3200, Eligibility

Revision 23-2; Effective May 15, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required. 

A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days (or up to 90 days) if it is necessary to obtain a disability determination) to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of: 

• the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
• upon receipt of an incomplete or unsigned Form H1200. 

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

3210 Service Areas

Revision 18-0; Effective September 4, 2018

STAR+PLUS services are currently available statewide broken down by service areas:

3220 Eligible Groups

Revision 18-0; Effective September 4, 2018

3221 STAR+PLUS Mandatory Groups

Revision 18-0; Effective September 4, 2018

The following groups of individuals must receive services through the STAR+PLUS program. The program designations are used in the following list.

• Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) type of assistance (TA) 01, TA 02 and TA 22 — Individuals age 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
• Pickle Amendment Group, TIERS type program (TP) 03 — Individuals age 21 or over who would continue to be eligible for SSI benefits if cost of living adjustment (COLAs) increases were deducted from his or her countable income.
• Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), aged 60-65 and with a disability, who:
  • were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
  • are ineligible for Medicare; and
  • would continue to be eligible for SSI benefits in the absence of those early aged widow's or widower's benefits and any increases in those benefits.
• Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), aged 50-60 and with a disability, who:
  • are ineligible for Medicare and were denied SSI due to an increase in widow's/widower's benefits as a result of the relaxing of disability criteria; and
  • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
• Disabled Adult Children (DAC), TIERS TP 18 — Adults over age 21 with a disability that began before age 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
• Medicaid Buy-In, TIERS TP 87 (designated in TIERS as "ME — Medicaid Buy In") — Disabled working adults over age 21 who receive full Medicaid benefits as a result of buying into the Medicaid program.
• Medicaid for Breast and Cervical Cancer (MBCC) recipients, TIERS TA 67 — Individuals aged 18 to the 65th birth month who meet eligibility requirements defined in Texas Administrative Code (TAC), Title 1, Part 15, Chapter 366, Subchapter D.
• STAR+PLUS Home and Community Based Services (HCBS) program members who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program.  
• Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (medical assistance only (MAO)) — Most individuals residing in an NF.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact Program Support Unit (PSU) staff and provide the details for disenrollment from STAR+PLUS.

3222 STAR+PLUS Excluded Groups

Revision 18-0; Effective September 4, 2018

For excluded groups, refer to Texas Administrative Code (TAC), Title 1, §353.603, Member Participation.

3223 Hospice Services in STAR+PLUS

Revision 18-0; Effective September 4, 2018

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF hospice services can be identified in the Service Authorization System Online (SASO) as service group (SG) 8, service code (SC) 31. The NF counter is activated by non-hospice NF authorizations, which appear in SASO as SG1/SC1 or SG1/SC3.

3230 Financial Eligibility

Revision 23-2; Effective May 15, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days (or up to 90 days) if it is necessary to obtain a disability determination) to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of:

• the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
• upon receipt of an incomplete or unsigned Form H1200.

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

3231 Individual with a Qualified Income Trust

Revision 22-3; Effective Sept. 27, 2022

An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. A person or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their individual service plan (ISP).

PSU staff must refer questions regarding QIT to Access and Eligibility Services (AES) by generating and faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist.

3232 Payments from the Qualified Income Trust

Revision 23-2; Effective May 15, 2023

An Applicant or member with a qualified income trust (QIT) is responsible for a copayment if they are living in an adult foster care (AFC), assisted living facility (ALF) or home setting. The managed care organization (MCO) must explain to the applicant or member that the funds from the QIT made available for the copayment must be used to purchase STAR+PLUS Home and Community Based Services (HCBS) program services. The member must make payments directly to the AFC, ALF or other service providers. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determine the copayment amount for members with a QIT. 

PSU staff must document the copayment amount for services other than AFC or ALF using Form H2065-D, Notification of Managed Care Program Services. PSU staff must refer to Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, when generating Form H2065-D. PSU staff must refer to Section 3233, Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL, if the available QIT copayment amount is sufficient to pay the AFC or ALF.

The total available QIT copayment amount is not entered on Form H1700-1, Individual Service Plan, and is not reflected in SASO copayment screens for a QIT member that lives at home.

