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 Transfer Scenarios

Revision 18-0; Effective September 4, 2018

 

3411 Transferring to Another Service Area with Prior Knowledge

Revision 21-4; Effective March 26, 2021

When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS service area, within two business days, the losing PSU staff:

  • notify the gaining PSU staff a member is transferring to its service area and provides the following:
    • member name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • email Form H1700-1, Individual Service Plan (Pg. 1), to the gaining PSU staff;
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals;
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address; and
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization's (MCO's) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, and request Form H1700-1 and all forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the Medical Necessity and Level of Care (MN/LOC) Assessment;
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.

Once the gaining PSU staff receive Form H1700-1, PSU staff will confirm all STAR+PLUS HCBS program eligibility. The process is abbreviated since the member already has:

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

The gaining PSU staff coordinates all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining service area.

The gaining PSU staff maintains contact with the member until the transfer is complete. Within five business days after the transfer is complete, PSU staff:

  • send an email to the ERS mailbox notifying ERS the member has moved;
  • manually close the current Service Authorization System Online (SASO) records for the losing MCO effective the end of the month the member moves;
  • manually update SASO with the gaining MCO's information effective the first day of the month after the move;
  • mail Form H2065-D, Notification of Managed Care Program Services, to the member and include the begin and end dates of the individual service plan (ISP) in the Comments section; and
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.

3412 Transferring to Another Service Area Without Prior Knowledge

Revision 21-10; Effective October 25, 2021

The losing Program Support Unit (PSU) staff must complete the following activities within two business days of being notified a member has already transferred from one STAR+PLUS service area (SA) to another SA:

  • Notify the gaining PSU staff a member has transferred to their SA and provide the member's:
    • name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move;
  • Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, requesting all forms listed below from the losing MCO:
    • Form H1700-1, Individual Service Plan;
    • Form H1700-2, Individual Service Plan - Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the Medical Necessity and Level of Care (MN/LOC) Assessment;
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.
  • Fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for medical assistance only (MAO) members; and
  • Advise the MCO to notify the member with Social Security benefits to contact the Social Security Administration (SSA) to change the address.

PSU staff must upload the following documents received from the losing MCO to the gaining MCO to TxMedCentral, following the instructions in Appendix XXXIV, within two business days:

  • Form H2067-MC, advising the gaining MCO of the member's SA transfer;
  • Form H1700-1;
  • Form H1700-2;
  • Form H1700-3;
  • Form H1700-A1;
  • Form 8604;
  • the MN/LOC Assessment;
  • Form H2060;
  • Form H2060-A; and
  • Form H2060-B, as applicable.

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

The gaining MCO must contact the member within one business day of receipt of Form H2067-MC and begin services within two business days of receipt of Form H2067-MC.

The gaining PSU staff must confirm all STAR+PLUS Home and Community Based Services (HCBS) program eligibility criteria is met upon receipt of Form H1700-1. The process is abbreviated since the member already has:

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

The gaining PSU staff coordinate all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) Unit staff and other key parties to help ensure a successful transition. PSU staff must track each step of the process through the start of the new STAR+PLUS HCBS program in the gaining SA.

The gaining PSU staff must complete the following activities within two business days of completing the steps above:

  • manually close Service Authorization System Online (SASO) records effective the end of the month the member moves;
  • manually update SASO with the gaining MCO's information effective the first of the following month in which the move occurred;
  • notify the ERS Unit staff by email at HPO_STAR_PLUS@hhsc.state.tx.us. The email to the ERS Unit must include the following information:
    • the member's name;
    • Medicaid identification (ID) number;
    • type of request (i.e., SA change);
    • MN approval date;
    • ISP begin date;
    • ISP end date;
    • MCO;
    • effective date of enrollment; and
    • Form H2065-D;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • document and close the HEART case record.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.

3413 Transferring from One MCO to Another Within the Same Service Area

Revision 22-3; Effective Sept. 27, 2022

A member or authorized representative (AR) can request to change managed care organization (MCO) plans as often as they want, but the change cannot be made more than once per month.

