Appendix XXII, MCO Transition Specialist Pilot Project

Revision 22-3; Effective August 3, 2022


This information provides the details and scope of the MCO Transition Specialist Pilot (TS Pilot) Project and the requirements for MCOs involved in the two pilot service areas, Bexar and Travis. This is a federally funded Money Follows the Person Demonstration (MFPD) project with a time limited scope for calendar years 2021-2024. 

Section I. Overview 

The Centers for Medicare and Medicaid Services (CMS) approved and awarded the Texas Health and Human Services Commission (HHSC) 100% federal administrative funding within the Texas Money Follows the Person Demonstration (MFPD) to conduct the Transition Specialist Pilot project from Jan. 1, 2022 through Dec. 31, 2024. The purpose of this project is to support eligible STAR+PLUS members with serious and persistent mental illness (SPMI) who meet a nursing facility level of care (NF LOC) in transitioning to the most integrated setting of their choice. 

In the TS Pilot, participating STAR+PLUS managed care organizations (MCOs) hire a transition specialist to provide intensive psychosocial rehabilitative supports to STAR+PLUS members transitioning out of a nursing facility into the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO transition specialist works within the already-existing MCO structure that supports members transitioning to community settings.

The TS Pilot will fund positions within the MCOs in two TS Pilot service areas (Travis and Bexar). 

Voluntary TS Pilot project participation is available to eligible STAR+PLUS members within the Bexar and Travis service areas. 

Section II. Legal Basis

The Money Follows the Person Demonstration (MFPD) is a component of the Texas Promoting Independence Initiative (PI) Plan. The PI Plan, most recently revised in December 2020, is required by Senate Bill 367, 77th Legislature Regular Session, 2011 and Executive Order RP-13. STAR+PLUS MCOs are required to participate in the PI initiative, pursuant to Uniform Managed Care Contract Section (“Participation in Texas Promoting Independence Initiative”).

Section III. Program Service Area: 

Travis and Bexar County service areas

Section IV. Transition Specialist Pilot Participant Requirement

Participation in the TS Pilot is voluntary. To participate, the member must meet the following requirements: 

  • be a member of an MCO participating in the TS Pilot;
  • currently live in a nursing facility;
  • intend to live within the Travis or Bexar service area; 
  • have a diagnosis of SPMI;
  • meet NF LOC criteria;
  • receive Medicaid;
  • have a desire to and be eligible to transition to the community using the STAR+PLUS HCBS program;
  • be willing to meet with the TS Pilot transition specialist throughout TS Pilot period; and
  • participate in surveys, assessments or other evaluation activities for the duration of the Pilot.

Eligible members may be identified through the Promoting Independence Initiative process outlined in the Uniform Managed Care Contract Section (“Participation in Texas Promoting Independence Initiative”). Potential participants can also be directly referred to TS Pilot via the Pre-Admission Screening and Resident Review (PASRR) process, by an MCO service coordinator, by a relocation specialist, facility staff or others. 

MCOs follow processes outlined in Section 3000 of the STAR+PLUS Handbook to assess if the member is eligible to receive STAR+PLUS HCBS services before enrolling the member in the TS Pilot. See Section 3000, STAR+PLUS HCBS Program and Eligibility Services. 

Members may voluntarily leave the TS Pilot by notifying their MCO, transition specialist, or service coordinator.

Section V. Transition Specialist Pilot Services

Members who meet TS Pilot eligibility criteria and volunteer to participate can access the supports and services provided by the MCO transition specialist, including Cognitive Adaptation Training (CAT), other therapeutic interventions, and intensive transition supports. See Section VI, Transition Specialists, for detailed list of supports and services that can be provided by the MCO transition specialist. 

The TS Pilot services do not replace existing STAR+PLUS Medicaid services and supports. For example, a TS Pilot participant would be eligible to receive needed Medicaid psychosocial rehabilitation services regardless of the services they receive from the transition specialist.   

Section VI. Transition Specialists

Transition specialists will provide the following intensive psychosocial rehabilitation and transition services to TS Pilot participants:

  1. CAT

    The transition specialist will provide CAT and related services to TS Pilot Participants and continue to provide these services upon discharge into the community for up to one year after date of discharge. CAT is a psychosocial intervention provided in the person’s home which seeks to bypass the cognitive challenges associated with mental illness to improve independent living. CAT relies on the use of environmental supports, such as signs, calendars, hygiene supplies, pill containers, and other resources to cue and sequence adaptive behavior.
  2. Intensive Transition Services

    The transition specialist will provide intensive transition services to TS Pilot participants, which include all the following:
    1. Evidenced-based skills training, including CAT. 
    2. Other therapeutic interventions, as determined to be appropriate by the MCO, fostering skills necessary to manage symptoms, obtain and maintain employment or housing, or to obtain services such as education, medical care, nutritional assistance, financial assistance, transportation, legal assistance, and resources fulfilling any basic need.
    3. Pre-Tenancy housing supports to include assisting member to access documents necessary to obtain housing, negotiating with landlords, working with the participant to locate and apply for housing and get a housing voucher if applicable.
    4. Coordination of services with MCO staff, network providers and external providers to support participants in achieving independent functioning.

      The transition specialist must collect and enter data into an HHSC-specified data system at participants’ entry into the TS Pilot, every six months while in the TS Pilot, and upon the participants’ program completion, using all the following instruments:
    5. The Questionnaire about the Process of Recovery (QPR)
    6. Personal Well-Being Index (PWB)
    7. World Health Organization Disability Assessment Scale (WHODAS 2.0)

The transition specialist must contact the member within five business days of the member expressing interest in participating in the TS Pilot to schedule an initial meeting. At this meeting, the transition specialist must obtain a signed agreement from the member to participate, collect the member’s information to determine eligibility for the TS Pilot, and schedule needed follow-up meetings.