3233 Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL

Revision 18-0; Effective September 4, 2018

If the available qualified income trust (QIT) copayment amount exceeds the daily rate for adult foster care (AFC) or assisted living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment funds remain after the monthly copayment is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to Section 3235, Refusal to Pay Qualified Income Trust Copayment.

3234 Qualified Income Trust Copayment Agreement

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

• service purchased;
• amount available for copayment;
• unit rate;
• units purchased; and
• monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or an assisted living facility (ALF), the copayment amount is first applied to the cost of AFC or ALF. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase nursing, PAS or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

3234.1 Calculation Example and Completion of Form 1578

Revision 18-0; Effective September 4, 2018

There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through the QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to be entered on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization (MCO) discusses the copayment with the applicant or member and the trustee of the trust. After explaining the requirements, the applicant, member, authorized representative (AR) and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant, member or AR and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant or member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.

3235 Refusal to Pay Qualified Income Trust Copayment

Revision 18-0; Effective September 4, 2018

The trustee of the qualified income trust (QIT) must pay the QIT copayment directly to the provider(s) by the 10th day of the month, or not later than 10 days after STAR+PLUS Home and Community Based Services (HCBS) program services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

• write a letter to the member and the trustee explaining the consequences of continued failure to pay; and
• notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the trustee has refused to make the copayment.

If the copayment is not fully paid within 30 days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form H2067-MC.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify the MEPD specialist of the refund.

Refer to Section 7100, Adult Foster Care, for procedures related to failure to pay copayment.

3236 Copayment and Room and Board

Revision 18-0; Effective September 4, 2018

Members who are determined to be financially eligible based on the special medical assistance only (MAO) institutional income limit may be required to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for the STAR+PLUS HCBS program.

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the STAR+PLUS HCBS program and specified on the member's individual service plan (ISP). The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized STAR+PLUS HCBS program services.

To determine the room and board (R&B) amounts for members residing in adult foster care (AFC) or assisted living facility (ALF), apply the following post-eligibility calculations:

• for individuals, the R&B amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance;
• for SSI couples, the R&B amount is the SSI FBR [for a couple] minus the personal needs allowance for an individual multiplied by two; or
• for couples with incomes that exceed the SSI FBR for couples, the R&B amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the R&B amount for an individual.

Some individuals will be responsible for contributing toward the cost of STAR+PLUS HCBS program services. This is referred to as copayment and/or R&B charges. The copayment amount is not a factor in determining the individual's eligibility for services.

The MEPD specialist calculates the copayment and deducts allowable incurred medical expenses (IMEs) for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a qualified income trust (QIT). Refer to Section 3123, Incurred Medical Expenses, and Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance (RSDI), are not required to make a copayment and no copayment calculation is necessary for them. STAR+PLUS HCBS program members who reside in AFC or ALF settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the individual, if it is determined the individual must pay a monthly copayment, that the copayment amount must be paid directly to the AFC or ALF provider. All STAR+PLUS HCBS program members, including SSI recipients, are required to pay R&B in an AFC and ALF.

The MCO must also explain to the individual that the individual is required to pay the AFC or ALF provider an R&B charge. If the member fails to pay the agreed-upon R&B charge and/or copayment, the member could be terminated from the STAR+PLUS HCBS program.

Program Support Unit (PSU) staff notify the member and MCO of new copayment amounts to be collected on Form H2065-D, Notification of Managed Care Program Services.

Refer to Section 3232, Payments from the Qualified Income Trust, and Section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

3237 Determining Room and Board Charges

Revision 23-2; Effective May 15, 2023

All STAR+PLUS Home and Community Based Services (HCBS) program members must pay the room and board (R&B) charges to be eligible for an adult foster care (AFC) or assisted living facility (ALF).

The AFC or ALF can negotiate a lower R&B amount with the member, but they cannot waive it. There is no impact to PSU staff processes if there is an agreement for a lower R&B amount between the AFC or ALF and the member. PSU must continue to enter the R&B fixed amount on the Form H2065-D, Notification of Managed Care Program Services.

The member must pay the R&B charges to the AFC or ALF to remain eligible for Medicaid through the STAR+PLUS HCBS program. Refer to Section 6400, Disenrollment Request Policy, if a member refuses to pay their R&B charges.

