Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language

Revision 24-3; Effective Sept. 10, 2024

Program Support Unit (PSU) staff must use Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix IV.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

Denial and Termination Language

This table contains Reason for Denial and Comments field language for Form H2065-D and Form H2065-DS generated for denials and terminations.

PSU staff must enter the associated STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) section supporting the denial reason on Form H2065-D and H2065-DS, listed in the SPOPH Section column.

Purpose for Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSPOPH SectionService Authorization System Online (SASO) Code
Unable to LocateYou are not eligible for STAR+PLUS HCBS program because HHSC staff or your health plan cannot locate you to complete the assessment required for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el personal de la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.PSU staff must not enter comments language.6300.636 – Individual’s Whereabouts Unknown
Voluntarily Declined ServicesYou are not eligible for STAR+PLUS HCBS program because you voluntarily withdrew from the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque abandonó voluntariamente el programa.PSU staff must not enter comments language.6300.305 – Client Requests Service Termination
Enrolled in Another Medicaid Waiver ProgramYou are not eligible for STAR+PLUS HCBS program. This is because you are enrolled in another Medicaid waiver program.  You can only be enrolled in one Medicaid waiver program at a time. Usted no reúne los requisitos para el programa STAR+PLUS HCBS. Esto se debe a que usted está inscrito en otro programa con exenciones de Medicaid. Solo puede estar inscrito en uno de los programas con exenciones a la vez.

You are not eligible for STAR+PLUS HCBS program. This is because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); Home and Community Based Services – Adult Mental Health (HCBS-AMH);  MDCP; Texas Home Living (TxHmL)]. STAR+PLUS HCBS program cannot be authorized. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa STAR+PLUS HCBS. Esto se debe a que usted está inscrito actualmente en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Servicios en el Hogar y en la Comunidad para la Salud Mental del Adulto (HCBS-AMH); MDCP; Programa de Texas para Vivir en Casa (TxHmL)]. No se puede autorizar el programa STAR+PLUS HCBS. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

611039 – Other
Financial EligibilityYou are not eligible for STAR+PLUS HCBS program because you do not meet the financial criteria necessary for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no cumple los criterios económicos necesarios para participar en el programa.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.406 – Client Denied Medicaid Eligibility
Declined AssessmentYou are not eligible for STAR+PLUS HCBS program because you did not let your health plan complete the assessment required for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no permitió que el plan médico realizara la valoración que requiere el programa.PSU staff must not enter comments language.611039 – Other
Does Not Have an Unmet Need for MAOYou are not eligible for STAR+PLUS HCBS program because you do not need services offered through the program. Usted no puede recibir los servicios del programa HCBS de STAR+PLUS porque no los necesita.PSU staff must not enter comments language.611013 – no unmet need (Six hour)
Does Not Have an Unmet Need for SSIYou are not eligible for STAR+PLUS HCBS program because you do not need services offered through the program.

Usted no puede recibir los servicios del programa HCBS de STAR+PLUS porque no los necesita.

Your provider services will continue uninterrupted.

Los servicios de su proveedor continuarán sin interrupción.

611013 – no unmet need (Six hour)
Failure to Obtain Physician SignatureYou are not eligible for STAR+PLUS HCBS program because your doctor didn’t tell us you need the level of care provided in a nursing home. Usted no puede recibir los Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.PSU staff must not enter comments language.6300.839 – Other
Medical Necessity and Level of CareReason for Denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).You are not eligible for STAR+PLUS HCBS program. See the Reason for Denial text box on page 1 of this form and the STAR+PLUS HCBS Program Medical Necessity Denial Attachment for more information. Usted no reúne los requisitos del programa HCBS de STAR+PLUS. Para más información, vea el cuadro “Motivo de la denegación” en la página 1 de este formulario, así como el anexo “Denegación por no existir necesidad médica” del programa HCBS de STAR+PLUS.6300.508 – Loses Level-of-Care (Medical Necessity)
Exceeding the ISP Cost LimitYou are not eligible for STAR+PLUS HCBS program because the cost of your individual service plan exceeds the maximum amount allowed. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el costo de su plan individual de servicios excede la cantidad máxima permitida.PSU staff must not enter comments language.6300.718 – Exceeds Cost Ceiling
Failure to Return Form H1200You are not eligible for STAR+PLUS HCBS program because you did not return the Medicaid application. Usted no puede recibir Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque no entregó su solicitud de Medicaid.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.406 – Client Denied Medicaid Eligibility  
MFP NF Discharge Prior to Eligibility DeterminationYou are not eligible for the STAR+PLUS HCBS program because you left the nursing facility before HHSC could determine program eligibility.

