-CCPPSU StaffMCO
Not ApplicablePPECC-CCPPSU StaffMCO

3421.2 Nine Months Prior to the Member's 21st Birthday

Revision 23-2; Effective June 30, 2023

Nine months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO):

  • monitors transition activities with the member and the member’s available supports, including her or his authorized representative (AR), every 90 days during the year before the member turns age 21; and
  • notifies Program Support Unit (PSU) staff of any issues or concerns by using Form H2067-MC, Managed Care Programs Communication, and uploads to MCOHub.

PSU staff:

  • monitor the MDCP PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and/or PDN/PPECC turning age 21 in nine months and not enrolled in one of the following intellectual and developmental disability (IDD)1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); and
    • Texas Home Living (TxHmL);
  • send the STAR Kids member Form 2114, Nine-Month Transition Letter, along with a STAR+PLUS enrollment packet (including the STAR+PLUS MCO list and comparison chart). The letter will serve as an introduction to the process and advise the member, support person or AR. PSU staff will contact the member or member’s support person, or AR, within 30 days to discuss the transition process and review the enrollment packet; and
  • update the case in the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) by:
    • documenting the date the Initial Transition letter was sent out;
    • uploading the Initial Transition letter to HEART;
    • documenting the due date for the telephonic contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
    • uploading Form H2067-MC if the MCO documented any issues or concerns.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

Within 30 days of the enrollment packet mailing, PSU schedule and complete a telephonic contact with the member or the member’s available supports, including her or his authorized representative, to explain the following:

  • STAR Kids eligibility, MDCP or PDN/PPECC services will terminate on the last day of the month in which the member’s 21st birthday occurs.
  • The STAR+PLUS HCBS program is an option available to eligible members at age 21. PSU staff also presents an overview of the array of services available within the STAR+PLUS HCBS program.
  • The STAR+PLUS program enrollment packet sent to the member is reviewed. The packet contains a list of the STAR+PLUS MCOs in the service area and a comparison chart to assist the member in making a selection. The member will choose a STAR+PLUS MCO in her or his service area that will perform the assessment for services and oversee the delivery of services.
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid having a gap in services.
  • The member can change MCOs any time after the first month of enrollment.
  • The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the Medical Necessity and Level of Care (MN/LOC) Assessment. The assessment results in the cost limit for the individual service plan (ISP).
  • To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit that will meet the member's needs and ensure health and safety.
  • If an ISP cannot be developed within the cost limit that ensures member’s health and safety in the community, the STAR+PLUS HCBS program will be denied.
  • The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
  • The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. If an MCO has not been selected, then 30 days is allowed for a selection. After 30 days, an MCO is selected for the member.
  • After the MCO is selected, the MCO service coordinator will contact the member to begin the assessment for services and assist the member, the member’s support person, or his/her authorized representative in identifying and developing additional resources and community supports to help meet the member's needs.
  • The MCO service coordinator will assist the member in determining the services needed within this service array to meet his needs and ensure health and safety. Example: If other needs are met, but the member primarily requires nursing, then an ISP can be developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
  • Reassure the member, support person or AR that every effort will be made to help him or her make a successful transition to the STAR+PLUS HCBS program.
  • The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

3421.3 Five Months Prior to the Member's 21st Birthday

Revision 23-2; Effective June 30, 2023

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP and/or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

  • the member or AR receiving MDCP and/or CCP/PDN or PPECC informs PSU staff of the MCO choice; and
  • PSU staff inform the:
    • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
    • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub in the MCO's SPW folder, using the appropriate naming convention; and
    • MCO of a member receiving 50 or more PDN hours by noting the PDN hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

  • PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU contact, one will be assigned; and
  • if the selection is not made within seven days from the PSU contact, PSU staff:
    • select an MCO for the member;
    • inform the member that:
      • the state has selected an MCO; and
      • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
    • inform the MCO of the choice by uploading Form H3676 to MCOHub in the MCO's SPW folder, using the appropriate naming convention.

Note: Within 14 days of the PSU Form H3676 uploading date, the MCO must schedule the initial home visit with the MDCP or CCP/PDN member or AR.

3421.4 Within 45 Days of Receiving Notification of a Form H3676 Referral

Revision 23-2; Effective June 30, 2023

Within 45 days of receiving email notification of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, the managed care organization (MCO):

  • completes either Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment;
  • completes the Medical Necessity and Level of Care (MN/LOC) Assessment, using Service Group 19, and submits the form to the Long Term Care (LTC) Online Portal (Note: The initial MN/LOC may not be submitted earlier than 150 days prior to the first day of the month following the 21st birthday of the member);
  • makes a referral to a Local Intellectual and Developmental Disability Authority (LIDDA), for members who may have an intellectual or developmental disability (IDD), so the LIDDA can complete the necessary assessments used to determine whether the member meets the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level of care (LOC) necessary to qualify for Community First Choice (CFC);
  • completes Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, according to STAR+PLUS HCBS program eligibility referenced in Section 3421.6 that follows;
  • uploads Form H1700-1 and Form H1700-3 to MCOHub in the MCO's ISP folder, using the appropriate naming convention. An approved MN/LOC must be received before uploading Form H1700-1, if the member has a need for the STAR+PLUS HCBS program;
  • completes Section B of Form H3676; and
  • uploads Form H3676 to MCOHub in the MCO's SPW folder, using the appropriate naming convention.

