Revision 21-10; Effective October 25, 2021

 

2001 Eligibility

Revision 21-10; Effective October 25, 2021

Title 1 Texas Administrative Code (TAC) §353.1155 applies to Medically Dependent Children Program (MDCP) services provided under a Medicaid managed care program. The managed care organization (MCO) must assess an individual’s functional eligibility for MDCP. To be eligible for MDCP, an individual must:

  • be under 21 years of age;
  • be a U.S. citizen and reside in Texas;
  • meet the level of care (LOC) criteria for medical necessity (MN) for nursing facility (NF) care as determined by Texas Health and Human Services Commission (HHSC);
  • have an unmet need for support in the community that can be met through one or more MDCP service;
  • not be receiving Community Care for the Aged and Disabled (CCAD) services;
  • choose MDCP as an alternative to nursing facility services, as described in 42 CFR §441.302(d);
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL); or
    • Youth Empowerment Services (YES); and
  • live in:
    • the individual’s home; or
    • an agency foster home as defined in the Texas Human Resource Code §42.002, (relating to Definitions); and
  • be determined by HHSC to be financially eligible for Medicaid, as described in Title 1 TAC §358 ( relating to Medicaid Eligibility for the Elderly and People with Disabilities), and Title 1 TAC §361 (relating to Medicaid Buy-In for Children Program).

An individual receiving Medicaid NF services is approved for MDCP if the individual requests services while residing in an NF and meets the eligibility criteria listed above. If an individual is discharged from an NF into a community setting before being determined eligible for Medicaid, NF services and MDCP, the individual is denied immediate enrollment in the program.

HHSC maintains a statewide interest list of individuals interested in receiving services through MDCP. An individual or legally authorized representative (LAR) may request an individual's name to be added to the MDCP interest list by:

  • calling HHSC toll-free at 877-438-5658;
  • submitting a written request to HHSC; or
  • generating a referral through the YourTexasBenefits.com, Find Support Services screening and referral tool.

The ILM Unit will add an individual’s name to the MDCP interest list as requested above:

  • if the individual is a Texas resident; and
  • using the date HHSC receives the request as the MDCP interest list date.

HHSC removes an individual's name from the MDCP interest list if:

  • the individual is deceased;
  • the individual is assessed for MDCP and determined to be eligible or ineligible;
  • the individual or LAR requests the removal of the individual's name from the interest list; or
  • the individual moves out of Texas, unless the individual is a military family member living outside of Texas as described in Texas Government Code §531.0931:
    • while the military member is on active duty; or
    • for less than one year after the former military member's active duty ends.

An individual or LAR may request placement at the bottom of the interest list immediately following a determination of ineligibility for MDCP.

The MCO develops a person-centered STAR Kids Individual Service plan (SK-ISP) for each member enrolled in MDCP. All applicable documentation, as described in the STAR Kids Handbook (SKH), the Uniform Managed Care Manual (UMCM) and managed care contracts, must be in the member’s case file maintained by the MCO. The SK-ISP must:

  • include services described in the waiver;
  • include services necessary to protect the member's health and welfare in the community;
  • include services that supplement rather than supplant the member's natural supports and other non-MDCP supports and services for which the member may be eligible;
  • include services designed to prevent the member's admission to an institution;
  • include the most appropriate type and amount of services to meet the member's needs in the community;
  • be reviewed and revised if a member's needs or natural supports change or at the request of the member or LAR;
  • be approved by HHSC; and
  • be under the annual cost limit.

The MCO must submit a request for a clinical assessment to HHSC if a member's SK-ISP exceeds 50 percent of the cost of the member's LOC in a NF to safely serve the member's needs in the community.

HHSC Utilization Review (UR) may request a clinical review of the case to consider the use of state general revenue funds to cover costs exceeding 50 percent of the cost limit. HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU) if a clinical review is conducted. PSU staff must refer to Section 3324, Individual Service Plan Exceeding Cost Limit for MDCP Services, for information about exceeding the MDCP cost limit.

The MCO is responsible for conducting initial assessments, reassessments and developing the SK-ISP to determine eligibility for MDCP. The MCO must follow the policies and procedures outlined in the SKH, UMCM, managed care contracts and materials designated by HHSC.

A member participating in MDCP has the same rights and responsibilities as an individual enrolled in managed care, as described in Title 1 TAC §353, Subchapter C  (relating to Member Bill of Rights and Responsibilities), including the right to appeal a decision made by HHSC or an MCO and the right to a fair hearing, as described in Title 1 §357, Subchapter A , of this title (relating to Uniform Fair Hearing Rules). HHSC conducts utilization reviews of STAR Kids MCOs as described in Texas Government Code §533.00281.

 

2002 Medical Necessity

Revision 21-10; Effective October 25, 2021

Title 26 Texas Administrative Code (TAC) §554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the Medically Dependent Children Program (MDCP). To verify that MN exists, an individual must meet the following conditions:

  • Demonstrate a medical condition that:
    • is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and
    • requires a licensed nurse’s supervision, assessment, planning and intervention that are available only in an institution; and
  • Require medical or nursing services that:
    • are ordered by a physician;
    • are dependent upon the individual's documented medical conditions;
    • require the skills of a registered or licensed vocational nurse;
    • are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and
    • are required on a regular basis.

 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list, regardless of the program’s enrollment status, according to the date and time of the request. Individuals are released from the MDCP interest list in the order of their request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual’s name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

 

2020 Interest List Management Unit Responsibilities

Revision 21-10; Effective October 25, 2021
 
Interest List Management (ILM) Unit staff are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the Medically Dependent Children Program (MDCP) interest list. ILM Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the MDCP program. ILM Unit staff must release individuals from the MDCP program interest list as slots become available in the program.

ILM Unit staff perform the following activities for individuals who request placement on the MDCP interest list:

  • Place individuals on the interest list;
  • Maintain annual contact requirements;
  • Release individuals from the interest list when funding is available; and
  • Confirm individuals on the interest list are viable MDCP candidates before release by:
    • verifying all contact information is correct;
    • checking the Texas Integrated Eligibility Redesign System (TIERS) to determine the Medicaid eligibility status;
    • confirming Texas residency; and
    • verifying the individual is still interested in the MDCP.

ILM Unit staff are required to complete annual contacts for individuals on the MDCP interest list to verify the current address, phone number and confirm continued interest in the program. The interest list status will automatically update to an inactive status if no response is received from the individual within 120 days of the annual contact. The individual will remain in an inactive status until the individual notifies ILM Unit staff of continued interest in MDCP.

ILM Unit staff perform the following activities upon an individual’s release from the MDCP interest list:

  • Verify the individual’s Medicaid type of assistance (TOA) in TIERS, if applicable;
  • Contact the individual by phone to notify them of reaching the top of the interest list;
  • Confirm continued interest in MDCP;
  • Provide a general description of MDCP services;
  • Discuss managed care organizations (MCOs) operating in the individual’s service area (SA);
  • Encourage the individual to contact the MCO for additional information and available services, if applicable;
  • Create a Program Support Unit (PSU) MDCP interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Assign each MDCP ILR HEART case record to PSU staff for individuals who confirm interest in MDCP; and
  • Update the CSIL database record’s status to assigned.

If the individual does not wish to pursue MDCP:

  • The individual can be added back to the bottom of the interest list for an offer in the future, at the individual’s request; or
  • The ILR will be closed with the appropriate closure code in the CSIL database.

See the Uniform Managed Care Manual (UMCM) §16.2 for specific requirements regarding MDCP interest list releases for STAR Health members.

