STAR Kids Program Support Unit Operational Procedures Handbook

 

Section 1000, STAR Kids Overview and Eligibility

Section 2000, Medically Dependent Children Program Intake and Initial Application

Section 3000, STAR Kids Screening and Assessment and Service Planning

Section 4000, STAR Kids Community Services

Section 5000, Reserved for Future Use

Section 6000, Denials and Terminations

Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings

Section 8000, Utilization Management and Review by the State

Section 1000, STAR Kids Overview and Eligibility

Revision 19-10; Effective June 14, 2019

 


Senate Bill 7 from the 83rd Legislature, Regular Session, in 2013, required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).

STAR Kids does not change or impact an individual’s Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, age birth through 20, enrolled with a STAR Kids MCO, are called members of the MCO. All STAR Kids members have access to service coordination provided by an MCO employee or through a member’s primary care provider, authorized by the MCO.

Service coordination is specialized care management performed by an  MCO service coordinator and includes, but is not limited to:

All STAR Kids members receive an annual comprehensive assessment of their physical and functional needs by an MCO service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI). Within the time frame listed in the STAR Kids Contract, Section 8.1.39, STAR Kids Initial Screening and Assessment Process, if a member has a change in their physical or behavioral health, a change in functional ability or caregiver supports, the MCO must reassess the member and update their ISP, as applicable, and authorize necessary services upon request from the member, legally authorized representative (LAR), authorized representative (AR) or health home.

In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, Flexible Family Support Services (FFSS), adaptive aids, minor home modifications, employment services and Transition Assistance Services (TAS) to children and young adults who meet the level of care (LOC) provided in a nursing facility (NF) so he or she can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list of MDCP applicants. A child, young adult, LAR or AR may ask their MCO about how to be placed on the MDCP interest list at any time or call the HHSC Interest List Management (ILM) Unit staff’s toll-free number at 1-877-438-5658.

 

1100 Legal Basis and Values

Revision 18-0; Effective September 4, 2018

STAR Kids Medicaid Managed Care Program is required by Texas Government Code §533.00253. Title 1 Texas Administrative Code (TAC) §353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of STAR Kids services, as well as  Medically Dependent Children Program (MDCP) services. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract.

The STAR Kids Program Support Unit Operational Procedures Handbook includes operational procedures for the Texas Health and Human Services Commission (HHSC) Program Support Unit (PSU) staff.

The STAR Kids Handbook includes policies and procedures to be used by managed care organizations (MCOs), contractors and service providers in the delivery of STAR Kids MDCP services to eligible members.

 

1110 Mission Statement

Revision 18-0; Effective September 4, 2018
 
The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:

 

1120 Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

The Medically Dependent Children Program (MDCP) is a home and community based services program authorized under §1915(c) of the Social Security Act. MDCP provides respite, Flexible Family Support Services (FFSS), minor home modifications, adaptive aids, Transition Assistance Services (TAS), employment assistance (EA), supported employment (SE) and financial management services (FMS) through a STAR Kids managed care organization (MCO). This section provides an overview of MDCP, including its eligibility requirements.

 

1130 Medically Dependent Children Program Goal

Revision 18-0; Effective September 4, 2018

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults age 20 and younger who are medically dependent, and to encourage de-institutionalization of children and young adults who reside in nursing facilities (NFs).
MDCP accomplishes this goal by:

 

1200 Medically Dependent Children Program Eligibility

Revision 18-0; Effective September 4, 2018

An individual becomes eligible to be assessed for Medically Dependent Children Program (MDCP) services when their name reaches to the top of the MDCP interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if he or she is already enrolled in STAR Kids. Once an individual’s name reaches the top of the interest list, the individual selects an MCO who beings the determination of eligibility as the individual applies for services. An individual going through the application and eligibility process for STAR Kids is referred to as an applicant. An individual enrolled in STAR Kids is referred to as a member.

MDCP 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 MDCP, the applicant or member must meet the following criteria:

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F), states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

 

1210 Medical Necessity Determination

Revision 19-10; Effective June 14, 2019
 
A Medically Dependent Children Program (MDCP) applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before admission into the MDCP. The determination of MN is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant’s or member’s individual service plan (ISP) cost limit is calculated based on information gathered through the SK-SAI MDCP module.

The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care (LTC) Online Portal for MDCP applicants or members. TMHP processes the SK-SAI for applicants or members 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 applicants or members and establish the ISP cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG is generated and appears in the TMHP LTC Online Portal, as well as the MCO response file. An SK-SAI with incomplete RUG information results in a "BC1" code instead of a RUG value. An SK-SAI resulting in a “BC1” code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. A “BC1” code is not a valid RUG 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. The MCO nurse must also submit any corrections to SK-SAI items used to determine MN within 14 days. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. See the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for detailed instructions pertaining to the MCO communicating inactivation and corrections to the SK-SAI to TMHP.

Applicants without Medicaid require a Medicaid eligibility financial determination. For these individuals, the HHSC Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when the applicant meets MN. This notification is documented on Form H1746-A, MEPD Referral Cover Sheet, which PSU staff fax to the MEPD specialist. This process is outlined in more detail in Section 2210, Income and Resource Verifications for Medicaid Eligibility.

 

1211 Medical Necessity Determination for an Applicant or Member Residing in a Nursing Facility

Revision 19-10; Effective June 14, 2019
 
During initial contact with the applicant or member, the managed care organization (MCO) service coordinator must explore the applicant’s or member’s status in the nursing facility (NF) and desire to transition to the community. The MCO service coordinator completes the STAR Kids Screening and Assessment Instrument (SK-SAI) and submits the assessment to Texas Medicaid & Healthcare Partnership (TMHP) indicating a request for a determination of medical necessity (MN). This process is described in more detail in the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

 

1212 Medical Necessity Determination for an Applicant or Member Not Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018
 
For applicants or members not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the STAR Kids Screening and Assessment Instrument (SK-SAI) completed by the managed care organization (MCO) selected by the applicant or member.

The MCO must electronically submit the SK-SAI to TMHP through the TMHP Long Term Care (LTC) Online Portal indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO’s records.

 

1220 Individual Cost Limit

Revision 18-0; Effective September 4, 2018
 
The cost of Medically Dependent Children Program (MDCP) services on the STAR Kids individual service plan (ISP) cannot exceed 50 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the managed care organization (MCO) service coordinator must develop an ISP consisting of MDCP services requested by the applicant and the cost of those services. The cost must be developed at or below 50 percent of the cost to provide services to the applicant, based on the Resource Utilization Group (RUG) in an NF.

Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if the Medicaid state plan services and the MDCP services would pose a risk to the individual’s health, safety or welfare.

 

1230 Unmet Need for at Least One Medically Dependent Children Program Service

Revision 18-0; Effective September 4, 2018
 
The §1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a §1915(c) Medicaid waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.

 

1240 Age

Revision 18-0; Effective September 4, 2018
 
To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

 

1250 Citizenship and Identity Verification

Revision 18-0; Effective September 4, 2018
 
As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long term services and supports (LTSS) members whose financial eligibility is based on a determination from the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD specialists, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry of those programs.

 

1260 Living Arrangement and Texas Residency

Revision 18-0; Effective September 4, 2018
 
The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services as outlined in Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(B), Medically Dependent Children Program.

If the applicant is under age 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, as outlined in Title 1 TAC §353.1155(b)(1)(G)(ii).

Managed care organization (MCO) service coordinators must confirm the applicant or member, if under age 18, lives with a family member, such as a parent, guardian, grandparent or sibling, as defined in the Glossary. The MCO service coordinator must review guardianship documentation or obtain a statement from the applicant, member, legally authorized representative (LAR), authorized representative (AR) or family member regarding relation. The MCO service coordinator must maintain this documentation in the member’s case file.

 

1270 Financial Eligibility

Revision 18-0; Effective September 4, 2018
 
Applicants or members who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. Program Support Unit (PSU) staff must determine if an applicant or member is currently on Medicaid and check the Texas Integrated Eligibility Redesign System (TIERS) to confirm the current status of an applicant or member. A Medicaid for the Elderly and People with Disabilities (MEPD) determination may have already been completed for an applicant or member and must be used unless there have been changes in the applicant’s or member’s financial situation.

If the applicant does not have a Medicaid eligibility determination, it is PSU staff’s responsibility to assist the applicant with completing the application and obtaining the necessary verifications to establish eligibility from MEPD specialists. These processes are described in Section 2100, Enrollment Following Release from the Interest List.

 

1300 STAR Kids Services and Service Delivery Options

Revision 18-0; Effective September 4, 2018
 
STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service (FSS) Medicaid, described in the Texas Medicaid state plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).

 

1310 Acute Care Services

Revision 18-0; Effective September 4, 2018
 
STAR Kids members may receive medically necessary services through their managed care organization (MCO), and as required under Title 42 Code of Federal Regulations (CFR) §441, Subpart B, Early and Periodic Screening, Diagnostics and Treatment (EPSDT) of Individuals Under Age 21. This includes, but is not limited to:

STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members will receive dental care through their primary insurer, their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service (FSS) model.

 

1320 Long Term Services and Supports

Revision 18-0; Effective September 4, 2018
 
STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):

STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following services through their STAR Kids MCO:

STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in an NF. Receipt of MDCP services does not impact a member’s eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP include:

 

1330 Service Delivery Options for Certain Long Term Services and Supports

Revision 18-0; Effective September 4, 2018
 
STAR Kids provides members with an array of services, as identified on each member’s individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.

STAR Kids members may choose from three service delivery options for the delivery of certain long term services and supports (LTSS). The options available are the Agency Option (AO), Service Responsibility Option (SRO) and Consumer Directed Services (CDS) option. State plan LTSS which can be delivered through these service delivery options are:

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:

STAR Kids members, legally authorized representatives (LARs) or authorized representatives (ARs) may choose to participate in the AO, CDS option or SRO delivery models.

Members who choose the AO model select an MCO-contracted agency to coordinate service delivery for the services on their ISP.

In the CDS option model, the member, LAR or AR work with assistance from a financial management services agency (FMSA). FMSA personnel may be employed directly by or through personal service agreements or subcontracts with the providers. Members who choose the CDS option model are given the authority to self-direct certain services. If the member chooses to self-direct certain services, the MCO coordinates delivery of non-member directed services.

In the SRO model, an agency is the attendant’s employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before mailing them to the member’s home. The member, LAR, or AR is responsible for most of the day-to-day management of the attendant’s activities, beginning with interviewing and selecting the person who will be the attendant.

More information about these service delivery options is available in Section 5000, Service Delivery Options.

 

1400 Service Coordination through the Managed Care Organization

Revision 18-0; Effective September 4, 2018
 
All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member’s health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the MCO service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing facility (NF) or other long-term care facility, the MCO service coordinator must inform the member, LAR or AR about options available through home and community based services programs, in addition to facility-based options.

MCO service coordinators are responsible for assessing a member’s needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the MCO service coordinator must:

 

1410 Service Coordination Requirements

Revision 18-0; Effective September 4, 2018
 
Managed care organizations (MCOs) provide a different level of service coordination, depending on a member’s needs. Members with more complex needs receive more service coordination than members whose needs are less complex.

Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits from a named MCO service coordinator annually, in addition to monthly telephone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 MCO service coordinators must be a registered nurse (RN), nurse practitioner (NP), physician’s assistant (PA), social worker (MSW, LCSW or LBSW), or licensed professional counselor (LPC) if the member’s service needs are primarily behavioral. Level 1 members include those who:

Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named MCO service coordinator, unless otherwise requested by the member, LAR or AR. Level 2 MCO service coordinators must be either an RN, NP, PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who:

Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 MCO service coordinators must have a minimum of a high school diploma or a general education diploma (GED) and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years.

Members receiving Level 1 or Level 2 service coordination must have a single named person as their assigned MCO service coordinator. Level 3 members, LARs or ARs may request a single named MCO service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who qualify for Level 3 who reside in a nursing facility (NF) or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following non-capitated §1915(c) Medicaid waiver programs: Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL). The MCO must notify members within five business days of the name and telephone number of the new MCO service coordinator, if the service coordinator changes.

MCOs must notify all members in writing of the:

 

1420 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities

Revision 18-0; Effective September 4, 2018
 
Members who have intellectual and developmental disabilities (IDD) living in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or who receive services through one of the following IDD waivers, receive their acute care services and some long term services supports (LTSS) (e.g., private duty nursing (PDN)) through STAR Kids and continue to receive most of their LTSS through the following programs:

A member with IDD that meets the above criteria has a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member, legally authorized representative (LAR) or authorized representative’s (AR’s) personal preference.

These members also have a person(s) outside of the MCO who develops and implements a service plan and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member’s IDD waiver case manager or service coordinator. The member’s IDD waiver case manager or service coordinator should invite MCO service coordinators to their care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in-person or telephonically. The MCO service coordinator is responsible for the coordination of these members’ acute care services and capitated LTSS.

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

 

1430 Service Coordination and the Youth Empowerment Services Waiver Program

Revision 18-0; Effective September 4, 2018
 
A member who receives services through the Youth Empowerment Services (YES) waiver program receive their acute care services and some long term services and supports (LTSS) (e.g., Day Activity and Health Services (DAHS), private duty nurse (PDN), and Community First Choice (CFC)) only through STAR Kids and continues to receive their waiver services through the YES waiver program. A member served by the YES waiver program will have a named managed care organization (MCO) service coordinator and is considered a Level 1 member.

YES waiver program members also have a case manager outside of the MCO who develops and implements the YES waiver service plan and monitors YES waiver service delivery. This case management is provided through the capitated Mental Health Targeted Case Management (MHTCM) benefit, which the MCO must authorize for any member receiving YES waiver program services. The MCO service coordinator must respond to requests from the member’s YES waiver case manager. The member’s YES waiver case manager should invite the MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be either in-person or telephonically. The MCO service coordinator is responsible for the coordination of these member’s acute care services and capitated LTSS.