The member or AR must contact the Texas Health and Human Services Commission (HHSC) enrollment broker by phone at 800-964-2777 to change from one MCO to another MCO in the same service area (SA). The HHSC enrollment broker must ask if the member is in a hospital or living in a nursing facility (NF). The member is not eligible to change MCO plans until the member has been discharged from the hospital or NF.

MCO enrollment changes become effective based on the date the MCO change is requested and processed in relation to state cutoff. Refer to Appendix XVII, State Cutoff Dates, for additional information on current cutoff dates.

Monthly Plan Changes Report

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes Report to Program Support Unit (PSU) staff and the gaining MCOs. PSU staff receive a full list of all plan changes and the MCO receives a list of their members only. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month.

PSU staff must correct the contract number in the Service Authorization System Online (SASO) to reflect the new MCO contract number for all MCO changes within 14 days of receipt of the Monthly Plan Changes Report. PSU staff must refer to Section 9300, Transfers, for more information on SASO actions.

The losing MCO is responsible for transferring all relevant member information to the gaining MCO, including the individual service plan (ISP) and Medical Necessity and Level of Care (MN/LOC) Assessment. The gaining MCO must notify Managed Care Contracts & Oversight (MCCO) Unit staff if the losing MCO fails to provide member information. MCCO Unit staff may contact PSU staff for assistance in transferring member information to the gaining MCO through TxMedCentral.

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

Refer to Appendix I-E, Monthly Plan Changes Report, for more information on report contents.

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

Under Age 21 MDCPUnder Age 21 Other Services ReceivedMonitors MDCP-PDN Transition Report12-Month Contact
MDCPPDN-CCP or PPECC-CCPPSU StaffMCO
MDCPNonePSU StaffMCO
Not ApplicablePDN-CCPPSU StaffMCO
Not ApplicablePPECC-CCPPSU StaffMCO

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:

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

Under 21 MDCPUnder 21 Other Services ReceivedMonitors MDCP-PDN Transition Report:Nine-Month Contact:
MDCPPDN-CCP or PPECC-CCPPSU StaffPSU Staff
MDCPNonePSU StaffPSU Staff
NonePDN-CCPPSU StaffPSU Staff
NonePPECC-CCPPSU StaffPSU Staff

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

Under Age 21 Current ProgramUnder Age 21 Other Services ReceivedPSU Staff Action
MDCPPDN-CCP or PPECC-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
MDCPNot ApplicableMonitors the MDCP-PDN Transition Report and contacts the member.
Not ApplicablePDN-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
Not ApplicablePPECC-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
CLASS, DBMD, HCS or TxHmLNot Applicable, CCP/PDN or PPECCContacts the member when the referral is received.

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 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must confirm STAR+PLUS Home and Community Based Services (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 Medical Necessity and Level of Care (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); 
    • Note: A valid MN does not exceed 150 days from the date of TMHP approval. PSU staff must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting the managed care organization (MCO) resubmit 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 follow the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading documents to TxMedCentral.
  • at least one STAR+PLUS HCBS program service is listed on Form H1700-1, Individual Service Plan;
  • the ISP does not exceed the allowable cost limit; and
  • continued Medicaid financial eligibility in the Texas Integrated Eligibility Redesign System (TIERS).

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

  • establish the start of care (SOC) date. The SOC date 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 generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language;
    • upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV; 
    • mail Form H2065-D to the member;
    • notify Enrollment Resolution Services (ERS) Unit staff by email. The email sent to ERS Unit staff must include:
      • an email subject line that reads: "MDCP Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]." For example, the email subject line for an MDCP transition into the STAR+PLUS HCBS program for Ann Smith would be "MDCP Transition to STAR+PLUS HCBS for AS";
      • the member's name;
      • Medicaid identification (ID) number;
      • ISP begin and end date for the STAR+PLUS HCBS program;
      • MCO selection and plan code; and
      • Form H2065-D;
    • for medical assistance only (MAO) members, 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 to the STAR+PLUS HCBS program;
    • coordinate with the Intellectual or Developmental Disability (IDD) Waiver/Community Services/Hospice Utilization Review (UR) Unit staff on the termination date by email if the individual is 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);
    • 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, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; 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).