PSU staff must refer to Section 2100, Enrollment Following Release from the Interest List, for MDCP procedures following an individual’s release from the MDCP interest list.

An individual requesting MDCP through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the ILM Unit or their MCO. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in bypassing the interest list through the MFP limited stay option.

PSU staff must refer to Section 2400, Money Follows the Person, for ILM procedures related to MFP processes.

 

2030 Program Support Unit Staff Responsibilities

Revision 18-0; Effective September 4, 2018

The Program Support Unit (PSU) staff are regional Texas Health and Human Services Commission (HHSC) staff responsible for facilitating the required components of the Medically Dependent Children Program (MDCP) eligibility process by coordinating between HHSC, managed care organizations (MCOs) and MDCP individuals. PSU staff document all coordination efforts in the individual’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

 

2100 Enrollment Following Release from the Interest List

Revision 21-10; Effective October 25, 2021

Interest List Management (ILM) Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the Medically Dependent Children Program (MDCP). ILM Unit staff must release individuals from the MDCP interest list as slots become available in the program.

ILM Unit staff contact all individuals by phone to notify them of their names reaching the top of the list and to confirm interest in applying for MDCP. ILM Unit staff will create an interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and assign it to Program Support Unit (PSU) staff when the individual confirms their interest to pursue MDCP.

 

2100.1 Individual  Not Enrolled in Medicaid, Including an Individual Enrolled in the Children’s Health Insurance Program  

Revision 21-10; October 25, 2021

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO) must go through the process of MCO selection, medical necessity (MN) assessment, and financial eligibility determination including individuals enrolled in the Children’s Health Insurance Program (CHIP).

Program Support Unit (PSU) staff must complete the following activities within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waivers programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or LAR, and any delays in the HEART case record. PSU staff must contact the individual or LAR to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Explain the Medicaid application process;
  • Give a general description of MDCP services;
  • Explain the need to select an MCO as quickly as possible within 14 days from the mail date of the above enrollment packet;
  • Inform the individual or LAR that any delay in selecting an MCO could result in a delay in an eligibility determination for MDCP;
  • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible;
  • Advise the individual or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS; and
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, and Form H1200 to the Medicaid for Elderly and People with Disabilities (MEPD) specialist within two business days of the receipt of a completed Form H1200 for medical assistance only (MAO) applicants.

PSU staff must indicate on Form H1746-A that this is a financial eligibility request for an MDCP applicant.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the ILR closure;
  • Close the ILR in the Community Services Interest List (CSIL) database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain an MCO selection if PSU staff have not received the MCO selection;
  • Obtain confirmed interest in MDCP if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual:
    • does not select an MCO;
    • does not express interest in MDCP; or
    • has not provided Form H1200; and
  • Advise the individual or LAR to immediately submit Form H1200, if PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

The individual, applicant or LAR must select an MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP.

PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual’s or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must refer to Section 2210.1, Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program, when PSU staff receive:

  • Confirmed interest in MDCP; and
  • An MCO selection.  

 

2100.2 Individual Who Receives Supplemental Security Income or SSI-Related Medicaid

Revision 21-10; Effective October 25, 2021

An individual with Supplemental Security Income (SSI) or SSI-related Medicaid is already enrolled with a STAR Kids managed care organization (MCO) and does not need to go through the process of selecting a STAR Kids MCO or financial eligibility determination. The individual must receive a medical necessity (MN) assessment.

Program Support Unit (PSU) staff must complete the following activities within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or the Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind and Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
    • Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income;
    • Form 2602, Application Acknowledgement;
    • Appendix IV, MDCP Frequently Asked Questions;
    • Appendix XX, MDCP Program Description; and
    • a postage-paid envelope.

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or LAR and any delays in the HEART case record. PSU staff must contact the individual or LAR:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Give a general description of MDCP services; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual or LAR has not expressed interest in MDCP.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual does not express interest in MDCP.

PSU must document all contact attempts in the HEART case record.

The individual or LAR is not required to select an MCO since the individual is already enrolled with a STAR Kids MCO. PSU staff can accept the individual or LAR’s verbal statement of interest in MDCP.

 

2100.3 Individual Who Receives STAR Health

Revision 18-0; Effective September 4, 2018

See the Uniform Managed Care Manual (UMCM) for STAR Health members.

The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

An individual enrolled with a STAR Health managed care organization (MCO) must remain enrolled with the STAR Health MCO.

If the medical consenter chooses to decline MDCP services, refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements.

 

2100.4 Individual Who Receives Other Types of Medicaid

Revision 21-10; Effective October 25, 2021

An individual who receives other types of Medicaid, i.e., non-Supplemental Security Income (SSI) or is enrolled with a STAR managed care organization (MCO), must go through the process of selecting a STAR Kids MCO, medical necessity (MN) assessment and a financial eligibility determination, if applicable.

Program Support Unit (PSU) staff must refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for Medically Dependent Children Program (MDCP).

PSU staff must complete the following activities within three business days of the receipt of the MDCP interest list release (ILR) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and determine if Form H1200 and Form H1746-A are required;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind and Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waivers programs and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to individuals who do not require Form H1200:
  • Mail the following enrollment packet to individuals who require Form H1200:
    • Form 2600-A, MDCP Waiver Release Letter – Medicaid Assistance Only;
    • Form 2602;
    • Form H2053-B;
    • Form H1200;
    • STAR Kids Comparison Charts;
    • STAR Kids Report Cards;
    • Appendix IV;
    • Appendix XX; and
    • a postage-paid envelope.

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or legally authorized representative (LAR) and any delays in the HEART case record. PSU staff must contact the individual or LAR to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Explain the Medicaid application process, if applicable;
  • Give a general description of MDCP services;
  • Explain the need to select a STAR Kids MCO as quickly as possible within 14 days from the mail date of the above enrollment packet;
  • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
  • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
    • has not expressed interest in MDCP;
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual or LAR to immediately submit Form H1200, if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS; and
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200, if applicable.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR not have an interest in pursuing MDCP.

PSU staff must fax Form H1746-A and Form H1200 to the Medicaid for Elderly and People with Disabilities (MEPD) specialist within two business days of the receipt of a completed Form H1200, if appropriate. PSU staff must indicate on Form H1746-A that this is a financial eligibility request for an MDCP applicant.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual, if appropriate:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the ILR closure;
  • Close the ILR in the Community Services Interest List (CSIL) database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant, if appropriate:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; and
    • has not provided Form H1200, if applicable; and
  • Advise the individual or LAR to immediately submit Form H1200 if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of a STAR Kids MCO selection or interest in MDCP. PSU staff must assign a STAR Kids MCO based on criteria developed by HHSC from the list of available STAR Kids MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must refer to Section 2210.4, Individual Receiving Other Types of Medicaid, when PSU staff receive:

  • Confirmed interest in MDCP; and
  • A STAR Kids MCO selection from the individual or LAR.  

 

2110 Managed Care Organization Selection

Revision 18-0; Effective September 4, 2018

The individual has 30 days from the date the enrollment packet is mailed to complete and return the enrollment packet to Program Support Unit (PSU) staff. If the individual has expressed interest in pursuing Medically Dependent Children Program (MDCP) services, verbally or in writing, but has not selected a managed care organization (MCO) within 30 days from the date the enrollment packet was mailed, an MCO is assigned based on criteria developed by Texas Health and Human Services Commission (HHSC) from the list of available MCOs in the individual’s service area (SA).