 

1440 Service Coordinators and Home and Community Based Services - Adult Mental Health

Revision 18-0; Effective September 4, 2018
 
The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves members who have serious and persistent mental illness (SPMI) and:

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program’s population. HCBS-AMH is operated on a fee-for-service (FFS) basis for members age 18 and up. Each participant is assigned a recovery manager (RM) who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with the Texas Department of State Health Services (DSHS). Additional information about HCBS-AMH can be found at https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

 

1441 Program Point of Contact

Revision 18-0; Effective September 4, 2018

Each managed care organization (MCO) must have a designated program point of contact (PPOC) for the Home and Community Based Services - Adult Mental Health (HCBS-AMH) program. The PPOC is responsible for:

 

1442 Managed Care Organization Service Coordination Responsibility

Revision 18-0; Effective September 4, 2018

Managed care organization (MCO) service coordinators must participate in telephonic recovery plan meetings, as scheduled by Texas Health and Human Services (HHSC) or recovery managers (RMs), and provide any requested member-specific information prior to the meeting. MCO service coordinators must:

HCBS-AMH may provide transitional planning for members who reside in an institution and also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, telephonically or in-person, during the member’s stay. Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.

 

1600 Disclosure of Information

Revision 18-0; Effective September 4, 2018

 

 

1610 Confidential Nature of Medical Information - Health Insurance Portability and Accountability Act

Revision 18-0; Effective September 4, 2018
 
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to secure the confidentiality of protected health information (PHI). PHI is information that identifies or could be used to identify an applicant or member and that relates to the:

PHI includes an applicant or member’s date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number, and demographic data.

 

1611 Confidential Nature of a Case Record

Revision 18-0; Effective September 4, 2018
 
Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify an applicant or member. An applicant, member, legally authorized representative (LAR) or authorized representative (AR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

 

1612 Custody of Records

Revision 18-0; Effective September 4, 2018
 
Texas Health and Human Services Commission (HHSC) staff must use reasonable diligence to safeguard, protect and preserve records and prevent disclosure of the protected health information (PHI) he or she contain, except as provided by the HHSC regulations.

Reasonable diligence for employees responsible for records includes keeping records:

 

1613 Responsible Party to Authorize Disclosure

Revision 18-0; Effective September 4, 2018

 

 

1613.1 Legally Authorized Representatives and Authorized Representatives

Revision 18-0; Effective September 4, 2018
 
Only the member’s legally authorized representative (LAR) or authorized representative (AR) can exercise the applicant’s or member’s rights with respect to protected health information (PHI). Therefore, only an applicant, member, LAR or AR may authorize the use or disclosure of PHI or obtain PHI on behalf of an applicant or member. Exception: Texas Health and Human Services Commission (HHSC) is not required to disclose the information to the LAR or AR if the applicant or member is subjected to domestic violence, abuse or neglect by the LAR or AR. Consult HHSC Privacy Office, as described in Section 1615, Information That May Be Disclosed, if it is believed that health information should not be released to the LAR or AR.

Note: A responsible party is not automatically an LAR or AR.

 

1613.2 Unemancipated Minors

Revision 18-0; Effective September 4, 2018

A parent is the legally authorized representative (LAR) for a minor child except when:

 

1613.3 Adults and Emancipated Minors

Revision 18-0; Effective September 4, 2018
 
If the applicant or member is an adult or emancipated minor, including married minors, the applicant’s or member’s legally authorized representative (LAR) or authorized representative (AR) is a person who has the authority to make health care decisions about the member and includes a:

Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, for approval.

 

1613.4 Deceased Applicant or Member

Revision 18-0; Effective September 4, 2018
 
The legally authorized representative (LAR) or authorized representative (AR) for a deceased applicant or member is an executor, administrator or other person with authority to act on behalf of the applicant, member or the member’s estate. These include:

Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, about whether a particular person is the LAR or AR of an applicant or member.

 

1614 Verifying the Identity of an Applicant, Member, LAR, AR or Third Party Individual

Revision 18-0; Effective September 4, 2018

 

 

1614.1 Telephone Communication

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must establish the identity of an individual who identifies himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) by verifying the individual’s knowledge of two of the following:

Establish the identity of an attorney, LAR or AR by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the applicant or member.

 

1614.2 In-Person Communication

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must establish the identity of the individual who presents himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) office by examining two forms of identification with at least one form of identification being a government-issued photo identification (ID):

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers or contractors by examining at least one source such as:

Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access confidential information through one of the following:

Contact the HHSC Office of Chief Counsel when federal agency staff, contractors, researchers or other HHSC or MCO staff come to the office without prior notification or adequate identification and request permission to access records.

 

1614.3 Electronic Mail Communication

Revision 18-0; Effective September 4, 2018

If Program Support Unit (PSU) staff receive electronic mail, also known as email, from an applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party that contains protected health information (PHI), PSU staff must respond using the following procedures:

PSU staff must not send PHI by email to non-government entity individuals, including applicants, members, LARs, ARs or third-party individuals. Refer to Section 1616, Verification and Documentation of Disclosure, for approved methods of transmitting PHI to applicants, members, LARs, ARs, and third party individuals to whom the applicant, member, LAR or AR have provided written consent for the release of PHI.

PSU staff may share PHI by email with Medicaid for the Elderly and People with Disabilities (MEPD), Texas Medicaid & Healthcare Partnership (TMHP), managed care organization (MCO) the applicant or member is enrolled with, and other Texas Health and Human Services Commission (HHSC) staff for work-related purposes, but only if the email:

Password-protected documents sent by email and electronic fax (e-fax) documents are not considered a secure method for transmitting PHI.

 

1615 Information That May Be Disclosed

Revision 18-0; Effective September 4, 2018

Reasonable effort must be made to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to determine eligibility and operate the program. The disclosure of the applicant or member’s PHI from the Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant or member.

PHI may only be disclosed to a person who has written permission from the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to obtain the information. The applicant, member, LAR or AR authorizes the release of information by completing and signing:

Note: If the case information to be released includes PHI, the document must also tell the applicant, member, LAR or AR that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally, requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and their survivors.

The HHSC Privacy Office handles questions about the release of information. All questions and problems encountered by individuals concerning release of information should be referred to this office. MCO staff should contact HHSC Managed Care Compliance & Operations (MCCO) staff.

 

1616 Verification and Documentation of Disclosure

Revision 18-0; Effective September 4, 2018
 
It is only acceptable for Program Support Unit (PSU) staff to disclose protected health information (PHI) to the applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party individual to whom the applicant, member, LAR or AR has provided written consent for the release of PHI.

PSU staff verify the identity of the person who requests disclosure of PHI by examining two forms of identification, with at least one form of identification being a government-issued photo identification (ID):

When disclosing PHI, PSU staff must document transactions and maintain documentation in the member’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record pertaining to how the identity of the person was verified and the method of how the information was released to the individual. Approved methods of releasing PHI include providing the requestor copies of documentation in person, by facsimile or by regular mail.

 

1620 Alternate Means of Communication with the Applicant or Member

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant, member, legally authorized representative (LAR) or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member, LAR or AR must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the applicant or member.

 

1630 Confidential Information on Notifications

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member, legally authorized representative (LAR) or authorized representative (AR) during the eligibility determination process. This includes inclusion of PHI by HHSC staff to third parties who receive a copy of a notification of eligibility form.

HHSC staff must not include PHI on the eligibility notice shared with the service provider or another third party.

Examples:

In the examples above, revealing specifics of the applicant or member’s income or the condition of his home environment is a violation of his or her right to confidentiality. In all cases, HHSC staff must assess any information provided by the applicant or member to determine if its release would be a confidentiality violation.

 

1631 Program Support Unit Communications with Managed Care Organizations

Revision 18-0; Effective September 4, 2018
 
In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member’s protected health information (PHI) to be shared only with his or her selected managed care organization (MCO). This makes it crucial that when documents containing member information are posted in the incorrect MCO folder in TxMedCentral, it be corrected immediately upon realization an error was made.

Program Support Unit (PSU) staff must send notification of all TxMedCentral posting errors to PSU Operations staff, including the document identifying information, the name of the folder in which it was erroneously posted, the name of the folder into which it should have been posted, and the time the correction was made.

Example: Posted XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been posted to MOLSKW. Corrected at 9:22 a.m. December 20.

 

1640 Applicant or Member Correction of Information

Revision 18-0; Effective September 4, 2018
 
An applicant, member, legally authorized representative (LAR) or authorized representative (AR) has a right to correct any information that the Texas Health and Human Services Commission (HHSC) has about the applicant or member and any other individual on the applicant or member’s case.

A request for correction must be in writing and:

If HHSC agrees to change protected health information (PHI), the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the member’s request.

Notify the member, LAR or AR in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or the MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC or the MCO makes a correction to PHI, HHSC or the MCO must ask the member for permission before sharing with third parties. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if those persons may have relied or could rely on it to the disadvantage of the member. HHSC staff must follow regional procedures to contact the HHSC Office of Chief Counsel for a record of disclosures. MCOs must follow HHSC procedures as stated in the STAR Kids Managed Care Contract.

Note: Do not follow above procedures when the accuracy of information provided by a member, LAR or AR is determined by another review process, such as a:

The decision in the above review processes is the decision on the request to correct information.

 

1650 Disposal of Records

Revision 18-0; Effective September 4, 2018

To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data, as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.

 

1700 Member Rights and Responsibilities

Revision 18-0; Effective September 4, 2018
 
Member rights and responsibilities are included in the Member Handbook. The required critical elements can be found at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.

In addition, an applicant, member, LAR or AR may refer to the Title 1 Texas Administrative Code (TAC) §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.

 

1800 Notifications

Revision 18-0; Effective September 4, 2018
 

 

1810 Program Support Unit Staff Notification Requirements

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member, LAR or AR of the actions taken regarding Medically Dependent Children Program (MDCP) services. Form H2065-D must be completed in plain language that can be understood by the applicant, member, LAR or AR. The language preference of the applicant, member, LAR or AR must be considered.

The applicant, member, LAR or AR must be notified on Form H2065-D within two business days of the date a case is certified for MDCP. Form H2065-D also includes information on the individual’s room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is terminated. PSU staff must notify the applicant, member, LAR or AR using Form H2065-D of the denial of application within two business days of the decision. Refer to Section 6000, Denials and Terminations.

Depending on when the notification is generated, Form H2065-D will either be posted to the MCO STAR Kids folder in TxMedCentral or generated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal on the case action date.

 

1820 Managed Care Organization Notification Requirements

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) is responsible for notifying the member, legally authorized representative (LAR) or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member, LAR or AR has a right to appeal. Appeal rights of STAR Kids members are in the STAR Kids Managed Care Contract.
 

1830 Notifications with Medicaid for the Elderly and People with Disabilities or Texas Works Involvement

Revision 18-0; Effective September 4, 2018
 
Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Program Support Unit (PSU) staff must coordinate changes, approvals, and denials of Medically Dependent Children Program (MDCP) services with the MEPD specialist.

Although the MEPD specialist is required to notify the applicant, member, legally authorized representative (LAR) or authorized representative (AR) of all Medicaid eligibility decisions, PSU staff are required to mail the MDCP applicant, member, LAR or AR the notification of denial of MDCP services on Form H2065-D, Notification of Managed Care Program Services. PSU staff also fax the MEPD specialist a copy of Form H2065-D at initial certification and denial for case actions that involve Medicaid eligibility. PSU staff communications with MEPD that do not include Form H2065-D must include Form H1746-A, MEPD Referral Cover Sheet. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.

Section 2000, Medically Dependent Children Program Intake and Initial Application

Revision 18-0; Effective September 4, 2018
 

 

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 18-0; Effective September 4, 2018
 
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. All time frames and due dates will be communicated to ILM Unit staff by the ILM Unit manager as releases are authorized.

ILM Unit staff perform the following activities related to the MDCP interest list:

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

Additional instructions on MDCP interest list releases for STAR Health members are located in the STAR Health MDCP Policy §16.2 of the UMCM.

 

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 18-0; Effective September 4, 2018

 

 

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

Revision 18-0; Effective September 4, 2018

Within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) from Interest List Management (ILM) Unit staff, Program Support Unit (PSU) staff must mail the following documents to the MDCP individual for completion:

Within 14 days from the mail date of the above enrollment packet, PSU staff contact the individual to verify receipt of the enrollment packet and the need to select an MCO as quickly as possible. PSU staff must inform the individual that a delay in selecting an MCO could result in a delay in an eligibility determination for MDCP services. An MCO must be selected before the STAR Kids Screening and Assessment Instrument (SK-SAI) can be performed and the initial individual service plan (ISP) developed. PSU staff should encourage the individual to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC). PSU staff can accept a verbal statement from the individual, legally authorized representative (LAR) or authorized representative (AR) regarding the selection of an MCO and interest in pursuing MDCP services.

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

If the individual has expressed an interest in applying for MDCP and has not selected an MCO within 30 days from the date the enrollment packet is mailed, an MCO will be assigned by PSU staff based on criteria developed by HHSC from the list of available MCOs in the individual’s service area (SA). If an individual does not have an interest in pursuing MDCP services, refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements.

 

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

Revision 18-0; Effective September 4, 2018

An individual with Supplemental Security Income (SSI) or SSI-related Medicaid is already enrolled with a managed care organization (MCO) and is receiving benefits through STAR Kids. Within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) from Interest List Management (ILM) Unit staff, Program Support Unit (PSU) staff must mail the following documents to the individual for completion:

Within 14 days from the mail date of the above enrollment packet, PSU staff contact the individual to verify receipt of the enrollment packet. PSU staff should encourage the individual to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC). PSU staff can accept a verbal statement from the individual, legally authorized representative (LAR) or authorized representative (AR) regarding the interest in pursuing MDCP services.

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

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

 

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 18-0; Effective September 4, 2018

An individual who receives other types of Medicaid [i.e., non-Supplemental Security Income (SSI)) and served in fee-for-service or enrolled with a STAR managed care organization (MCO)] must select a STAR Kids MCO.

