An official State of Texas website.
Revision 25-1; Effective Feb. 19, 2025
Program Support Unit (PSU) staff must complete the following activities for applicants within two business days of receipt of a denied case assignment for the Medically Fragile group or General Revenue (GR) funds process:
- manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), using the exceeds the individual service plan (ISP) cost limit denial reason;
- mail Form H2065-D to the applicant;
- upload Form H2065-D to the MCOHub;
- for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
- document and close the CSIL record, if applicable;
- invalidate the ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
- upload applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
- document and close the HEART case record.
PSU staff must complete the following activities for members within two business days of receipt of a denied case assignment for the Medically Fragile group or GR funds process:
- manually generate Form H2065-D using the exceeds the ISP cost limit denial reason;
- mail Form H2065-D to the member;
- upload Form H2065-D to the MCOHub;
- terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
- verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
- Authorizing Agent;
- Enrollment;
- Service Plan;
- Service Authorization;
- upload applicable documents to the HEART case record; and
- document the HEART case record.
PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:
- for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
- for MAO members, email ERS Unit staff the following information:
- an email subject line that reads: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
- the member’s name;
- Medicaid ID number;
- type of request: STAR+PLUS Home and Community Based Services (HCBS) program eligibility termination;
- ISP end date, if applicable;
- effective date of termination, if applicable;
- Form H2065-D;
- upload applicable documents to the HEART case record; and
- document and close the HEART case record.
The managed care organization (MCO) will not be able to modify the ISP to make it under the cost limit for an applicant or member who was attempting to pursue the Medically Fragile group or GR funds process, unless the applicant or member experiences a change in medical condition.
PSU staff must follow all other existing policies and procedures for processing a STAR+PLUS HCBS program denial or termination.
PSU staff are not required to notify the PSU supervisor or Utilization Review (UR) Unit staff if Medically Fragile group member is denied for reasons not related to clinical criteria. UR staff monitor the Texas Integrated Eligibility Redesign System (TIERS) monthly to determine if a Medically Fragile group member has been denied for reasons not related to clinical criteria.