PSU staff must contact the individual within three business days of an MCO assignment to inform the individual:

  • which MCO he or she is assigned to; and
  • the MCO in which he or she is enrolled can be changed at any time, but will not go into effect until after one full calendar month of MDCP service provision.

 

2120 Inability to Contact the Individual

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must make one additional attempt to contact the individual by the 30th day from the date the enrollment packet was mailed if:

  • PSU staff are unable to contact the individual by telephone within 14 days from the enrollment packet mail date; and
  • The individual has not returned the enrollment packet or expressed interest in the Medically Dependent Children Program (MDCP).

PSU staff must complete the following activities within two business days from the 30th day of the enrollment packet mail date if PSU staff have not:

  • Made contact with the individual by the 30th day from the enrollment packet mail date;
  • Received the enrollment packet; or
  • Received notification from the individual of their interest in MDCP:
    • Manually generate Form 2442, Notification of Interest List Release Closure;
    • Mail Form 2442 and Appendix XX, MDCP Program Description to the individual or legally authorized representative (LAR);
    • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the closure reason ‘Released From List/No Response to Letter’;
    • Document the closure date, reason for closure and contact attempts in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
    • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
    • Document and close the HEART case record using the appropriate closure reason.

The interest list closure date is the 31st day after the issuance date on Form 2600-A, MDCP Waiver Release Letter - Medical Assistance Only, or Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income.

PSU staff must mail a request to reopen the interest list release to the Interest List Management (ILM) Unit manager at StarPlusWaiverInterestList@hhsc.state.tx.us if the individual contacts PSU or ILM Unit staff after the interest list release closure requesting to pursue MDCP.

PSU staff must refer to Section 2310, Contacting the Interest List Management Unit to Reopen a Closed Interest List Release, for additional information about processing reopen requests.

PSU staff should not attempt to contact an individual if the Texas Health and Human Services Commission (HHSC) receives information about the individual’s death. PSU staff must not mail Form 2442 or Appendix XX to the responsible party if the interest list release was closed due to the death of the individual. The effective date of the interest list release closure is the date staff received notification of the individual’s death.

 

2130 Declining Medically Dependent Children Program Services

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must complete the following activities within two business days from the receipt of an individual’s completed Form 2602, Application Acknowledgement, indicating no interest in applying for Medically Dependent Children Program (MDCP) or if the individual verbally declines MDCP:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the appropriate closure reason;
  • Document the closure date, reason for requesting closure and how PSU staff received the individual’s request for closure (e.g., if by telephone, then document the date, caller’s name and caller’s contact information) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record using the appropriate closure reason.

See the Uniform Managed Care Manual (UMCM) §16.2 for specific requirements regarding the denial of MDCP for STAR Health members.

 

2200 Receipt of Enrollment Packet

Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff receive the enrollment packet from the individual, PSU staff must review it to ensure all documents are completed.

If the enrollment packet is incomplete, PSU staff must contact the individual within two business days to obtain completed documents.

If the Medicaid for the Elderly and People with Disabilities (MEPD) specialist receives an unsigned Form H1200, Application for Assistance - Your Texas Benefits, from PSU staff with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns Form H1200 to PSU staff with an annotation on Form H1746-A that Form H1200 is unsigned and must be signed before the Texas Health and Human Services Commission (HHSC) can establish a file date. Therefore, PSU staff must ensure Form H1200 is signed prior to referring to the MEPD specialist.

Once PSU staff receive notice of an unsigned application from the MEPD specialist, PSU staff must contact the individual within two business days to inform the individual of the need to return a signed application for processing.

Faxing unsigned applications delays the MEPD specialist’s eligibility determination process and could adversely affect service delivery to the individual.

 

2210 Income and Resource Verifications for Medicaid Eligibility

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must obtain a completed Form H1200, Application for Assistance – Your Texas Benefits, for medical assistance only (MAO) individuals or applicants. PSU staff must verify if Form H1200 is required for Medically Dependent Children Program (MDCP) eligibility by checking Appendix XVI, Medicaid Program Actions.

PSU staff must complete the following for individuals and applicants who require Form H1200 to determine MDCP eligibility:

  • Inform MAO individuals or applicants of the importance of providing Form H1200 and all required documents to the Medicaid for Elderly and People with Disabilities (MEPD) specialist;
  • Explain that failure to submit the required documentation to the MEPD specialist could result in a delay or denial of their application;
  • Fax Form H1200, Form H1746-A, MEPD Referral Cover Sheet, and any additional relevant financial information obtained, including information on third-party insurance, to the MEPD specialist if received;
  • Maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in Texas Integrated Eligibility Redesign System (TIERS); and
  • Maintain a copy of page one of Form H1200 in the applicant’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

Individuals and applicants with the appropriate type of Medicaid do not require Form H1200 [e.g., individuals and applicants with Supplemental Security Income (SSI)].

PSU staff must use Form H1746-A when communicating with the MEPD specialist. PSU staff must indicate the following on Form H1746-A, as applicable:

  • The individual or applicant is requesting MDCP;
  • The applicant is pending the medical necessity (MN) determination;
  • The applicant is pending the STAR Kids Individual Service Plan (SK-ISP); or
  • The applicant has an approved MN and SK-ISP.

PSU staff must fax a second Form H1746-A noting the applicant’s start of care (SOC) for MDCP if the applicant’s MN and SK-ISP were pending when the initial Form H1746-A was sent to the MEPD specialist.

The Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination, if an MDCP individual’s or applicant’s application for SSI disability has been pending for more than 90 days. The SSI decision must be adopted upon receipt from SSA.

 

2210.1 Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must complete the following activities within two business days from receiving the enrollment packet or confirmed interest in the Medically Dependent Children Program (MDCP) from the individual or legally authorized representative (LAR):

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, and upload it to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • Upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

PSU staff must complete the following activities within two business days following the receipt date of the signed Form H1200, Application for Assistance - Your Texas Benefits:

  • Fax the following documents to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist:
    • Form H1200;
    • Form H1746-A, MEPD Referral Cover Sheet, requesting a financial eligibility determination for MDCP; and
    • any other verification documents provided by the individual or LAR; and
  • Record the date Form H1200 was received from the applicant and the date PSU staff faxed Form H1200 to the MEPD specialist in the HEART case record;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must check the Texas Integrated Redesign System (TIERS) to verify Medicaid eligibility.

 

2210.2 Individual Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

An individual who receives Supplemental Security Income (SSI) or SSI-related Medicaid meets the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive SSI or SSI-related Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • confirm the STAR Kids enrollment in TIERS;
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

 

2210.3 Individual Enrolled in STAR Health

Revision 18-0; Effective September 4, 2018

See the Uniform Managed Care Manual (UMCM) for STAR Health members.

 

2210.4 Individual Receiving Other Types of Medicaid

Revision 18-0; Effective September 4, 2018

An individual who receives other types of Medicaid (non-Supplemental Security Income (SSI) related Medicaid), may or may not meet the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral, following the instructions in Appendix IX, Naming Conventions. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN;
  • fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist requesting the individual’s Medicaid type to be changed to Medically Dependent Children Program (MDCP) Medicaid; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s email communication in the HEART case record.

 

2210.5 Individual with a Qualified Income Trust

Revision 18-0; Effective September 4, 2018

Financial eligibility for an individual with a qualified income trust (QIT) is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. The MEPD specialist provides information to the individual about maintaining the QIT to remain eligible for Medicaid. A trustee is designated to manage the QIT and disburse payment to service providers on behalf of the member. The individual is informed that any funds deposited into the trust must be used toward the copayment for the cost of services delivered. The MEPD specialist will calculate the amount of income available from the trust for copayment and use the MEPD Communication Tool to provide the amount to Program Support Unit (PSU) staff. PSU staff must upload the MEPD specialist’s determination in the HEART case record. PSU staff must notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder following the instructions in Appendix IX, Naming Conventions, noting the copayment amount.

