An official State of Texas website.
Revision 25-1; Effective Feb. 19, 2025
An applicant or member’s individual service plan (ISP) cost limit is calculated by Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). It is based upon information the managed care organization (MCO) gathered in the Medical Necessity and Level of Care (MN/LOC) Assessment. Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, Chapter 353.1153©(1)(H), STAR+PLUS Home and Community Based Services (HCBS) Program, states the cost of STAR+PLUS HCBS program services on the individual service plan (ISP) should not exceed 202 percent of the cost of care Texas Health and Human Services Commission (HHSC) would pay if the individual was served in a nursing facility (NF).
The MCO must notify the Office of the Medical Director (OMD), Utilization Review (UR) Unit staff and Program Support Unit (PSU) staff when the cost of an ISP exceeds the cost limit. The MCO notifies the OMD, UR and PSU staff by completing the following activities:
- checking the Over Annual Cost Limit Override for GR and Medically Fragile box within the ISP record in the LTCOP; and
- uploading Form H2067-MC, Managed Care Programs Communication (PDF), to the MCOHub advising that the ISP submitted in the TMHP LTCOP exceeds the cost limit and is for an applicant or member being assessed for the Medically Fragile group or General Revenue (GR) funds process.
The OMD and UR Unit staff review the ISP to determine if eligibility can be provided through the Medically Fragile group or GR funds process. The Medically Fragile and GR funds process allows an applicant or member to be eligible for the STAR+PLUS HCBS program with an ISP that exceeds the cost limit.
UR Unit staff provide a determination to PSU program managers (PMs) on if an applicant or member meets the criteria for the Medically Fragile group or GR funds process. The determination is provided through an automated email generated from SharePoint. PSU PMs refer determinations to the PSU supervisors for assignment to PSU staff. UR Unit staff provide a separate determination letter to the MCO.
An applicant or member who exceeds the cost limit and is not approved for the Medically Fragile group or GR funds process cannot elect to receive reduced services for entry to the STAR+PLUS HCBS program if Medicaid state plan services and STAR+PLUS HCBS program services would pose a risk to the individual’s health, safety or welfare.
For applicants and members transferring service areas (SAs), the losing SA MCO must inform the gaining SA MCO of the Medically Fragile group or GR funds process status.