3400, Transferring Into STAR+PLUS

Revision 18-0; Effective September 4, 2018

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, Section 2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to his or her MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to Section 3125, STAR+PLUS HCBS Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants or members, the losing service area must inform the gaining service area of the GR status. The gaining service area must follow the GR process.

3410 MCO Transfer Scenarios

Revision Notice 24-2; Effective May 21, 2024

The applicant, member, or authorized representative (AR) must contact the enrollment broker by phone at 800-964-2777 to change from one managed care organization (MCO) to another MCO. The MCO transfer may occur within the same service area (SA) or in another SA.

An applicant, member, or AR may request to change MCOs at any time, for any reason, and regardless of their living arrangement. However, for an applicant requesting an MCO change, the transfer will not go into effect until after one full calendar month of STAR+PLUS Home and Community Based Services (HCBS) program service provision. All MCO enrollment changes become effective based on the date the MCO change is requested and processed, in relation to the state cutoff. Refer to Appendix XVII, State Cutoff Dates, for more information.

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes Report to PSU staff and gaining MCOs. PSU staff receive a complete list of all plan changes and the MCO receives a list of their new members. The report lists STAR+PLUS HCBS program members who have changed MCOs from the previous month. Refer to Appendix I-E, Monthly Plan Changes Report, for information on the contents of the report.

3411 Transferring from One MCO to Another Within the Same Service Area

Revision Notice 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must ensure the contract number in the Service Authorization System Online (SASO) is updated to reflect the new managed care organization’s (MCO’s) contract number. This must be done within 14 days of receipt of the Monthly Plan Changes Report from Enrollment Operations Management (EOM) staff. Refer to Section 9300, Transfers, for more information on SASO actions.

The losing MCO must transfer all relevant information to the gaining MCO using a secure file transfer protocol (SFTP) or secure email. Relevant information includes the individual service plan (ISP), Medical Necessity and Level of Care (MN/LOC) Assessment, and Form H2065-D, Notification of Managed Care Program Services. 

The gaining MCO is responsible for service delivery beginning the first day of enrollment. The gaining MCO honor authorizations included in the prior ISP until the member requires a new MN/LOC Assessment.

The gaining MCO must notify Managed Care Compliance and Operations (MCCO) staff if they encounter issues getting the transfer packet from the losing MCO. MCCO Unit staff may contact PSU staff for help transferring member information to the gaining MCO.

3412 Transferring from One MCO to Another in a Different Service Area

Revision Notice 24-2; Effective May 21, 2024

The losing Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of the Monthly Plan Change report from Enrollment Operations Management (EOM) staff for an applicant or member changing service areas (SAs):

• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
• verify the applicant or member’s address and managed care enrollment is updated in Texas Integrated Eligibility Redesign System (TIERS);
• email the gaining PSU staff  the following information: 
  • an email subject line that reads “STAR+PLUS HCBS MCO Transfer for XX [applicant or member’s first and last name initials]”;
  • applicant or member name;
  • Medicaid identification (ID) number;
  • current and future contact information; 
  • date of the move or anticipated move; and
  • Form H1700-1, Individual Service Plan, if available.

The losing PSU staff must complete the following activities within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

• for Supplemental Security Income (SSI) applicants and members: 
  • advise the MCO to help the applicant or member to contact the Social Security Administration (SSA) to update their address; and
• for medical assistance only (MAO) applicants and members:
  • fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the address change.

TIERS will attempt to assign an applicant or member to a companion plan automatically when their address is updated in TIERS and reflects a SA change. A companion plan is defined as an MCO that operates the same managed care line in multiple SAs. TIERS will systematically refer the applicant or member to the enrollment broker if a companion plan is unavailable.

The enrollment broker will attempt to get a new MCO selection from the member. The enrollment broker will default the member to an MCO if a selection is not provided within 15 days. The defaulted MCO selection is made using the Texas Health and Human Services Commission (HHSC) approved default logic and is processed at the next state cutoff. The HHSC-approved default logic considers the member’s medical history, including prior enrollments, primary care providers (PCPs), claims data, and any family plans, about the program type and SA.

