1710 PSU Staff Notification Requirements for Applicants and Members

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member or authorized representative (AR) advising of actions taken regarding STAR+PLUS Home and Community Based Services (HCBS) program eligibility and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent indicating program-level approvals, denials and terminations. Form H2065-D must be completed in plain language that can be understood by the applicant, member or AR, following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language. PSU staff must mail English and Spanish versions of Form H2065-D to the applicant, member or AR.

Form H2065-D is used to notify interest list release (ILR) and Money Follows the Person (MFP) applicants who are certified as meeting STAR+PLUS HCBS program eligibility. Form H2065-D is also used to notify members of ongoing STAR+PLUS HCBS program eligibility at annual reassessment.

PSU staff must notify the applicant or AR of program eligibility approval using Form H2065-D within two business days of the decision for ILR and upgrade applicants. For MFP applicants, PSU staff must notify the applicant or AR of program eligibility approval using Form H2065-D within one business day of the nursing facility (NF) discharge. For reassessments, PSU staff must notify the member or AR of ongoing program eligibility using Form H2065-D within five business days of the ISP being submitted by the managed care organization (MCO). Form H2065-D also includes information on the member’s room and board (R&B) charges and copayment amounts, if applicable.

Form H2065-D is also used to notify an applicant who is denied STAR+PLUS HCBS program eligibility or a member whose eligibility is being terminated. PSU staff must notify the applicant, member or AR on Form H2065-D of the denial of application or program termination within two business days of the decision. Refer to Section 6000, Denials and Terminations.

PSU staff must also provide English and Spanish versions of Form H2065-D to the MCO. PSU staff can generate Form H2065-D manually or through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). PSU staff must upload Form H2065-D to TxMedCentral in the MCOs SPW folder on the case action date, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, if Form H2065-D is generated manually. The MCO will be receive a copy of Form H2065-D through the TMHP LTCOP on the date Form H2065-D is generated if Form H2065-D is generated electronically through the TMHP LTCOP.

1720 PSU Staff Notification Requirements for MCOs

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must use Form H2067-MC, Managed Care Programs Communication, for all communications sent to the managed care organization (MCO). PSU staff upload Form H2067-MC to TxMedCentral in the MCO’s STAR+PLUS folder, following the instruction in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Time frames for PSU staff uploading Form H2067-MC can vary between one and five business days depending on the situation. PSU staff must refer to policy in this handbook for specific time frame direction.

1730 PSU Staff Notification Requirements for Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 19-13; Effective November 5, 2019

Some Program Support Unit (PSU) staff actions are based on decisions related to Medicaid financial eligibility determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or Texas Works (TW) advisor. PSU staff must coordinate approvals, denials and terminations of STAR+PLUS Home and Community Based Services (HCBS) program eligibility with the MEPD specialist. All PSU staff notifications to the MEPD specialist must be sent by fax and include Form H1746-A, MEPD Referral Cover Sheet. PSU staff must refer to Appendix V, Medicaid Program Actions, to determine if MEPD notification is required. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.

For applicants, PSU staff must fax Form H1746-A and Form H1200, Application for Assistance – Your Texas Benefits, to MEPD, if applicable. For applicants pending a Medicaid eligibility determination, PSU staff must fax Form H1746-A to the MEPD specialist when medical necessity (MN) is determined by Texas Medicaid & Healthcare Partnership (TMHP). Once an applicant is authorized to enter the STAR+PLUS HCBS program, PSU staff must fax Form H1746-A to the MEPD specialist.

For denials and terminations not related to a Medicaid financial denial, PSU staff must fax Form H1746-A to the MEPD specialist.

1740 PSU Staff Notification Requirements for Enrollment Resolution Services Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Enrollment Resolution Services (ERS) Unit for medical assistance only (MAO) applicants that meet STAR+PLUS Home and Community Based Services (HCBS) program eligibility and do not show a managed care organization (MCO) enrollment in the Texas Integrated Eligibility Redesign System (TIERS). PSU staff must also notify the ERS Unit of MAO members having their STAR+PLUS HCBS program eligibility terminated.

The email to the ERS Unit mailbox must include:

  • a subject line including the type of request with the applicant’s first and last initial;
  • applicant or member name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • eligibility or termination effective date;
  • any other relevant information; and
  • any supporting documentation (e.g., Form H2065-D, Notification of Managed Care Program Services).

1750 PSU Staff Notification Requirements for Managed Care Compliance and Operations Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Managed Care Compliance and Operations (MCCO) Unit staff for managed care organization (MCO) noncompliance or delinquency within two business days.

The email to the MCCO Unit mailbox must include:

  • a brief statement explaining the complaint;
  • applicant or member name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO;
  • individual service plan (ISP) effective dates; and
  • any other relevant information.

1760 MCO Notification Requirements for Applicants and Members

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) is responsible for notifying the applicant, member or authorized representative (AR) when a service is denied, reduced or terminated. This is considered an adverse action and the applicant, member or AR has a right to appeal. Appeal rights of STAR+PLUS Home and Community Based Services (HCBS) program applicants or members are in the Uniform Managed Care Contract (UMCC).

1770 MCO Notification Requirements for PSU Staff

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must use Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, and Form H2067-MC, Managed Care Programs Communication, for all communications sent to Program Support Unit (PSU) staff, as applicable. The MCO must upload Form H3676, Section B, or Form H2067-MC to TxMedCentral. PSU staff will retrieve all MCO postings daily from TxMedCentral.

The MCO has 45 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral, to upload Form H3676, Section B, for individuals or applicants. The MCO has between one business day and 14 days to upload Form H2067-MC, depending on the situation for an individual, applicant or member. Specific MCO time frames for Form H2067-MC are defined throughout this handbook.