3421.5 Confirm STAR+PLUS Home and Community Based Services Program Eligibility

Revision 23-2; Effective June 30, 2023

Program Support Unit (PSU) staff confirm eligibility within five business days of receipt of all required eligibility documentation from the managed care organization (MCO) and Texas Medicaid & Healthcare Partnership (TMHP), based on:

  • an approved medical necessity and level of care (MN/LOC);

    Note: A valid MN does not exceed 150 days from the date of TMHP approval. If MN exceeds 150 days from date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO, and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to MCOhub in the MCO’s SPW folder.

  • at least one STAR+PLUS Home and Community Based Services (HCBS) program service is listed on the individual service plan (ISP); and
  • an ISP cost within 202 percent of the Resource Utilization Group (RUG) cost limit. Note: If the ISP exceeds 202 percent of the RUG, refer to 3421.6, ISP Cost Exceeds 202 Percent of the RUG Cost Limit.

PSU staff must request STAR+PLUS HCBS program enrollment from Enrollment Resolution Services (ERS) no later than 60 days prior to the individual's 21st birthdate so the Texas Health and Human Services Commission (HHSC) enrollment broker does not send a STAR+PLUS HCBS program enrollment packet to the individual.

If STAR+PLUS HCBS program eligibility is approved, within two business days, PSU staff:

  • establish the start-of-care date, which is the first of the month following the member’s 21st birthday;
    For example, the 21st birthday of the member receiving the Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) is March 3, 20XX:
    • STAR+PLUS HCBS program registration is effective April 1, 20XX;
    • ISP is entered for the STAR+PLUS HCBS program ISP period; and
    • STAR+PLUS HCBS program registration is April 1, 20XX, to March 31, 20XX;
  • complete Form H2065-D, Notification of Managed Care Program Services, and
    • send the original to the member;
    • upload Form H2065-D to the HHS Enterprise Administrative Report and Tracking System (HEART); and
    • upload From H2065-D to MCOHub in the MCO's SPW folder, using the appropriate naming convention.

Within five business days of receipt of Form H2065-D from PSU staff, ERS:

  • forces enrollment of the member into STAR+PLUS in the Texas Integrated Eligibility Redesign System (TIERS); and
  • establishes STAR+PLUS enrollment effective the first day of the month following the 21st birthday of the member receiving MDCP or CCP/PDN or PPECC. Note: If the member's birthday is the first day of the month, enrollment is effective the same day and month following the 21st birthday of the member receiving MDCP or CCP/PDN or PPECC.

3421.6 Individual Service Plan Cost Exceeds 202 Percent of the Resource Utilization Group Cost Limit

Revision 23-3; Effective Dec. 1, 2023

If the initial or annual reassessment individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits the documents below. The documents must first be reviewed and approved by the MCO medical director. They are submitted to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator.

  • Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • 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, if applicable;
  • Form H2060-B, Needs Assessment Addendum;
  • Form 1024, Individual Status Summary;
  • Form 1747, Acknowledgement of Nursing Requirements, which is only for individuals who have elected nursing through Consumer Directed Services;
  • Form 485, CMS Home Health Certification and Plan of Care, or Plan of Care with the same components in Form 485, effective during the time the nursing notes provided for review;
  • Two weeks of nursing notes, including medication administration records, seizure, ventilator and suction logs, as applicable;
  • Primary care or specialty physician office visit notes that:
    • document the current medical condition;
    • describe the needs of the individual and support the MCO determination that they require care exceeding the cost ceiling;
    • are dated within the last 12 months;
    • are from a visit conducted by a physician and are not from a specialty care visit conducted by a nurse practitioner or physician assistant; and
    • are more comprehensive than a summary of the patient visit and
  • Current documentation supporting legally authorized representation status, such as legal guardianship, medical power of attorney, or durable power of attorney paperwork.

HHSC expects the MCO to review the documentation before submission. This is to ensure completeness and that the assessments completed by the MCO do not show discrepancies from the in-home nursing documentation.

UR staff conduct a desk review once all the documents noted above are received. They may request an HHSC physician clinically review the case and consider the coverage of costs exceeding the 202 percent cost limit. If HHSC is unable to make a determination based on the documentation submitted, the MCO will receive a request for more information. 

MCOs must submit documentation supporting a request to provide services over the cost limit no later than 45 days:

  • from the MCO’s receipt of Form H3676, Managed Care Pre-enrollment Assessment Authorization;
  • from identified need or request for STAR+PLUS Home and Community Based Services (HCBS) for an individual who is enrolled in STAR+PLUS and has experienced a change in condition;
  • before the ISP effective date for individuals enrolled in STAR+PLUS HCBS who have experienced a change in condition at the time of their reassessment; or
  • before the ISP effective date for individuals enrolled in STAR+PLUS HCBS who are already approved for services over the cost limit at the time of their reassessment.

Note: HHSC UR staff coordinate a conversation with the member, their authorized representative (if applicable), and the MCO to discuss the process for HHSC to authorize services above the cost limit.

3422 Intrapulmonary Percussive Ventilator

Revision 19-1; Effective June 3, 2019

Members who were approved for and are using an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by Texas Health and Human Services Commission (HHSC) Office of the Medical Director.