For applicants, the gaining PSU staff must ensure the MCO submits the Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP) within 45 days from the date the losing PSU staff upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub.

For members, the gaining PSU staff must confirm all STAR+PLUS Home and Community Based Services (HCBS) program eligibility within five business days of receipt of Form H1700-1. The process is abbreviated since the member already has the following:

• an MN/LOC Assessment;
• a Resource Utilization Group (RUG); and
• financial eligibility determination by the MEPD specialist, if applicable.

The gaining PSU staff coordinates all appropriate activities between the losing PSU staff, MCOs, applicant, member or authorized representative (AR), Enrollment Resolution Services (ERS) Unit staff and other key parties to help ensure a successful transition.

The gaining PSU staff must complete the following activities within five business days from notification of the transfer:

• confirm the applicant or member’s address and managed care enrollment is updated in TIERS;
• ensure the contract number in the Service Authorization System Online (SASO) is updated to reflect the gaining MCO’s contract number;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads “STAR+PLUS HCBS MCO Transfer Enrollment Request for XX [member’s first and last name initials]”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (i.e., MCO change);
  • medical necessity (MN) approval date;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • MCO selection;
  • effective date of enrollment; 
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

The gaining PSU staff must complete the following activities within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

• contact the applicant or member by phone to select an MCO from the gaining SA;
• mail the enrollment packet containing:
  • Form H2053-B, Health Plan Selection;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for more information, and for SA changes occurring for a Money Follows the Person (MFP) case.

3420 Individuals Transitioning Services for Adults

Revision 18-0; Effective September 4, 2018

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults beginning the first day of the first month following the individuals 21st birthday. The following services end at the end of the month following the member's 21st birthday.

• Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
• Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

In addition to the programs and services above, individuals for Community First Choice (CFC) services and personal care services (PCS) must transition to an adult program.

Members who receive MDCP, PDN, PPECC, CFC or PCS and transition to adult programs may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018

Members may receive a combination of the following services:

• Medically Dependent Children Program (MDCP);
• private duty nursing (PDN); or
• prescribed pediatric extended care center (PPECC) services.

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit provides a copy of the MDCP-PDN Transition Report, which lists members enrolled in STAR Kids or STAR Health receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

• Program Support Unit (PSU) staff; and
• UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice staff.

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including the authorized representative (AR), if applicable, to initiate the transition process.

During the home visit with the member, member's support person or AR, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to the STAR+PLUS program. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids Program Support Unit Operational Procedures Handbook, Appendix VI, STAR Kids Transition Activities, or for STAR Health, in the Uniform Managed Care Manual (UMCM).

The STAR Kids MCO must:

• make a referral to Program Support Unit (PSU) staff by email at the Managed Care Program Support mailbox, using Form H2067-MC, Managed Care Programs Communication, and include, "PDN/PPECC and/or MDCP Transition" in the subject line;
• monitor transition activities with the member or the support person, including the AR, every 90 days during the year before the member turns age 21; and
• email the UR Unit mailbox indicating this may be a high needs member, if the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program.

The STAR Health MCO:

• emails the UR Unit mailbox if the member appears to meet the high needs criteria below:
  • the member is on ventilator care; and/or
  • the member has high skilled nursing needs, such as tracheostomy care, wound care, suctioning or feeding tubes.

The UR Unit Transition/High Needs coordinator must:

• monitor the MDCP-PDN Transition Report and identify all STAR Health members turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL); and
• coordinate with UR Unit staff for the IDD waivers and PSU staff if it is determined the member has high needs and/or needs to be assessed for the STAR+PLUS HCBS program.

ILM Unit staff must:

• monitor the Managed Care Program Support mailbox for referrals submitted with the subject line "PDN/PPECC and/or MDCP Transition";
• perform a search prior to assigning the referral to see if a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record has been created by PSU staff from monitoring the CCP Transition Report; and
• if a HEART case record is found, upload the MCO's referral and advise PSU staff by email; or
• if a HEART case record is not found, create a HEART case record, upload the referral and assign to PSU staff for further action.

PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members receiving MDCP, PDN or PPECC services turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
  • CLASS;
  • DBMD;
  • HCS; or
  • TxHmL;
• create a case record in HEART noting:
  • if the MCO determines the member is high needs; the program type (MDCP, or PDN or PPECC) the member is transitioning from; and
  • the due date for the nine-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for monitoring the MDCP-PDN Transition Report and contacting members transitioning from STAR Kids or STAR Health who receive MDCP, PDN or PPECC 12 months prior to the member's 21st birthday.

12-Month Transition Chart

3421.2 Nine Months Before the Member's 21st Birthday

Revision 23-4; Effective Dec. 7, 2023

Nine months before the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO) must:

• monitor transition activities with the member and the member's available supports, including his or her authorized representative (AR), every 90 days during the year before the member turns 21; and
• notify Program Support Unit (PSU) staff of any issues or concerns by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and PDN or PPECC turning 21 in nine months and not enrolled in one of the following Medicaid waiver programs:
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL);
• mail the STAR Kids member or AR a STAR+PLUS enrollment packet, including:
  • Form 2114, Nine-Month Transition Letter;
  • Form H2053-B, Health Plan Selection;
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Appendix XII, STAR+PLUS HCBS Program Description;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards.

PSU staff must update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record by:

• documenting the date Form 2114 was sent out to the member or AR;
• documenting the due date for the phone contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
• upload all applicable documents to the HEART case record.

Note: PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub no earlier than five months before the member's 21st birthday.

PSU staff must contact the member or AR within 30 days from the date the enrollment packet was mailed to discuss:

• The transition process and review the enrollment packet.
• STAR Kids eligibility, MDCP, PDN and PPECC services will terminate on the last day of the month that the member's 21st birthday occurs.
• The STAR+PLUS HCBS program is an option available to eligible members at 21. PSU staff must also present an overview of the array of services available within the STAR+PLUS HCBS program.
• The STAR+PLUS HCBS program enrollment packet sent to the member is reviewed. The enrollment packet contains a list of the STAR+PLUS MCOs in the SA and a comparison chart to help the member in making an MCO selection. The member will choose a STAR+PLUS MCO in their SA to conduct the Medical Necessity and Level of Care (MN/LOC) Assessment for services and oversee the delivery of services.
• The importance of choosing an MCO six months before the 21st birthday to avoid having a gap in services.
• The member can change MCOs any time after the first month of enrollment.
• The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the MN/LOC Assessment. The assessment determines the cost limit for the individual service plan (ISP).
• To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit, meet the member's needs and ensure health and safety.
• The STAR+PLUS HCBS program will be denied if an ISP cannot be developed within the cost limit that ensures member's health and safety in the community.
• The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
• The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. The member has 30 days to select an MCO. An MCO will be selected for the member after 30 days if one has not been selected.
• The MCO service coordinator will contact the member to begin the MN/LOC Assessment for services and assist the member or AR identify and develop additional resources and community supports to help meet the member's needs.
• The MCO service coordinator will help the member determine the services needed within this service array to meet his or her needs and ensure health and safety. Example: A member who primarily requires nursing services can have an ISP developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
• Reassure the member or AR every effort will be made to ensure a successful transition to the STAR+PLUS HCBS program.
• The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

PSU staff must update the HEART case record by noting the due date for the six-month contact.

The following chart outlines the responsibilities to monitor the MDCP-PDN Transition Report and contact members transitioning from STAR Kids or STAR Health and receiving MDCP and PDN or PPECC nine months before the member's 21st birthday:

Nine-Month Transition Chart

3421.3 Six Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Six months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care (PPECC) services, the following process begins.
The Utilization Review (UR) Unit must:

• monitor the MDCP-PDN Transition Report and identify all members turning age 21 in six months receiving CCP/PDN through fee-for-service (FFS) or STAR Health and not enrolled in one of the following Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waivers:
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL).
• coordinate with Program Support Unit (PSU) staff if it is determined the member is high needs and/or will need to be assessed for the STAR+PLUS Home and Community Based Services (HCBS) program.

