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Effective Date: 
1/2021

Documents

 

Instructions

Updated: 1/2021

 

Purpose

Form H2053-B and Form H2053-BS, Health Plan Selection, provides a means for the individual to inform the Texas Health and Human Services Commission (HHSC) of the individual’s health plan selection.

 

Procedure

When to Prepare

Program Support Unit (PSU) staff must prepare Form H2053-B and Form H2053-BS when the individual needs to select a health plan.

Copies and Transmittal

STAR Kids PSU staff must mail Form H2053-B and Form H2053-BS to the individual, AR or LAR along with:

  • Form 2600-A and Form 2600-AS, MDCP Waiver Release Letter-Medical Assistance Only;
  • Form H2602 and Form H2602-S, Application Acknowledgement;
  • Form H1200, Application for Assistance-Your Texas Benefits;
  • STAR Kids Comparison Charts;
  • STAR Kids Report Cards;
  • STAR Kids Program Support Unit Operational Procedures Handbook Appendix IV, MDCP Frequently Asked Questions – English and Spanish;
  • STAR Kids Program Support Unit Operational Procedures Handbook Appendix XX, MDCP Program Description – English and Spanish; and
  • a postage-paid envelope.

STAR+PLUS HCBS program PSU staff must mail Form H2053-B and Form H2053-BS to the individual, member, AR or LAR along with:

  • Form H2053-A and H2053-AS, STAR+PLUS Selection Letter;
  • Form 2114 and Form 2114-S, Nine-Month Transition Letter;
  • Form H2116 and Form H2116-S, Age-Out MDCP and PDN Contact Letter;
  • STAR+PLUS Comparison Charts;
  • STAR+PLUS Report Cards;
  • STAR+PLUS Program Support Unit Operational Procedures Handbook Appendix XII, STAR+PLUS HCBS Program Description – English and Spanish; and
  • a postage-paid envelope.

Form Retention

The Health and Human Services Enterprise Administrative Report and Tracking System (HEART) is the electronic case record for the STAR+PLUS HCBS program and Medically Dependent Children Program (MDCP). PSU staff must upload a copy of the completed Form H2053-B and Form H2053-BS to the HEART case record. Paper copies of Form H2053-B and H2053-BS, and accompanying documents, are not retained. PSU staff must dispose of paper copies of Form H2053-B and Form H2053-BS by following established procedures for the destruction of confidential data, as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.

 

Detailed Instructions

Name — Enter the individual’s or member’s name.

Social Security No. — Enter the individual’s or member’s Social Security number.

Type of Service — PSU staff must check the box for either STAR+PLUS HCBS Program or Medically Dependent Children Program. A paragraph will appear informing the individual how to begin the application process.

Please select a health plan by checking one of the boxes below — PSU staff must enter the health plan names available in the individual’s or member’s area of the state on the lines provided, using the Add Line or Remove Line features. Note: The individual, member, AR or LAR will check the box of the health plan the individual, member, AR or LAR chooses.

Signature of Individual/Authorized Representative/Legally Authorized Representative —The individual, member, AR or LAR must sign the form after checking the box to select a health plan.

Date —The individual, member, AR or LAR enters the date and returns the form to PSU staff.