3600, Ongoing Service Coordination | Texas Health and Human Services

Printer-friendly version

Revision 19-1; Effective June 3, 2019

Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

revising the individual service plan (ISP) as necessary to meet the needs of the member, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services, respite or requests for service suspension;
coordinating and consulting with MCO-contracted providers regarding delivery of services;
reminding the member to complete and return Medicaid renewal eligibility documents sent by Program Support Unit (PSU) staff or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
monitoring services delivered to members, evaluating the adequacy and appropriateness of the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program, and documenting monitoring activities;
assisting the member in accessing and using community, Medicare, family and other third-party resources (TPR);
assisting with crisis intervention; and
responding to situations of potential denial of an active member whose ISP costs exceed the individual's assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of the STAR+PLUS HCBS program.

3610 Revising the Individual Service Plan

Revision 23-2; Effective June 30, 2023

It may be necessary to revise the individual service plan (ISP) within the ISP period due to changes in the needs of the member or changes in the services offered or emergency situations. The managed care organization (MCO) documents revision to the ISP on Form H1700-1, Individual Service Plan. A revised ISP is not submitted to the Program Support Unit (PSU) via MCOHub, but is kept in the member's case record.

3611 MCO Required Notifications from the Provider

Revision 18-2; Effective September 3, 2017

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

the member leaves the service area for more than 30 days;
the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
the member is not financially eligible for Medicaid benefits;
providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
the member fails to pay her or his qualified income trust (QIT) copayment;
the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
the member requests that services end.

3611.1 Immediate Suspension of Services

Revision 20-1; Effective March 16, 2020

If the member or someone in the member's place of residence exhibits behavior that results in imminent danger to the health and safety of service providers or others, the provider must verbally inform the managed care organization (MCO) by the following business day and follow up with written notification to the MCO within two business days of verbal notification. The written notification must include a detailed description of the member’s behavior and how it impaired the provider’s ability to safely provide services to the member. Upon notification of suspected abuse, neglect or exploitation, the MCO must ensure an immediate report is made to the Texas Department of Family and Protective Services (DFPS) and may notify the police and immediately suspend services, as needed.

The MCO must provide written notice of suspension of service to the member, as stated in the Uniform Managed Care Manual (UMCM) Chapter 3.21, including an explanation of the member’s right to request an MCO Internal Appeal. The MCO must inform members that they have the right to access the State Fair Hearing process only after exhausting the MCO Internal Appeal System provided by the MCO. The written notification must also specify the reason for the suspension, the effective date and the regulatory reference, such as 1 Texas Administrative Code (TAC), Section 353.203(1)(D)(iv), relating to Member Bill of Responsibilities and the responsibility to treat providers and staff with respect.

The MCO must make efforts to resolve the situation, as appropriate for the level of danger, and document such efforts. The MCO must document whether the behavior is related to a developmental, intellectual, or physical disability or behavioral health condition. If the suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the provider may continue providing services to assist in the resolution of the situation. If it is not satisfactorily resolved, then the MCO must follow the established procedures for denial of services located in UMCM Chapter 3.21 or disenrollment from managed care, located in UMCM Chapter 11.5. Services do not continue during the appeal process.

3611.2 Required Notification of Service Denial from the Managed Care Organization

Revision 19-1; Effective June 3, 2019

If the managed care organization (MCO) determines that documentation supports initiation of denial, the MCO provides written notification of denial to the member within five business days.

The MCO's denial notice must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal. The MCO forwards a copy of the denial notice to the provider within two business days.

If the member appeals the notification of denial within the 10-day adverse action period, the MCO must continue the STAR+PLUS Home and Community Based Services (HCBS) program until notification of the decision by the state fair hearings officer. The MCO must not reduce the STAR+PLUS HCBS program until the outcome of the state fair hearing is known.