For an individual who is financially eligible based on a QIT, the eligibility based on the individual service plan (ISP) cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase §1915(c) Medicaid waiver services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of §1915(c) Medicaid waiver eligibility. The MCO must ensure the individual meets the initial ISP cost limit requirement before deducting the copayment. If the MCO does not properly establish this plan of care and the member’s cost exceeds the individual limit, the MCO must continue to provide Medically Dependent Children Program (MDCP) services to the member at the MCO’s expense. The MCO may not terminate MDCP services if a member exceeds his or her cost limit on the ISP.

The ISP is developed by the MCO without consideration of the trust. If the individual is eligible for MDCP within the cost limit, the copayment is allocated to purchase MDCP services identified on the electronic Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool. The ISP total and the amount of the provider service authorizations are reduced by the amount of the copayment. The member must pay the provider(s) directly for the amount of services. The MCO must document the QIT in the ISP. Continuing Medicaid eligibility through the MDCP is contingent upon copayment to the provider(s).

 

2220 Managed Care Organization Coordination

Revision 18-0; Effective September 4, 2018

The STAR Kids managed care organization (MCO) has 30 days following the initial notice from Program Support Unit (PSU) staff to complete all assessments for an individual enrolled in the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, for a total of 60 days following the initial notice from PSU staff. The MCO must:

  • verify the individual meets all other eligibility criteria referenced in the STAR Kids Handbook, Section 1000, Overview and Eligibility;
  • complete Section B, Waiver Assessment Report, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
  • complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items; and
  • complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and submit electronically through the TMHP LTC Online Portal. For MAO individuals, complete Form 2604 and post to TexMedCentral.

If the MCO does not submit Form 2604 within 60 days after PSU staff posted Form H3676, Section A, authorizing the MCO to begin the eligibility process, PSU staff must email Managed Care Compliance & Operations (MCCO) to notify them of the MCO delinquency.

The MCO must schedule and complete the SK-SAI, including the MDCP module and record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG, within 30 days of notice from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP, by posting to TMHP LTC Online Portal within 72 hours of completion. For the purposes of this requirement, a SK-SAI is considered "complete" when the MCO has obtained the physician’s signature on Form 2601, Physician Certification, and retains Form 2601 in the individual’s case file at the MCO.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI and NCAM module (record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG). The MN determination must be approved by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff processes the SK-SAI for an individual to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in §1915(c) Medicaid waiver programs to categorize needs for an individual or member and establish the individual service plan (ISP) cost limit.

Once TMHP staff process the SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG value. This code may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A“BC1” code indicates the SK-SAI does not have all of the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a “BC1” code. If the MCO fails to submit the correction within 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTC Online Portal. Information about the process of transmitting and correcting a SK-SAI is available in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MDCP module of the SK-SAI (Section R, MDCP Related Items) establishes an annual cost limit for each individual or member receiving MDCP services. The cost limit is based on the anticipated cost of the individual/member residing in an NF.

As a part of the ISP planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit. If the MCO does not properly establish this plan of care (POC) and the individual or member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual or member’s ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member’s MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member, legally authorized representative (LAR) or authorized representative (AR) no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and authorizations are consistent with information in the member’s ISP.

The member’s MDCP ISP Narrative must include the components of a person-centered ISP, as described in Title 42 Code of Federal Regulations (CFR) §441.301(c)(2) Subpart G, Contents of Request for a Waiver.

 

2230 Program Support Unit Staff Coordination for an Applicant Enrolling in MDCP

Revision 18-0; Effective September 4, 2018

Within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, Program Support Unit (PSU) staff must ensure the applicant has met all the following eligibility criteria:

  • is under age 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • is a Texas resident in TIERS;
  • has an approved medical necessity (MN) in the TMHP LTC Online Portal;
  • has an individual service plan (ISP) with at least one Medically Dependent Children Program (MDCP) service; and
  • has an ISP within the individual’s cost limit.

For an applicant needing a Medicaid eligibility financial decision, PSU staff must also notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days that the applicant meets MN and document this notification in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. This notification must be documented on Form H1746-A, MEPD Referral Cover Sheet, and faxed within two business days to the MEPD specialist.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s determination in the HEART case record.

The start of care (SOC) date for MDCP services is the first day of the month following the applicant meeting all the eligibility criteria.

Example: If a managed care organization (MCO) submits all eligibility criteria on March 1 and PSU staff verifies the applicant meets all eligibility criteria on March 3, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D, Notification of Managed Care Program Services, will be April 1.

Example: If an MCO submits all eligibility criteria on March 31 and PSU staff verifies the applicant meets all eligibility criteria on April 2, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D will be April 1. The individual met the eligibility criteria on March 31. Delay in services must not occur due to PSU staff processing times.

Eligibility must be approved by PSU staff within two business days of the applicant meeting all eligibility criteria and receiving Form H3676 and Form 2604 from the MCO. PSU staff must generate Form H2065-D in the TMHP LTC Online Portal and:

  • mail the original Form H2065-D to the applicant;
  • email Enrollment Resolution Services (ERS) the following information:
    • the applicant’s name;
    • Medicaid identification (ID) number;
    • type of request (interest list or Money Follows the Person (MFP));
    • date of MFP limited nursing facility (NF) stay, if applicable;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D;
  • document the interest list closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to HEART case record and close the HEART case record using the appropriate closure code.

The MCO must monitor the TMHP LTC Online Portal for the status of the member’s ISP and to retrieve Form H2065-D.

 

2240 Coordination for Program Denial

Revision 18-0; Effective September 4, 2018

If the applicant fails to meet any of the eligibility criteria for the Medically Dependent Children Program (MDCP), not related to financial eligibility, within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, from the managed care organization (MCO) and Form H2067-MC, Managed Care Programs Communication, notifying Program Support Unit (PSU) staff of the program denial, PSU staff must:

  • manually complete Form H2065-D, Notification of Managed Care Program Services;
  • mail the original Form H2065-D to the individual, legally authorized representative (LAR) or authorized representative (AR);
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions;
  • for medical assistance only (MAO) applicants, fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and Persons with Disabilities (MEPD) specialist;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable case documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and close the HEART case record using the appropriate closure code.

If the individual fails to meet financial eligibility criteria established by MEPD, within two business days of receiving notification through the MEPD Communication Tool, PSU staff must:

  • manually complete Form H2065-D;
  • mail the original Form H2065-D to the individual;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • document the closure date and reason in the CSIL database and close the record; and
  • upload all applicable documents to HEART and close the HEART case record using the appropriate closure code.

 

2300 Interest List Release Closures

Revision 21-10; Effective October 25, 2021

An individual can be placed on multiple interest lists but may only enroll in one Medicaid waiver program at a time.

The individual may choose to:

  • Pursue eligibility for another program and decline Medically Dependent Children Program (MDCP) at the time of interest list release; or
  • Decline MDCP at the time of interest list release but choose to remain on the MDCP interest list.

Individuals who decline MDCP at the time of interest list release but choose to remain on the MDCP interest list will move to the bottom of the interest list.

