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Revision 14-1; Effective March 3, 2014
4410 Continuation of STAR+PLUS Waiver Services During an Appeal
Revision 23-2; Effective June 30, 2023
HCBS STAR+PLUS Waiver (SPW) services must continue until the hearings officer makes a decision regarding the appeal of an active SPW member, if the appeal is filed by the effective date of the action pending the appeal. If an appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO).
SPW services must continue to be provided until the hearings officer renders a decision by posting to MCOHub Form H2067-MC, Managed Care Programs Communication.
If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four calendar months or until the outcome of the appeal is determined. PSU does not extend the medical necessity/level of care records in the Service Authorization System (SAS). Do not send Form H2065-D, Notification of Managed Care Program Services, to the member notifying of continued eligibility related to the reassessment action taken to continue services until the appeal decision is made.
If an appeal is initially dismissed and subsequently re-opened, the Health and Human Services Commission (HHSC) continues/restarts services pending the appeal outcome, if the member requests continued services. When the hearing officer sets a date for a new hearing, he/she, in effect, voids the prior decision. Because services are continued until a decision is rendered, and the hearing officer is stating there is still a hearing to be held, HHSC continues/re-starts services again.
4420 Discontinuation of HCBS STAR+PLUS Waiver Services During an Appeal
Revision 23-2; Effective June 30, 2023
If the appeal is not filed by the effective date of the action, HCBS STAR+PLUS Waiver (SPW) services continue until the effective date of denial notated on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If an appeal was not requested by the effective date of the action, the Program Support Unit must complete Form H2067-MC, Managed Care Programs Communication.
- For Medical Assistance Only (MAO) members, Form H2067-MC is:
- posted to MCOHub to inform the managed care organization (MCO) SPW services must continue until the end of the ISP period or the Medicaid denial date, as notated on Form H2065-D; and
- emailed to Operations Coordination to disenroll from STAR+PLUS following the disenrollment policy effective the day immediately following the ISP expiration date.
- For Supplemental Security Income (SSI) members, Form H2067-MC should be posted to MCOHub to inform the MCO that SPW services should continue until the end of the ISP period.
SSI members are still enrolled in STAR+PLUS services and are still eligible for State Plan services, which include acute care and long-term services and supports, such as Primary Home Care and Day Activity and Health Services.