3620 Reassessment

Revision 18-2; Effective September 3, 2018

3621 Reassessment Procedures

Revision 23-2; Effective June 30, 2023

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System Online (SASO) annually. PSU staff:

check MCOHub to determine if the managed care organization (MCO) has submitted Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, before the ISP end date;
verify the SASO case record has an approved medical necessity and level of care (MN/LOC) (both must have the same end date as the ISP being registered; if not, extend the MN/LOC record through the end of the ISP being registered);
confirm ongoing Medicaid eligibility;
verify continuing enrollment in SASO reflects any plan change;
verify the ISP is within the cost limit;
determine if the ISP was submitted on time and if:
- on time, enters service group (SG) 19 service code (SC) 12;
- not on time, enters SG 19 SC 13 for the month(s) for which the ISP was late and SG 19 SC 12 for the remaining ISP period; and
enter the ongoing ISP in SASO within five business days of receipt, not to exceed the ISP end date.

The Supplemental Security Income (SSI)-denied Medicaid program types referenced in 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services (HCBS) Program, do not change in the Texas Integrated Eligibility Redesign System (TIERS) either during the initial or annual review by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. As part of reassessment procedures, PSU staff will remain responsible for confirming ongoing Medicaid eligibility, but is not required to request MEPD test an individual for the additional criteria, or request a change in the Medicaid program type.

If the reassessment ISP is being submitted due to the participant's timely appeal of a STAR+PLUS HCBS program denial, PSU staff enter the information from the old ISP, extending the end date an additional four months. Services continue using this ISP until a decision is received from the hearing officer. At that time, changes are made, if necessary, to comply with the hearing officer's decision.

3621.1 Individual Service Plan Expiring Report

Revision 20-2; Effective October 1, 2020

Program Support Unit (PSU) staff and managed care organizations (MCOs) will review the Individual Service Plan (ISP) Expiring Report for the STAR+PLUS Home and Community Based Services (HCBS) program on a monthly basis to ensure annual reassessments are conducted timely. The ISP Expiring Report lists the STAR+PLUS HCBS program members with ISPs that will expire within 90 days from the date of the report.

PSU staff must email the ISP Expiring Report to the MCOs five business days prior to the monthly conference call with PSU staff. The MCOs must provide a written status update for all STAR+PLUS HCBS program members who have ISPs expiring within 45 days. The MCOs must return the status update to PSU staff within two business days prior to the monthly conference call. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.

3622 Notification Requirements

Revision 23-2; Effective June 30, 2023

If the member continues to meet STAR+PLUS Home and Community Based Services (HCBS) program requirements, it is not necessary to send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. If the member does not meet STAR+PLUS HCBS program requirements, Program Support Unit (PSU) staff must, within two business days of notification:

send Form H2065-D to the member indicating why the case is being terminated;
upload a copy of Form H2065-D in MCOHub to the MCO's SPW folder using the appropriate naming convention; and
after the effective date of the action on Form H2065-D, send a copy of Form H2065-D to Enrollment Resolution Services (ERS), if applicable.

If no appeal is filed, ERS disenrolls the member from STAR+PLUS effective the date of the action on Form H2065-D.

If the member files an appeal timely, PSU staff, within two business days of notification:

send Form H1746-A, MEPD Referral Cover Sheet, for cases in the Centralized Representation Unit, which forwards the information to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
upload Form H2067-MC, Managed Care Programs Communication, in MCOHub to the MCO's SPW folder, using the appropriate naming convention, informing the MCO to continue services due to the timely appeal (if services have already ended, the MCO reinitiates services immediately);
extend the end date of the current ISP an additional four months; and
send an email to ERS on medical assistance only (MAO) cases as notification that a timely appeal was submitted and enrollment should remain open.

ERS, within 10 days of receiving the fair hearings officer's decision, carries out the decision. See 4234, Hearing Decision.

3623 STAR+PLUS Home and Community Based Services Program Eligibility Date on Form H2065-D

Revision 18-2; Effective September 3, 2018

Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

upgrades and interest list releases;
members transitioning out of children's programs; and
transfers from a nursing facility (NF) using Money Follows the Person (MFP).

