Form H2065-D, Notification of Managed Care Program Services

Instructions for Opening a Form

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Documents

Effective Date: 1/2019

Instructions

Updated: 4/2019

Purpose

To notify the applicant or member of:

  • initial or ongoing eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program or Medically Dependent Children Program (MDCP);
  • denial or termination of the STAR+PLUS HCBS program or MDCP;
  • the right to appeal decisions regarding eligibility;
  • room and board (R&B) and copayment charges, if any; and
  • member transfers from one service area to another service area.

Procedure

When to Prepare

Program Support Unit (PSU) staff prepare Form H2065-D and Form H2065-DS when:

  • an applicant or member is initially determined eligible for the STAR+PLUS HCBS program or MDCP;
  • a member is determined eligible at reassessment for the STAR+PLUS HCBS program or MDCP;
  • an application is denied eligibility for the STAR+PLUS HCBS program or MDCP;
  • a member’s eligibility is terminated from the STAR+PLUS HCBS program or MDCP;
  • there is a change in a member’s R&B or copayment amount; or
  • a member transfers from one service area to another service area for STAR+PLUS HCBS program.

Copies and Transmittal

PSU staff mail the original Form H2065-D and Form H2065-DS to the applicant, member, authorized representative (AR) or medical consenter. PSU staff send one copy of Form H2065-D to the managed care organization (MCO) and, when applicable, one copy to the Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) specialist.

Form Retention

Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is the electronic case record for STAR+PLUS HCBS program and MDCP. PSU staff upload a copy of the completed Form H2065-D and Form H2065-DS to the HEART case record within two business days of Form H2065-D and Form H2065-DS being mailed to the applicant, member, AR or medical consenter. Paper copies of Form H2065-D and Form H2065-DS are not retained. PSU staff dispose of paper copies of Form H2065-D and Form H2065-DS by following established procedures for destruction of confidential data, as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.

Supply Source

Form H2065-D and Form H2065-DS can be found in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH), STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH), STAR Kids Handbook (SKH), STAR+PLUS Handbook (SPH), and Chapter 16.2 of the Uniform Managed Care Manual (UMCM) for STAR Health.

Detailed Instructions

Page 1 Upper Section (required for all forms)

Date of Notice — Enter the date PSU staff complete and mail the form to the applicant or member.

HHSC Staff — Enter the name of PSU staff completing the form.

Office Address and Telephone Number — Enter the mailing address for PSU staff, including the street address or post office box, mail code, city, state, ZIP code and direct telephone number.

Name and Address — Enter the applicant’s, member’s, AR’s or medical consenter’s name and mailing address. For STAR Health, this will be the address of the medical consenter, as provided by the STAR Health MCO. If the AR or medical consenter’s name is used, the applicant or member’s name must also be included for identification purposes.

STAR+PLUS Home and Community Based Services (HCBS) Program or Medically Dependent Children Program (MDCP) — Select the appropriate box to indicate the program the applicant or member has been approved, denied or terminated.

Program Approvals – Block of check boxes that begin with “You are eligible . . .”

Follow the instructions according to the appropriate program approval action the form is being prepared for.

1. Program Approval for Interest List Release and Upgrade (does not include Money Follows the Person (MFP))

You are eligible for ______ beginning ______ — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the first day of the month following all eligibility criteria being met. PSU staff processing does not delay the eligibility begin date.

Services identified on your Individual Service Plan (ISP) are effective _______ through _______ as long as you are eligible for the program — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date will be the same as the eligibility begin date. The ISP end date will be 12 months from the ISP effective date, unless an MDCP applicant will be turning 21 years old in less than 12 months. If an MDCP applicant will be turning 21 years old, the ISP end date will be the last day of the month of the applicant's 21st birthday.

2. Program Approval for MFP (does not include MDCP MFP limited nursing facility stay)

Two forms are completed and sent for the STAR+PLUS HCBS program and MDCP MFP eligibility. The first form will provide the eligibility begin date and is issued while the individual resides in the nursing facility (NF). The second form is sent after the individual discharges from the NF and provides the ISP effective and end dates. The eligibility effective date will remain the same on both forms.

