3500, Money Follows the Person

Revision 18-2; Effective September 3, 2018

See 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List as a tracking system for Money Follows the Person (MFP) applications from individuals who are not yet members of a managed care organization (MCO).

3510 Money Follows the Person and Managed Care

Revision 19-1; Effective June 3, 2019

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). For residents who need the STAR+PLUS Home and Community Based Services (HCBS) program, the managed care organization (MCO) will perform the functional assessment and service planning.

Note: MCOs can use an NF's Minimum Data Set (MDS) Assessment, medical necessity and level of care (MN/LOC), and Program Support Units (PSUs) can accept an NF’s MDS Assessment for MFP applicants as long as they are approved and have not yet expired. The NF’s MDS Assessment may not be used for upgrades. For more information about upgrades, see 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program.

One of the eligibility requirements for MFP is that the individual be approved for the STAR+PLUS HCBS program prior to leaving the NF. Individuals must reside in the NF until a final determination is made indicating approval of the STAR+PLUS HCBS program. Individuals leaving before receiving Form H2065-D, Notification of Managed Care Services, for an approval are denied using Denial Code 39 (Other).

Once the assessment process has been completed and the resident is determined eligible for the STAR+PLUS HCBS program, the MCO must be prepared to initiate the individual service plan (ISP) upon notification of eligibility. Individuals are enrolled in managed care on the first day of the month in which discharge from the NF is planned. This flexible enrollment process only applies to MFP.

See 3310, Intake and Enrollment, for more information about MFP.

The MCO participates in community planning groups (for example, the Community Transition Team) and other activities related to the state's Promoting Independence Initiative.

3511 Money Follows the Person Procedure

Revision 18-2; Effective September 3, 2018

A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility when a nursing facility (NF) resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. Intake staff must refer all Money Follows the Person (MFP) requests to Program Support Unit (PSU) staff. Referrals can be made by anyone, including family members, NF staff, relocation specialists and HHSC case managers.

3512 Money Follows the Person Applications Pending Due to Delay in Nursing Facility Discharge

Revision 19-1; Effective June 3, 2019

In keeping with the Promoting Independence Initiative, the Program Support Unit (PSU) and managed care organizations (MCOs) are obligated to assist the nursing facility (NF) applicant or member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, PSU staff have the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four-month time frame is the guideline used in determining pending or denying requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the member is ready to discharge from the NF.

Examples:

  • A STAR+PLUS Home and Community Based Services (HCBS) program applicant has a definite date of discharge within four months from the date services were requested. Allow the referral to remain open until the member is ready to discharge and coordinate the transfer to the community.
  • A STAR+PLUS HCBS program applicant is in the process of making living arrangements that will allow him to leave the NF within four months from the date services were requested. Allow the application to remain open.

If the applicant has an estimated date of discharge that may or may not go beyond the four–month period, PSU staff should keep the request for services open. See Section 3513 below for information about applications pending more than four months.

3513 Applications Pending More than Four Calendar Months Due to Delay in Nursing Facility Discharge

Revision 19-1; Effective June 3, 2019

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but are not finalized. If the applicant has an estimated date of discharge that goes beyond the four–month period, PSU staff should keep the request for services open.

Applicants who have not made any living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community should be denied. PSU staff deny the request for services by sending Form H2065-D, Notification of Managed Care Program Services, to the applicant within two business days after the end of the four-month pending period. PSU staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's SPW folder.

If an assisted living (AL) applicant meets eligibility criteria but is on an interest list for a contracted STAR+PLUS HCBS program AL facility (ALF), PSU staff verify through the MCO that the applicant is on the list and may leave the service request pending until the slot opens.

3514 STAR+PLUS Members Residing in a Facility

Revision 22-1; Effective March 1, 2022

When a managed care organization (MCO) receives a request from, or becomes aware of, a STAR+PLUS member who is requesting to transition to the community, the MCO service coordinator must contact the applicant or member within five business days and must meet with the member within 14 business days to explain the process of transitioning to the community.

  • Within three business days after meeting with the member, the MCO service coordinator must make a referral for relocation assistance by completing Form 1579, Referral for Relocation Service, if applicable.
  • Inform Program Support Unit (PSU) staff of the request to transition to the community by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral using the appropriate naming convention for Money Follows the Person (MFP).

Within two business days after the MCO has uploaded Form H2067-MC, PSU staff must:

  • inform the MCO if the member is on a 1915(c) Medicaid interest list, in a 1915(c) Medicaid waiver notated as open enrollment or services temporarily suspended, or neither, by uploading Form H2067-MC to TxMedCentral.