3623.1 Upgrades and Interest List Releases

Revision 23-2; Effective June 30, 2023

The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant being released from the interest list or a member requesting/being processed for an upgrade is based on the:

Medicaid eligibility effective date;
date the approved and valid medical necessity and level of care (MN/LOC) was submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long-Term Care Online Portal; and
Note: A valid MN does not exceed 120 days from the date of Texas Medicaid and Healthcare Partnership (TMHP) approval. If MN exceeds 120 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.
date the member's individual service plan (ISP) was uploaded to MCOHub.

Program Support Unit (PSU) staff determine the eligibility and effective date based on the later of the above dates. If the date falls on the first day of the month, the eligibility and ISP effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month. If the date falls between the second and the last day of the month, the eligibility and ISP effective date is the first date of the following month.

3623.2 Members Transitioning Out of Children's Programs

Revision 19-1; Effective June 3, 2019

The eligibility and the individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the 1st of the month following their 21st birthday:

Medically Dependent Children Program (MDCP)
The Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing or Prescribed Pediatric Extended Care Center

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22. In this scenario, the eligibility and ISP effective date is the 1st of the month following their 22nd birthday.

3623.3 Money Follows the Person Nursing Facility Releases

Revision 19-1; Effective June 3, 2019

The individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program via the Money Follows the Person (MFP) process is the date of discharge. The STAR+PLUS eligibility date on Form H2065-D for members transferring from NFs to the STAR+PLUS HCBS program through the MFP process is the date used on the initial Form H2065-D. Service Authorization System Online (SASO) registration for MFP releases from NFs must occur as follows:

NF Service Group 1 SAS registrations must be closed the day before the discharge.
STAR+PLUS HCBS program Service Group 19 SAS ISP period. The effective date on Form H2065-D is the date of discharge.

3630 Denial or Termination

Revision 21-1; Effective May 1, 2021

An applicant or member may be denied or terminated from the STAR+PLUS Home and Community Based Services (HCBS) program if they do not meet the eligibility criteria outlined in Title 1 Texas Administrative Code (TAC) §353.1153 or any other applicable state or federal laws. All applicants or members must receive adequate notice of their denial or termination, including the reason for their denial or termination, and the right to a state fair hearing.

3631 Adverse Determination Notification

Revision 22-1; Effective March 1, 2022

Managed care organizations must comply with the requirements regarding Member notices of Adverse Benefit Determination, described in the Medicaid managed care contracts and the Uniform Managed Care Manual 3.21.

3632 STAR+PLUS Home and Community Based Services (HCBS) Denial/Termination Reasons

Revision 23-2; Effective June 30, 2023

Program level denials or terminations are initiated when the applicant or member does not meet one or more STAR+PLUS HCBS eligibility criteria.

STAR+PLUS HCBS may be denied or terminated for the following reasons, which will be included on Form H2065-D, Notification of Managed Care Program Services:

Death;
Institutional Stay;
Member Request;
Medicaid Financial Eligibility;
Medical Necessity/Level of Care (MN/LOC);
Exceeding the ISP Cost Limit;
Inability to Locate Member;
Not Requiring At Least One Waiver Service; or
Other Reasons.

If the managed care organization (MCO) is made aware of a reason an applicant or member must be denied or terminated from the STAR+PLUS HCBS program, the MCO must:

submit a request for denial or termination to Program Support Unit (PSU) staff, including notification of the reason for the denial, on Form H2067-MC, Managed Care Programs Communication, to MCOHub in accordance with the conventions identified in the Uniform Managed Care Manual Chapter 16.2; and
monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal and MCOHub for denial notices issued by PSU staff.

If PSU staff receive a denial or termination request from the MCO or learn of an applicant’s or member’s ineligibility for STAR+PLUS HCBS from Managed Care Compliance Operations (MCCO), Enrollment Resolution Services (ERS), monthly reports or other reliable sources, within two business days of notification, PSU staff will:

mail the member Form H2065-D;
upload Form H2065-D to MCOHub in the MCO’s SPW folder; and
notify Medicaid for the Elderly and People with Disabilities (MEPD) staff, as appropriate.