Program Support Unit (PSU) staff must complete the following activities within two business days if the individual chooses to decline MDCP and wants to continue receiving or pursue eligibility for another program:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the date the individual declined MDCP;
  • Document the closure date, the individual’s reason for requesting closure and how PSU staff received the individual’s request for closure (e.g., if by telephone, then document the date, caller’s name and caller’s contact information) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record using the appropriate closure reason.

 

2310 Contacting the Interest List Management Unit to Reopen a Closed Interest List Release

Revision 20-4; Effective December 18, 2020

Program Support Unit (PSU) staff must submit a request to Interest List Management (ILM) Unit staff to reopen an individual’s closed interest list record.

Within two business days of receiving the request to reopen a closed interest list release, PSU staff must email their immediate supervisor to reopen the Community Services Interest List (CSIL) record. The email must include the following:

  • an email subject line that reads: “MDCP Reopen Request for XX [individual’s first and last initials].” For example, the email subject line for a request to reopen a closed CSIL record for Ann Smith would be “MDCP Reopen Request for AS”;
  • individual’s name;
  • interest list identification (ID) number;
  • individual’s Medicaid ID or Social Security number (SSN);
  • the individual’s, authorized representative’s (AR’s) or legally authorized representative’s (LAR’s) contact name and phone number; and
  • reason for the request to reopen. For example, a statement indicating that the application for an alternate 1915(c) Medicaid waiver program was denied and the individual now wishes to reapply for MDCP.

The PSU supervisor will forward the reopen request to the ILM Unit manager at StarPlusWaiverInterestList@hhsc.state.tx.us if the PSU supervisor agrees the reopen request is appropriate. ILM Unit staff will email PSU staff to provide the outcome of the request within five business days.

If an exception is granted, PSU staff must:

  • contact the individual to begin the application process;
  • document the reopen request in the Health and Human Services Enterprise Administrative Report and Tracking System (HEART) case record;
  • upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • keep the HEART case record open until MDCP eligibility is approved or denied.

If an exception is not granted, PSU staff must:

  • upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XVIII; and
  • close the HEART case record.

 

2320 Earliest Date for Adding an Individual Back to the Interest List After Denial or Termination

Revision 18-0; Effective September 4, 2018

The earliest date an individual may be added back to the Community Services Interest List (CSIL) database, for the same program the individual is denied, is the date the individual is determined to be ineligible for the program.

Example: The individual is released from the Medically Dependent Children Program (MDCP) interest list on August 2. The individual is denied eligibility for MDCP on August 28, and a notification is sent to the individual of ineligibility. The first date the denied individual can be added back to the MDCP interest list is August 28.

Example: The individual’s MDCP services are terminated July 31 due to denial of medical necessity (MN). The first date the individual can be added back to the MDCP interest list is August 1. The earliest date an individual may be added back to the CSIL database for the same program the individual is terminated from is the first date the individual is no longer eligible for the terminated program, which in this example is August 1.

 

2400 Money Follows the Person

Revision 18-0; Effective September 4, 2018

 

2410 Traditional Money Follows the Person

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aging or have disabilities live in the most integrated setting possible. The PI Initiative is Texas’ response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

  • state’s treatment professionals determine the placement is appropriate; and
  • affected persons do not oppose the treatment and placement and can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Title 4 Texas Government Code §531.151, as amended by Senate Bill 368, 77th Legislature, Regular Session, 2001).

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with the Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with EveryChild, Inc. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

In accordance with legislative direction, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another §1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other §1915(c) Medicaid waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Refer to the STAR Kids Managed Care Contract, Section 8.1.15, for additional information.

The MCO must have a protocol for quickly assessing the needs of members who will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

  • determine the member’s assigned permanency planner;
  • contact the member’s assigned permanency planner within seven days of the member’s facility admission;
  • collaborate with the member, legally authorized representative (LAR) or authorized representative (AR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
  • contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC’s contracted permanency planner to work with the member and LAR or AR to review community based options; and
  • work with the member, LAR, AR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid and not enrolled in STAR Kids, requesting MDCP services through the MFP option, must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff must authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because he or she meets the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference Section 2420, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

 

2410.1 Non-STAR Kids Individuals Residing in a Nursing Facility

Revision 21-10; Effective October 25, 2021

The Texas Health and Human Services Commission (HHSC) contracts with EveryChild Inc., who acts as the designated individual’s permanency planner to assist an individual under age 21 in transitioning from a nursing facility (NF) to the community.

The individual’s permanency planner contacts the Interest List Management (ILM) Unit within two business days of the individual’s selection of Medically Dependent Children Program (MDCP) under traditional Money Follows the Person (MFP) to:

  • Notify HHSC that the individual has selected MDCP under the traditional MFP process; and
  • Update the address on the individual or legally authorized representative (LAR)’s file if needed.  

ILM Unit staff complete the following activities for individuals who are on the MDCP interest list and request to pursue the traditional MFP process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the traditional MFP process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within two business days of the receipt of the MDCP interest list case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or LAR:
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

PSU staff are responsible for completing the following activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or LAR and any delays in the HEART case record. PSU staff must contact the individual or LAR to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Explain the Medicaid application process, if applicable;
  • Give a general description of MDCP services;
  • Explain the need to select a STAR Kids MCO as quickly as possible within 14 days from the mail date of the above enrollment packet;
  • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
  • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual:
    • has not expressed interest in MDCP;
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual, LAR or NF to immediately submit Form H1200 if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS; and
  • Confirm Form H1200 appears in TIERS if the individual, LAR or NF informs PSU staff that they have completed and submitted Form H1200, if applicable.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP.

PSU staff must fax Form H1746-A and Form H1200 to the Medicaid for Elderly and People with Disabilities (MEPD) specialist within two business days of the receipt of a completed Form H1200, if appropriate. PSU staff must notate the applicant is requesting to pursue the MDCP traditional MFP process on Form H1746-A. PSU staff must indicate on Form H1746-A that this is a financial eligibility request for an MDCP applicant.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual, if applicable:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant or LAR, if applicable:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP. PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes an MCO selection or from the date they are defaulted to an MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating:
    • if the individual or applicant in has a current medical necessity (MN) by entering the Resource Utilization Group (RUG) value; and
    • the MN expiration date in Item 6, which is 365 days from the effective date of the current MN approval date indicated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual or LAR to immediately submit Form H1200 if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

The MCO initiates contact with the individual, applicant or LAR to begin the assessment process within 10 business days of receipt of Form H3676. The MCO must perform the SK-SAI within 15 business days from contact with the individual, applicant or LAR. The MCO must submit the SK-SAI to the TMHP LTCOP within 72 hours of the assessment’s completion. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification.

The MCO must complete the SK-SAI within a total of 30 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral.

The MCO must submit the complete SK-SAI to TMHP LTCOP within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral. PSU staff must monitor the TMHP LTCOP for receipt of the completed SK-SAI.

The MCO must submit the following documents within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The SK-ISP to the TMHP LTCOP or Form 2604 to TxMedCentral; and
  • Form H3676, Section B to TxMedCentral.

PSU staff must monitor TxMedCentral for receipt of the completed:

  • Form 2604, if applicable; and
  • Form H3676, Section B.

PSU staff must monitor the TMHP LTCOP for receipt of the completed SK-ISP.

The MCO must complete and submit the SK-SAI and SK-ISP or Form 2604 before NF discharge.

The MCO must upload Form H2067-MC to TxMedCentral, as needed, to notify PSU staff of the proposed NF discharge date.

PSU staff must collaborate, as needed, with all involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document delays. PSU staff track all actions and communications in the HEART case record until all MDCP enrollment activities are complete.

