1200, STAR+PLUS Program Eligibility

Revision 19-13; Effective November 5, 2019

An individual becomes eligible to be assessed for STAR+PLUS Home and Community Based Services (HCBS) program services when their name reaches the top of the STAR+PLUS HCBS program interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if he or she is already enrolled in STAR+PLUS. For medical assistance only (MAO) individuals, once their name reaches the top of the interest list, the individual selects an MCO who begins the STAR+PLUS HCBS program eligibility determination process. For individuals currently receiving Medicaid and who are already enrolled with an MCO, they may be able to bypass the interest list through the upgrade process.

A person going through the application and eligibility process for the STAR+PLUS HCBS program is referred to as an applicant once Form H1200, Application for Assistance – Your Texas Benefits, is received by Program Support Unit (PSU) staff or the MCO has crossed the threshold into the person’s home to conduct the Medical Necessity and Level of Care (MN/LOC) Assessment. A person enrolled in STAR+PLUS is referred to as a member. A person who is not an applicant or a member is referred to as an individual.

The STAR+PLUS HCBS program is provided by authority granted to the state of Texas to allow delivery of long term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility (NF). To be eligible for services under the STAR+PLUS HCBS program, the applicant or member must meet the following criteria:

  • be 21 years or older;
  • have full Medicaid financial eligibility;
  • be a U.S. citizen;
  • be a resident of Texas;
  • have an approved medical necessity (MN) for an NF level of care (LOC);
  • have an individual service plan (ISP) with services under the established cost limit;
  • have an unmet need for at least one STAR+PLUS HCBS program service; and
  • be living in an appropriate living situation.

Title 1 Texas Administrative Code (TAC) §353.1153(a)(1)(F) states STAR+PLUS HCBS program members cannot be enrolled in more than one Medicaid waiver program at the same time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

1210 Age

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(A), STAR+PLUS Home and Community Based Services (HCBS) Program, states an applicant or member must be age 21 or older to be eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff verify the applicant’s age in the Texas Integrated Eligibility Redesign System (TIERS) upon initial entry into the STAR+PLUS HCBS program.

1220 Medicaid Financial Eligibility

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(G) states an applicant or member must be determined financially eligible for Medicaid to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must determine if an applicant or member is eligible for Medicaid by checking the Texas Integrated Eligibility Redesign System (TIERS).

For individuals who do not have Medicaid eligibility, PSU staff must mail Form H1200, Application for Assistance – Your Texas Benefits, to the individual. Once Form H1200 is received back from the applicant, PSU staff must fax Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for a Medicaid eligibility determination. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the applicant is eligible for Medicaid.

Individuals who do not have Medicaid eligibility may have Form H1200 on file with the Texas Health and Human Services Commission (HHSC). These individuals may not need to complete a new Form H1200, if Form H1200 was received by HHSC within 90 days. PSU staff must encourage the individual to submit a new Form H1200 if there have been changes in the individual’s financial situation since the last submission of Form H1200. If the individual states there is a current Form H1200 on file with HHSC, PSU staff must verify by faxing Form H1746-A to the MEPD specialist. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the individual has a current Form H1200 on file. If the individual has a current Form H1200 on file, the MEPD specialist will also inform PSU staff if the applicant is eligible for Medicaid.

For individuals who have Medicaid eligibility, PSU staff must refer to Appendix V, Medicaid Program Actions, to determine if:

  • Form H1200 must be mailed to the individual;
  • Form H1746-A must be faxed to the MEPD specialist; or
  • no action is required.

If Form H1200 was required to be mailed to the individual, PSU staff must wait for the individual to complete and send Form H1200 back to PSU staff. Once PSU staff receive Form H1200, PSU staff must fax Form H1746-A and Form H1200 to the MEPD specialist. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the applicant is eligible for Medicaid.

If only Form H1746-A is required to be sent by PSU staff, the MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the individual is eligible for Medicaid.

1230 U.S. Citizenship

Revision 19-13; Effective November 5, 2019

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long-term services and supports (LTSS) members whose financial eligibility is based on a determination from a Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Verification of citizenship and identity for eligibility purposes is a one-time activity conducted by an MEPD specialist, as documented in the MEPD HandbookChapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by an MEPD specialist, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry in those programs.

1240 Texas Residency

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(B), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must be a Texas resident to be eligible for the STAR+PLUS HCBS program. Upon initial entry into the STAR+PLUS HCBS program, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will verify Texas residency. Upon annual assessment, the managed care organization (MCO) verifies ongoing Texas residency.