Within 45 days after becoming aware of a member requesting to transition to the community, the MCO service coordinator must have completed the assessment for the applicant or member for the appropriate services and community settings. The MCO completes the following activities:

  • The MCO completes the Medical Necessity and Level of Care (MN/LOC) assessment if there is no valid Minimum Data Set (MDS) assessment or has the option to complete its own MN/LOC assessment in lieu of using the nursing facility's (NF's) MDS.
    • The MCO should ask the NF for a courtesy copy of the MDS Assessment completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS Home and Community Based Services (HCBS) program applicant who has a valid NF MDS. The NF MDS and Resource Utilization Group (RUG) are used for STAR+PLUS HCBS program eligibility determinations.
    • An MN record must be located in the SASO so the individual service plan (ISP) registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.
  • If a Supplemental Security Income (SSI) or SSI-related member will only be receiving state plan Long-term Services and Supports (e.g., personal assistance services (PAS) or Day Activity and Health Services (DAHS)), the MCO must inform the PSU staff by uploading Form H2067-MC to TxMedCentral.
  • If the member meets functional criteria for the STAR+PLUS HCBS program, the MCO follows policy in Section 3514.1, Transition to Community with STAR+PLUS Home and Community Based Services Program.
  • The MCO relocation specialist completes the relocation assessment.

3514.1 Transition to Community with STAR+PLUS Home and Community Based Services Program

Revision 22-1; Effective March 1, 2022

During the initial 45-day time frame for the assessment, if the member is temporarily suspended from a Texas Health and Human Services Commission (HHSC) 1915(c) Medicaid waiver, the managed care organization (MCO) service coordinator explains the STAR+PLUS Home and Community Based Services (HCBS) program to the member so he or she can choose between applying for the STAR+PLUS HCBS program or remaining in their previous HHSC 1915(c) Medicaid waiver.

  • If the member chooses the STAR+PLUS HCBS program, the MCO service coordinator:
    • reviews the current Form H1700-1, Individual Service Plan, or develops a new individual service plan (ISP) if one previously did not exist or if the ISP has expired;
    • coordinates Transition Assistance Services (TAS) as part of the STAR+PLUS HCBS program, if needed;
    • coordinates Supplemental Transition Support (STS) with the MCO relocation specialist, if needed;
    • notifies Program Support Unit (PSU) staff the member has selected the STAR+PLUS HCBS program; and
    • notifies PSU staff of the selection by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral using the Money Follows the Person (MFP) naming convention.
  • If the member chooses to remain with the HHSC 1915(c) Medicaid waiver, the MCO service coordinator notifies PSU staff of the selection by uploading Form H2067-MC to TxMedCentral using the MFP naming convention.

When the member chooses the STAR+PLUS HCBS program, the MCO coordinates with MCO relocation specialists and Local Intellectual and Developmental Disability Authority (LIDDA) service coordinators, as needed, to ensure everything required for community living is in place at the time of discharge from the NF. STS services must be coordinated between the MCO relocation specialist and the MCO service coordinator when the MCO relocation specialist determines the member may benefit from STS services. See 7612, Supplemental Transition Services, and 3516, Relocation Coordination, for responsibilities of relocation specialists (RSs) and MCOs. 

The MCO and/or MCO RS are responsible for obtaining independent housing for the member and are responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network.

For all members transitioning into the STAR+PLUS HCBS program, within 45 days, the MCO shall upload the following information to TxMedCentral:

  • Form H1700-1 and Form H1700-3, if the ISP has expired or one did not previously exist; and
  • Form H2067-MC notifying PSU staff if the NF discharge date is known.

PSU staff will send an email to the Managed Care Compliance & Operations if the MCO does not upload the above information within 45 days after the member's request to return to the community. PSU staff will continue to monitor for receipt of the above information when required. Within five business days after receipt of all required documentation, PSU staff will:

  • confirm STAR+PLUS HCBS program eligibility; 
  • send an initial Form H2065-D, Notification of Managed Care Program Services, to the member as notification he or she has met the eligibility qualifications to participate in the STAR+PLUS HCBS program; and
  • upload a copy of Form H2065-D to TxMedCentral within two business days to inform the MCO PSU staff sent the notice of initial eligibility determination to the member.

Once HHSC approves STAR+PLUS HCBS program eligibility, the MCO, MCO RS, NF, NF resident and PSU staff shall collaborate to identify a proposed discharge date. The MCO is responsible for notifying PSU staff of the discharge date by uploading Form H2067-MC to TxMedCentral. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO must respond with the correct scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of PSU staff's Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO must upload Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff will complete a second Form H2065-D containing the service effective date and:

  • mail Form H2065-D to the member;
  • upload a copy of Form H2065-D to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • if HHSC denies STAR+PLUS HCBS program eligibility, PSU staff complete Form H2065-D;
  • mail form H2065-D to the member; and
  • upload a copy of Form H2065-D to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

If a Medicaid eligibility NF Medical Assistance Only (MAO) member chooses to leave the NF and return to the community before being determined eligible for the STAR+PLUS HCBS program, PSU staff will perform the following steps in addition to those referenced above:

  • mail Form H2065-D to the member; and
  • upload a copy of Form H2065-D to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