Within three business days of the receipt of the Medically Dependent Children (MDCP) interest release case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) from Interest List Management (ILM) Unit staff, Program Support Unit (PSU) staff must mail the following documents to the individual for completion:

Within 14 days from the mail date of the above enrollment packet, PSU staff must contact the individual to verify receipt of the enrollment packet and the need to select an MCO as quickly as possible. PSU staff must inform the individual that a delay in selecting an MCO could result in a delay in eligibility determination for MDCP services. An MCO must be selected before the initial STAR Kids Screening and Assessment Instrument (SK-SAI) can be performed and the individual service plan (ISP) developed. PSU staff should encourage the individual to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC). PSU staff can accept a verbal statement from the individual, legally authorized representative (LAR) or authorized representative (AR) regarding the selection of an MCO and interest in pursuing MDCP services.  

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

If the individual has not selected an MCO within 30 days from the date the enrollment packet was mailed, an MCO is assigned based on criteria developed by HHSC from the list of available MCOs in the individual’s service area (SA).

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

 

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:

 

2120 Inability to Contact the Individual

Revision 18-0; Effective September 4, 2018
 
If Program Support Unit (PSU) staff are unable to contact the individual by telephone within 14 days from the date the enrollment packet was mailed, PSU staff must make one additional attempt to contact the individual by the 30th day. If PSU staff have not made contact with the individual by the 30th day from the date the enrollment packet was mailed, PSU staff must mail Form 2442, Notification of Interest List Release Closure, within two business days of the 30th day from the date the enrollment packet was mailed and document contact attempts in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Form 2442 must include the interest list release date, release closure date, and indicate PSU staff have not been able to contact the individual to begin the eligibility determination process. 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.

If the individual contacts PSU or Interest List Management (ILM) Unit staff after the interest list release closure requesting to pursue Medically Dependent Children Program (MDCP) eligibility, staff must mail the request to re-open the interest list release to the ILM Unit manager. The ILM Unit manager will notify PSU or ILM Unit staff of the decision to re-open an interest list release and advise if PSU staff may proceed with processing the enrollment.

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. The effective date of the interest list release closure is the date staff received information of the individual’s death. PSU staff must not mail Form 2442 or Form H2065-D, Notification of Managed Care Program Services, to the responsible party if the interest list release was closed due to death of the individual.
 

2130 Declining Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
If the individual completes and mails Form 2602, Application Acknowledgement, indicating no interest in applying for Medically Dependent Children Program (MDCP) services, or verbally declines MDCP services, within two business days Program Support Unit (PSU) staff must:

See the Uniform Managed Care Manual (UMCM) for specific requirements around 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 18-0; Effective September 4, 2018
 
All financial information associated with Form H1200, Application for Assistance - Your Texas Benefits, including information on third-party insurance obtained by Program Support Unit (PSU) staff, must be  faxed to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist with Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to prevent delays and the individual from providing duplicate information. The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool.

PSU staff must upload all documents received from the individual to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must upload the MEPD specialist’s determination in the HEART case record. Form H1200 is not required for an individual receiving Supplemental Security Income (SSI) or SSI-related Medicaid, as these individuals already have Medicaid eligibility established and are enrolled in STAR Kids.

 

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

Revision 18-0; Effective September 4, 2018

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:

PSU staff must fax the following documents to the Medicaid for the Elderly and People with Disabilities (MEPD) within two business days following the date of receipt of the signed Form H1200, Application for Assistance - Your Texas Benefits:

PSU staff must upload all documents to the HEART case record, including Form H1200 with the applicant’s signature. Once Form H1200 is uploaded in the HEART case record, the original hard copy must be properly disposed of by PSU staff following HHS Computer Usage and Information Security Training procedures for secure disposal. PSU staff must record the date Form H1200 was received from the individual in the HEART case record and faxed 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.

 

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:

 

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:

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:

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:

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:

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:

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:

 

2300 Interest List Release Closures

Revision 18-0; Effective September 4, 2018

An individual can be placed on multiple interest lists, but may only be enrolled in one §1915(c) Medicaid waiver program at a time. If the individual prefers not to apply for Medically Dependent Children Program (MDCP) services at the time of interest list release, the individual may request to remain on the MDCP interest list, but his or her name will be placed at the bottom of the interest list. If the individual chooses to decline MDCP and wants to continue receiving or pursue eligibility for another program, within two business days Program Support Unit (PSU) staff must:

 

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

Revision 18-0; Effective September 4, 2018
 
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 for the following reasons:

Within two business days of receiving the request to reopen a closed interest list release, PSU staff must send an email to ILM Unit staff. The following elements must be included in the email:

The ILM Unit manager will notify PSU staff of the outcome of the request. If an exception is granted, PSU staff must contact the individual to begin the application process.

 

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:

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:

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 18-0; Effective September 4, 2018

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

Once the individual 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 the Texas Health and Human Services Commission (HHSC) of the individual’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 individual, 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 individual 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 individual, LAR, or AR chooses MDCP, ILM Unit staff will verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database and immediately release the individual from the interest list 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:

PSU staff are responsible for completing the following activities 14 days following the initial contact with the individual. PSU staff must document in the HEART case record all attempted contacts with the NF resident, LAR and/or AR and any delays. PSU staff must:

If Form H1200 is applicable and during the 14-day follow-up contact with the individual, LAR, AR or NF, PSU staff are notified Form H1200 has been completed and submitted, PSU staff must check TIERS to verify Form H1200 has been submitted. If the individual, LAR or AR communicates Form H1200 has not been submitted, or if TIERS does not have a record of Form H1200 being submitted, PSU staff notify the individual, LAR or AR to immediately return Form H1200 to PSU staff because the application for MDCP services will be denied for failure to return Form H1200 within 45 days from the date PSU staff sent the form to the individual, LAR or AR.

Upon receipt of the completed Form H1200, PSU staff must fax the document to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days of receipt. Form H1200 must be accompanied by Form H1746-A, MEPD Referral Cover Sheet, indicating this is an application for MDCP. 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.

If Form H1200 is not received within 45 days from the date the PSU staff sent it to the individual, LAR or AR, PSU staff deny the application for MDCP by:

Within two business days of the individual, LAR, AR or the permanency planner notifying PSU staff of the MCO selection verbally or in writing, or by default, PSU staff must:

Prior to the individual’s discharge from the NF, the individual’s selected MCO service coordinator must perform the initial SK-SAI and establish the initial ISP to reflect both MDCP services and any other identified supports, such as nursing or Personal Care Services (PCS). The MCO initiates contact with the individual, 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 individual, LAR or AR, the MCO service coordinator performs the SK-SAI, including the MDCP module (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 the assessment’s completion.

Within five business days of the MCO service coordinator receiving confirmation that the individual meets MN, the service coordinator, in conjunction with the permanency planner, individual, 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 notify PSU staff within five business days of the planned NF discharge date using by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX.

Within one business day of completing Form 2604, the MCO service coordinator must:

As needed, PSU staff collaborate with 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.

If within 30 days after the individual’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 will 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.

Within two business days following receipt of all MCO documentation required for MDCP eligibility, PSU staff complete and fax Form H1746-A to the MEPD specialist to notify of the approved SK-SAI and ISP. 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.

Within one business day following communication from the MEPD specialist of the individual’s Medicaid eligibility, PSU staff must:

Within one business day prior to the individual’s discharge, PSU staff generate the final Form H2065-D in the TMHP LTC Online Portal containing the service effective date and:

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

If the individual fails to meet any of the eligibility criteria for MDCP other than Medicaid eligibility, the MCO must post on TxMedCentral within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff must:

If the individual fails to meet Medicaid financial eligibility, the MEPD specialist will notify PSU staff through the MEPD Communication Tool. Within two business days of receiving notification through the MEPD Communication Tool, PSU staff must:

If the individual chooses to leave the NF before being determined eligible for MDCP, the MDCP case must be denied and the above steps followed.

 

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:

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:

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:

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:

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

If MDCP eligibility is denied, PSU staff must:

 

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:

 

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:

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:

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:

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:

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 the Children’s Health Insurance Program)

Revision 18-0; Effective September 4, 2018
 
When an individual who is not enrolled in Medicaid 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 five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff must contact the applicant, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) to:

PSU staff mail the following enrollment packet to the applicant for completion:

Within two business days of receipt of the enrollment packet from the applicant, PSU staff must:

An MCO must be selected prior to the limited NF stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option. Within two business days of the MCO selection, verbally or in writing, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post to TxMedCentral in the MCO STAR Kids folder.

 

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

Revision 18-0; Effective September 4, 2018
 
When an individual with Medicaid eligibility, but who is not 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 five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff must contact the applicant, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) to:

PSU staff mail the following to the applicant for completion:

PSU staff upload all documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record once received from the applicant.

An MCO must be selected prior to the limited NF stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option. Within two business days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post to TxMedCentral in the MCO STAR Kids folder.
 

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:

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:

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:

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

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:

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:

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.

Section 3000, STAR Kids Screening and Assessment and Service Planning

Revision 18-0; Effective September 4, 2018
 

 

3100 STAR Kids Screening and Assessment

Revision 18-0; Effective September 4, 2018
 
All children and young adults enrolled with a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and Community First Choice (CFC), Personal Care Services (PCS) and/or Medically Dependent Children Program (MDCP) services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member, legally authorized representative (LAR) or authorized representative (AR) should notify the MCO of the intended provider of services and the MCO will reach out to the provider.
 

3110 Assessment of Medical Necessity for Community First Choice

Revision 18-0; Effective September 4, 2018
 
A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. A physician certification is required for all initial assessments for MN for CFC services. Form 2601, Physician Certification, must be obtained by the MCO, maintained in the MCO member case file signed and dated by the member’s physician prior to the submission of the SK-SAI for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is attached to the MCO member case file.

If an individual who is released from the MDCP interest list is receiving CFC services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Z5a as a “No” (indicated by a “0”). The MCO must note when the member’s MN expires and arrange for a reassessment with the member, legally authorized representative (LAR) or authorized representative (AR). A physician’s certification, Form 2601, is not required for a reassessment of MN.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and Emergency Response Services (ERS). For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the MCO member case file, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including the PCAM and Section P, but leaves Field Z5a marked “No” (indicated by a “0”). The MCO must note when the member’s MN expires and arrange for a reassessment with the member, legally authorized representative (LAR) or authorized representative (AR). If a member meets MN and has a need for CFC services, the MCO prepares an individual service plan (ISP) for the member and provides an authorization to the network provider of the member, LAR or AR’s choice.

 

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018
 
A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields on the STAR Kids Screening and Assessment Instrument (SK-SAI) for a determination of MN and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP).

An applicant or member coming off the MDCP interest list must be assessed using the SK-SAI no later than 30 days following notification from Program Support Unit (PSU) staff, of the MCO selection as detailed in Section 2220, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is considered complete when the physician’s signed and dated certification is on file with the MCO. MCOs assessing applicants or members for MDCP services must complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate “Yes” on Field Z5a (indicated by a "1") when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be signed and dated by the physician and maintained by the MCO in the MCO member case file. Form 2601 must be signed and dated by the member’s physician prior to the submission of the SK-SAI when Field Z5a is marked “Yes” (indicated by a “1”) on initial assessments for MDCP.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.
 

3200 Member Reassessment

Revision 18-0; Effective September 4, 2018
 
All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days prior to the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid eligibility. Before the end date of the annual SK-SAI, the MCO must initiate a reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the end of the ISP. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about the Consumer Directed Services (CDS) option and Service Responsibility Option (SRO). The MCO is expected to complete the same activities for each annual assessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member, legally authorized representative (LAR) or authorized representative (AR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive Personal Care Services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The MCO must also complete the NCAM at any time the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

 

3210 Reassessment of Medical Necessity or Level of Care

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI) no earlier than 90 days before, and no later than 30 days prior to, the expiration of the member’s current individual service plan (ISP) on file for members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services. The MCO must indicate “Yes” in Field Z5a (indicated by a “1”) to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the MCO member case file contains Form 2601 from a previous assessment and there has been no change to the member’s health status. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member, legally authorized representative (LAR) or authorized representative (AR) to schedule a reassessment prior to the expiration of the member’s LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member’s ISP is completed by the MCO annually. PSU staff must search the TMHP Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of an MDCP denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting PSU staff to manually generate Form H2065-D. Form H2065-D is not generated in the TMHP LTC Online Portal at reassessment for denials; PSU staff must manually complete Form H2065-D. PSU staff mail Form H2065-D to the member and post Form H2065-D to the appropriate MCO STAR Kids folder in TxMedCentral, following the instructions in Appendix IX, Naming Conventions. See Section 3328, Reassessment Notification Requirements, for additional information.
 

3300 Member Service Planning and Authorization

Revision 18-0; Effective September 4, 2018
 
Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. For new Medically Dependent Children Program (MDCP) members, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). For existing MDCP members, the ISP must be completed within 60 days of completion of the SK-SAI at reassessment. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs and member preferences. The ISP must be used to communicate and help align expectations between the member, legally authorized representative (LAR), authorized representative (AR), MCO and key service providers. The STAR Kids individual service plan (ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member, LAR or AR, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The ISP is used for:

For STAR Kids members receiving MDCP services, the ISP must fall within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member, LAR or AR following any significant update, and not less than annually, within five business days of meeting with the member, LAR or AR. The MCO must provide a copy of the ISP to the member’s providers and other individuals specified by the member, LAR or AR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member, LAR or AR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports (LTSS) no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member’s current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member’s MCO service coordinator, or a representative of the MCO, must review and update each member’s ISP with the member, LAR or AR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

 

3310 Service Planning

Revision 18-0; Effective September 4, 2018
 
All STAR Kids individual service plan (ISP) narratives must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

The ISP must be formed by findings from the SK-SAI, in addition to input from the member, family and caretakers, providers and any other individual with knowledge and understanding of the member’s strengths and service needs who is identified by the member, LAR, AR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member to provide, a copy of the member’s Individualized Education Plan (IEP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by TPR, like Medicare or available community services. Form 2603 is updated, per Section 3311 below, and is maintained in the MCO member case file.
 