First Form Instruction for MFP Cases:

The first form is prepared when the applicant has met all eligibility criteria. The purpose of the first form is to notify the applicant or member he or she may discharge from the NF without an adverse impact to the STAR+PLUS HCBS program or MDCP eligibility.

You are eligible for ______ beginning _______ — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the day all eligibility criteria is met. The eligibility begin date may be a mid-month date. PSU staff processing does not delay the eligibility begin date.

Second Form Instruction for MFP Cases:

The second form is prepared after the applicant discharges from the NF. Upon NF discharge, PSU staff can establish the ISP effective and end dates. The purpose of the second form is to advise the applicant of the service effective and end dates.

You are eligible for _______ beginning _______ —Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the day all eligibility criteria is met. The eligibility begin date may be a mid-month date. The eligibility effective date must remain the same on both forms. PSU staff processing does not delay the eligibility begin date.

Services identified on your Individual Service Plan (ISP) are effective _____ through _____ — as long as you are eligible for the program — Select this box on the second form prepared. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the day the applicant was discharged from the NF. The ISP effective date and the eligibility begin date may or may not be the same date. The ISP end date is last day of the month the applicant was discharged from the NF, 12 months from the date the applicant was discharged from the NF, unless an MDCP applicant will be turning 21 years old in less than 12 months. For example, if an applicant discharged from an NF on January 15, 2019, their ISP dates would be January 15, 2019, through January 31, 2020. If an MDCP applicant will be turning 21 years old, the ISP end date will be the last day of the month of the applicant’s 21st birthday.

3. Program Approval for MDCP MFP Limited NF Stay

You are eligible for _____ beginning _____ — Select this box if the applicant is eligible for MDCP. Select “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the first day of the month the individual discharges from the NF.

Services identified on your Individual Service Plan (ISP) are effective ______ through ______ — as long as you are eligible for the program — Select this box if the applicant is eligible for MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date will match the eligibility begin date. The ISP end date will be 12 months from the ISP effective date, unless an MDCP applicant will be turning 21 years old in less than 12 months. If an MDCP applicant will be turning 21 years old, the ISP end date will be the last day of the month of the applicant's 21st birth month.

4. Annual Reassessment

You are eligible for _____ beginning _____ — Select this box if the member continues to be eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the member is eligible for services in the second blank. The eligibility begin date is the first day of the month following the historical ISP’s end date.

Services identified on your Individual Service Plan (ISP) are effective ____ through ____ as long as you are eligible for the program — Select this box if the member remains eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the first day of the month following the historical ISP’s end date. The ISP effective date will be the same as the eligibility begin date. The ISP end date will be 12 months from the ISP effective date, unless an MDCP member will be turning 21 years old in less than 12 months. If an MDCP member will be turning 21 years old, the ISP end date will be the last day of the month of the applicant or member’s 21st birth month.

5. Program Approval due to Medicaid Reinstatement

If a member is terminated from the STAR+PLUS HCBS program or MDCP due to a loss of Medicaid eligibility then regains Medicaid eligibility within four calendar months, PSU staff may reinstate STAR+PLUS HCBS program or MDCP eligibility. See policy for specific eligibility criteria.

You are eligible for ______ beginning _____ — Select this box if a member is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the first day of the month Medicaid eligibility is reinstated. PSU staff must verify all other STAR+PLUS HCBS program or MDCP eligibility criteria continue to be met.

Services identified on your Individual Service Plan (ISP) are effective _____ through _____ as long as you are eligible for the program — Select this box if a member is eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the first day of the month Medicaid eligibility is reinstated. The ISP effective date will be the same as the eligibility begin date. The ISP end date will match the historical ISP end date.

Examples:

  • Medicaid reinstatement within four months without a gap — A member’s historical ISP effective and end dates are November 1, 2018, through October 31, 2019. The member lost Medicaid eligibility January 31, 2019, and regained Medicaid eligibility on February 1, 2019, with no gap in Medicaid eligibility. The eligibility begin date will be February 1, 2019, and the ISP effective and end dates will be February 1, 2019 through October 31, 2019.
  • Medicaid reinstatement within four months with a gap — A member’s historical ISP effective and end dates are November 1, 2018, through October 31, 2019. The member lost Medicaid eligibility January 31, 2019, and regained Medicaid eligibility on May 1, 2019 with a gap in Medicaid eligibility for February 1, 2019 through April 30, 2019. The eligibility begin date will be May 1, 2019, and the ISP effective and end dates will be May 1, 2019 through October 31, 2019.