The IDD Waiver/Community Services/Hospice UR Unit staff will:

• monitor the MDCP-PDN Transition Report for members enrolled in one of the following 1915(c) Medicaid waivers for IDD and who are turning age 21 in the next six months:
  • CLASS;
  • DBMD;
  • HCS; or
  • TxHmL; or
• make a STAR+PLUS HCBS program referral to PSU staff by email using Form H2067-MC, Managed Care Programs Communication, for members requesting a STAR+PLUS HCBS program assessment, or whose proposed waiver plan exceeds the member cost limit for the IDD 1915(c) Medicaid waiver listed above.

PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members referenced in Section 3421, Children Transitioning from STAR Kids or STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC, turning age 21 in six months and not enrolled in one of the IDD 1915(c) Medicaid waivers listed above;
• not reach out to members in CLASS, DBMD, HCS or TxHmL, unless the IDD Waiver/Community Services/Hospice UR Unit submits a referral, as documented above;
• send Form H2116, Age-Out MDCP and PDN Contact Letter, to the member if the MCO choice has not been obtained;
• contact the member or authorized representative (AR) if the MCO choice has not been obtained by telephone to:
  • review the STAR+PLUS enrollment packet discussed at the 12-month or the nine-month contact;
  • inform the member or AR of a 30-day time frame to choose a managed care organization (MCO) and a primary care physician (PCP);
  • explain if the member or AR does not timely choose an MCO, the Texas Health and Human Services Commission (HHSC) will assign an MCO for the member; and
  • explain that the member can change MCOs any time after the first month of enrollment.
• email the UR Unit at the HHSC UR High Needs CCR mailbox regarding all possible high needs situations; and
• update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, documenting the:
  • contact or contact attempt date;
  • MCO selection; and
  • due date for the five-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for agency referrals and PSU staff action for members enrolled in STAR Kids or STAR Health and receiving MDCP, PDN or PPECC transitioning six months prior to the member's 21st birthday.

Six-Month Transition Chart

3421.4 Five Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

• the member or AR receiving MDCP-PDN or PPECC informs PSU staff of the MCO choice; and
• PSU staff inform the:
  • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
  • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions; and
  • MCO of members receiving 50 or more PDN hours, by noting the PDH hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

• PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU staff contact, one will be assigned; and
• if the selection is not made within seven days from the PSU staff contact, PSU staff:
  • select an MCO for the member;
  • inform the member that:
    • an MCO has been selected; and
    • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
• inform the MCO of the choice by uploading Form H3676 to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

Note: Within 14 days of the PSU staff uploading date of Form H3676, the MCO must schedule the initial home visit with the MDCP or CCP or PDN member or AR.

3421.5 MCO Actions After Receiving Form H3676 Referral

Revision 23-2; Effective May 15, 2023

The managed care organization (MCO) must complete the following activities within 45 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff:

• conduct and submit the Medical Necessity and Level of Care (MN/LOC) Assessment to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); 
  • Note: The MCO must not submit the initial MN/LOC Assessment earlier than 150 days prior to the member’s 21st birthday;
• complete Form H1700-1, Individual Service Plan, Form H1700-2, Individual Service Plan – Addendum and Form H1700-3, Individual Service Plan – Signature Page;
• upload Form H1700-1 to TxMedCentral, once an approved MN/LOC Assessment is received; and
• complete Form H3676, Section B, and upload to TxMedCentral.

3421.6 Confirm STAR+PLUS HCBS Program Eligibility

Revision 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must confirm ongoing Medicaid eligibility in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, from the managed care organization (MCO).

PSU staff must coordinate with the Intellectual or Developmental Disability (IDD) waiver program staff by email, if the member is enrolled in an IDD waiver program, within five business days of receipt of the following from the MCO: 

• Form H3676, Section B;
• an approved and valid Medical Necessity and Level of Care (MN/LOC) assessment; and
• the STAR+PLUS Home and Community Based Services (HCBS) program individual service plan (ISP).

The email to the IDD waiver program staff must include: 

• a subject line that reads "[IDD waiver program acronym] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]"; 
• member’s name;
• Medicaid identification (ID) number;
• the IDD waiver program termination date; and 
• the STAR+PLUS HCBS program start of care (SOC) date.