3311 Updates to the Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
Each member’s individual service plan (ISP) must be updated at least annually, or sooner in the following situations outlined in the STAR Kids Managed Care Contract, Section 8.1.39.1:

 
3320 Service Planning for Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) service coordinator must work with the member, legally authorized representative (LAR) or authorized representative (AR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member’s cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member’s Resource Utilization Group (RUG), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG are found in Appendix VIII, RUG IPC Cost Limits.

The MCO service coordinator documents MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Agency Option (AO), Consumer Directed Services (CDS) option, or Service Responsibility Option (SRO), if applicable. Form 2603 must also include a brief rationale (i.e., why the service is needed or requested).

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the MCO completes and submits the electronic ISP within 60 days of the initial referral from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic ISP within 60 days following receipt of a Texas Medicaid & Healthcare Partnership (TMHP) response to the SK-SAI submission. The response file from TMHP contains the determination of medical necessity (MN) and the member’s RUG. The start date for the ISP must be the first day of the month following the MN approval date. If a Medicaid eligibility determination is required, the start of care (SOC) date on the ISP is the first day of the month following the applicant meeting all eligibility criteria. An ISP is valid for one year.

When the member’s ISP is complete and within the member’s established cost limit, the MCO submits Form 2604 to the TMHP Long Term Care (LTC) Online Portal. The MCO must submit the electronic ISP prior to the start date of the member’s ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

If the member is turning age 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member’s cost limit. To calculate the prorated cost, the MCO must:

Example: The member’s 21st birthday is July 9, the ISP start date is April 1, and the end date will be on July 31. The member’s cost limit is $25,000.

$8,355.78 is the prorated cost limit for the individual for the ISP.
 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 18-0; Effective September 4, 2018
 
If a member, legally authorized representative (LAR) or authorized representative (AR) requests a change to the member’s Medically Dependent Children Program (MDCP) individual service plan (ISP), but the member has not experienced a change in condition that affects his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 14 days.

To revise a member’s MDCP ISP when there is no change in the member’s RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and submits the ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the MCO member case file.
 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 18-0; Effective September 4, 2018
 
If a member, legally authorized representative (LAR), authorized representative (AR), service provider or service coordinator notify the managed care organization (MCO) about a change in the member’s condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days. The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, including the Medically Dependent Children Program (MDCP) module, and complete the following fields according to Appendix I, MCO Business Rules for SK-SAI and SK-ISP:

Following the MCO receipt of a TMHP response file indicating the member’s new RUG and associated cost limit, the MCO completes a new STAR Kids individual service plan (ISP) that reflects the member’s, LAR’s or AR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member’s new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the MCO member case file.

If a member will turn age 21 between the start and end date of the member’s ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or Transition Assistance Services (TAS) are provided prior to the end of the month of the member’s 21st birthday. If the MCO authorizes adaptive aids, minor home modifications or TAS, the MCO remains responsible for payment for those services, including applicable warranties.
 

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member, legally authorized representative (LAR) or authorized representative (AR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member, LAR or AR chooses to set aside funds, the MCO must document the member’s, LAR’s or AR’s preferences and maintain documentation in the MCO member case file. A member, LAR or AR may not carry forward funds between ISP periods.
 

3324 Individual Service Plan Exceeding the Cost Limit for MDCP Services

Revision 18-0; Effective September 4, 2018
 
If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits by email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

HHSC UR may request a clinical review of the case to consider the use of state General Revenue (GR) funds to cover costs exceeding the 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and Program Support Unit (PSU) staff.

Note: MCOs must not discuss with applicants, members, legally authorized representatives (LARs) or authorized representatives (ARs), or request use of state GR funds for services above the cost ceiling.
 

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 18-0; Effective September 4, 2018
 
In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each member.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member’s care is based on his or her individual service plan (ISP) and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.
 

3326 Suspension of Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
To remain eligible for Medically Dependent Children Program (MDCP) services, a member must receive one MDCP service monthly. In the event that the member travels out of state, is admitted to a hospital or nursing facility (NF), or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. The MCO must document the:

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

 
3327 Reassessment Individual Service Plan Provider Procedures

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must ensure the member’s individual service plan (ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.
 

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) on a monthly basis to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that expire within the next 90 days.

PSU staff will provide this report to the managed care organizations (MCOs) prior to the monthly call with PSU staff. The MCOs must provide a status update for all members who have ISPs expiring within the next 45 days. Although the ISP Expiring Report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update from the MCO.

The process for managing the ISP Expiring Report is as follows:

Note: There will not be a need to review each member for the status of the ISP if the MCO response is sufficient.

 

3328 Reassessment Notification Requirements

Revision 18-0; Effective September 4, 2018
 
If the member continues to meet MDCP requirements, Program Support Unit (PSU) staff do not mail Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. PSU staff do not send any notification to the member. For an approved MDCP reassessment, PSU staff must upload into the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record:

If the member does not meet MDCP requirements, within two business days of receiving Form H2067-MC from the MCO, PSU staff must:

If the member files a state fair hearing within the 10-day adverse action period (refer to Section 6100, Ten Day Adverse Action Notification), within two business days of notification PSU staff must:

PSU staff carry out the decision within 10 days of receiving the fair hearings officer’s decision.

 

3400 Member Transfers

Revision 18-0; Effective September 4, 2018

 

 

 
3410 Transfer from One Managed Care Organization to Another

Revision 18-0; Effective September 4, 2018
 
Once the initial enrollment period of one calendar month of service authorization has passed, a member is eligible to change managed care organization (MCO) plans. When a member, legally authorized representative (LAR) or authorized representative (AR) chooses to change from one MCO to another MCO in the same service area (SA), the member, LAR or AR must contact the state contracted enrollment broker by telephone at 800-964-2777 or via written correspondence.

The member can request to change MCOs as many times as the member wants, but the change cannot be made more than once per month. If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day of the month, the change will take place the first day of the second month following the change request.

Examples:

Texas Health and Human Services Commission (HHSC) Operations prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. PSU staff receive a full list and share MCO specific information with Managed Care Compliance & Operations (MCCO) staff by email. MCCO staff share the list with MCOs. The MCO receives a member-specific report that gives a list of STAR Kids members who have changed MCOs from the previous month.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning the result of the MCO assessment upon the gaining MCO request. Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the MCO member case file from the losing MCO, such as the member’s Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must ensure the member’s new service coordinator, once assigned, contacts the member’s former service coordinator at the losing MCO to ensure a seamless transition of service coordination. The gaining MCO must contact the losing MCO for additional information maintained in the MCO member case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify MCCO staff.

MCCO staff must contact the losing MCO and require the MCO to upload information contained in the MCO member file to TxMedCentral, including Form 2603 and any current authorizations, within two business days of notification. MCCO staff inform PSU staff by email, the date by which the MCO must upload the information to TxMedCentral. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from MCCO staff. The STAR Kids Screening and Assessment Instrument (SK-SAI) and electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, as well as historical SK-SAIs and ISPs, will be available to the gaining MCO upon enrollment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within five business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 15 business days of enrollment of the new member, the gaining MCO must conduct a home visit to assess the member’s needs. For continuity of care, this includes authorizations, additional assessments, and pending delivery of adaptive aids, minor home modifications or Transition Assistance Services (TAS). This home visit may include conducting the SK-SAI if the member is due for a new assessment, has experienced a significant change in condition, or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires a new assessment or until the gaining MCO is able to complete its own SK-SAI, update the ISP, and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs. If the gaining MCO is in a different SA because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member, LAR or AR. Out-of-network authorizations must continue until the existing ISP expires or the gaining MCO can provide comparable services to transition the member to a provider that will be able to meet the member’s needs.
 

3420 Transfer from Medicaid Waiver Program to Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018
 
Participants in other §1915(c) Medicaid waiver programs operated by the state may be on the interest list for the Medically Dependent Children Program (MDCP). If a STAR Kids member in another §1915(c) Medicaid waiver program comes up on the interest list for MDCP, Interest List Management (ILM) Unit staff make a referral to Program Support Unit (PSU) staff.

Within 14 days of the initial request for an MDCP assessment, PSU staff must:

All attempted contacts with the individual or encountered delays must be documented in the Texas Health and Human Services (HHS) Enterprise Administrative Record and Tracking System (HEART) case record.

Within two business days of notification of the MCO selection by the §1915(c) Medicaid waiver applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post to the MCO STAR Kids folder on TxMedCentral, following the instructions in Appendix IX, Naming Conventions,.

The MCO completes:

If the information from the MCO is not received within 60 days after the assessment is authorized, PSU staff email the assigned Managed Care Compliance & Operations (MCCO) staff as notification the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required MDCP eligibility documentation, PSU staff determine MDCP eligibility based upon medical necessity (MN) and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for MDCP is denied or the individual decides not to accept MDCP services, PSU staff must:

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

If eligibility is approved and the individual chooses to accept MDCP services, the individual is enrolled in MDCP the first day of the next month. Within two business days of determining the start of care (SOC) date for MDCP services, PSU staff must:

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current §1915(c) Medicaid waiver services end the day before enrollment in MDCP. The MCO must monitor the TMHP LTC Online Portal for the status of the member’s ISP and to retrieve Form H2065-D.
 

3430 Transfer from MDCP to Another Medicaid Waiver Program

Revision 18-0; Effective September 4, 2018
 
STAR Kids members receiving Medically Dependent Children Program (MDCP) services may be on an interest list for another Medicaid program such as Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD) or Texas Home Living (TxHmL). The Texas Health and Human Services Commission (HHSC) informs the managed care organization (MCO) that a member receiving MDCP services has come to the top of the interest list for another program and is assessed as eligible for that program.

The MCO service coordinator or case manager must contact Program Support Unit (PSU) staff to assist in coordinating the end of MDCP services the day prior to the member’s enrollment in the new program. PSU staff must coordinate with the member’s MCO about the end of MDCP services and the member’s transition to another §1915(c) Medicaid waiver. The member remains in the same STAR Kids MCO he or she is currently enrolled for his or her state plan services.

PSU staff are responsible for completing the following activities within 14 days of the initial request for an MDCP assessment. All attempted contacts with the member or encountered delays must be documented in the member’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must:

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that MDCP members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.
 

3440 Transfer from Community Care for Aged and Disabled Services to STAR Kids

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must coordinate the termination of Community Care for Aged and Disabled (CCAD) services with the CCAD case worker so the individual does not experience a break in services and does not receive concurrent services through another §1915(c) Medicaid waiver or CCAD.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), PSU staff coordinate the termination of CCAD services with the §1915(c) Medicaid waiver or CCAD case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through CCAD services.

CCAD services are terminated by the CCAD case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.
 

3500 Transition from Medically Dependent Children Program to Adult Programs

Revision 18-0; Effective September 4, 2018
 
Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are age 15 and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including the STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.
 

3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018
 
Possible §1915(c) Medicaid waiver and service combinations the member may be receiving prior to transition:

 
3511 Twelve Months Prior to the Member’s 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Twelve months prior to the 21st birthday of a member receiving services from the Medically Dependent Children Program (MDCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, Utilization Review (UR) Unit staff provide a copy of the Comprehensive Care Program (CCP) Transition Report, which lists individuals enrolled in STAR Kids and receiving MDCP and/or PDN/PPECC and/or CFC services who may transition to STAR+PLUS or the STAR +PLUS Home and Community Based Services (HCBS) program in the next 18 months, to the:

Procedures for managing this report, including time frames, can be found in Appendix VI, STAR Kids Transition Activities.

The managed care organization (MCO) identifies all members turning age 21 within the next 12 months and schedules a face-to-face visit with the member and the member’s available supports, including the legally authorized representative (LAR) or authorized representative (AR), if applicable, to initiate the transition process.

During the home visit with the member, LAR or AR, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member’s 21st birthday. The transition activity points to be discussed by the MCO include:

The STAR Kids MCO must:

PSU staff for the STAR+PLUS HCBS program must:

The following chart outlines the responsibilities for monitoring the STAR Kids Transition Report and contacting members transitioning from STAR Kids who receive MDCP, PDN or PPECC, or CFC within the next 12 months:

Twelve Month Transition Chart
Under Age 21 MDCP Under Age 21 Other Services Received Monitors STAR Kids Report: 12-Month Contact:
MDCP PDN/PPECC PSU Staff STAR Kids MCO
MDCP CFC PSU Staff STAR Kids MCO
MDCP PCS PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP None PSU Staff STAR Kids MCO
None PDN/PPECC PSU Staff STAR Kids MCO
None PDN/PPECC and CFC PSU Staff STAR Kids MCO
None PDN/PPECC and PCS PSU Staff STAR Kids MCO

 

3512 STAR+PLUS Transition Activities

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines as outlined in the STAR+PLUS Handbook, Section 3420, Individuals Transitioning to an Adult Program.
 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 18-0; Effective September 4, 2018
 
Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity (MN) criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

 
3520 Transition Policy for Non-Waiver Members Receiving PCS or CFC Only

Revision 18-0; Effective September 4, 2018

STAR Kids eligibility will terminate the last day of the month in which the member’s 21st birthday occurs, after which the member will need to receive services through programs serving adults. Members must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program.

The Texas Health and Human Services Commission’s (HHSC’s) state contracted enrollment broker will reach out to the member 30 days prior to the member’s 21st birthday and provide the member with a STAR+PLUS enrollment packet (containing the STAR+PLUS managed care organization (MCO) list). The member must make an MCO selection within 15 days. If the member has not made an MCO selection after 15 days, the state contracted enrollment broker will select an MCO for the member, as outlined in Title 1 Texas Administrative Code (TAC) §353.403(3).