3515 Non-STAR+PLUS Members Residing in a Nursing Facility

Revision 21-2; Effective August 1, 2021

For requests to transition to the community for a non-STAR+PLUS member, the Texas Health and Human Services Commission (HHSC) Access and Eligibility staff make a referral to Program Support Unit (PSU) staff. Within two business days of the referral from HHSC, PSU staff:

  • determine whether the individual has either an open enrollment or services have been temporarily suspended in an HHSC 1915(c) Medicaid waiver according to the following:
    • For either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waivers, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify if the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
    • For the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to see if the service authorization record for these waivers has an end date and a termination code. If the service authorization has an end date and no termination code, this indicates the waiver has been temporarily suspended.
  • coordinate with the Local Intellectual and Developmental Disability Authority (LIDDA) to schedule a conference call with the individual to explain the benefits of the STAR+PLUS Home and Community Based Services (HCBS) program and the HHSC 1915(c) Medicaid waivers;
  • open a case in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART); and
  • document the member's STAR+PLUS HCBS program choice in HEART.

Within two business days of receipt of the notification of the nursing facility (NF) resident's STAR+PLUS HCBS program selection, PSU staff determine the individual's Medicaid status to evaluate for proper coordination with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

When the individual has elected to apply for the STAR+PLUS HCBS program, PSU staff must complete the following activities within two business days of notification of the selection:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify if either Form H1200, Application for Assistance – Your Texas Benefits, has already been submitted for the NF stay, or the individual already has full Medicaid eligibility for a type program applicable to the STAR+PLUS HCBS program.
  • Contact or attempt to contact the NF resident or authorized representative (AR) party by phone to explain the Medicaid application process, when applicable, the selection of a managed care organization (MCO) and the importance of promptly returning the forms that PSU staff mail to the individual.
  • Inform the NF resident during the telephone contact that he or she may change the MCO in which he or she is enrolled at any time after one full month of the STAR+PLUS HCBS program provision.
  • Send Form H1200, when applicable, and the appropriate STAR+PLUS MCO enrollment packet to the NF resident, responsible party or AR.
  • Check the Community Services Interest List (CSIL) to see if the resident is already on the STAR+PLUS HCBS program interest list. If not, add and immediately release the individual from the STAR+PLUS HCBS program interest list.
  • Refer the individual for relocation assistance by completing Form 1579, Referral for Relocation Services.
  • Notify HHSC the individual is applying for the STAR+PLUS HCBS program.

PSU staff are responsible for completing the following activities 14 days following the STAR+PLUS HCBS program selection. PSU staff must document in HEART all attempted contacts with the NF resident and any encountered delays. PSU staff:

  • contact the NF resident if PSU staff have not received Form H1200; and
  • discuss with the NF resident the importance of choosing an MCO if the individual did not select one during the initial contact, explaining the MCO conducts the assessment and develop the initial individual service plan (ISP) to facilitate an eligibility determination for the STAR+PLUS HCBS program.

If, during the 14-day follow-up contact, the NF resident states that he or she, the AR or the NF has already submitted a completed Form H1200, PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to verify Form H1200 has been submitted. If the NF resident communicates Form H1200 has not been submitted, or if TIERS does not have a record Form H1200 has been submitted, the PSU notifies the NF resident to immediately return Form H1200 to PSU staff because the application for SPW services will be denied for failure to return the Form H1200 within 45 days from the date the PSU sent the form to the NF resident. Upon receipt of the completed Form H1200, PSU staff make a referral to the MEPD specialist within two business days by completing Form H1746-A, MEPD Referral Cover Sheet, to include submission of the returned Medicaid application.

If Form H1200 is not received within 45 days from the date PSU staff sent Form H1200 to the NF resident, PSU staff deny the application for the STAR+PLUS HCBS program by:

  • documenting in HEART Form H1200 was not received within 45 days;
  • sending the NF resident Form H2065-D, Notification of Managed Care  Program Services; and
  • uploading Form H2065-D to TxMedCentral using the appropriate naming convention.

Within two business days from when the NF resident notifies PSU of the MCO selection orally or in writing, or from when the member is defaulted to an MCO, PSU staff must:

  • check SASO to determine if the applicant has a current medical necessity and level of care (MN/LOC);
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the applicant has a current MN by entering the Resource Utilization Group (RUG) and expiration date in Item 6;
  • upload Form H3676 to the MCO's XXXSPW folder on TxMedCentral using the appropriate naming convention;
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, notating whether or not the applicant is on an HHSC 1915(c) Medicaid waiver interest list; and
  • ensure the appropriate items on Form H3676 are completed and faxed to the relocation specialist, if the NF resident requires assistance transitioning to the community because of lack of supports, lack of housing or other barriers.