PSU staff must email Managed Care Compliance & Operations (MCCO) Unit staff at PSU_Past_Due_Assessments@hhsc.state.tx.us to advise if the MCO has not completed and submitted the following items within 60 days of the date of PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The completed SK-SAI;
  • The completed SK-ISP or Form 2604; and
  • Form H3676, Section B.

PSU staff must fax Form H1746-A to notify the MEPD specialist within two business days of receipt of the approved SK-ISP or Form 2604 and the SK-SAI if Medicaid is still pending, if applicable. PSU staff must notate the following on Form H1746-A:

  • The applicant is requesting to pursue the MFP process;
  • The applicant has an approved MN; and
  • The applicant has an approved SK-ISP or Form 2604.

PSU staff must check TIERS to verify Medicaid eligibility.

PSU staff must complete the following activities within one business day of receipt of all MCO documentation required for MDCP eligibility, in addition to the MEPD specialist’s Medicaid eligibility determination:

  • Confirm MDCP eligibility by verifying the applicant:
    • is under age 21 in TIERS;
    • is a Texas resident in TIERS;
    • has Medicaid eligibility for MDCP in TIERS;
    • has an approved MN in the TMHP LTCOP;
    • has an SK-ISP or Form 2604 with a least one MDCP service;
    • has an SK-ISP or Form 2604 within the individual’s cost limit; and
  • Manually generate the initial Form H2065-D;
  • Mail the initial Form H2065-D to the applicant or LAR, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX; and
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII.

The MCO collaborates with the applicant, LAR and PSU staff to identify a proposed discharge date. The MCO must notify PSU staff of the discharge date, once determined, within two business days by uploading Form H2067-MC to TxMedCentral.

PSU staff must complete the following activities if any other entity provides a different discharge date than the date previously established by the MCO within two business days of notification:

  • Upload Form H2067-MC to TxMedCentral, following the instructions in Appendix IX; and
  • Advise the MCO on Form H2067-MC of the discrepant discharge date.

PSU staff manually or electronically generate the final Form H2065-D containing the start of care (SOC) date within one business day of the member’s discharge, and complete the following activities:

  • Mail the final Form H2065-D to the member or LAR, following the instructions in Appendix II;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • For MAO members, fax Form H2065-D and Form H1746-A to the MEPD specialist, indicating the SOC date;
  • Close the MDCP ILR in the CSIL database using the appropriate closure reason and date;
  • Email Enrollment Resolution Services (ERS) at ManagedCareEligibilityEnrollment@hhsc.state.tx.us, requesting enrollment effective the first of the month in which the discharge occurred. The email must include:
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request  (i.e., Money Follows the Person);
    • MN approval date;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D; and
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The MCO must upload Form H3676, Section B, to TxMedCentral within two business days if the applicant fails to meet any MDCP eligibility criteria other than Medicaid financial eligibility.

PSU staff must complete the following activities within two business days of notification the applicant does not meet MDCP eligibility:

  • Electronically generate Form H2065-D in the TMHP LTCOP if the applicant was denied for MN;
  • Manually generate Form H2065-D, following the instructions in Appendix II, if the applicant is denied for reasons other than MN;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if manually generated;
  • Fax Form H2065-D and Form H1746-A to the MEPD specialist for MAO members, if appropriate;
  • Close the MDCP interest list release in the CSIL database, using the appropriate closure reason and date;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must check TIERS to verify Medicaid eligibility. PSU staff must complete the following activities within two business days of verifying Medicaid financial ineligibility:

  • Manually generate Form H2065-D, following the instructions in Appendix II;
  • Mail the original Form H2065-D to the individual, applicant or LAR, following the instructions in Appendix II;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;  
  • Document the closure date and reason in the CSIL database and close the record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must deny eligibility for MDCP following the steps above if the applicant chooses to leave the NF before being determined eligible for MDCP.

 

2410.2 STAR Kids Member Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

  • contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner, EveryChild Inc., within seven days of the member’s admission;
  • coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
  • perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
  • update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the member, family, legally authorized representative (LAR) or authorized representative (AR) as part of the permanency planning process;
  • lead the development of the member’s permanency plan;
  • coordinate with the MCO service coordinator in updating the member’s ISP, if applicable;
  • educate the member, LAR and AR on §1915(c) Medicaid waiver options, including MDCP; and
  • document the member’s choice of the §1915(c) Medicaid waiver program.

Once the member selects a §1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the member’s §1915(c) Medicaid waiver selection under MFP, and update the address on file to that of the LAR or AR, if needed.

If the member, LAR or AR chooses a §1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the §1915(c) Medicaid waiver program selected and immediately release the member from the interest list in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will forward the request to the selected §1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, AR, and selected §1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community.

If the member, LAR or AR chooses MDCP, ILM Unit staff will verify the individual is on the interest list for MDCP and immediately release the individual from the interest list in the CSIL database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) within one business day of the request and assign to the appropriate Program Support Unit (PSU) staff to proceed with necessary case actions.

Within two business days of the referral from ILM Unit staff, PSU staff must:

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify the member has a Medicaid type of assistance (TOA) applicable to MDCP;
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the member has a current medical necessity (MN) by entering the Resource Utilization Group (RUG) and expiration date in Item 6 retrieved from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal;
  • post Form H3676 to TxMedCentral in the MCO STAR Kids folder; and
  • upload Form H3676 to the HEART case record.

The MCO initiates contact with the member, LAR or AR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member, LAR or AR, the MCO service coordinator performs the SK-SAI, including the NCAM module and record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG. The MCO service coordinator must submit the SK-SAI to TMHP by posting to TxMedCentral within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member, LAR and AR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to the TMHP LTC Online Portal within one business day of completion.

As needed, PSU staff collaborates with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays. PSU staff must track all actions and communications in the HEART case record until all MDCP enrollment activities are complete.

If within 30 days after the member’s, LAR’s or AR’s request to return to the community the MCO has not completed the MN process and submitted the ISP, PSU staff must email Managed Care Compliance & Operations (MCCO) staff to advise of the delay. PSU staff will continue to monitor TxMedCentral for receipt of Form H3676 or Form H2067-MC, Managed Care Programs Communication.

Within one business day following receipt of Form H2067-MC from the MCO, PSU staff must:

  • confirm MDCP eligibility by verifying the member:
    • is under age 21 in TIERS;
    • is a Texas resident in TIERS;
    • has an approved MN in the TMHP LTC Online Portal;
    • has an ISP with at least one MDCP service;
    • has an ISP that is within the individual’s cost limit; and
    • has an appropriate Medicaid TOA in TIERS.
  • generate the initial Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTC Online Portal;
  • mail the initial Form H2065-D to the member; and
  • upload Form H2065-D, Form 2604, and Form H2067-MC to the HEART case record.

Within one business day prior to the member’s discharge from the NF, PSU staff must:

  • generate the final Form H2065-D in the TMHP LTC Online Portal containing the service effective date;
  • mail the original Form H2065-D to the member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions;
  • document the closure date and reason in the CSIL database and close the record; and
  • upload Form H2065-D to the HEART case record.

If MDCP eligibility is denied, PSU staff must:

  • manually complete Form H2065-D;
  • mail the original Form H2065-D to the member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • upload Form H2065-D, Form 2604, and Form H2067-MC to HEART and close the HEART case record using the appropriate closure code; and
  • document the closure date and reason in the CSIL database and close the record.

 

2410.3 MDCP Money Follows the Person Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

Example: If an individual is anticipating an NF discharge on December 15, the four month period would end the last day of April.