PSU staff must confirm STAR+PLUS HCBS program eligibility no earlier than 45 days before the transition to an adult program. PSU staff must confirm STAR+PLUS HCBS program eligibility by verifying the following eligibility criteria:

• an approved and valid MN/LOC Assessment submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and updated in the Service Authorization System Online (SASO);
• an ISP within the cost limit that includes at least one STAR+PLUS HCBS program service; and
• continued Medicaid financial eligibility in the Texas Integrated Eligibility Redesign System (TIERS).
  
  Note: A valid MN does not exceed 150 days from the date of TMHP approval for applicants transitioning to an adult program. PSU staff must upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub requesting the MCO submit a new initial MN/LOC Assessment in the TMHP LTCOP if the MN exceeds 150 days from the date of TMHP approval.

PSU staff must complete the following activities within five business days of confirming approval of STAR+PLUS HCBS program eligibility:

• establish the SOC date which is the first of the month following the member's 21st birthday;
  • SOC Date Examples:
    • A member receiving Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Centers (PPECC) services has their 21st birthday on March 3, 2019. STAR+PLUS enrollment is effective April 1, 2019.
    • A member receiving MDCP or CCP, PDN or PPECC services has their 21st birthday on April 1, 2019. STAR+PLUS enrollment is effective May 1, 2019.
• manually or electronically generate Form H2065-D, Notification of Managed Care Program Services;
• upload Form H2065-D to the MCOHub, if manually generated; 
• mail Form H2065-D to the member;
• email Enrollment Resolution Services (ERS) Unit staff the following information:
  • an email subject line that reads: "[MDCP or IDD waiver program] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]";
  • the member's name;
  • Medicaid ID number;
  • ISP begin and end date for the STAR+PLUS HCBS program;
  • MCO selection and plan code; and
  • Form H2065-D;
  • fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist as notification of the program change from MDCP or an IDD waiver program to the STAR+PLUS HCBS program for medical assistance only (MAO) members;
  • verify IDD waiver program staff have closed IDD records in SASO, if applicable;
  • make SASO entries, following procedures in Section 9600, MDCP/CCCP Transitioning to STAR+PLUS HCBS Program;
  • upload applicable documents to the HHS Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, for more information on denying an applicant trying to transition to an adult program.

3421.7 ISP Cost Exceeds 202% of the RUG Cost Limit

Revision 23-2; Effective  May 15, 2023

The managed care organization (MCO) must provide documentation to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator if the individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit.

The UR Unit may request a clinical review of the case to consider the use of state General Revenue (GR) funds to cover costs exceeding the 202 percent cost limit. The UR Unit will provide the final determination letter to the MCO and Program Support Unit (PSU) staff if a clinical review is conducted. 

Note: HHSC UR staff will coordinate with the member, authorized representative (AR) and the MCO to discuss the process for HHSC to request the use of GR for services above the cost limit.

3422 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only

Revision 21-10; Effective October 25, 2021

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the non-waiver program individual's or applicant's 21st birthday occurs. The individual or applicant must receive services through programs serving adults beginning the first day of the month following the individual's or applicant's 21st birthday.

Individuals and applicants with STAR+PLUS must transition their personal care services (PCS) and Community First Choice (CFC) services to an adult program. Some individuals or applicants may continue to receive PCS or CFC through STAR Health until age 22, depending on eligibility requirements.

The Texas Health and Human Services Commission (HHSC) enrollment broker will reach out to the individual or applicant 30 days prior to the individual's or applicant's 21st birthday and provide the individual or applicant with a STAR+PLUS enrollment packet. The individual or applicant is allowed 15 days to make a managed care organization (MCO) selection. The HHSC enrollment broker will select an MCO for the individual or applicant if the individual or applicant has not made a selection after 15 days, as outlined in Title 1 Texas Administrative Code (TAC), §353.403(d)(3), Enrollment and Disenrollment.

3423 Intrapulmonary Percussive Ventilator

Revision 18-0; Effective September 4, 2018

Members who were approved for, and are using, an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by the Texas Health and Human Services Commission (HHSC) Office of the Medical Director (OMD).