3238 Determining Copayment Amounts

Revision 23-2; Effective May 15, 2023

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determines the amount of money available for copayment after determining financial eligibility for Medicaid. The copayment amount will leave a personal needs allowance (PNA) of $85 for a single person and $170 for a couple. The MEPD specialist must notify Program Support Unit (PSU) staff of the amount available for the monthly copayment through the MEPD Communication Tool. PSU staff must provide this information to the managed care organization (MCO) by uploading Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

3239 Copayment Changes

Revision Notice 23-4; Effective Dec. 7, 2023

A member's copayment may change during the time he or she is receiving the STAR+PLUS Home and Community Based Services (HCBS) program. Copayment changes are typically due to a change in income, medical expenses or other circumstances.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialists is responsible for calculating copayment amounts. The MEPD specialist notifies Program Support Unit (PSU) staff through the MEPD Communications Tool of copayment amounts or PSU staff may determine the copayment amount has changed in Texas Integrated Eligibility Redesign System (TIERS) at reassessment. The MEPD specialist will inform PSU staff if corrections to the member's copayment are necessary based on a change in the income amount available for copayment.

Copayment changes are always effective on the first day of the month.

PSU staff must complete the following activities within five business days of obtaining the copayment amounts:

• mail Form H2065-D, Notification of Managed Care Program Services, to the member;
• upload Form H2065-D to the MCOHub;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

Adverse action is required if the copayment amount is increasing. The copayment increase is effective the first day of the month after the adverse action period has expired.

Adverse action is not required when:

• the initial Form H2065-D is generated advising the member of the copayment amounts for the first time;
• no changes are occurring to ongoing copayment amounts; or
• copayment amounts are decreasing.

The copayment amount is effective the first day of the month following the copayment amount being determined when adverse action is not required.

The MEPD specialist and MCO will handle issues related to underpayments, refunds, and copayment amount appeals.

3240 STAR+PLUS HCBS Program Requirements

Revision 18-0; Effective September 4, 2018

The STAR+PLUS Home and Community Based Services (HCBS) program is provided by virtue of authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility (NF). To be eligible for services under the STAR+PLUS HCBS program, the following criteria must be met:

• medical necessity (MN) (Refer to Section 3241, Medical Necessity Determination);
• services under the established cost limits (Refer to Section 3242.1, Maximum Limit);
• the member's unmet need for at least one STAR+PLUS HCBS program service (Refer to Section 3242.2, Unmet Need for at Least One STAR+PLUS HCBS Program Service); and
• approved Medicaid eligibility.

3241 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 STAR+PLUS Home and Community Based Services (HCBS) program. 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.

3241.1 Medical Necessity Determination

Revision 21-10; Effective October 25, 2021

A STAR+PLUS Home and Community Based Services (HCBS) program applicant or member must have a valid medical necessity (MN) determination before admission into the STAR+PLUS HCBS program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant or member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for STAR+PLUS HCBS program applicants or members. The MN/LOC Assessment for applicants requires a physician’s signature attesting the applicant does meet the criteria to reside in a nursing facility (NF) setting. TMHP processes MN/LOC Assessments to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of NF staffing intensity and used in the STAR+PLUS HCBS program to:

• categorize needs for applicants or members; and
• establish the ISP cost limit.

The TMHP Long Term Care Online Portal (LTCOP) generates an alphanumeric three-digit RUG value when processing an MN/LOC Assessment, which appears in the Level of Service record in the Service Authorization System Online (SASO). An MN/LOC Assessment with incomplete information results in a “BC1” code instead of a RUG value. An MN/LOC Assessment resulting with a “BC1” code does not have all of the information necessary for TMHP to calculate a RUG value for the applicant or member accurately. Code “BC1” is not a valid RUG value to determine STAR+PLUS HCBS program eligibility.

The MCO must correct the MN/LOC Assessment information within 14 days of submitting the assessment that resulted in a “BC1” code. The MCO must inactivate the MN/LOC Assessment and resubmit the MN/LOC Assessment with correct information to TMHP within 14 days.