Transition specialists must communicate at a minimum of twice a month via email or phone with the member’s service coordinator to ensure continuity of care. 

Section VII. Managed Care Organization Responsibilities

MCOs are required to perform the following activities in the manner and timeframes specified in this section. 


MCOs must hire and administratively support one full-time equivalent (FTE) transition specialist per TS Pilot service area to provide CAT and intensive transition services to TS Pilot participants. 

MCOs are required to hire transition specialists with the following qualifications:

  1. Minimum of a bachelor’s degree in health, social services or a related field and relevant experience in assisting people in transitioning from institutional settings to the community. Individuals selected for these positions must complete training specified by HHSC and demonstrate knowledge and skills in delivering the TS Pilot interventions.
  2. Preferred experience working with people with serious and persistent mental illness (SPMI), lived experience of mental illness or both.

MCOs will develop a TS Pilot program participant identification, engagement, and monitoring process which integrates the transition specialist function into the MCO’s existing infrastructure. 

MCOs are required to submit expenditures for payment as outlined in Section IX, Managed Care Organization Billing Instructions. See Section IX, Managed Care Organization Billing Instructions. 

Collaboration Requirements

  1. Collaboration with Technical Assistance Contractor

    HHSC has contracted with the University of Texas Health Science Center San Antonio (UTHSCSA) to train TS Pilot transition specialists in CAT and provide on-going technical assistance. The transition specialists are required to participate in virtual or in-person multi-day training, on-going weekly calls, and a learning community supporting the work of transitioning people out of nursing facilities into the community.

    The point of contact for UTHSCSA will be designated by UTHSCSA.
  2. Collaboration with the Third-Party Evaluator

    HHSC has contracted with the University of Texas at Austin (UT Austin) to conduct evaluation activities for the TS Pilot. MCOs are required to provide UT Austin requested data on work completed with TS Pilot Participants and help coordinate  interviews with participants and key staff in the MCOs such as the transition specialists and their supervisors. See Section VI, Transition Specialist.

    The point of contact for UT Austin will be designated by UT Austin.
  3. Collaboration with HHSC staff and contractors

    The MCO must work with staff and contractors identified by HHSC to plan and effect transitions. These may include, but are not limited to, local mental health authorities, state hospital staff and other contractors.
  4. Meetings, Conference Calls and Other Activities

    MCOs must fulfill the following requirements: 
    1. Participate in all HHSC–scheduled meetings to discuss the project. 
    2. Participate in conference or teleconference calls as requested by the HHSC project director. These may include calls with state agencies, federal funding entities and subrecipients, technical assistance entities, local stakeholders or other persons or entities related to the project. 
    3. Participate in face-to-face meetings as requested by HHSC project director. 
    4. Notify HHSC project director within one business day of receipt of a request to participate in non-routine calls and activities.

Section VIII. Managed Care Organization Performance Measures

The following requirements will be used to assess the MCOs’ effectiveness in providing the services described herein.

MCOs will submit the following reports with participant level data in a reporting format agreed upon by HHSC and MCO:

  1. Electronically submit a quarterly TS Pilot report on or before Jan. 10, April 10, July 10, and Oct.10 to HHSC. The TS Pilot runs on the calendar year from Jan. 1 through Dec. 31. The quarterly TS Pilot report will include:
    1. Name of the transition specialist, their supervisor, and any changes in these staff that might occur during the quarter.
    2. Required data and documentation described in Section VI(2), Intensive Transition Services, of this section. 
    3. Activities completed in Sections VI, Transition Specialist, of this section.
  2. All reports, documentation, and other information required of the MCO will be submitted electronically to the HHSC Innovation mailbox: If HHSC determines the MCO needs to submit deliverables by mail or fax, the MCO must send the required information to one of the following addresses:

    U.S. Postal Mail
    Texas Health and Human Services Commission
    Mental Health Contracts Management Unit (Mail Code 2058) 
    P. O. Box 149347
    Austin, TX 78714-9; 347

    Overnight Mail
    Texas Health and Human Services Commission
    Mental Health Contracts Management Unit (Mail Code 2058)
    909 West 45th Street, Bldg. 552
    Austin, TX 78751
    Fax: 512-206-5307 

Section IX.  Managed Care Organization Billing Instructions

Payments under the TS Pilot are excluded from the MCO capitation payments. The contracted MCO will submit expenditures and request payment on or before the 10th of every month following the month services were provided using the Authorization for Expenditures (Form 4116), which can be downloaded here. When required by this section, supporting documentation for reimbursement of the services and deliverables will also be submitted. At a minimum, invoices will include: 

  • name, address, and phone number of transition specialist;
  • HHSC contract or purchase order number ; 
  • itemized expenses broken down by salaries, fringe benefits, in-state travel, and supplies   
  • identification of service(s) provided; 
  • dates services were delivered; 
  • name of the person performing the activities; 
  • total hours worked for each person performing the activities; 
  • total invoice amount; 
  • a copy of the general ledger for the period which supports the budget items requesting reimbursement; and 
  • any additional supporting documentation which is required by this section or as requested by HHSC.  

Contractor will electronically submit all invoices with supporting documentation to the Claims Processing Unit with a copy to