1250 Medical Necessity Determination

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(C), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) to be eligible for the STAR+PLUS HCBS program.

For STAR+PLUS HCBS program applicants not residing in a nursing facility (NF), the managed care organization (MCO) service coordinator completes and submits the Medical Necessity and Level of Care (MN/LOC) Assessment electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) after obtaining a physician signature.

For STAR+PLUS HCBS program applicants currently residing in an NF and STAR+PLUS HCBS program members at reassessment, the MCO service coordinator completes and submits the MN/LOC Assessment electronically through the TMHP LTCOP. The MCO is not required to obtain a physician signature for STAR+PLUS HCBS program applicants currently residing in an NF and STAR+PLUS HCBS program member reassessment.

Once the MN/LOC Assessment is submitted by the MCO, TMHP staff will review the MN/LOC Assessment to determine if the applicant or member has an MN for an NF LOC.

TMHP staff will also calculate a Resource Utilization Group (RUG) associated with the MN. A RUG is a measure of NF staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for applicants or members and establish the individual service plan (ISP) cost limit. The MCO must retain the MN/LOC Assessment and the physician’s signature, if applicable, in the MCO’s member case file.

1260 Individual Service Plan Cost Limit

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(c)(1)(H), STAR+PLUS Home and Community Based Services (HCBS) Program, states the cost of STAR+PLUS HCBS program services on the individual service plan (ISP) should not exceed 202 percent of the cost of care Texas Health and Human Services Commission (HHSC) would pay if the individual was served in a nursing facility (NF). The applicant's or member’s ISP cost limit is calculated by Texas Medicaid & Healthcare Partnership (TMHP) based on information the managed care organization (MCO) service coordinator gathered through the Medical Necessity and Level of Care (MN/LOC) Assessment. The ISP cost limit is represented as a three-digit alphanumeric Resource Utilization Group (RUG). A RUG is a measure of NF staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for applicants or members.

For initial eligibility, the MCO service coordinator must develop an ISP consisting of STAR+PLUS HCBS program services requested by the applicant and the cost of those services. The cost should be developed at or below 202 percent of the cost to provide services to the applicant, based on the RUG in an NF. If the cost exceeds 202 percent, HHSC staff must review the circumstances and, when approved, provide funds through general revenue (GR).

Applicants exceeding the cost limit who are not approved for GR funds cannot elect to receive reduced services for entry to the STAR+PLUS HCBS program if Medicaid state plan services and STAR+PLUS HCBS program services would pose a risk to the individual’s health, safety or welfare.

1270 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 19-13; Effective November 5, 2019

Title 42 Code of Federal Regulations (CFR) §441.302(c) and Title 1 Texas Administrative Code (TAC) §353.1153(a)(1)(D) states individuals must have a need for at least one STAR+PLUS Home and Community Based Services (HCBS) program service to be eligible for the STAR+PLUS HCBS program. For initial and continued eligibility for the STAR+PLUS HCBS program, a member must have an unmet need for support in the community, and therefore use at least one STAR+PLUS HCBS program service during the individual service plan (ISP) year. Therefore, a STAR+PLUS HCBS program ISP which has $0.00 as the “Total Est. Waiver Cost” in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) will be rejected by Program Support Unit (PSU) staff. Members who do not use at least one STAR+PLUS HCBS program service per ISP year are subject to disenrollment from the STAR+PLUS HCBS program. For medical assistance only (MAO) Medicaid members, disenrollment from the STAR+PLUS HCBS program may result in a loss of Medicaid eligibility.

MAO Medicaid members receiving Community First Choice (CFC) services through a 1915(c) Medicaid waiver program must meet eligibility requirements stated in Title 42 CFR §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all STAR+PLUS HCBS program requirements and must receive one STAR+PLUS HCBS program service per month. Managed care organization (MCO) service coordinators are responsible for tracking monthly services and notifying PSU staff if an MAO member with CFC services is not receiving the minimum requirement of one service per month.

1280 Appropriate Living Arrangement

Revision 19-13; Effective November 5, 2019

Title 42 Code of Federal Regulations (CFR) §441.301(b)(1)(ii) states applicants or members enrolled in the STAR+PLUS Home and Community Based (HCBS) program must not be an inpatient of a hospital, nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID). Non-state group homes are ICF/IID.

Applicants or members who are incarcerated may or may not be able to maintain STAR+PLUS Home and Community Based Services (HCBS) program enrollment. Program Support Unit (PSU) staff must not deny an applicant or member due to incarceration. PSU staff must wait until the applicant or member loses Medicaid eligibility and deny them due to loss of Medicaid eligibility.