Section 4000, STAR Kids Community Services

Revision 18-0; Effective September 4, 2018

 

 

4010 Outline

Revision 18-0; Effective September 4, 2018

This section outlines the delivery of STAR Kids community long term services and supports (LTSS). Sections 4100-4520 describe Medicaid state plan LTSS, assessment and reassessment requirements, and provider requirements.

Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements, limitations and provider requirements.
 

4100 Community First Choice

Revision 18-0; Effective September 4, 2018
 
Community First Choice (CFC) is a group of services delivered under the authority of §1915(k) of the Social Security Act. CFC is under federal regulations governing home and community based services. Therefore, the settings in which CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) §441.301(c)(4) and Title 42 CFR §441.710, respectively. Permissible home and community based settings include member homes, apartment buildings and non-residential settings. Community based settings exclude:

Provider owned and controlled settings are also excluded from CFC because those providers are paid for CFC-like services as part of the provider rates, and to provide CFC would be duplicative.

Assessment for CFC services and the development of a member’s service plan must be person-centered, per Title 42 CFR §441.540. STAR Kids managed care organizations (MCOs) may not require CFC providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for CFC services.
 

4110 Community First Choice Eligibility

Revision 18-0; Effective September 4, 2018
 
Eligibility for Community First Choice (CFC) requires a STAR Kids member to meet the following conditions:

All STAR Kids members are Medicaid eligible. Members whose eligibility is established due to eligibility for Youth Empowerment Services (YES) or the Medically Dependent Children Program (MDCP) are eligible for CFC services, per the Social Security Act §1902(a)(10)(A)(ii)(VI), as these members meet eligibility for an institution providing psychiatric or NF services. To maintain CFC eligibility, the managed care organization (MCO) must ensure the member receives at least one waiver service per month. A member may not be authorized to receive both personal care services (PCS) and CFC services at the same time.

Members who receive services through the following §1915(c) Medicaid waiver programs receive CFC services through their §1915(c) Medicaid waiver provider and are not eligible to receive CFC through the MCO:

 
4111 Determining Institutional Level of Care

Revision 18-0; Effective September 4, 2018

 

 

4111.1 STAR Kids Screening and Assessment Instrument

Revision 18-0; Effective September 4, 2018

For members with physical disabilities, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP), on behalf of the Texas Health and Human Services Commission (HHSC), to determine if an applicant or member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or nursing facility (NF). Once the SK-SAI is completed, the managed care organization (MCO) must obtain the member’s physician’s signature on Form 2601, Physician Certification, certifying the applicant or member requires NF services or alternative community based services under the supervision of a physician.

Further information about the MN determination process for Community First Choice (CFC) may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.

 

4111.2 Intellectual Disability or Related Condition Assessment

Revision 18-0; Effective September 4, 2018

Upon notification from the managed care organization (MCO), Local Intellectual or Development Disability Authorities (LIDDAs) conduct an intellectual disability or related condition (ID/RC) assessment to determine whether an applicant or member meets the level of care (LOC) provided by an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID). Medically Dependent Children Program (MDCP) members already have an established LOC for ICF/IID and do not require an ID/RC assessment. MDCP members will be assessed using the Community First Choice (CFC) module of the STAR Kids Screening and Assessment Instrument (SK-SAI). In addition to the ID/RC assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if an applicant or member does not have a DID on file or the DID on file is determined to be outdated. The LIDDA submits this information to the Texas Health and Human Services Commission (HHSC) for a determination of ID/RC. HHSC notifies the LIDDA about the determination and the LIDDA notifies the applicant or member’s MCO. If an applicant or member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment and forwards the assessment to the applicant’s or member’s MCO. If the applicant or member does not agree to the CFC service plan, he or she may file an appeal with the MCO. If the applicant or member does not agree to the CFC service plan or refuses CFC services, the MCO must notify the LIDDA within 10 business days of the applicant or member refusing or ending CFC services.  
 

4111.3 Child and Adolescent Needs and Strengths or Adult Needs and Strengths Assessment

Revision 18-0; Effective September 4, 2018
 
A comprehensive provider of mental health rehabilitative services or a Local Mental Health Authority (LMHA) conducts the Child or Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the applicant or member meets an inpatient psychiatric facility level of care (LOC). If the applicant or member meets that LOC, or receives services through Youth Empowerment Services (YES), the managed care organization (MCO) conducts the Community First Choice (CFC) functional assessment if the applicant or member requests CFC services.
 

4120 Community First Choice Services

Revision 18-0; Effective September 4, 2018
 
Community First Choice (CFC) services include personal assistance services (CFC-PAS), habilitation (CFC-HAB), Emergency Response Services (CFC-ERS) and support management.
 

4121 Community First Choice Personal Assistance

Revision 18-0; Effective September 4, 2018
 
Community First Choice personal assistance service (CFC-PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Such assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC-PAS includes:

In the Consumer Directed Services (CDS) model, the member, legally authorized representative (LAR) or authorized representative (AR) determines health-related tasks without a nurse assessment, in accordance with state laws; Texas Government Code §531.051(e),  and Title 22 Texas Administrative Code (TAC) §225.4.

CFC-PAS is the same service (i.e., attendant care) as personal care services (PCS). The only difference is the member’s level of care (LOC) and how the service is billed. Information used to build a plan of care (POC) for CFC-PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by the appropriate items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC-PAS if he or she meets CFC LOC criteria.

Members may choose to receive CFC-PAS only if he or she does not need or want CFC habilitation (CFC-HAB).
 

4122 Community First Choice Habilitation

Revision 18-0; Effective September 4, 2018
 
Community First Choice habilitation (CFC-HAB) assists members with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is provided to allow a member to reside successfully in a community setting by assisting the member to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the member on ADLs and IADLs. Personal assistance may be a component of CFC-HAB for some members. CFC-HAB services include training, which is interacting face-to-face with a member to train the member in activities, such as:

Information used to build a plan of care (POC) for CFC-HAB may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. Section P of the PCAM should only be administered after the assessor or managed care organization (MCO) service coordinator explains the CFC benefit and the member wishes to be assessed for CFC-HAB.

 

4123 Community First Choice Emergency Response Services

Revision 18-0; Effective September 4, 2018
 
Community First Choice Emergency Response Services (CFC-ERS) is designed to assist individuals who do not require supervision during the day or are alone for large parts of the day, and are cognitively able to recognize an emergency. This service connects a member to a CFC-ERS provider who notifies local authorities, like paramedics or a fire department, to a member’s emergency. This service is not routinely authorized for members who are minors.

CFC-ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports and are available for members who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.
Need for CFC-ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Z.
 

4124 Community First Choice Support Management

Revision 18-0; Effective September 4, 2018
 
Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model. Need for support management is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Z.
 

4130 Community First Choice Assessment and Authorization

Revision 18-0; Effective September 4, 2018
 
 

 

4131 Assessment for a Nursing Facility Level of Care

Revision 18-0; Effective September 4, 2018
 
Nursing facility (NF) level of care (LOC) for members seeking Community First Choice (CFC) services is established using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member’s eligibility for NF services according to the Title 40 Texas Administrative Code (TAC) §19.101(88) definition of “medical necessity.”

To ensure TMHP evaluates the submitted SK-SAI for the NF LOC, the MCO must submit the SK-SAI with field Z5a as “Yes” (indicated by a “1”) to indicate that an MN determination is needed. TMHP’s determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines the member does not meet MN, the member is not eligible to receive CFC through the NF LOC. This does not preclude the member or MCO from seeking determination of a different institutional LOC. If TMHP determines the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the NF LOC.
 

4131.1 Reassessment for a Nursing Facility Level of Care

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file for members requiring a reassessment for Community First Choice (CFC) services. The managed care organization (MCO) must indicate “Yes” in Field Z5a (indicated by a "1") to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member’s file contains a physician signed Form 2601 for a previous assessment. The MCO must ensure the reassessment is timed to prevent a lapse in service authorization.
 

4132 Assessment for an Intermediate Care Facility Level of Care

Revision 18-0; Effective September 4, 2018
 
Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member’s named service coordinator and his or her contact information to assist in coordinating assessment activities. Following completion of the determination ID/RC, the LIDDA submits the assessment for a determination of level of care (LOC) to the state. Texas Health and Human Services Commission (HHSC) staff inform both the LIDDA and MCO of the determination. If a member is determined to not meet the LOC provided in an intermediate care facility (ICF), the MCO is responsible for notifying the member through the established denial process.

If a member meets an ICF LOC, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member’s individual service plan (ISP). When the member selects a service provider, the MCO updates the SFTP site noting the member’s selected provider. If a member declines or discontinues Community First Choice (CFC) services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
 

4132.1 Reassessment for an Intermediate Care Facility Level of Care

Revision 18-0; Effective September 4, 2018
 
Ninety days prior to the expiration of the member’s level of care (LOC) assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility (ICF) LOC. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an Intermediate Care Facility Level of Care, for all reassessments.

If a member continues to meet an ICF LOC, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member’s individual service plan (ISP). When the member selects a service provider, the MCO updates the SFTP site noting the member’s selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
 

4133 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 18-0; Effective September 4, 2018
 
Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider of mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member’s age. Based on an algorithm, the assessment determines the member’s level of care (LOC). A licensed practitioner must concur with the assessment or may deviate a member to a higher or lower LOC, based on his or her clinical judgement. A licensed practitioner must review the CANS or ANSA at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member’s CANS or ANSA is valid for 12 months.

Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional LOC and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their health plan for functional necessity of CFC services at any time while enrolled in the YES waiver.
 

4133.1 Reassessment for an Institution for Mental Disease Level of Care

Revision 18-0; Effective September 4, 2018
 
Assessment of a psychiatric institutional level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member’s CFC individual service plan (ISP), the managed care organization (MCO) must refer the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet a psychiatric institutional LOC, the MCO may conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity (MN) for a nursing facility (NF) LOC. If the MCO believes the member will not meet MN and does not have an intellectual or developmental disability, the MCO must notify the member or his or her representative of the denial for CFC services. The member may be eligible for Personal Care Services (PCS), if functionally necessary.
 

4140 Functional Assessment for Community First Choice Services

Revision 18-0; Effective September 4, 2018
 
Functional need for Community First Choice (CFC) services is primarily established by Sections J, K, L, M, N, O, and P of the STAR Kids Screening and Assessment Instrument (SK-SAI) which collectively form the Personal Care Assessment Module (PCAM). This module contains assessment questions for the personal assistance services (CFC-PAS) and habilitation (CFC-HAB) services available through CFC. The following questions or information in the SK-SAI core module are triggers for the PCAM and may indicate the member has functional need for CFC services:

If triggered, the managed care organization (MCO) service coordinator completes the PCAM (Sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should be completed if the member is specifically seeking CFC services. The MCO service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of CFC services. The MCO service coordinator works with the member, LAR or AR to locate an appropriate provider and sends an authorization to the selected provider.
 

4140.1 Reassessment of Functional Need for Community First Choice

Revision 18-0; Effective September 4, 2018
 
The need, amount and duration of Community First Choice (CFC) services must be reassessed every 12 months, or when requested due to a change in the member’s health condition or living situation.
 

4200 Personal Care Services

Revision 18-0; Effective September 4, 2018
 
Personal Care Services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through age 20. PCS is considered medically necessary when a member requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member’s disability or chronic health condition. The member’s disability or chronic health condition must be substantiated by a physician statement of need. STAR Kids managed care organizations (MCOs) may not require PCS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typical developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a responsible adult must perform ADLs, IADLs and HMAs on behalf of the member to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member’s physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to assist the individual in performing a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.
PCS includes:

The amount and duration of PCS is determined by the MCO and must take the following into account:

PCS may be authorized to support a member’s primary caregiver(s) but may not be authorized to supplant a member’s natural support, nor to provide a member’s total care. PCS may be authorized in an individual or group setting including:

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, is required to meet the member’s personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation may be submitted to the MCO with documentation of medical necessity (MN).

PCS may not be authorized in a hospital, nursing facility (NF), institution providing psychiatric care, or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

PCS may not be used as respite, child care, or for the purposes of restraining a member.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following §1915(c) Medicaid waiver programs receive CFC services through their §1915(c) Medicaid waiver program and are not eligible to receive PCS through the MCO:

 

4210 Assessment for Personal Care Services

Revision 18-0; Effective September 4, 2018
 
Sections J, K, L and M of the STAR Kids Screening and Assessment Instrument (SK-SAI) collectively form the Personal Care Assessment Module (PCAM). This module contains assessment questions for Personal Care Services (PCS). The following questions in the SK-SAI core module are triggers for the PCAM and may indicate the member requires PCS:

If triggered, the managed care organization (MCO) service coordinator completes the PCAM (Sections J, K, L, M, N and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The MCO service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of PCS. The MCO service coordinator works with the member, LAR or AR to locate an appropriate provider and sends an authorization to the selected provider.

 

4211 Reassessment for Personal Care Services

Revision 18-0; Effective September 4, 2018
 
The need for and the amount and duration of Personal Care Services (PCS) must be reassessed every 12 months, or when requested due to a change in the member’s health or living condition. The managed care organization (MCO) must obtain a new physician statement of need to substantiate the member’s continued need for PCS upon each annual reassessment.
 

4220 Personal Care Services Providers

Revision 18-0; Effective September 4, 2018
 
Personal Care Services (PCS) must be provided by an individual who:

 
4300 Private Duty Nursing

Revision 18-0; Effective September 4, 2018
 
Private duty nursing (PDN) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PDN is available to STAR Kids members from birth through age 20. PDN services must be available when the services are medically necessary to correct or ameliorate a member’s disability, physical or mental illness, or condition. The services correct or ameliorate when the services improve, maintain or slow the deterioration of the member’s health status.

Nursing services are medically necessary under the following conditions:

PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize member health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options.

PDN is considered only when the services are consistent with the definition of “nursing,” as described in the Texas Nursing Practice Act or its implementing regulations. PDN must not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the member’s nursing needs.

