Form 2442, Notification of Interest List Release Closure

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Documents

Effective Date: 4/2024

Instructions

Updated: 12/2024

Purpose

Interest List Management (ILM) Unit or Program Support Unit (PSU) staff must mail Form 2442 and Form 2442-S, Notification of Interest List Release Closure, to provide notice of interest list release closure to the individual, legally authorized representative (LAR), authorized representative (AR) or medical consenter.

Procedure

When to Prepare

ILM Unit or PSU staff prepare and mail Form 2442 and Form 2442-S when an individual:

  • is released from the Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) program interest list; and
  • fails to respond or opts out of the enrollment process.

ILM

ILM Unit staff must mail Form 2442 and Form 2442-S within two business days of:

  • the individual, LAR, AR, or medical consenter declining to apply for the MDCP or STAR+PLUS HCBS program;
  • the 45th day from the date of interest list release and the individual, LAR, AR, or medical consenter fails to respond to contact attempts made by ILM Unit staff;  
  • notice from the individual, LAR, AR, or medical consenter that the individual no longer lives in Texas; or
  • the individual, LAR, AR, or medical consenter advising the individual will be turning 21 years old and will no longer be eligible for MDCP.

ILM Unit staff must close the interest list release in the Community Services Interest List (CSIL) database within two business days of the 60th day from the date of release from the MDCP or STAR+PLUS HCBS program interest list.

STAR Kids PSU

STAR Kids PSU staff must mail Form 2442 and Form 2442-S within two business days from the date the individual, LAR or medical consenter:

  • declines to apply for MDCP;
  • advises PSU staff the individual no longer lives in Texas;
  • informs PSU staff the individual will be accepting or receiving services through another program; or
  • advises PSU staff the individual will be turning 21 years old and will no longer be eligible for MDCP.

STAR Kids PSU staff must mail Form 2442 and Form 2442-S within two business days from the 30th day that PSU staff mailed:

  • the enrollment packet or Form 2606, Managed Care Enrollment Processing Delay, and:
    • are unable to contact the individual, LAR or medical consenter; or
    • have not received Form H1200, Application for Assistance – Your Texas Benefits, from the individual, LAR or medical consenter.

Note: STAR Kids PSU must mail Form 2442 with the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Appendix XX, MDCP Program Description.

STAR+PLUS PSU

STAR+PLUS PSU staff must mail Form 2442 and Form 2442-S within two business days from the date the individual or AR:

  • declines to apply for the STAR+PLUS HCBS program;
  • advises PSU staff that the individual no longer lives in Texas; or
  • informs PSU staff the individual will be accepting or receiving services through another program.

STAR+PLUS PSU staff must mail Form 2442 and Form 2442-S within two business days from the 30th day that PSU staff mailed:

  • the enrollment packet or Form 2606, and:
    • are unable to contact the individual or AR; or
    • have not received Form H1200 from the individual or AR.

Note: STAR+PLUS PSU must mail Form 2442 with the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) Appendix XII, STAR+PLUS HCBS Program Description.

STAR Kids and STAR+PLUS PSU staff must close the interest list slot in the CSIL database within two business days from mailing Form 2442.

STAR Kids and STAR+PLUS PSU staff must use Form H2065-D, Notification of Managed Care Program Services, to deny MDCP or STAR+PLUS HCBS program applicants. An individual becomes a program applicant when:

  • Form H1200, Application for Assistance – Your Texas Benefits, has been submitted; or
  • a referral for assessment was submitted or received by PSU staff.

PSU staff do not generate Form 2442 when Form H2065-D is used.

Note: Form 2442 is not used for a deceased individual, requesting to withdraw to the bottom of the interest list, or applying for MDCP or the STAR+PLUS HCBS program through the Money Follows the Person (MFP) process.

Copies and Transmittal

ILM Unit or PSU staff mail the original Form 2442 and Form 2442-S along with SKOPH Appendix XX, MDCP Program Description, and SPOPH Appendix XII, STAR+PLUS HCBS Program Description, as applicable, to the individual, LAR, AR or medical consenter.

ILM Unit or PSU staff upload an electronic copy of Form 2442 and Form 2442-S to the HEART case record.

Form Retention

HEART is the repository for electronic case records. ILM Unit or PSU staff must not keep paper copies of Form 2442 and Form 2442-S. ILM Unit and PSU staff dispose of paper copies of Form 2442 and Form 2442-S by following established procedures for destroying confidential data per the Health and Human Services (HHS) Computer Usage and Information Security Training. ILM Unit or PSU staff upload a copy of the completed Form 2442 and Form 2442-S to the HEART case record on the same date ILM Unit or PSU staff mails Form 2442 and Form 2442-S to the individual, LAR, AR or medical consenter.

Supply Source

Forms 2442 and 2442 are in the following handbooks for ILM Unit and PSU staff:

  • SPOPH;
  • SKOPH;
  • STAR+PLUS Handbook (SPH); and
  • STAR Kids Handbook (SKH).

Detailed Instructions

Date of Notice — Enter the date the form is completed and mailed to the individual, LAR, AR or medical consenter.

Texas Health and Human Services Commission Staff — Enter ILM Unit or PSU staff name.

Office Address — Enter ILM Unit or PSU staff office address of the staff mailing the form.

Area Code and Phone No. — Enter the direct phone number of the ILM Unit or PSU staff mailing the form. Once this field is entered, the phone number field in the body of the form auto-populates with the same number.

Name and Address — Enter the individual, LAR, AR or medical consenter’s name and address. ILM Unit or PSU staff must include the individual’s name for identification purposes if the LAR, AR or medical consenter’s name is used. For STAR Health members, use the address of the primary medical consenter.

On ____, you came to the top of the interest list for: — Enter the date the individual was released from the interest list, as recorded in the CSIL database. PSU must select the appropriate program from the drop-down box:

  • Medically Dependent Children Program (MDCP); or
  • STAR+PLUS Home and Community Based Services (HCBS) program.

On ____, Texas Health and Human Services Commission staff closed or will close your release from the interest — ILM Unit or PSU staff must enter the date the individual’s interest list is closed in the CSIL database. Once this field is entered, the 90th day from this date auto-populates in the body of the form.

We are closing your release because: — Select the appropriate reason from the drop-down box for the interest list release closure:

  • Select we haven’t been able to contact you to begin the eligibility process if ILM Unit or PSU staff have not been able to contact or locate the individual, LAR, AR, or medical consenter within the time frames described above. 

    Note: This includes if ILM Unit or PSU staff can contact the individual at one point, but they later stop responding. 
     
  • Select we haven’t received the completed and signed enrollment packet back from you if PSU staff have not received the completed Form H1200 from an individual, LAR, AR or medical consenter within the time frames described above.
  • Select you told us you don’t live in Texas if the individual, LAR, AR, or medical consenter informs ILM Unit or PSU staff that the individual no longer lives in Texas.
  • Select you told us you don’t want to apply for services if the individual, LAR, AR or medical consenter informs ILM Unit or PSU staff that the individual does not want to apply for MDCP or STAR+PLUS HCBS program.
  • Select you told us you’ll be accepting or are receiving services through another program if the individual, LAR, AR, or medical consenter informs ILM Unit or PSU staff that the individual does not want to apply for MDCP or STAR+PLUS HCBS program because the individual is pursuing or receiving services from another program that meets their needs.
  • Select you told us you’ll be turning 21 years old if ILM Unit or PSU staff determine the individual will turn 21 before MDCP services can begin.