3632.1 Denial or Termination Due to Death

Revision 23-2; Effective June 30, 2023

STAR+PLUS Home and Community Based Services (HCBS) must be terminated upon verification of the death of a member.

Program Support Unit (PSU) staff will not upload Form H2065-D, Notification of Managed Care Program Services, to MCOHub for applicant or member deaths.

Managed care organizations must notify the family of their responsibility to communicate the member’s death to the Social Security Administration (SSA).

3632.2 Denial or Termination Due to Institutional Stay

Revision 21-1; Effective May 1, 2021

STAR+PLUS Home and Community Based Services (HCBS) must be terminated when a member resides in a nursing facility (NF) for 90 days or more.

Program Support Unit (PSU) staff will terminate the member from the STAR+PLUS HCBS program by the end of the month in which the 90th day occurred.

3632.3 Denial or Termination Due to Member Request

Revision 21-1; Effective May 1, 2021

STAR+PLUS Home and Community Based Services (HCBS) must be denied or terminated when the managed care organization (MCO) is made aware that an applicant or member no longer chooses to participate in the STAR+PLUS HCBS program.

3632.4 Denial or Termination of Medicaid Financial Eligibility

Revision 21-1; Effective May 1, 2021

An applicant’s or member's eligibility for the STAR+PLUS Home and Community Based Services (HCBS)program is dependent on financial eligibility determined by the Social Security Administration (SSA) for Supplemental Security Income (SSI) or Medicaid for the Elderly and People with Disabilities (MEPD) for medical assistance only (MAO) program requirements. STAR+PLUS HCBS must be denied or terminated when SSA or MEPD staff determine the applicant or member does not meet financial eligibility requirements. The applicant or member is notified of their denial or termination of financial eligibility by SSA staff for SSI or MEPD staff for MAO. The applicant or member may appeal the decision using SSA or MEPD processes, as appropriate.

3632.5 Denial or Termination of MN/LOC

Revision 21-1; Effective May 1, 2021

An applicant or member must meet a nursing facility level of care to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) must assess the applicant’s or member’s level of care by completing the Medical Necessity and Level of Care (MN/LOC)Assessment and obtaining a physician’s signature.

Note: If the MCO does not receive a signed copy of the physician’s signature page within five business days of the initial request to the applicant’s or member’s physician, the MCO must make at least three additional attempts to obtain the signature. If unsuccessful, the MCO must contact the applicant or member for assistance in obtaining the required signature. If the MCO needs additional time beyond 45 days to make the required contacts to obtain the physician’s signature, the MCO must notify Program Support Staff (PSU) staff.

If an MCO is unable to obtain the physician’s signature required to make an eligibility determination or if the MN/LOC Assessment is denied, PSU staff will deny or terminate STAR+PLUS HCBS program eligibility for the applicant or member.

When the MN/LOC Assessment status is "MN Denied" in the Texas Medicaid & Healthcare Partnership(TMHP) Long-term Care (LTC) Online Portal, the STAR+PLUS HCBS program applicant's or member's physician has
14 business days to submit additional information. Once an MN/LOC Assessment is in "MN Denied" status, several actions may occur:

MN Approved: The status changes to "MN Approved" if the TMHP physician overturns the denial because additional information is received.
Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the
14-business-day period for the TMHP physician to overturn the denied MN has expired and no additional information was submitted for the physician review or the additional information submitted was not enough to overturn the denial. The “Overturn Doctor Review Expired” status remains unless the applicant or member requests a state fair hearing.
Doctor Overturn Denied: The status may change to "Doctor Overturn Denied" when additional information is received but the TMHP physician does not believe the information submitted is sufficient to approve MN. The "Doctor Overturn Denied" status remains unless the applicant or member requests a state fair hearing.