The managed care organization (MCO) may deny or reduce PDN hours if the member’s PDN needs decrease. The MCO may not:

 
4310 Assessment for Private Duty Nursing

Revision 18-0; Effective September 4, 2018
 
Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for private duty nursing (PDN). The following questions/information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires PDN:

If triggered, the MCO service coordinator completes the NCAM addendum (Section Q) to determine the member’s nursing needs. The MCO service coordinator also completes SK-SAI Section Y to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of PDN. The MCO service coordinator works with the member, legally authorized representative (LAR) or authorized representative (AR) to locate an appropriate provider and send an authorization to the selected provider.
 

4311 Reassessment and Reauthorization

Revision 18-0; Effective September 4, 2018
 
At a minimum, the need for and the amount and duration of private duty nursing (PDN) must be reassessed 90 days following the initial authorization and every six months thereafter, or when requested due to a change in the member’s health or living condition. A physician order must be renewed with any reassessment.
 

4320 Providers of Private Duty Nursing

Revision 18-0; Effective September 4, 2018
 
Private duty nursing (PDN) may be provided by a licensed Home and Community Support Services Agency (HCSSA), an independently enrolled registered nurse (RN) or a licensed vocational nurse (LVN) under the supervision of an RN, contracted with the STAR Kids managed care organization (MCO).

An RN must develop a plan of care (POC) that accounts for the following items, at a minimum:

Adults legally responsible for the member cannot be the paid PDN provider if the member is under age 18 or the spouse of the member.
 

4330 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018
 
Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400, Prescribed Pediatric Extended Care Centers, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service area (SA). A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual’s medical condition or the authorized hours are not commensurate with the individual’s medical needs. Per Title 1 Texas Administrative Code (TAC) §363.209(c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. Texas Medicaid & Healthcare Partnership’s (TMHP’s) fee-for-service (FSS) Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual’s medical needs. The PDN provider would be notified by the managed care organization (MCO) of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity (MN) for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care (POC) for the individual. The MCO service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.
 

4400 Prescribed Pediatric Extended Care Centers

Revision 18-0; Effective September 4, 2018
 
Prescribed Pediatric Extended Care Center (PPECC) services may be a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP) for STAR Kids members who meet the following medical necessity (MN) criteria for admission:

PPECC services require prior authorization and are intended as an alternative to private duty nursing (PDN). However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), Home Health Skilled Nursing (HHSN), Home Health Aide (HHA), and therapies (physical therapy (PT), occupational therapy (OT), speech therapy (ST)), as well as respiratory therapy and Early Childhood Intervention (ECI) services rendered in the member’s residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but PPECC services must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

Note: A member or responsible adult may decline a PPECC’s transportation and choose to be transported by other means, including his or her responsible adult. A member’s legally authorized representative (LAR) or authorized representative (AR) is not required to accompany a member when the member receives services in a PPECC, including transportation services to and from the center and therapy services that are billed separately. Fee-for-service (FSS) Medicaid does not require prior authorization for the transportation billing code. Rather, authorization for PPECC services implies authorization for transportation.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

 

4410 Assessment for Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018
 
Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

If triggered, the managed care organization (MCO) service coordinator completes the NCAM addendum (Section Q) to determine the member’s nursing needs. The MCO service coordinator also completes SK-SAI Section Y to assist in developing a recommended number of service hours. Based on the SK-SAI, the MCO service coordinator develops a recommended individual service plan (ISP) for the services of a PPECC. The MCO service coordinator works with the member, legally authorized representative (LAR) or authorized representative (AR) to locate an appropriate provider and sends an authorization to the selected provider.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.
 

4411 Reassessment and Reauthorization of Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018
 
At a minimum, the need for and the amount and duration of services from a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed 90 days following initial authorization and every 180 days following, or when requested due to a change in the member’s health or living condition. A physician order must be renewed with any reassessment.
 

4420 Providers of Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018
 
A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with Title 40 Texas Administrative Code (TAC) §15, and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions and in-state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24 hour period. Services may not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual (TMPPM) and PPECC medical policy. These components include:

A face-to-face evaluation must be performed annually by the ordering physician. A physician order is required for each initial and recertification authorization, and revisions. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician’s order, unless the physician is the member’s treating physician and has examined the member outside of the PPECC setting. The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

Authorization Requirements

Per Title 1 Texas Administrative Code (TAC) §363.211, initial, recertification and revision requests for PPECC services must include the following documentation, which adheres to requirements in the TMPPM:

  1. physician order for services (a physician signature on the PPECC POC serves as a physician order for authorization purposes);
  2. a POC developed by the PPECC;
  3. all required prior authorization forms listed in the TMPPM, or MCO forms if the forms contain comparable content; and
  4. signed consent of the participant or participant’s responsible adult documenting the choice of PPECC services. The signed consent must include an acknowledgement by the participant or the participant’s responsible adult that he or she has been informed that other services such as PDN might be reduced as a result of accepting PPECC services. Consent to share the participant’s protected health information (PHI) with the participant’s other providers, as needed to ensure coordination of care, must also be obtained.

Forms available online for PPECC include:

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service (FSS) forms, and are subject to approval by HHSC.
 

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018
 
Refer to Section 4330, Private Duty Nursing and Prescribed Pediatric Extended Care Center Services, for details on coordination of services between private duty nursing (PDN) and Prescribed Pediatric Extended Care Center (PPECC). Both PDN and PPECC are ongoing skilled nursing services, and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC, or a combination of both services.
 

4500 Day Activity and Health Services

Revision 18-0; Effective September 4, 2018
 
Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations (MCOs) may not require DAHS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for DAHS.

 

4510 Assessment for Day Activity and Health Services

Revision 18-0; Effective September 4, 2018
 
The potential for therapeutic benefit must be established by a physician’s assessment and requires a physician’s order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse (RN) or licensed vocational nurse (LVN), based upon the member’s condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member’s home. Health assessments must be conducted, at minimum, when:

The member, legally authorized representative (LAR) or authorized representative (AR) must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member’s functioning.
 

4511 Reassessment for Day Activity and Health Services

Revision 18-0; Effective September 4, 2018
 
Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may be no older than 90 days from the date at which an authorization is requested.

A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation and nutritional services when a member:

 

4520 Day Activity and Health Services Providers

Revision 18-0; Effective September 4, 2018
 
To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission (HHSC) and comply with Title 40 Texas Administrative Code (TAC) §98, Adult Day Care and Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

 

4600 Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
The Medically Dependent Children Program (MDCP) provides respite, Flexible Family Support Services (FFSS), minor home modifications, adaptive aids, Transition Assistance Services (TAS), supported employment (SE), and employment assistance (EA). These services are for eligible members to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility (NF) residents under 21 years of age.

Only applicants and members who are released from the MDCP interest list and assessed as meeting medical necessity (MN) are eligible for MDCP services. Federal guidelines require that members must need and use one or more MDCP service to qualify and maintain eligibility for MDCP. All members must have an unmet need for and use for at least one MDCP service per individual service plan (ISP) year to qualify for MDCP.

The managed care organization (MCO) service coordinator must inform all members receiving MDCP services that, at a minimum, one MDCP service must be used per ISP year to qualify and maintain enrollment in MDCP.

Upon initial assessment for MDCP or at an MDCP member’s reassessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the MCO service coordinator will discuss the applicant’s or member’s needs in relation to the available MDCP services. The MCO service coordinator will develop a recommended ISP if the member’s Resource Utilization Group (RUG) is not known. The RUG determines the member’s budget.

Example: The MCO service coordinator could ask the applicant, member, legally authorized representative (LAR) or authorized representative (AR) if he or she would like respite or have a desire for employment services. The MCO service coordinator could ask if the applicant or member requires adaptive aids, minor home modifications, or could benefit from FFSS. The MCO service coordinator could inquire which services the member, LAR or AR would like more of, should the member’s budget be unknown during the assessment. Based on the discussion, the MCO service coordinator will develop a recommended ISP for that member and work with the member, LAR or AR in person or telephonically to develop a final ISP once the member’s budget is known.
 

4700 Medically Dependent Children Program Respite and Flexible Family Support Services

Revision 18-0; Effective September 4, 2018
 

 

 

4710 Medically Dependent Children Program Respite

Revision 18-0; Effective September 4, 2018
 
Respite is a service that provides temporary relief from caregiving to the applicant, member or his or her primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the member’s parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the CDS option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member’s relative. Out-of-home respite may be provided in a facility setting, such as a nursing facility (NF) or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member’s primary caregiver would normally provide the member’s care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or private duty nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite is a service to provide relief to the primary caregiver, if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member’s home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member’s, legally authorized representative’s (LAR’s) or authorized representative’s (AR’s) preferences and the member’s approved cost limit. MCOs must develop internal processes related to respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to “bank” respite hours to use at a later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP.

 

4711 In-Home Respite

Revision 18-0; Effective September 4, 2018
 
In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option.

A member’s in-home respite is limited by the amount of the member’s cost limit. If the member chooses the CDS option, the member is limited by his or her available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member’s budget. The provision of in-home respite is documented on the individual service plan (ISP).
 

4711.1 Attendant with Delegated Tasks

Revision 18-0; Effective September 4, 2018
 
A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician’s supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his or her supervision, per BON rules. A practitioner or RN may delegate skilled tasks to an attendant required to meet a member’s needs.

If the member does not have a skilled task need during the delivery of respite, he or she does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the managed care organization (MCO) service coordinator or the Home and Community Support Services Agency (HCSSA) provider determines the use of this provider type places the individual’s health and welfare at risk, the MCO service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member’s physician.

If a member, legally authorized representative (LAR) or authorized representative (AR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member, LAR or AR is directing the member’s services, he or she must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
 

4712 Out-of-Home Respite

Revision 18-0; Effective September 4, 2018
 
Respite may be provided out of the home if indicated in a physician’s order or if the member, legally authorized representative (LAR) or authorized representative (AR) prefer. Out-of-home respite providers are:

Facility-based respite is limited to 29 days per the individual service plan (ISP) period. The 29-day limit applies to the total number of days a member receives respite in a hospital or NF.

 

4720 Respite Limits

Revision 18-0; Effective September 4, 2018
 
Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member’s admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29 day facility-based respite limit. Within five days of the request to exceed the 29 day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

 

4730 Flexible Family Support Services

Revision 18-0; Effective September 4, 2018
 
Flexible Family Support Services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

FFSS include personal care supports for basic activities of daily living (ADL) and instrumental activities of daily living (IADL), skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. FFSS may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option. FFSS are documented on the individual service plan (ISP). STAR Kids managed care organizations (MCOs) may not require FFSS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for FFSS.
 

4731 Flexible Family Support Services in Child Care

Revision 18-0; Effective September 4, 2018
 
The member’s parent or guardian is responsible for basic child care either in or out of the member’s home. Flexible Family Support Services (FFSS) support the member’s participation in child care when the service provided by the child care does not support the member’s disability-related needs. If the member’s child care is not able to meet the member’s activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs, the managed care organization (MCO) service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the MCO service coordinator must discuss the parent’s or guardian’s plan for obtaining basic child care and whether it will be provided in or out of the member’s home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver’s cost for child care does not impact the member’s need for FFSS. The MCO service coordinator must determine the amount of hours needed to support the member’s needs within the Medically Dependent Children Program (MDCP) individual service plan (ISP) cost limit. The MCO service coordinator should ask the caregiver about the member’s personal and skilled task needs and the time needed to address those needs. The MCO service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member’s health and welfare.

FFSS does not replace Personal Care Services (PCS) provided through Texas Health Steps (THSteps) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home, or participates in a community program or educational service.
 

4732 Flexible Family Support Services for Independent Living

Revision 18-0; Effective September 4, 2018
 
A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task, the managed care organization (MCO) service coordinator may authorize Flexible Family Support Services (FFSS) to help the member with his or her goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills he or she will need to live independently as adults.

To determine the need for FFSS for independent living, the MCO service coordinator must discuss the member’s and primary caregiver’s plan for the member’s independent living. When identifying the member’s need for this service, the MCO service coordinator should address age appropriateness for the tasks required to meet these needs. The MCO service coordinator must determine the amount of FFSS needed to support the member’s needs. The MCO service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member’s age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.
 

4733 Flexible Family Support Services in Post-Secondary Education

Revision 18-0; Effective September 4, 2018
 
A member can access Flexible Family Support Services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the managed care organization (MCO) service coordinator may authorize FFSS so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member’s personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the MCO service coordinator must identify the member’s need for assistance and the amount of FFSS needed to support the member’s needs. The MCO service coordinator should identify the member’s personal and skilled task needs and the amount of time needed to address those needs. The MCO service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member’s health and welfare.
 

4734 Flexible Family Support Services Requiring Delegated Tasks

Revision 18-0; Effective September 4, 2018
 
A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician’s supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his or her supervision, per BON rules. A practitioner or RN may delegate skilled tasks to an attendant required to meet a member’s needs.

If the member does not have a skilled task need during the delivery of Flexible Family Support Services (FFSS), he or she does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the managed care organization (MCO) service coordinator or the Home and Community Support Services Agency (HCSSA) provider determines the use of this provider type places the individual’s health and welfare at risk, the MCO service coordinator should not authorize an attendant with delegated tasks to deliver FFSS, unless determined appropriate by the member’s physician.

If a member, legally authorized representative (LAR) or authorized representative (AR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member, LAR or AR is directing the member’s services, he or she must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
 

4740 Flexible Family Support Services Limits

Revision 18-0; Effective September 4, 2018
 
Flexible Family Support Services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the managed care organization (MCO) service coordinator may not authorize FFSS during the same time period the individual receives Personal Care Services (PCS) or Community First Choice (CFC) services.

Title 42 Code of Federal Regulations (CFR) §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, not be provided to a member who is admitted to a hospital, a resident of a nursing facility (NF) or a resident of an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

The MCO service coordinator may not authorize FFSS during the member’s school hours in primary or secondary educational settings.
 