Example: If an individual is anticipating an NF discharge on January 1, the four month period would end the last day of April.

An individual who has not made living arrangements to return to the community, cannot decide when to return to the community, or has no viable plan or support system in the community should be denied Medically Dependent Children Program (MDCP). PSU staff deny the request for services and must:

  • mail Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions; and
  • upload Form H2065-D and all other relevant documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and close the HEART case record using the appropriate closure code.

 

2410.4 Money Follows the Person Demonstration (MFPD) References in STAR Kids

Revision 18-0; Effective September 4, 2018

Money Follows the Person Demonstration (MFPD) does not apply to an individual enrolled in the Medically Dependent Children Program (MDCP). Children will transition to the least restrictive setting under Money Follows the Person (MFP). Therefore, managed care organization (MCO) service coordinators will not be required to track the enrollment period or seek informed consent from the member, legally authorized representative (LAR) or authorized representative (AR). The "MFPD" check box should be disregarded on Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool.

 

2420 Money Follows the Person Limited NF Stay Option for a Medically Fragile Individual

Revision 18-0; Effective September 4, 2018

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
  • renal dialysis;
  • 24 hour/day supplemental oxygen dependence;
  • total nutrition through enteral tube feeding;
  • total parenteral nutrition (TPN);
  • seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
  • congestive heart failure requiring hospitalization and routine medication within the past six months; or
  • in hospice care.

An individual determined to be medically fragile and is approved for a limited NF stay, must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress to the individual, legally authorized representative (LAR) or authorized representative (AR), in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from an NF on a Friday, Saturday, Sunday, or any day preceding a state holiday as services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

 

2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-0; Effective September 4, 2018

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual’s name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in bypassing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to bypass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • an overview of MDCP services;
  • the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
  • the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
  • required medical documentation from the individual’s clinical record at the physician’s office, hospital or clinic (not from a patient portal) must be within 12 months of the date the documentation is submitted to ILM Unit staff; and
  • admission and discharge documentation from the NF will be required.

ILM Unit staff will mail Form 2406 to the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian, LAR or AR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian, LAR or AR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

 

2422 Money Follows the Person Limited Nursing Facility Stay Procedures

Revision 18-0; Effective September 4, 2018

 

2422.1 Processing Form 2406 and Medical Documents

Revision 18-0; Effective September 4, 2018

Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed by the individual’s physician, licensed to practice in the state of Texas through the Texas Medical Board, and signed by the physician within 90 days of receipt by Interest List Management (ILM) Unit staff, to be considered for the Money Follows the Person (MFP) limited nursing facility (NF) stay option. The Texas physician must attach to Form 2406 documentation (such as a visit note or hospital discharge summary) of chronic conditions. The medical documentation provided must include:

  • documentation of the individual’s chronic conditions and the current health status of the individual  that will substantiate the boxes checked on Form 2406; and
  • medical records from within 12 months of the date the documentation is being submitted. Medical records must be physician-originated (not from a patient portal).

Upon receipt of Form 2406 and medical documentation, ILM Unit staff will identify the physician’s recommendation.

If the individual’s physician attests the individual does meet the medically fragile criteria and is too medically fragile to reside in an NF setting for an extended period of time on Form 2406, ILM Unit staff will verify the following within two business days:

  • the individual’s name and date of birth are present and legible on Form 2406;
  • the individual is under age 21;
  • the physician’s name, address, license number, signature and date are on Form 2406;
  • physician that signed Form 2406 is licensed in the state of Texas by conducting a license search on the Texas Medical Board’s website; and
  • physician signature on Form 2406 is within 90 days of receipt.

If Form 2406 contains all required information and medical documentation appears to be from an appropriate source and dated within the allowable date range, ILM Unit staff will email all documents to the Texas Health and Human Services Commission (HHSC) nurse to determine if the individual meets the medically fragile criteria. ILM Unit staff must submit each request in a separate email to the HHSC nurse. The email’s subject line must read: Medically Dependent Children Program Form 2406 for XX. The “XX” in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "Medically Dependent Children Program Form 2406 for AS."

ILM Unit staff must place the individual in a “Release” status in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will also create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload Form 2406. ILM Unit staff must not upload medical records to the HEART case record.

If the individual’s physician attests the individual does not meet the medically fragile criteria for a limited NF stay, ILM Unit staff must contact the individual within two business days, to inform him or her of the physician’s recommendation. The individual can remain on the interest list until his or her name reaches the top, or follow the traditional MFP option as described in Section 2410, Traditional Money Follows the Person.

If Form 2406 does not contain the required information, ILM Unit staff must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within two business days of receipt to discuss the elements of the form that are incomplete, and that Form 2406 and associated documents will be returned.

This includes medical documentation that is over 12 months old or not from an appropriate source (such as a patient portal). The individual, parent, guardian, LAR or AR, may submit additional records to satisfy the medical record requirement. If additional records are not submitted before the physician signature on Form 2406 expires (90 days from the physician signature date), the Medically Dependent Children Program (MDCP) MFP limited NF stay interest list request will remain in an “Open” status until the individual reaches the top of the interest list and no additional action is taken.

 

2423 HHSC Nurse or Physician Review of Medical Fragility

Revision 18-0; Effective September 4, 2018

A Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and medical documentation within two business days to determine if an individual meets the limited nursing facility (NF) stay criteria.

If the individual’s physician attests the individual meets the medically fragile criteria and the physician’s documentation clearly substantiates the individual meets two or more criteria on Form 2406, the HHSC nurse may approve the limited NF stay request. Within two business days of the decision, the HHSC nurse will document his or her decision that the individual “meets criteria” in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

If the documentation does not substantiate the individual meets two or more criteria on Form 2406, the HHSC nurse will forward Form 2406 and associated medical records to the HHSC physician for a decision. ILM Unit staff are also included in the email.

 

2424 Physician Determination of Medical Fragility

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the ILM Unit staff and reply all to notify ILM Unit staff of the decision.

 

2425 Individual Not Meeting the Medically Fragile Criteria

Revision 18-0; Effective September 4, 2018

If the Texas Health and Human Services Commission (HHSC) physician determines the individual does not meet the medically fragile criteria, Interest List Management (ILM) Unit staff will contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) by telephone within two business days of receipt of the HHSC physician’s decision email. If the HHSC physician has a comment regarding the information submitted, this will be noted in the HHSC physician response to ILM Unit staff. ILM Unit staff must include this comment when advising the individual of the outcome of the limited nursing facility (NF) stay request. ILM Unit staff will inform the individual that a limited NF stay is not approved and the individual has the option to transition from an NF stay, as described in Section 2410, Traditional Money Follows the Person, to access Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) traditional option.

If the individual does not choose to complete an NF stay as described in Section 2410, his or her name will return to an “Open” status in the Community Services Interest List (CSIL) database and the “Residing in a Nursing Facility” bypass code removed. The individual will remain on the interest list until his or her name comes to the top of the list. If the individual, parent, guardian, LAR or AR requests to reapply for the limited NF stay process, ILM Unit staff must inform the individual, parent, guardian, LAR or AR that a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

 

2426 ILM Unit Procedures for Assigning an Individual Approved for a Limited NF Stay to PSU Staff

Revision 18-0; Effective September 4, 2018

 
Within two business days of an individual being approved for a limited nursing facility (NF) stay, Interest List Management (ILM) Unit staff must assign the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to the appropriate Program Support Unit (PSU) staff. No further action is required for ILM Unit staff.