PSU staff will not mail Form H2065-D to deny STAR+PLUS HCBS eligibility until after 14 business days
from the date the "MN Denied" status appears in the TMHP LTC Online Portal. After the 14-business-day
period has expired, PSU staff will send Form H2065-D to deny services if the TMHP LTC Online Portal status is “Overturn Doctor Review Expired” or “Doctor Overturn Denied.”

3632.6 Denial or Termination Due to Exceeding the ISP Cost Limit

Revision 21-1; Effective May 1, 2021

The managed care organization (MCO) must consider all available support systems when determining whether the STAR+PLUS Home and Community Based Services (HCBS) individual service plan (ISP) adequately meets the needs of the applicant or member.

As part of the individual service planning process, the MCO must establish an ISP where the total cost of services does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid & Healthcare Partnership (TMHP). When a STAR+PLUS HCBS applicant’s or member’s service needs exceed their assigned cost limit, the MCO must notify Program Support Unit (PSU) staff and request denial of the STAR+PLUS HCBS program, maintaining appropriate documentation to support the denial. The MCO's documentation of this type of denial must demonstrate that the ISP, including both the STAR+PLUSHCBS program and non-STAR+PLUS HCBS program services, allowed within the RUG cost limit do not adequately meet the needs of the applicant or member.

3632.7 Denial or Termination Due to Inability to Locate the Member

Revision 21-1; Effective May 1, 2021

The managed care organization (MCO) must make at least three efforts to contact members who request or are receiving STAR+PLUS Home and Community Based Services (HCBS) by telephone. The telephone contact attempts must be made on separate days, over a period of no more than five business days, and must be made at a different time of day upon each attempt.

If an MCO is unable to reach a member or a member’s legally authorized representative (LAR) by telephone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible.

If the MCO has not made any contact with the member or LAR 15 business days after sending the written correspondence, the MCO must attempt to contact the member or LAR in person by visiting the member’s address on file.

If the MCO is still unable to locate the member and wishes to request a denial or termination, the MCO must include all documented attempts when sending notification to Program Support Staff (PSU) staff.

3632.8 Denial or Termination Due to Not Requiring at Least One Waiver Service

Revision 21-1; Effective May 1, 2021

STAR+PLUS Home and Community Based Services (HCBS) must be denied or terminated if the managed care organization assesses the applicant or member and the results indicate the applicant or member does not have a need that requires one or more of the STAR+PLUS HCBS program services.

3632.9 Denial or Termination for Other Reasons

Revision 21-1; Effective May 1, 2021

If the managed care organization (MCO) wants to request a denial or termination for a reason not listed above, the MCO must notify Program Support Unit staff of the STAR+PLUS Home and Community Based Service program denial or termination request. The notification must include detailed information that supports the denial or termination request.

3633 Disenrollment

Revision 21-1; Effective May 1, 2021

Texas Health and Human Services Commission (HHSC) conducts member disenrollment activities. Although a STAR+PLUS member may request disenrollment from managed care, membership in managed care is mandatory, with limited exceptions. See Chapter 533 of the Government Code and Title 1 of the Texas Administrative Code, Sections 353.601 and 353.603 (related to STAR+PLUS Medicaid managed care), and Section 353.403 (related to enrollment and disenrollment standards for Medicaid managed care).

Members who receive HHSC approval to disenroll from managed care and who maintain Medicaid eligibility may continue to receive services available through fee-for-service (FFS) Medicaid. All members who transition to FFS Medicaid lose any value-added services provided by the managed care organization (MCO). Those members who were receiving services under STAR+PLUS Home and Community Based Services (HCBS) may also lose some, if not all, of their HCBS waiver services in the transition to FFS Medicaid.

3633.1 Disenrollment Request by MCO

Revision 21-1; Effective May 1, 2021

A managed care organization (MCO) has a limited right to request a member be disenrolled from the MCO’s plan without the member’s consent pursuant to 42 Code of Federal Regulations §438.56. Refer to the HHSC Uniform Managed Care Manual, Chapter 11.5, Medicaid Managed Care Member Disenrollment Policy, for procedures to request the involuntary disenrollment of members.