4800 Adaptive Aids, Minor Home Modifications and Transition Assistance Services

Revision 18-0; Effective September 4, 2018
 

 

 

4810 Adaptive Aids

Revision 18-0; Effective September 4, 2018
 
Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

A member must exhaust any applicable Medicare, Medicaid or other third-party resources (TPR) for durable medical equipment (DME) and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.
 

4811 Service Limits on Adaptive Aids

Revision 18-0; Effective September 4, 2018
 
The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the managed care organization (MCO) member case file. After any applicable state plan benefits (e.g., durable medical equipment (DME)) are exhausted, adaptive aids covered in the Medically Dependent Children Program (MDCP) include:

The MCO may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member’s annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member’s agreement to pay these costs in the MCO member case file. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member’s signature, the date of the member’s agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.
 

4820 Minor Home Modifications

Revision 18-0; Effective September 4, 2018
 
A minor home modification is a physical modification to a member’s residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in his or her home. If a home modification is requested and the member, legally authorized representative (LAR) or authorized representative (AR) does not own the home in which the modification will take place, the member, LAR, AR or the managed care organization (MCO) service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids MCOs may not require minor home modification providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for minor home modifications services.
 

4821 Service Limits on Minor Home Modifications

Revision 18-0; Effective September 4, 2018
 
The minor home modification lifetime limit is $7,500. The managed care organization (MCO) service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with Medically Dependent Children Program (MDCP) funds. The MCO service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the MCO member case file. A minor home modification must not create a new structure or add square footage to the home.

The MCO may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member’s lifetime limit for minor home modifications.

Minor home modifications are limited to:

Minor home modifications must:

Minor home modifications do not include the use of deluxe materials such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider’s warranty, the MCO service coordinator may authorize up to $300 for the member, legally authorized representative (LAR) or authorized representative (AR) to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member’s agreement to pay these costs in the MCO member case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member’s signature, the date of the member’s agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.
 

4830 Transition Assistance Services

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) service coordinator must advise applicants or members who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or member needs assistance in setting up a household when relocating into the community from the NF. STAR Kids MCOs may not require TAS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for TAS. The applicant or member may access TAS if he or she:

TAS may be available to pay for non-recurring set-up expenses for applicants or members transitioning from NFs into MDCP and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant’s or member’s transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to attest that the items requested for TAS are the basic, essential needs required to move into the community, and he or she agree the TAS agency selected is authorized to make the purchases for them. The MCO service coordinator must explain to the applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP services, and notified in writing that he or she is eligible. The MCO service coordinator must contact the applicant, member, LAR or AR before certification to verify the applicant or member has made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member receives must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.
 

4831 Deposits

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant’s or member’s name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months’ rent. The MCO service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the applicant’s or member’s service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant’s or member’s name, or to pay for arrears on previous utilities if the account is in the applicant’s or member’s name and he or she will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The MCO may have internal policies regarding the type of telephone that may be authorized.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the applicant’s or member’s transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the applicant’s or member’s place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or member identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the applicant or member not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.
 

4832 Moving Expenses

Revision 18-0; Effective September 4, 2018
 
Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant’s or member’s belongings from the nursing facility (NF) to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or member from the NF to his or her residence in the community.
 

4833 Site Preparation

Revision 18-0; Effective September 4, 2018
 
Transition Assistance Services (TAS) can be used to pay for preparing the applicant’s or member’s place of residence for occupancy if the current condition of the residence prevents the applicant’s or member’s transition from the nursing facility (NF). Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and is in need of some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the applicant or member is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the applicant’s or member’s residence has been unattended or the applicant or member is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.
 

4834 Limits on Transition Assistance Services

Revision 18-0; Effective September 4, 2018
 
The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per applicant or member. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the managed care organization (MCO) member case file. The MCO service coordinator must be as specific as possible when describing the items purchased. A nursing facility (NF) resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to NF placement may receive a one-time TAS authorization if the MCO service coordinator determines that no other resources are available to pay for the basic services or items needed by the applicant or member. TAS may not be used for:

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to applicants or members who are discharged from an NF and require TAS to set up a household.
 

4835 Transition Assistance Services Agency Responsibilities

Revision 18-0; Effective September 4, 2018
 
The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member, legally authorized representative (LAR) or authorized representative (AR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member, legally authorized representative (LAR) or authorized representative (AR), if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member, LAR or AR by the completion date to confirm that all authorized TAS services were delivered.
 

4836 Three-Day Monitor Requirement

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the MCO member case record.
 

4837 Failure to Leave the Nursing Facility

Revision 18-0; Effective September 4, 2018
 
While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the nursing facility (NF), there may be situations in which the member changes his mind or has a change in health making it impossible for him to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave an NF does not count against a member’s lifetime TAS limit.

If the member is only in the community for a few days and returns to the NF, the member keeps the item(s) purchased through TAS.
 

4900 Supported Employment and Employment Assistance

Revision 18-0; Effective September 4, 2018
 
Senate Bill 45, 83rd Legislature, Regular Session, 2013, required all §1915(c) Medicaid waiver programs offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program (MDCP) are EA and SE. STAR Kids managed care organizations (MCOs) may not require EA or SE providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for EA or SE services.
 

4910 Employment Assistance

Revision 18-0; Effective September 4, 2018
 
Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) services to help the individual locate paid employment in the community and includes:

For an MDCP member, the managed care organization (MCO) service coordinator must ensure and document that employment services are not available to the member from the member’s school district or other available community resource before authorizing MDCP EA services.

The MCO service coordinator refers the member to the Texas Workforce Commission (TWC) within 30 days of meeting with a member and identifying an interest in obtaining employment. The MCO service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.

A member who has been referred for TWC or contacted TWC himself or herself is not eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed the IPE or the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive MDCP-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.

If the member has exhausted TWC services or been determined ineligible for TWC services, the MCO service coordinator authorizes a minimum of 10 hours for employment on the member’s individual service plan (ISP). EA can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member’s MDCP budget.
 

4911 Coordination with Texas Workforce Commission for Employment Assistance

Revision 18-0; Effective September 4, 2018
 
Upon request and with proper authorization for disclosure, the managed care organization (MCO) service coordinator will assist the member to provide the Texas Workforce Commission (TWC) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

If the VRC determines TWC is not the appropriate resource to meet the member’s needs and does not take an application for services, documentation of this decision in the member’s record serves as sufficient evidence that TWC is not available and the member is eligible to receive Medically Dependent Children Program (MDCP)-funded employment assistance (EA).

TWC will:

If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member’s MCO service coordinator will attempt to contact the assigned TWC VRC to determine the status of the application and document the contact in the narrative notes.

The member’s MCO service coordinator will ensure that communication is maintained with the assigned TWC VRC regarding MDCP-funded services provided between the Vocational Rehabilitation (VR) referral and the “start date” of TWC, as defined in the individual’s TWC VR IPE.

At the request of a member determined eligible for TWC, the MCO service coordinator, if possible, will assist the member and:

The member’s provider must begin providing or subcontracting for those services and supports approved in the member’s ISP without a gap between the provision of TWC and MDCP services.
 

4912 Employment Assistance Providers

Revision 18-0; Effective September 4, 2018
 
Employment assistance (EA) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option. At a minimum, the EA provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and satisfy one of these options:

Option 1:

Option 2:

Option 3:

Under the CDS option, the provider cannot be the member’s legal guardian or the spouse of the legal guardian.
 

4920 Supported Employment

Revision 18-0; Effective September 4, 2018
 
Supported employment (SE) services provide assistance to help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

SE services include:

Competitive employment is work:

An integrated setting is a setting typically found in the community in which members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

An MDCP member may seek SE to provide assistance to the member in maintaining self-employment. Self-employment is work in which the member:

SE may only be authorized through MDCP if documentation is maintained in the member’s record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (Title 20 United States Code (U.S.C.) §1401 et seq.) or the Texas Workforce Commission (TWC).
 

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third-party resources (TPR) before using Medically Dependent Children Program (MDCP) employment services.

Activities include:

 

4922 Supported Employment Providers

Revision 18-0; Effective September 4, 2018
 
Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the member, and satisfy one of these options:

Option 1:

Option 2:

Option 3:

Under the CDS option, the provider cannot be the member’s legal guardian or the spouse of the legal guardian.

Section 5000, Reserved for Future Use

Section 6000, Denials and Terminations

Revision 18-0; Effective September 4, 2018

 

 

6050 Description

Revision 18-0; Effective September 4, 2018
 
This section provides information, procedures and references pertaining to denial or termination of Medically Dependent Children Program (MDCP) services for active members, along with adequate notice of a member’s rights and opportunities to due process.

Title 42 Code of Federal Regulations (CFR) Part 431, Subpart E, governs fair hearing rights for Medicaid applicants and beneficiaries. In general, the managed care organization (MCO) must adhere to the federally-mandated 10-day adverse action period for denials and terminations related to MDCP services. However, Title 42 CFR §431.213 specifies situations in which an adverse action period is not required. The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a beneficiary;
(b) The agency receives a clear written statement signed by a beneficiary that —

(1) He or she no longer wishes to receive services; or
(2) Gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information;

(c) The beneficiary has been admitted to an institution where he or she is ineligible under the plan for further services;
(d) The beneficiary’s whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See §431.231(d) of this subpart for procedure if the beneficiary’s whereabouts become known);
(e) The agency establishes the fact that the beneficiary has been accepted for Medicaid services by another local jurisdiction, state, territory, or commonwealth;
(f) A change in the level of medical care is prescribed by the beneficiary’s physician;
(g) The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
(h) The date of action will occur in less than 10 days, in accordance with §483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30-days notice requirements of §483.15(b)(4)(i) of this chapter.

Title 1 Texas Administrative Code (TAC) §353.1209, which is cited on Form H2065-D, Notification of Managed Care Program Services, is the basis for all STAR Kids case actions.
 

6100 Ten-Day Adverse Action Notification

Revision 18-0; Effective September 4, 2018
 
Title 42 Code of Federal Regulations (CFR) §431.230 requires that the Texas Health and Human Services Commission (HHSC) provide a notice to the member at least 10 days before the action effective date. The member must be given the full 10-day adverse action period to give him or her time to file an appeal or request a fair hearing, as described below:

(a) If the agency mails the 10-day or five-day notice, as required under Title 42 CFR §431.211 or Title 42 CFR §431.214, and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless —

(1) It is determined at the hearing that the sole issue is one of federal or state law or policy; and
(2) The agency promptly informs the beneficiary in writing that services are to be terminated or reduced pending the hearing decision.

(b) If the agency’s action is sustained by the hearing decision, the agency may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary, to the extent they were furnished solely by reason of this section.

The managed care organization (MCO) must calculate time periods related to adverse actions in accordance with instruction provided in Title 3 Code Construction Act §311.014. It specifies that:

(a) In computing a period of days, the first day is excluded and the last day is included.
(b) If the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 10-day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when HHSC offices are officially open, even with limited workforce.

The full adverse action period may be waived if the individual signs a statement to waive the adverse action period.
 

6110 Denial of Medical Necessity/Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet medical necessity (MN) criteria or does not have a valid individual service plan (ISP), the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date Informed Eligibility Lost Date Form H2065-D Sent Current ISP End Date 10-Day Adverse Action Expiration Date Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal Data Entry
April 10 April 12 May 31 April 22 May 31 None
May 20 May 21 May 31 May 31 May 31 None
May 20 May 22 May 31 June 1 June 30 ISP must be extended to June 30.
June 5 June 7 May 31 June 17 June 30 ISP must be extended to June 30.
June 22 June 24 May 31 July 4 July 31 ISP must be extended to July 31.

 

6120 Denial of Medicaid Eligibility

Revision 18-0; Effective September 4, 2018
 
When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet Medicaid eligibility, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Actual Date of Medicaid Eligibility Denial Date PSU Informed Eligibility Lost Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal Data Entry
12-31-2016 12-31-2016 5-31-2017 1-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 12-31-2016 5-31-2017 11-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 2-5-2017 5-31-2017 2-7-2017 12-31-2016 ISP must be corrected to 12-31-2016.

Notes:

 

6130 Unable to Locate

Revision 18-0; Effective September 4, 2018
 
When a member is denied Medically Dependent Children Program (MDCP) services because he or she cannot be located, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date PSU Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal Data Entry
12-31-2016 5-31-2017 1-2-2017 1-31-2017 ISP must be corrected to 1-31-2017.
5-3-2017 5-31-2017 5-5-2017 5-31-2017 None
5-25-2017 5-31-2017 5-27-2017 6-30-2017* ISP must be corrected to 6-30-2017.
6-9-2017 5-31-2017 6-11-2017 6-30-2017 Managed care organization (MCO) should have submitted an ISP and medical necessity (MN) for 6-1-2017.

*The 10-day adverse action period expires after the end of the month.

 

6200 Program Support Unit Staff Initiated Denials/Terminations

Revision 18-0; Effective September 4, 2018
 
The following sections contain policy citations that must be included on Form H2065-D, Notification of Managed Care Program Services, when the denial or termination action is initiated by Program Support Unit (PSU) staff.
 

6210 Denial/Termination Due to Death

Revision 18-0; Effective September 4, 2018
 
Upon learning of the death of a member, Program Support Unit (PSU) staff must post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization (MCO) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions, within two business days of verification.

Form H1746-A, MEPD Referral Cover Sheet, must be faxed to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if no notification was received by PSU from MEPD. PSU staff do not send a notice to the member's address or family. The effective date is the date of death.

PSU staff upload Form H2067-MC and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

If the member was receiving Supplemental Security Income (SSI) and the eligibility record reflects that SSI has been denied, PSU staff must use the same effective date of denial as the SSI denial date. If the eligibility records reflect SSI is still active, it is the member’s family’s responsibility to notify the Social Security Administration (SSA) of the member’s death.