 

2427 PSU Procedures for an Individual Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

Within two business days of Program Support Unit (PSU) staff receiving the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment from Interest List Management (ILM) Unit staff, PSU staff must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual receives Medicaid.

 

2427.1 PSU Procedures for an Individual Approved for a Limited NF Stay without Medicaid (Including an Individual Enrolled in CHIP)

Revision 21-10; Effective October 25, 2021

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of MCO selection, medical necessity (MN) assessment and financial eligibility determination, including individuals enrolled in the Children’s Health Insurance Program (CHIP).

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process;
    • Give a general description of MDCP services;
    • Explain the need to select an MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting an MCO could result in a delay in an eligibility determination for MDCP;
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible; and
  • Advise the individual or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS;
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200;
  • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
    • Must be coordinated with the MCO service coordinator;
    • Cannot be completed until notified by the MCO service coordinator;
    • Requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
    • Must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
    • Process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200 and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant or LAR:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select an MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection and interest in MDCP. PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes an MCO selection or from the date they are defaulted to an MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants.

 

2427.2 PSU Procedures for an Individual Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 21-10; Effective October 25, 2021

An individual with Medicaid who is not enrolled in a STAR Kids managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of STAR Kids MCO selection, medical necessity (MN) assessment and financial eligibility determination, if applicable.

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process, if applicable;
    • Give a general description of MDCP services;
    • Explain the need to select a STAR Kids MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP services;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
      • has not selected a STAR Kids MCO;
      • has not expressed interest in MDCP; or
      • has not provided Form H1200, if applicable; and
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Advise the individual or LAR to immediately submit Form H1200 if:
      • the individual requires Form H1200 to determine Medicaid financial eligibility; and
      • PSU staff do not see Form H1200 in TIERS;
    • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200, if applicable; and
    • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
      • must be coordinated with the MCO service coordinator;
      • cannot be completed until notified by the MCO service coordinator;
      • requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
      • must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
      • process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200, if appropriate:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200, if available, and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A, identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant, if applicable:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP. PSU staff must assign a STAR Kids MCO based on criteria developed by HHSC from the list of available STAR Kids MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected a STAR Kids MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes a STAR Kids MCO selection or from the date they are defaulted to a STAR Kids MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200, if:
    • the individual or applicant requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants.

 

2427.3 PSU Procedures for an Individual Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A of Form H3676 stating the member resides at home. In the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option and post Form H3676 to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator.

 

2428 PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral advising the MCO of the decision to complete a limited NF stay. The STAR Kids Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian, LAR or AR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual must present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the limited NF stay admission and discharge. Form 3618 must be received by the MCO and posted to TxMedCentral by the MCO the same date as the NF discharge or MDCP services cannot be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so by the MCO. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay funding requirements. MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. MCO service coordinators must ensure Form 3618 is posted to TxMedCentral for Program Support Unit (PSU) staff to access the same day of NF discharge. Form 3618 is the only instrument accepted to verify the appropriate NF admission and discharge requirement. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

The MCO has 60 days to complete all assessments and submit required forms to PSU staff. The MCO must complete:

  • Section B of Form H3676, noting "MFP Limited NF Stay Assessment Completed" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items;
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool; and
  • Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.

The MCO must post Form H3676 to TxMedCentral in the MCO STAR Kids folder and submit the electronic Form 2604 in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. If the applicant is medical assistance only (MAO) and does not have a Medicaid identification (ID) number at the time the MCO is attempting to upload Form 2604 into the TMHP LTC Online Portal, the MCO uses “+” in the designated field for Medicaid ID. Once the applicant has been authorized for MDCP services for 30 days, a Medicaid ID number will be assigned to the individual and the Texas Integrated Eligibility Redesign System (TIERS) will update the TMHP LTC Online Portal. Refer to Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for additional information. The MCO must maintain a copy of Form 2603 in the applicant’s or member’s MCO case file.

If the MCO does not submit an ISP in the TMHP LTC Online Portal within 60 days after PSU staff posted Form H3676, Section A, PSU staff notify Managed Care Compliance & Operations by email indicating the MCO delinquency in performing the assessment.

Within two business days of receiving Form H3676 in TxMedCentral and Form 2604 in the TMHP LTC Online Portal, PSU staff verify the member:

  • is under age 21 in TIERS;
  • is a Texas resident in TIERS;
  • has an approved MN in the TMHP LTC Online Portal;
  • has ongoing financial eligibility in TIERS or by an email through the Medicaid for the Elderly and People with Disabilities (MEPD) Communication Tool stating Medicaid is approved pending the limited NF stay and 30 days of MDCP authorization;
  • has an ISP within the individual’s cost limit; and
  • has authorization of at least one MDCP service on the ISP.

For STAR Kids members accessing MDCP through the limited NF stay process, if the above criteria are met except for the limited NF stay, PSU staff post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions,  to notify the MCO of the MDCP approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff post Form H2067-MC to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by posting Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR, AR, NF staff and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator within 24 hours of the time of discharge. The NF must understand the importance of processing and providing Form 3618 to the family and/or MCO service coordinator prior to NF discharge.

MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

Within 24 hours of the limited NF stay, the following activities must occur:

  • the MCO must notify PSU staff the limited NF stay occurred by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX, requesting PSU staff approve MDCP services;
  • the MCO must post Form 3618 to TxMedCentral in the MCO’s STAR Kids folder;
  • PSU staff must respond to the MCO on Form H2065-D, Notification of Managed Care Program Services, by posting to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, noting the applicant or member is pending approval of Medicaid eligibility; however, the applicant or member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services; and
  • PSU staff upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff must:

  • complete and mail the original Form H2065-D to the member, LAR or AR;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record;
  • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist, indicating the individual has transferred from an NF to the MDCP, if applicable;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, if Form H2065-D was manually completed;
  • email Enrollment Resolution Services (ERS), if applicable, with the following:
    • the individual’s name;
    • Medicaid identification (ID) number;
    • type of request (MFP limited stay);
    • date of MFP limited NF stay;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment;
    • Form H2065-D; and
  • upload all applicable documents in HEART case record.

The MDCP effective date will be the first of the month in which the MFP individual was discharged from the NF.

Example: An individual who is not enrolled in STAR Kids leaves the NF December 12, 2016, and begins MDCP services December 12, 2016. The eligibility date on Form H2065-D will be December 1, 2016.

After the individual has been determined eligible for MDCP, ERS updates the individual’s Texas Integrated Eligibility and Redesign System (TIERS) record to indicate managed care enrollment, if applicable.

MCOs must monitor the TMHP LTC Online Portal for the status of their member’s ISP and to retrieve Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must post within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff must:

  • manually complete Form H2065-D;
  • mail the final Form H2065-D to the individual;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist, if applicable;
  • email Enrollment Resolution Services (ERS), if applicable;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to the HEART case record.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

 

2429 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request the MEPD specialist to delay Medicaid certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and fax Form H1746-A to the MEPD specialist. Form H1746-A must be uploaded to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.” If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny Medically Dependent Children Program (MDCP) eligibility by:

  • manually completing Form H2065-D, Notification of Managed Care Program Services;
  • mail the original Form H2065-D to the applicant or member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload Form H2065-D and all other applicable documents to the HEART case record and close the HEART case record.

MCOs must monitor the TMHP LTC Online Portal for the status of their member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting ILM Unit staff, as described in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian, LAR or AR requesting to reopen the Medicaid application. The MCO must post the letter on TxMedCentral in the MCO STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian, LAR or AR that a new Form H1200 must be completed.