The MCO initiates contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. Within 45 days from receipt of Form H3676, the MCO service coordinator assesses the applicant for the appropriate services and community settings. The MCO completes the following activities

  • The MCO completes the MN/LOC Assessment if there is no valid Minimum Data Set (MDS) or has the option to complete its own MN/LOC assessment in lieu of using the NF’s MDS. If there is no valid MDS, the MCO completes the MN/LOC for an MN determination.
    • The MCO should ask the NF for a courtesy copy of the MDS Assessment completed by the MDS. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS HCBS program applicant who has a valid NF MDS. The NF MDS and RUG are used for STAR+PLUS HCBS program eligibility determinations.
    • An MN record must be located in SAS so the ISP registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.
  • If the applicant requires services through the STAR+PLUS HCBS program, the MCO completes Section B of Form H3676 and develops the ISP using Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page.
  • If a referral for relocation services is not indicated in section A of Form H3676 and the applicant needs these services, the MCO updates Form H3676, Section B, and sends Form 1579 to the relocation specialist.
  • If the applicant is not eligible for the STAR+PLUS HCBS program, the MCO must inform PSU staff by uploading Form H2067-MC to TxMedCentral.

When the MCO has determined the applicant meets the functional eligibility requirements for the STAR+PLUS HCBS program, the MCO coordinates with the relocation specialists to ensure everything needed for community living is in place at the time of discharge from the NF. The MCO must coordinate Transition Assistance Services (TAS) when needed by the applicant as part of the STAR+PLUS HCBS program. The MCO is not responsible for obtaining independent housing for the NF resident, but is responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network. When the applicant needs Supplemental Transition Support (STS) services, relocation specialists must coordinate these through the MCO service coordinator.

As needed, PSU staff collaborate with involved parties throughout the STAR+PLUS HCBS program eligibility determination process to assist with problem resolution and to document any delays. PSU staff track all actions and communications in HEART until all STAR+PLUS HCBS program enrollment activities are complete.

Within 45 days of receiving Form H3676 with Section A, the MCO uploads the following information to TxMedCentral:

  • Form H1700-1;
  • Form H1700-3;
  • Form H3676 with Section B completed; and
  • Form H2067-MC, notifying PSU staff of the NF proposed discharge date.

PSU staff send an email to Managed Care Compliance & Operations (MCCO) if the MCO does not upload the above information within 45 days after the NF resident's request to return to the community. PSU staff continue to monitor for receipt of the above-referenced forms. Within two business days of receipt of this information, if Medicaid is pending, PSU staff complete and send Form H1746-A, MEPD Referral Cover Sheet, to notify the MEPD specialist of the approved ISP and MN/LOC so the MEPD specialist can complete the Medicaid eligibility determination.

Upon completion of the evaluation for financial eligibility, the MEPD specialist notifies PSU staff of the determination by sending an email to the appropriate mailbox designated for the MEPD specialist to submit communications to PSU staff.

Within five business days after receipt of all MCO documentation required for STAR+PLUS HCBS program eligibility, as well as communication from the MEPD specialist of the applicant's Medicaid eligibility, PSU staff:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility for STAR+PLUS;
    • an approved MN/LOC;
    • an ISP with:
      • at least one STAR+PLUS HCBS program;
      • a cost within the individual's cost limit; and
  • send the initial Form H2065-D to the member and upload a copy to TxMedCentral to inform the MCO PSU staff notified the individual of this determination.

The MCO collaborates with the relocation specialist, NF, NF resident and PSU staff to identify a proposed discharge date. Once the discharge date has been determined, the MCO must notify PSU staff of the discharge date within two business days by uploading Form H2067-MC to TxMedCentral. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO resolves this discrepancy and must confirm the scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of PSU’s Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO uploads Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff complete the final Form H2065-D containing the service effective date and:

  • mail the original to the individual;
  • upload it on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • fax or email a copy, as well as Form H1746-A, to the assigned MEPD specialist for generation of a pending task in TIERS; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) Unit mailbox requesting enrollment from STAR+PLUS, if applicable.

Within one business day of sending the final Form H2065-D, PSU staff:

  • verify that NF records in the SASO reflect the NF end date;
  • contact HHSC Long Term Care (LTC) Provider Claims at 512-438-2200 and select option 1 to request closure of the NF service authorization in SAS if the NF end date reflecting the discharge has not processed;
  • update the CSIL, ensuring accurate selection of the CSIL closure code(s); and
  • email Enrollment Resolution Services (ERS) requesting enrollment effective the first of the month in which the individual is discharged, as required by 3510, Money Follows the Person and Managed Care.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D, and:

  • mail the original to the applicant;
  • upload Form H2065-D on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • upload Form H2065-D to HEART;
  • close the case in HEART; and
  • close CSIL.

If the applicant chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program, PSU staff deny the STAR+PLUS HCBS program and fax Form H2065-D, along with Form H1746-A, to the MEPD specialist. Upon completion of all STAR+PLUS HCBS program actions, PSU staff close the case in HEART.

3516 Relocation Coordination

Revision 22-1; Effective March 1, 2022

 

3516.1 Relocation Overview

Revision 22-1; Effective March 1, 2022

The relocation function is a component of service coordination. The purpose of relocation is to support members and future members who desire to move from an institution into the community. A managed care organization relocation specialist (MCO RS) works for an entity contracted with a managed care organization (MCO) to perform the relocation services. 

