1710 PSU Staff Notification Requirements for Applicants and Members

Revision 24-4; Effective Dec. 1, 2024

Form H2065-D, Notification of Managed Care Program Services (PDF), is the legal notice showing program-level eligibility for approvals, denials, and terminations for the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff are responsible for preparing and mailing Form H2065-D to the applicant, member, or authorized representative (AR) advising of actions taken for STAR+PLUS HCBS program eligibility. PSU staff must mail English and Spanish versions of Form H2065-D to the applicant, member or AR.

Form H2065-D includes:

  • approval, denial or termination effective dates;
  • plain language that can be understood by the applicant, member or AR;
  • room and board (R&B) and copayment charges, if applicable;
  • cost-of-living adjustment (COLA) for room and board (R&B) charges, if applicable; and
  • fair hearing rights.

PSU staff generate Form H2065-D manually or electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) depending on the case action being taken. PSU staff must follow the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, to ensure language entered on the form can be understood by the applicant, member or AR.

PSU staff must notify the applicant, member, or AR of program eligibility approval within five business day of verifying eligibility criteria was met by using Form H2065-D. This time frame applies to all case types, including:

  • interest list releases (ILRs);
  • upgrades;
  • Money Follows the Person (MFP) process; and
  • reassessments.

PSU staff must notify the applicant, member or AR of a program eligibility denial or termination using Form H2065-D upon notification eligibility criteria is not being met. PSU staff time frames for mailing Form H2065-D varies depending on the denial or termination type. For example, PSU staff must mail Form H2065-D for a denial or termination within:

  • three business days for upgrades; and
  • two business days for all other denials and terminations.

PSU staff must provide the English version of Form H2065-D to the MCO. PSU staff can generate Form H2065-D manually or electronically through the TMHP LTCOP. PSU staff must upload Form H2065-D to the MCOHub, if Form H2065-D is generated manually. The MCO must retrieve a copy of Form H2065-D through the TMHP LTCOP if Form H2065-D is generated electronically.

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.