Usted no reúne los requisitos para recibir servicios del programa de HCBS de STAR+PLUS porque abandonó el centro de reposo antes de que la HHSC pudiera determinar si reunía los requisitos del programa    
PSU staff must not enter comments language.3200N/A
Institutional Stay Over 90 DaysYou are not eligible for STAR+PLUS HCBS program because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR Section 441.301(b)(1).

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).
You are not eligible for STAR+PLUS HCBS program services while an in-patient of a [Select one: hospital; nursing facility; or intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del programa HCBS de STAR+PLUS mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; or un centro de atención intermedia para personas con discapacidad intelectual].
6300.203 – Admitted to Institution
Moved Out of StateYou are not eligible for STAR+PLUS HCBS program because you are not a Texas resident.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no reside en Texas.
PSU staff must not enter comments language.611001 – Client Leaves the State/County (Catchment Area)
Under 21You are not eligible for STAR+PLUS HCBS because you are 20 or younger.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque es menor de 21 años.
PSU staff must not enter comments language.611039 – Other
OtherPSU staff must contact supervisor.PSU staff must contact supervisor.6300.1039 – Other

Approval Language

This table contains Comments field language for Form H2065-D and Form H2065-DS generated for approvals.

Purpose for Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSPOPH SectionService Authorization System Online (SASO) Code
Medicaid Eligibility Reinstated within Six MonthsN/AYour Medicaid was reinstated on [DATE]. Your STAR+PLUS HCBS program services will continue without interruption. Sus beneficios de Medicaid fueron restablecidos el [DATE]. 

Usted seguirá recibiendo servicios del programa HCBS de STAR+PLUS sin interrupción.
N/AN/A
Initial Form H2065-D for MFP to CommunityN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin. Usted cumple los requisitos del programa STAR+PLUS HCBS. 

Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS.
N/AN/A
Initial Form H2065-D for SSI MFP to AFC or ALFN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin. We will also send you a notice telling you how much your room and board and copayment will be. Usted cumple los requisitos del programa STAR+PLUS HCBS.

Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.
N/A N/A
Initial Form H2065-D for MAO MFP to AFC or ALFN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin. We will also send you a notice telling you how much your room and board and copayment will be. Usted cumple los requisitos del programa STAR+PLUS HCBS.

Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa STAR+PLUS HCBS. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.
N/A N/A
Room and Board and CopaymentN/A

You must pay room and board and copayment. You will pay them every month to your foster care home or assisted living facility. Your first month of room and board and copayment may be prorated based on your admission date to the facility. Your health plan will help you work with the facility on payments that are prorated.

Debe pagar alojamiento, comida y copago. Deberá pagarlos cada mes al hogar de acogida o al centro de vida asistida en el que se encuentre. El pago del primer mes de alojamiento, comida y copago puede prorratearse en función de la fecha de ingreso en el centro. Su plan médico le ayudará a coordinar con el centro los pagos prorrateados.

N/A N/A

PSU staff must enter Pending and Calculando in the Copayment fields on the English and Spanish versions of Form H2065-D if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist has not provided copayment amounts at the time Form H2065-D is being generated.

PSU staff must enter the full R&B and copayment amounts for members admitting to an ALF or AFC on the first day of the month. PSU staff must enter the full R&B and copayment amounts for the first month of eligibility along with prorate and prorrateo if the member is admitting to an ALF or AFC on any other day of the month.