For more information, refer to the Texas Promoting Independence Plan, which details the state’s strategies and efforts to improve the provision of community-based alternatives to institutional care.

The MCO relocation services include, but are not limited to:

  • Conducting outreach and education to staff of nursing facilities and residents on resident options for receiving long-term services and supports (LTSS) in the community;
  • Identifying members interested in relocating;
  • Responding to referrals for relocation and conducting relocation assessments;
  • Developing and implementing person-centered relocation plans;
  • Coordinating housing and non-Medicaid community services;
  • Providing support on the day of relocation and conducting follow-up; and
  • Collecting data on relocations, as specified by the Texas Health and Human Services Commission and/or MCOs.

The MCO and MCO RS conduct regular visits to nursing facilities to provide education about the availability of community-based services, including STAR+PLUS Home and Community Based Services (HCBS) and relocation assistance, to the following potential referral sources: members in the facility, nursing facility staff, family members and other potential referral sources. The MCO and MCO RS also provide group and individual training to nursing facility staff on relocation services.

3517 Relocation Tasks

Revision 22-1; Effective March 1, 2022

 

3517.1 Relocation Process

Revision 22-1; Effective March 1, 2022

When a managed care organization (MCO) or MCO relocation specialist (RS) learns of a member's desire to move to the community, they must notify the other party within three business days of receiving the information.

Upon receipt of referral, the MCO RS must make an initial contact with the member, or the member’s authorized representative (AR), face-to-face or by telephone within five business days to schedule a relocation assessment. This assessment will collect information such as personal information, basic health and personal care needs, housing preferences, sources of income and supports needed to relocate. An AR, such as a family member or friend who is knowledgeable of the member’s situation and services, may be engaged to supplement information provided by the member. 

The MCO service coordinator must contact the member to schedule an assessment for STAR+PLUS HCBS within 14 business days of notification by the MCO RS. The MCO has 45 days to complete all assessment activities related to STAR+PLUS HCBS eligibility. For a member with an intellectual or developmental disability (IDD) who is interested in relocation, both the MCO and MCO RS must provide the appropriate Local Intellectual and Developmental Disability Authority (LIDDA) with the member’s contact information. The MCO RS provides notification to the appropriate MCO that a referral was made to the LIDDA. 

3517.2 Relocation Referral and Assessment Requirements

Revision 22-1; Effective March 1, 2022

When contacted by the managed care organization (MCO) via Form 1579, Referral for Relocation Services, or after referral is received from another source, the MCO relocation specialist (RS) must conduct a face-to-face relocation assessment with the member or authorized representative (AR) within 14 business days. An AR, such as a family member or friend who is knowledgeable of the member’s situation and services, may be engaged to supplement information provided by the member. A specific assessment form is not required. The assessment includes, but is not limited to:

  • goals of the member regarding community living;
  • preferences for post-relocation housing;
  • information regarding informal support;
  • information regarding finances and need for support;
  • need for post-relocation supports that are not available under 1915(c) waivers or STAR+PLUS HCBS;
  • history of unsuccessful relocation attempts and reasons attempts; and
  • barriers to relocation. 

The MCO RS shall share the results from assessment with the MCO within the initial 45-day time frame. Both the MCO and MCO RS shall develop a person-centered relocation plan with the member, AR and others the member chooses to have involved. Both the MCO and MCO RS shall advocate with nursing facility staff and service coordinator(s) to support the member’s needs, preferences and goals. Through the combination of the MCO and MCO RS assessments, MCO service plan and MCO RS transition plan, the MCO and MCO RS must identify and address a member’s needs for non-Medicaid community services, including, but not limited to:

  • housing supports or aid;
  • help setting up a utility or telephone account;
  • non-medical transportation, including mainline, special transit and local transportation providers;
  • start-up groceries, as needed; or
  • banking, bill payment and direct deposit.

Both the MCO and MCO RS shall maintain regular and open communication with all parties who are involved in the relocation process.

3517.3 Relocation Housing Coordination

Revision 22-1; Effective March 1, 2022

If the member needs housing, both the managed care organization (MCO) and MCO relocation specialist (RS) shall help secure affordable, accessible and integrated housing consistent with the member’s preferences.

The MCO RS is primarily responsible for helping to secure housing and assists the member in applying for:

  • Project Access, if eligible and interested;
  • Section 811 Project Rental Assistance, as available; and
  • other affordable housing options, as necessary.

If the member is interested in moving into an assisted living facility or adult foster care, the MCO service coordinator shall review options available among contracted providers. In the case that a member is paying toward the cost of their nursing facility care, the service coordinator will explain that this income, including supplemental security income, may be used toward payment for the room and board, and if applicable a services copayment, in a community-based setting.