Program Support Unit (PSU) staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when a medical assistance only (MAO) applicant meets MN and an ISP has been received. PSU staff must indicate the start of care (SOC) for the STAR+PLUS HCBS program on Form H1746-A.

PSU staff must upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record by following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

3241.2 Medical Necessity Determination for an Individual or Applicant Residing in an NF

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must research the individual’s or applicant's status in the nursing facility (NF) at initial contact and determine whether the individual or applicant has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. PSU staff must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary, to avoid duplication of submittal to Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for an MN determination.

PSU staff must verify if the NF individual or applicant has an approved MN in the TMHP LTCOP. The MCO must not complete a new MN/LOC Assessment if there is a current and approved MN determination in the TMHP LTCOP.

The NF should complete the Minimum Data Set (MDS) if an individual or applicant is applying for Medicaid as a resident in the NF and is concurrently applying for the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO is not required to complete a new MN/LOC Assessment when there is a current and valid MDS in the TMHP LTCOP. PSU staff must notify the MCO that an MN exists by entering the Resource Utilization Group (RUG) value and expiration date in Section A, Item 6, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, or on Form H2067-MC, Managed Care Programs Communication, if the applicant is already enrolled in an MCO. If the NF refuses to complete the MDS in a timely manner, PSU staff must authorize the MCO to complete the MN/LOC Assessment for the individual or applicant by entering N/A in Section A, Item 6, of Form H3676 and uploading to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

PSU staff must authorize the MCO to complete the MN/LOC Assessment, as described above, when an individual or applicant enters the NF on Medicare and does not have a current and valid MDS in the TMHP LTCOP.

PSU staff must approve STAR+PLUS HCBS program eligibility based on a current and valid NF MDS and RUG value even if there is a previously denied MN determination on the MN/LOC Assessment in the TMHP LTCOP.

PSU staff must verify the following in SASO:

• an MN record is present on the Medical Necessity Summary page so the individual service plan (ISP) registration does not suspend; and
• the MN record matches the ISP end date.

PSU staff must adjust the MN/LOC Assessment end date to match the ISP end date on the Medical Necessity Summary page, if applicable.

3241.3 Medical Necessity Determination for Applicants Not Residing in NFs

Revision 21-10; Effective October 25, 2021

Texas Medicaid & Healthcare Partnership (TMHP) must make a determination based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) for all STAR+PLUS Home and Community Based Services (HCBS) program applicants not living in nursing facilities (NFs).

The MCO must submit the MN/LOC Assessment to the TMHP Long Term Care Online Portal (LTCOP) after obtaining the physician’s signature.

3242 Individual Cost Limit Requirement

Revision 18-0; Effective September 4, 2018

3242.1 Maximum Limit

Revision 18-0; Effective September 4, 2018

The cost of the STAR+PLUS Home and Community Based Services (HCBS) program cannot exceed 202 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the STAR+PLUS HCBS program applicant must have an individual service plan (ISP) developed that is at or below 202 percent of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.

3242.2 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 18-0; Effective September 4, 2018

The Code of Federal Regulations (CFR) specifies individuals are not eligible to receive the STAR+PLUS Home and Community Based Services (HCBS) program unless they have a need for at least one STAR+PLUS HCBS program service per individual service plan (ISP) year. Therefore, the Texas Health and Human Services Commission (HHSC) cannot approve any ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan (Pg. 1). When Program Support Unit (PSU) staff receive an ISP from the managed care organization (MCO) with a $0.00 STAR+PLUS HCBS program cost, the following activities occur.

Within two business days:

PSU staff upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. This will inform the MCO to verify if the ISP, which has no services, is accurate.

• If the ISP was submitted incorrectly:
  • the MCO must resubmit a corrected ISP within two business days (for example, the ISP uploaded correctly but is missing services); and
  • PSU staff must honor the original uploaded date if the MCO uploads the corrected ISP within two business days of notification by PSU staff; or
• If the ISP was submitted correctly:
  • the MCO must upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, informing PSU staff the ISP reflects the member's needs; and
  • PSU staff:
    • begin denial procedures for these cases by completing Form H2065-D, Notification of Managed Care Program Services;
    • mail Form H2065-D to the applicant or member;
    • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV;
    • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable; and
    • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox.