3600, Ongoing Service Coordination

Revision 18-0; Effective September 4, 2018

Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

  • revising the individual service plan (ISP) as necessary to meet the needs of the member, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services (ERS), respite or requests for service suspension;
  • coordinating and consulting with MCO-contracted providers regarding delivery of services;
  • reminding the member to complete and return Medicaid renewal eligibility documents sent by Program Support Unit (PSU) staff or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • monitoring services delivered to members, evaluating the adequacy and appropriateness of the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program, and documenting monitoring activities;
  • assisting the member in accessing and using community, Medicare, family and other third-party resources (TPR);
  • assisting with crisis intervention; and
  • responding to situations of potential denial of an active member whose ISP costs exceed the individual's assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of the STAR+PLUS HCBS program.

3610 Revising the Individual Service Plan

Revision 23-2; Effective May 15, 2023

It may be necessary for the managed care organization (MCO) to revise the individual service plan (ISP) within the ISP period due to: 

  • changes in the needs of the member; 
  • changes in the services offered; or 
  • emergency situations. 

The MCO must document revisions to the ISP on Form H1700-1, Individual Service Plan, and retains it in the member’s case record. The MCO must not submit the revised ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to TxMedCentral.
 

3611 MCO Required Notifications from the Provider

Revision 18-0; Effective September 4, 2018

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

  • the member leaves the service area for more than 30 days;
  • the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • the member is not financially eligible for Medicaid benefits;
  • providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
  • the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
  • the member fails to pay his or her qualified income trust (QIT) copayment;
  • the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
  • the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
  • the member requests that services end.

3611.1 Immediate Suspension or Reduction of Services

Revision 18-0; Effective September 4, 2018

If the member or someone in the member's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the managed care organization (MCO) and MCO contracted provider are required to make an immediate referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) and/or the police and suspend services. The MCO must immediately provide written notice of temporary suspension of service to the member, and the right of appeal to a state fair hearing must be explained to the member. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference and the right of appeal.

The provider must verbally inform the MCO by the following business day of the reason for the immediate suspension, and follow up with written notification to the MCO within two business days of verbal notification. The MCO must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the STAR+PLUS Home and Community Based Services (HCBS) program provider may continue providing services to assist in the resolution of the crisis. If the crisis is not satisfactorily resolved, the MCO follows the established denial procedures. Services do not continue during the appeal process.

3620 Reassessment

Revision 18-0; Effective September 4, 2018

3621 Reassessment Procedures

Revision 22-3; Effective Sept. 27, 2022

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System Online (SASO) annually. PSU staff must complete the following activities within 45 days of the ISP expiration date:

  • check the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to determine if the managed care organization (MCO) has submitted:
    • Form H1700-1, Individual Service Plan, containing the following:
      • at least one unmet need;
      • is within the cost limit;
      • personal assistance services (PAS) and emergency response services (ERS) can be included for a member who is part of the medical assistance only (MAO) Medicaid eligibility group;
      • PAS and ERS must be authorized through Community First Choice (CFC) for a Supplemental Security Income (SSI) member. An SSI or SSI-related (e.g., Medicaid for Disabled Adult Children (DAC) or Pickle Medicaid) member receiving CFC should not have the PAS or ERS boxes checked on Form H1700-1;
      • protective supervision as a component of PAS can only be authorized through the STAR+PLUS Home and Community Based Services (HCBS) program and is not a benefit of CFC. Therefore, if an MCO authorizes protective supervision for any STAR+PLUS HCBS program member (MAO Medicaid or SSI), the MCO must check the protective supervision box on Form H1700-1 for this service;
      • Note: PSU staff must upload Form H2067-MC to TxMedCentral advising the MCO to correct Form H1700-1 if the ERS and PAS checkboxes are selected in error for an SSI or SSI-related member receiving CFC;
    • an approved Medical Necessity and Level of Care (MN/LOC) Assessment;
  • confirm ongoing Medicaid eligibility the Texas Integrated Eligibility Redesign System (TIERS);
  • confirm ongoing Medicaid eligibility;
  • verify the Service Authorization System Online (SASO) service authorization records are accurate;
    • refer to Section 9200, Reassessment Service Authorization, for additional information on SASO record verifications.

PSU staff must ensure the member's ISP is entered into the SASO annually. PSU staff must manually enter the ISP into SASO within five business days, but prior to the ISP end date, if the MCO is not able to submit the Form H1700-1 electronically through the TMHP LTCOP.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox each month. The ISP Expiring Report sent to the PSORT mailbox must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies ISPs being reported as a MCO non-compliance. The subject line for the email must read: “STAR+PLUS HCBS Reassessment Delinquencies for [Month].”

3622 Reassessment Notification Requirements

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, at reassessment as notification of continuing services if the member continues to meet STAR+PLUS Home and Community Based Services (HCBS) program requirements. PSU staff must complete the following activities for an approved STAR+PLUS HCBS program reassessment within five business days of verification that the member continues to meet all STAR+PLUS HCBS program requirements:

  • electronically generate Form H2065-D in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); 
  • mail Form H2065-D to the member;
  • upload applicable documents to the Texas Health and Human Services (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, if the member does not meet STAR+PLUS HCBS program requirements at reassessment.

Refer to Section 7000, Applicant or Complaints, Internal MCO Appeals and State Fair Hearings, if the member files a state fair hearing within the adverse action notification period.

3623 Eligibility Date on Form H2065-D

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

  • upgrades and interest list releases;
  • members transitioning out of children's programs; and
  • transfers from a nursing facility (NF) using the Money Follows the Person (MFP).

3623.1 Upgrades and Interest List Releases

Revision Notice 23-3; Effective Aug. 21, 2023

The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant released from the interest list, or a member requesting or being processed for an upgrade is based on the following:

  • notification or verification of Medicaid eligibility;
  • date the Medical Necessity and Level of Care (MN/LOC) Assessment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) is approved; and
  • date the managed care organization (MCO) submits the individual service plan (ISP) in the TMHP LTCOP or submits to PSU staff in TxMedCentral.

The SOC for STAR+PLUS HCBS program is the first day of the month following the individual or member meeting all eligibility criteria. The eligibility and ISP effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month if the date the form is being generated is on the first day of the month. The eligibility and ISP effective date on Form H2065-D is the first date of the following month if the date the form is being generated falls between the second and the last day of the month. 

Note: A valid MN does not exceed 120 days from the date of TMHP approval. Program Support Unit (PSU) staff must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting the MCO submit a new initial MN/LOC Assessment in the TMHP LTCOP if the MN exceeds 120 days. PSU staff must follow the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading Form H2067-MC to TxMedCentral.
 

3623.2 Members Transitioning Out of Children's Programs

Revision 18-0; Effective September 4, 2018

The eligibility and the individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the first day of the month following their 21st birthday:

  • Medically Dependent Children Program (MDCP)
  • Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC)

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP through STAR Health until age 22. In this scenario, the eligibility and ISP effective date is the first day of the month following their 22nd birthday.

3623.3 MFP Initiative Nursing Facility Releases

Revision 18-0; Effective September 4, 2018

The ISP effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program through the Money Follows the Person (MFP) process is the date of discharge. The STAR+PLUS HCBS eligibility date on Form H2065-D for members transferring from NFs to the STAR+PLUS HCBS program through the MFP process, is the date used on the initial Form H2065-D. Service Authorization System Online (SASO) registration for MFP releases from NFs must occur as follows:

  • NF Service Group 1 SASO registrations must be closed the day before the discharge.
  • STAR+PLUS HCBS program service group (SG) 19 SASO registration covers the entire individual service plan (ISP) period. The ISP effective date on Form H2065-D is the date of discharge.