Both the MCO and MCO RS shall assist the member in accessing community supports such as food banks, utility assistance, emergency rental assistance and emergency Supplemental Nutrition Assistance Program (SNAP). Both the MCO and MCO RS shall participate in the discharge planning process with the member or legally authorized representative (LAR), service coordinator(s), MCO RS, their LIDDA and others important to the member. MCOs shall negotiate and schedule the discharge date in coordination with the MCO RS and other community and social supports, as necessary. If an MCO or MCO RS becomes aware of a change to the discharge date, the MCO or MCO RS must notify each other immediately. 

3517.4 Relocation Day and Follow-Up Requirements

Revision 22-1; Effective March 1, 2022

The managed care organization (MCO) and MCO relocation specialist (RS) shall coordinate with all parties to ensure living arrangements and community supports are in place at the time of discharge. Both the MCO and MCO RS shall help facilitate the member’s notification to Social Security of the member’s new address as soon as possible after relocating to the community. The MCO service coordinator shall remind nursing facility staff to transfer Medicaid benefits from the facility to the community. Both the MCO and MCO RS must be present at the new address on relocation day to ensure all services are in place, as well as assist in setting up the household, as needed. Both the MCO and MCO RS shall notify each other if the member does not have all necessary Medicaid and non-Medicaid supports in place on relocation day. The MCO and MCO RS shall coordinate follow up, which may include, but is not limited to:

  • determining if there are unresolved issues related to the transfer of benefits, condition of the member’s health, emotional well-being, etc.;
  • communicating all unresolved medical and non-medical issues to the MCO service coordinator; and
  • assisting the member in addressing unmet needs.

The MCO RS must contact the member at least seven times over the course of 90 days post-relocation to ensure a successful transition to the community. The MCO RS must also notify the MCO if the member has any unmet needs throughout the 90 days.

3517.5 Minimum Qualifications

Revision 22-1; Effective March 1, 2022

A managed care organization (MCO) must offer a contract to provide the relocation function to an entity with at least five years contracting with the state or an MCO to provide relocation functions to members transitioning from institutions to Medicaid community-based long-term services and supports (LTSS).

An MCO may contract with an entity that meets all the following qualifications to provide relocation services:

  • Adherence to Health Insurance Portability and Accountability Act (HIPAA) compliant data management requirements and other stipulations of the MCO;
  • Experience identifying barriers to relocation for members who express an interest in moving from nursing facilities in Texas to a home and community-based setting;
  • Knowledge of community resources for members with disabilities of all ages and how to access those resources;
  • Knowledge of community and federal housing resources and how to access those resources, as appropriate;
  • Knowledge of Medicaid including, but not limited to, Medicaid managed care, LTSS, eligibility requirements and how to apply and qualify for Medicaid;
  • Ability to hire, train, supervise and direct MCO relocation specialists (RSs) that ensures the successful transition of members from nursing facilities. The entity is responsible for ensuring any MCO RS is not listed in the HHSC employee misconduct registry, Inspector General (IG) list of excluded entities and individuals, and HHSC do-not-hire registries. The entity must conduct a fingerprint background check and share the results with the MCO prior to hiring an MCO RS;
  • Two years of experience developing transition plans for members; and
  • Three years of experience working directly with people with disabilities of all ages, or the entity must have at least three years of experience subcontracting with an entity described above to provide the relocation function.

3520 Money Follows the Person Demonstration

Revision 20-1; Effective March 16, 2020

 

3521 Money Follows the Person Demonstration Introduction

Revision 20-1; Effective March 16, 2020

The Money Follows the Person Demonstration (MFPD) was implemented to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities (NFs) to the community and receive necessary long-term services and supports (LTSS) in the setting of the individual's choice. Participation in MFPD does not affect the type or amount of services received or the manner in which services are delivered. Individuals participating in MFPD receive the same services delivered to other STAR+PLUS Home and Community Based Services (HCBS) program individuals.

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

Revision 22-1; Effective March 1, 2022

Managed care organizations (MCOs) and Medicare-Medicaid Plans (MMPs) are referred to as “MCOs” in this handbook. All requirements apply to MMPs unless an exception has been specifically noted. 

The MCO must apply the following screening criteria to determine if an individual is potentially eligible to participate in the Money Follows the Person Demonstration (MFPD). To be eligible for MFPD, the individual must be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program and meet the following criteria:

  • reside continuously in an institutional setting, including days during a Medicare certified skilled nursing facility (SNF) stay following a stay in a Medicaid certified nursing facility (NF), for at least 60 days prior to the STAR+PLUS HCBS eligibility date;
  • be enrolled in MFPD before leaving a Medicaid certified NF;
  • be Medicaid eligible under Title XIX of the Social Security Act;
  • be transitioning* from an NF into a qualified residence that includes:
    • a home owned or leased by the individual or individual's family member;
    • an apartment with an individual lease that includes living, sleeping, bathing and cooking areas in which the individual or family member has domain;
    • Assisted Living (AL) apartment (Service Code 19);
    • Residential Care apartment (Service Code 19A); and
    • Adult Foster Care (AFC) home (no more than four unrelated individuals living in the home); and
  • agree to participate in the MFPD by completing Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, signed by the individual or authorized representative (AR) and MCO staff, after explanation of MFPD and prior to delivery of services.*

*The MCO must include the AR in the actual transition planning, if applicable.