R&B, Qualified Income Trust, and Copayment (applicable to specific approvals)

1. STAR+PLUS HCBS Program Applicant or Member R&B

You must pay ______ for room and board by ______ — Select this box if the STAR+PLUS HCBS program applicant or member is moving to an adult foster care (AFC) home or assisted living facility (ALF), and must pay R&B. Enter the amount to be paid by the applicant or member for the first month in the AFC home or ALF. Enter the date as the first day of the first month the applicant or member resides in the AFC home or ALF.

And then pay _____ per month, beginning ______ — Enter the applicant’s or member’s ongoing R&B charge amount. Enter the date as due on the first day of the second month the applicant or member resides in the AFC home or ALF.

This section of the form is also completed to notify a STAR+PLUS HCBS program member of a change in R&B charges.

You must pay _____ for copayment by _____ — Select this box if the STAR+PLUS HCBS program applicant or member is moving into an AFC home or an ALF and must pay a copayment for care. Enter the amount to be paid by the applicant or member for the first month in the AFC home or ALF.

And then pay _____ per month, beginning ______ — Enter the applicant’s or member’s ongoing copayment charge amount. Enter the date as the first day of the second month the applicant or member resides in the AFC home or ALF.

This section of the form is also completed to notify a STAR+PLUS HCBS program member of R&B copayment changes.

For reassessments, enter the ISP effective date in the date field for the copayment on the line "You must pay ___ for copayment by ... (date)." The first day of the second month is entered as the due date for an ongoing copayment amount on the line "... and then pay ___ per month beginning ... (date)."

2. STAR+PLUS HCBS Program Applicant or Member Qualified Income Trust (QIT)

You must pay _____ for room and board by _____ — Select this box if the STAR+PLUS HCBS program applicant or member has a QIT and must pay R&B. Enter the amount to be paid by the applicant or member for the first month of R&B. Enter the date as the first day of the first month the applicant or member must pay R&B.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing R&B charge amount. Enter the date as the first day of the second month the applicant or member must pay R&B.

You must pay _____ for copayment by _____ — Select this box if the STAR+PLUS HCBS applicant or member has a QIT and must pay a copayment for care. Enter the amount to be paid by the applicant or member for the first month of service authorization. Enter the date as the first day of first month of service authorization.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing copayment charge amount. Enter the date as the first day of the second month the applicant or member resides in the AFC home or ALF.

This section of the form is also completed to notify a STAR+PLUS HCBS program member of R&B and copayment changes.

For reassessments, enter the effective date of the ISP year in the date field for the initial copayment on the line "You must pay ___ for copayment by . . . (date)." The first day of the next month is entered as the due date for an ongoing copayment amount on the line ". . . and then pay ___ per month beginning . . . (date)."

3. MDCP Applicant or Member QIT

You must pay _____ for room and board by _____ — Select this box if the STAR+PLUS HCBS program applicant or member has a QIT and must pay R&B. Enter the amount to be paid by the applicant or member for the first month of R&B. Enter the date as the first day of the first month the applicant or member must pay R&B.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing R&B charge amount. Enter the date as the first day of the second month the applicant or member must pay R&B.

You must pay _____ for copayment by _____ — Select this box if the STAR+PLUS HCBS applicant or member has a QIT and must pay a copayment for care. Enter the amount to be paid by the applicant or member for the first month of service authorization. Enter the date as the first day of first month of service authorization.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing copayment charge amount. Enter the date as the first day of the second month the applicant or member resides in the AFC home or ALF.

This section of the form is also completed to notify a STAR+PLUS HCBS program member of R&B and copayment changes.

For reassessments, enter the effective date of the ISP year in the date field for the initial copayment on the line "You must pay ___ for copayment by . . . (date)." The first day of the next month is entered as the due date for an ongoing copayment amount on the line ". . . and then pay ___ per month beginning . . . (date)."

Program Denials and Terminations – Block of check boxes that begin with “Based on a review of . . .”

Follow the instructions according to the appropriate program denial or termination action the form is being prepared for.

Based on a review of your current situation, it has been determined that — Select one of the following boxes if the applicant or member is being denied or terminated from the STAR+PLUS HCBS program or MDCP.

The last day you can get services for ______ is ______ — Select this box if the STAR+PLUS HCBS program or MDCP eligibility is being terminated. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the last day the MCO is authorized to deliver services to the member in the second blank provided.

You are not eligible for ______ — Select this box if an application for the STAR+PLUS HCBS program or MDCP is being denied. Select “STAR+PLUS HCBS Program” or “MDCP” in the blank provided.

Reason for denial — Select this box for all denials and terminations. Enter the reason the applicant or member is being denied or terminated. For the STAR+PLUS HCBS program, refer to SPOPH, Appendix IV, STAR+PLUS HCBS Program Closure Reasons/Codes, for appropriate language. For MDCP, refer to SKOPH, Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, for appropriate language.

Note: Form H2065-D and Form H2065-DS must be generated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for MN denials.

Legal Basis for the Action (required for all forms)

The above decision is based on: — Select the boxes associated with the appropriate program.

STAR+PLUS HCBS Program Rule §353.1153 — Select this box for all STAR+PLUS HCBS program notices.

STAR+PLUS Program Support Unit Operational Procedures Handbook reference: — Select this box for all STAR+PLUS HCBS program denial and termination notices. Enter the associated handbook reference supporting the denial or termination. Refer to SPOPH, Appendix IV, STAR+PLUS HCBS Program Closure Reasons/Codes, for the appropriate handbook section.

MDCP Program Rule §353.1155 — Select this box for all MDCP notices.

STAR Kids Program Support Unit Operational Procedures Handbook reference: — Select this box for all MDCP denial and termination notices. Enter the associated handbook reference supporting the denial or termination. Refer to SKOPH, Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, for the appropriate handbook section.

UMCM Chapter 16.2, STAR Health MDCP — Select this box if the applicant or member is also STAR Health MDCP.

Comments — For the STAR+PLUS HCBS program, refer to SPOPH Appendix IV, STAR+PLUS HCBS Program Closure Reasons/Codes, for appropriate language. For MDCP, refer to SKOPH, Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, for appropriate language. Do not enter comments without supervisor approval. Any comments entered by PSU staff on Form H2065-D must also appear in Spanish on Form H2065-DS. PSU staff must avoid use of confidential information according to SPOPH, Section 2290, Confidential Information on Notifications, and SKOPH, Section 1630, Confidential Information on Notifications.

Medicaid No. — Enter the applicant’s or member's Medicaid identification (ID) number. Leave blank if the applicant does not have a Medicaid ID number.

Page 2

Name — Enter the applicant’s or member's full name. This is required for all forms.

Medicaid No. — Enter the applicant’s or member's Medicaid ID number. Leave blank if the applicant does not have a Medicaid ID number.

You might be able to get free legal help from outside HHSC. Call — Enter the area code and phone number of the legal aid office in the applicant or member’s county of residence using the Attachment — Legal Aid List.

Right to a Fair Hearing (applicant or member instruction only)

I request a state fair hearing and want my services to continue during the fair hearing process — The member selects this box if he or she is requesting a state fair hearing and would like his or her STAR+PLUS HCBS program or MDCP services to continue during the state fair hearing process.

I request a state fair hearing. — The applicant or member selects this box if he or she is requesting a state fair hearing and does not want services to continue during the fair hearing process.

Services will not be provided to an applicant requesting a fair hearing.

Signature – Applicant/Member — The applicant, member, AR or medical consenter must sign in the blank provided.

Print Name – Applicant/Member — The applicant, member, AR or medical consenter must print his or her name in the blank provided.

Date — The applicant, member, AR or medical consenter must enter the date the form was signed in the blank provided and return the form to PSU staff.

Attachment — Legal Aid List