3522.1 Screening for 60-Day Qualifying Institutional Stay

Revision 22-1; Effective March 1, 2022

For purposes of the Money Follows the Person Demonstration (MFPD), an institutional setting is defined as a Medicaid certified nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state supported living center or hospital. The 60-day qualifying institutional stay may be met by a continuous stay in a combination of the settings. Days spent in a Medicare certified skilled nursing facility (SNF) also count toward the 60-day qualifying institutional stay when the Medicare SNF stay follows a stay in a Medicaid certified NF. See also 3525, Documentation of the 60-Day Qualifying Institutional Stay Required for MFPD Eligibility in the STAR+PLUS HCBS Program.

Example: An MFPD individual resided continuously in a Medicaid certified NF for 15 days, in a hospital for 15 days and then re-entered the NF for another 15 days. This would meet the 60-day institutional residency requirement for MFPD.

The individual does not have to reside in the Medicaid certified NF or other institution for 60 days at the time they indicate a desire to transition to the community. The individual meets the screening criteria if it appears likely they will reside in a Medicaid certified NF or other institution, including days spent in a Medicare certified SNF, for at least 60 days prior to the discharge date from the NF.

3522.2 Program Support Unit Staff Verification of 60-Day Qualifying Institutional Stay

Revision 22-1; Effective March 1, 2022

Program Support Unit Staff (PSU) must verify the 60-day residency requirements for eligibility in the Money

Follows the Person Demonstration (MFPD). To verify, PSU staff may:

  • use Minimum Data Set (MDS) information, available on the Texas Medicaid & Healthcare Partnership (TMHP) website;
  • view the Service Authorization System Online (SASO) NF records (Service Code 1);
  • contact the Medicaid or certified NF and Medicare certified SNF for admission dates; or
  • as a last resort, obtain confirmation from the individual.

PSU staff communicate to managed care organization (MCO) staff that the individual is potentially eligible for MFPD by completing the MFPD qualifying begin and end dates in Section A, Item 20, Qualifying Dates, on Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

3523 Enrollment in Money Follows the Person Demonstration

Revision 20-1; Effective March 16, 2020

Individuals who meet the eligibility requirements and choose to enroll in the Money Follows the Person Demonstration (MFPD) must be designated by Program Support Unit (PSU) staff, according to STAR+PLUS Program Support Unit Operational Procedures Handbook 9480, MFPD for STAR+PLUS HCBS Program Applicant, in the Service Authorization System Online (SASO), using the following procedures:

  • Enrollment Record — Enrolled from Field: Choose "12 — Money Follows the Person.”
  • Service Authorizations:
    • Force Box — Check the Force box for each service authorization.
    • Fund Type — Choose "19MFP-Money Follows the Person." This code applies only to MFPD recipients.
    • Force Comment — Enter "MFP Demonstration Member" and select "Force."

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD entitlement period is over or if the individual withdraws from MFPD. See 3524, Money Follows the Person Demonstration Entitlement Period Tracking.

PSU staff must maintain a list of MFPD participants. This list must contain the following:

  • Individual’s name;
  • Medicaid identification (ID) number; and
  • ISP start and end date.

The individual may withdraw from MFPD at any time by informing the managed care organization (MCO) service coordinator. To inform PSU staff of the withdrawal, the MCO service coordinator uploads Form H2067-MC, Managed Care Program Communications, to TXMedCentral, indicating withdrawal from MFPD. Although MFPD eligibility may end upon withdrawal from MFPD, the individual continues to receive STAR+PLUS Home and Community Based Services (HCBS) program services if all STAR+PLUS HCBS eligibility criteria are met.

3524 Money Follows the Person Demonstration Entitlement Period Tracking

Revision 20-1; Effective March 16, 2020

Money Follows the Person Demonstration (MFPD) individuals are entitled to 365 days of participation in MFPD. Time spent in an institutional setting does not count toward the 365-day entitlement period; therefore, tracking is required to ensure MFPD individuals receive the full 365-day entitlement period.

The entitlement period begins the date the MFPD individual is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

Example: The individual chooses to participate in MFPD and is enrolled in the STAR+PLUS HCBS program, effective June 1, 2019, with an initial individual service plan (ISP) effective June 1, 2019, through May 31, 2020.

  • If there are no institutional stays during the initial ISP period, the MFPD entitlement period ends when the ISP period ends on May 31, 2020.
  • If the MFPD individual is institutionalized for 10 days in April 2020, the MFPD entitlement period is suspended during the period of institutionalization and resumes when they return to the community until the end of the 365-day entitlement period. In this example, the MFPD entitlement period ends on June 10, 2020, which is after the ISP end date of May 31, 2020.
  • If the MFPD individual is authorized for a new MFPD service during the initial ISP period and there are no institutional stays, the MFPD entitlement period would still end on May 31, 2020.

Tracking is required to ensure MFPD individuals receive the full 365-day entitlement period unless the individual withdraws from MFPD. The MCO is responsible for tracking the MFPD entitlement period. Once the 365-day entitlement period has passed, the MCO is responsible for uploading Form H2067-MC to TxMedCentral in the MCO folder to inform PSU staff of the date the individual's entitlement period ended.

It is essential that complete and accurate records are maintained because MFPD tracking is subject to audit by the Centers for Medicare and Medicaid Services (CMS).

3525 Documentation of the 60-Day Qualifying Institutional Stay Required for MFPD Eligibility in the STAR+PLUS HCBS Program

Revision 22-1; Effective March 1, 2022

The individual's date of entry and date of discharge from a hospital, Medicaid certified nursing facility (NF) or other institutional setting are included in the number of days the individual is institutionalized for purposes of the 60-day qualifying institutional stay required for the Money Follows the Person Demonstration (MFPD).

Program Support Unit (PSU) staff must check the Service Authorization System Online (SASO) for verification of residence in qualified institutional settings. This may include stays in a combination of applicable settings, which include:

  • Service Group (SG) 1, Service Code (SC) 1, NF — Daily care;
  • SG 5, SC 1, State Operated Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
  • SG 6, SC 1, Non-State Operated ICF/IID; and
  • SG 4, SC 1, State Supported Living Centers.

PSU staff must send Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO), documenting MFPD 60-day qualifying begin and end dates. Institutional stays for the 60 days prior to the eligibility date must be documented even if it appears the individual does not meet the criteria.

If the individual is currently residing in a qualified institutional setting at the time Form H2067-MC is sent to the MCO, enter the begin date of coverage and use "ongoing" as the end date.

SASO records do not include any possible hospitalizations or stays in a Medicare certified skilled nursing facility (SNF), which also count toward the 60-day requirement. The MCO will determine if the individual was in a hospital or Medicare certified SNF directly before the begin date on Form H2067-MC. Refer to 3522.2, Program Support Unit Staff Verification of 60-Day Qualifying Institutional Stay, for acceptable verification sources. The MCO will also determine whether the 60-day residency requirement for MFPD eligibility has been met once the discharge date from the Medicaid certified NF is known.

Similarly, if the individual has a gap in institutional residency, the MCO will evaluate MFPD eligibility by checking for possible hospitalizations or stays in a Medicare certified SNF prior to the Medicaid certified NF stay or during the gap period, as well as considering the discharge date from the Medicaid certified NF.

3530 High/Complex Needs Members

Revision 18-2; Effective September 3, 2018

 

3531 Designation of High Needs Members

Revision 18-2; Effective September 3, 2018

The Uniform Managed Care Contract (UMCC), Attachments A and B-1, Section 8.1.12, specifies the managed care organization (MCO) must develop and maintain a system and procedures for identifying members with special health care needs (MSHCN), including people with disabilities or chronic or complex medical and behavioral health conditions and children with special health care needs (CSHCN).

The MCO must contact members pre-screened by the Texas Health and Human Services Commission (HHSC) Administrative Services contractor as MSHCN to determine whether they meet the MCO's MSHCN assessment criteria, and to determine whether the member requires special services. The MCO must provide information to the HHSC Administrative Services contractor identifying members who the MCO has assessed to be MSHCN, including any members pre-screened by the HHSC Administrative Services contractor and confirmed by the MCO as a MSHCN. The information must be provided in a format and on a time line to be specified by HHSC in the Uniform Managed Care Manual (UMCM), and updated with newly identified MSHCN by the 10th day of each month. In the event that an MSHCN changes MCOs, the MCO must provide the receiving contractor information concerning the results of the MCO's identification and assessment of that member's needs to prevent duplication of those activities.

CSHCN means a child (or children) who:

  • ranges in age from birth up to age 19;
  • has a serious ongoing illness, a complex chronic condition or a disability that has lasted or is anticipated to last at least 12 continuous months or more;
  • has an illness, condition or disability that results (or without treatment would be expected to result) in limitation of function, activities or social roles in comparison with accepted pediatric age-related milestones in the general areas of physical, cognitive, emotional, and/or social growth and/or development;
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel; and
  • has a need for health and/or health-related services at a level significantly above the usual for the child's age.

MSHCN includes a CSHCN and any adult member who:

  • has a serious ongoing illness, a chronic or complex condition, or a disability that has lasted or is anticipated to last for a significant period of time; and
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel.

3532 Determination of High Needs Status for Ongoing Members

Revision 19-1; Effective June 3, 2019

If during the individual service plan (ISP) period the managed care organization (MCO) determines the member's subsequent ISP may have the potential to exceed the cost limit, that member is considered to have high needs status. Once designated as having a high needs status, the MCO must initiate in the ninth month of the ISP period plans to bring the ISP at/or under the cost limit.

If it appears the subsequent ISP will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the MCO initiates a request for a staffing with the Texas Health and Human Services Commission (HHSC) to determine whether a request for the use of General Revenue (GR) funds is appropriate.