If a member’s Medicaid eligibility has been denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), PSU staff must end enrollment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal by terminating the individual service plan (ISP). PSU staff must also close any of the member’s Service Authorization System Online (SASO) legacy records, if applicable. PSU staff must upload screenshots of the TMHP LTC Online Portal ISP termination and the SASO record closures, if applicable.

Services must be terminated once death of the member has been confirmed by PSU staff via:

A 10-day adverse action period is not required for death denials.
 

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 18-0; Effective September 4, 2018
 
The process for members residing in a nursing facility (NF) (excluding Truman Smith*) is as follows:

Once a denial is complete, if a member decides to discharge from the NF, the member would be directed to pursue Money Follows the Person (MFP).

*Members enrolled in STAR Kids who enter the Truman Smith NF or a state veteran’s home are excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied.
 

6230 Denial/Termination Due to Member Request

Revision 18-0; Effective September 4, 2018
 
When Program Support Unit (PSU) staff have been notified a member no longer wants Medically Dependent Children Program (MDCP) services, within two business day of becoming aware the member no longer wants services, PSU staff must:

 
6240 Denial/Termination of Financial Eligibility

Revision 18-0; Effective September 4, 2018
 
A member’s continued receipt of STAR Kids services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or Medicaid for the Elderly and People with Disabilities (MEPD) specialists for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate. Within two business days of the denial, Program Support Unit (PSU) staff must:

Notification can come from:

The chart below describes how to proceed if financial eligibility is denied.

When the individual is denied SSI: When the individual is denied MAO:
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to SSA is available to the individual.
  • The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long term services and supports (LTSS) (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to MEPD is available to the individual.
  • The individual can contact the local HHSC office to request other LTSS (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.

For SSI members, the termination date must match the SSA termination date. For SSI denials, the 10-day adverse action notification period does not apply in this situation.

For MAO members, the termination date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past when PSU staff becomes aware of the denial.

 

6250 Denial/Termination of Medical Necessity

Revision 18-0; Effective September 4, 2018

Medically Dependent Children Program (MDCP) services must be denied/terminated when the member’s medical necessity (MN) is denied.

Notification can come from:

MCOs must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN status through completing a current activity query in the TMHP LTC Online Portal every seven days, at minimum. If an MN status appears as “MN Denied” in the TMHP LTC Online Portal, the applicant or member’s physician has 14 business days to submit additional information to the MTHP physician. If a member’s MN status enters “MN Denied,” the MCO must assist the member and physician with collecting and submitting any additional information pertinent to the member’s MN determination. The MCO must assist by calling the member and physicians and obtaining necessary documents to TMHP for consideration within the 14-business-day time frame.

Once a STAR Kids Screening and Assessment Instrument (SK-SAI) MN status is in "MN Denied" status, several actions may follow:

Program Support Unit (PSU) staff must not mail Form H2065-D, Notification of Managed Care Program Services, to deny the MDCP case until after 14 business days from the date the "MN Denied" status appears in the TMHP LTC Online Portal. After the 14-business-day period has expired, PSU staff must not deny MDCP services unless the TMHP LTC Online Portal status is either “MN Denied,” “Overturn Doctor Review Expired” or “Doctor Overturn Denied.” PSU staff must meet initial certification and annual assessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented. PSU staff must monitor the TMHP LTC Online Portal every five business days until a status of “MN Denied,” “Overturn Doctor Review Expired” or “Doctor Overturn Denied” is assigned.

After 14 business days from the “MN Denied” status initially appeared in the TMHP LTC Online Portal has expired, if the TMHP LTC Online Portal shows a status of “MN Denied,” “Overturn Doctor Review Expired,” or “Doctor Overturn Denied,” then within two business days PSU staff must:

 

6260 Denial/Termination Due to Inability to Locate the Member

Revision 18-0; Effective September 4, 2018
 
The Medically Dependent Children Program (MDCP) must be denied/terminated when Program Support Unit (PSU) staff are notified that a member cannot be found. Within two business days, PSU staff must:

Notification can come from:

 
6270 Denial/Termination Due to Failure to Meet Other Program Requirements

Revision 18-0; Effective September 4, 2018
 
Use this denial citation if the applicant or member does not meet a Medically Dependent Children Program (MDCP) requirement mentioned in Section 6210 through Section 6260 above. For example, this citation would be used if the applicant or member does not require at least one MDCP service per individual service plan (ISP) year. Within two business days of the denial, Program Support Unit (PSU) staff must:

 

6280 Denial/Termination for Other Reasons

Revision 18-0; Effective September 4, 2018
 
Use this citation if initiating denial/termination for a reason not covered in Section 6210 through Section 6270. Within two business days of the denial, Program Support Unit (PSU) staff must:

Notification can come from:

 
6300 Denial/Termination Initiated by the Managed Care Organization

Revision 18-0; Effective September 4, 2018
 
Section 6310 through Section 6370 contain policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. Within two business days of the notification by the MCO, Program Support Unit (PSU) staff must:


6310 Denial/Termination Due to Threats to Health and Safety

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) and provider staff must take special precautions when an applicant’s or member’s comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant or member, an MCO-contracted provider or an MCO employee. If an applicant or member exhibits such behavior, the staff member must immediately notify his or her manager.

Texas Health and Human Services Commission (HHSC) staff review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant’s or member’s safety may be at risk, the MCO must follow current policy regarding notification to the Department of Family and Protective Services (DFPS). If the MCO or service provider staff member believe there is a potential threat to others, HHSC management should determine the best method for notifying the MCO and/or the contracted service provider and for addressing the applicant’s or member’s needs without placing an MCO or service provider staff at risk.

Within two business days of the notification by the MCO, Program Support Unit (PSU) staff must:

The 10-day adverse action notification period does not apply in this situation.
 

6320 Denial/Termination Due to Hazardous Conditions or Reckless Behavior

Revision 18-0; Effective September 4, 2018
 
When there is no immediate threat to the health or safety of the service provider, but the situation, member or someone in the member’s home is hazardous to the health and safety of the service provider, appropriate documentation of denial is essential. For example, a situation where the member has a large dog that may bite if let loose could be resolved if the member or a neighbor or family member will agree to restrain the dog during times of service delivery.

However, if the provider shows up on numerous occasions at the designated time and the dog is loose, and the provider has documented a substantial pattern of being unable to deliver services due to this, services could be terminated.

Similarly, if there are illegal drugs in the member’s home used by the member or others, the service provider may not be in immediate danger, yet the situation still poses a threat. It is imperative that all available interventions are presented and the opportunity offered for the member to get rid of the illegal drugs and/or users, and agree to refrain and not allow the illegal drug use to resume. The managed care organization (MCO) should convene an interdisciplinary team meeting if the illegal drug usage occurs again, and the member must be warned in writing of the potential loss of services for allowing this activity to continue.

Within two business days of the notification by the MCO, Program Support Unit staff must:

The 10-day adverse action notification period does not apply in this situation.
 

6330 Denial/Termination Due to Harassment, Abuse or Discrimination

Revision 18-0; Effective September 4, 2018
 
A substantial demonstrated pattern of verbal abuse or discrimination must be clearly established and documented by the managed care organization (MCO) before services can be denied for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the member, family, legally authorized representative (LAR) or authorized representative (AR), explaining that the MCO does not condone discrimination, harassment and/or verbal abuse.

Appropriate interventions must be sought. This may include counseling, referral to other case management agencies and possibly changes to the individual service plan (ISP), such as attending Day Activity and Health Services (DAHS) for nursing.

There must be meetings of the Texas Health and Human Services Commission (HHSC) staff that include outside agencies, when appropriate, such as the Texas Department of Family and Protective Services (DFPS) Child or Adult Protective Services (APS). The results must be documented in letters sent to the member that offer an opportunity to stop the behavior, with clear indication that failure may result in loss of service. Copies of written warnings must be sent to all who attend the meetings and a copy must be retained in the case file.

If the situation persists and results in an inability to deliver services, the MCO may request disenrollment from HHSC. After HHSC staff approve the disenrollment, HHSC staff notify the Program Support Unit (PSU) supervisor via email. PSU staff send Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if appropriate.
Within two business days of the notification from the HHSC staff, PSU staff must:

The 10-day adverse action notification period does not apply in this situation.

If the denial or termination is being considered due to verbal abuse or harassment of the service provider, HHSC must determine if this behavior is directly related to the member’s disability. If the member produces a letter from his physician indicating the behavior stems from the member’s disability, services cannot be denied for this reason. Appropriate interventions to ensure service delivery, as noted above, should still be pursued.
 

6340 Denial as a Result of Exceeding the Cost Limit

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) must consider all available support systems in determining if the Medically Dependent Children Program (MDCP) is a feasible alternative that ensures the needs of the applicant are adequately met. If MDCP is not a feasible alternative, the MCO must notify Program Support Unit (PSU) staff of the denial and maintain appropriate documentation to support the denial. The MCO documentation of this type of denial is based on the inadequacy of the plan of care, including both MDCP and non-MDCP services, to meet the needs of the individual within the cost limit.

If the individual service plan (ISP) is over the cost limit, within two business days of receipt of the ISP, PSU staff must:

 
6350 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions

Revision 18-0; Effective September 4, 2018
 
If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, services may be denied/terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member’s home that prevent determining eligibility, carrying out the service plan or monitoring services. Within two business days of the notification, Program Support Unit (PSU) staff must:

 

6360 Denial/Termination Due to Failure to Pay

Revision 18-0; Effective September 4, 2018
 
If the member refuses to pay a required copayment, room and board payment or Qualified Income Trust (QIT) payment, the Medically Dependent Children Program (MDCP) must be denied. After notification by the managed care organization (MCO), within two business days of notification, the Program Support Unit (PSU) staff must:

The 10-day adverse action period does apply in this situation.
 

6370 Denial/Termination Due to Other Reasons

Revision 18-0; Effective September 4, 2018
 
Use this denial or termination citation if initiating denial for a reason not covered above. After notification by the managed care organization (MCO), within two business days of notification, Program Support Unit (PSU) staff must:

Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings

Revision 18-0; Effective September 4, 2018
 

 

7100 Managed Care Organization Procedures

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) must develop, implement and maintain a complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Title 42 Code of Federal Regulations (CFR) §431 Subpart E, Fair Hearings for Applicants and Beneficiaries, and Title 42 CFR §438, Subpart F, Safeguarding Information on Applicants and Beneficiaries.

If an MCO makes a benefit determination adverse to the member, the member must exhaust the internal MCO appeal system prior to requesting a state fair hearing. If the Texas Health and Human Services Commission (HHSC) denies a member’s Medicaid or program eligibility, the member does not exhaust the internal MCO appeal system, as the MCO did not make the determination. Instead, the member requests a state fair hearing to appeal the HHSC decision.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, for PSU staff responsibilities related to state fair hearings.
 

7110 Managed Care Organization Complaint Procedures

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) uses the term complaint to describe a grievance. Title 42 Code of Federal Regulations (CFR) §438.400(b)(7) defines a grievance as, “an expression of dissatisfaction about any matter other than an adverse benefit determination.” This definition also notes grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the [member’s] rights regardless of whether remedial action is requested. Grievance includes a [member’s] right to dispute an extension of time proposed by the [managed care organization (MCO)] to make an authorization decision.

If the member wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO member handbook. The MCO provides a designated member advocate to:

If the member is not satisfied with the outcome of the MCO complaint process or the complaint is not resolved within 30 days, the member may contact the HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 for assistance filing a complaint with HHSC. In addition, the member may send a written request to HHSC to investigate the complaint. The request is sent to:

Texas Health and Human Services Commission Managed Care Compliance & Operations (MCCO) – STAR Kids, 4900 North Lamar Blvd., Mail Code H320, Austin, TX 78751, or by email to HPM_Complaints@hhsc.state.tx.us.
 

7120 Internal Managed Care Organization Appeal Procedures

Revision 18-0; Effective September 4, 2018
 
In managed care, Title 42 Code of Federal Regulations (CFR) §438.400(b)(7) define an appeal as a review of a managed care organization (MCO) action, also called an adverse benefit determination. An adverse benefit determination is:

If a member, legally authorized representative (LAR), parent or guardian request to file an internal MCO appeal of an adverse benefit determination, the member must file an appeal by contacting the MCO following the procedures specified in the MCO member handbook or on the MCO notice of action. The member must request an internal MCO appeal no later than 90 days from the date of the MCO action. The MCO is required to regard any oral or written expression of dissatisfaction or disagreement related to an adverse benefit determination as a request to file an internal MCO appeal. The MCO must provide a designated member advocate to assist the member in filing an internal MCO appeal. The advocate must also assist the member by monitoring the internal MCO appeal throughout the process until the issue is resolved.

During the internal MCO appeal process, the MCO must provide the member with a reasonable opportunity to present evidence and any allegations of fact or law in person and in writing. The MCO must inform the member of the time available for providing this information. The MCO must provide the member the opportunity, before and during the internal MCO appeal process, to examine the member’s case file, including medical records and any other documents considered during the internal MCO appeal process.

As required by Title 42 CFR §438.420, the MCO must continue a member’s benefits pending the outcome of the internal MCO appeal if all the following criteria are met:

A member must request continued benefits no later than 10 days from the date of the MCO notice or date of the MCO proposed action.

 

7121 Expedited Managed Care Organization Internal Appeal

Revision 18-0; Effective September 4, 2018
 
In accordance with Title 42 Code of Federal Regulations (CFR) §438.410, the managed care organization (MCO) must establish and maintain an expedited review process for an adverse benefit determination when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that the time for a standard internal MCO appeal could seriously jeopardize the member’s life or health. The MCO must follow all internal MCO appeal requirements for standard internal MCO appeals as set forth in the CFR. The MCO must accept oral or written requests for expedited internal MCO appeals.

After the MCO receives a request for an expedited internal MCO appeal, the MCO must notify the member or LAR of the outcome of the expedited internal MCO appeal request within 72 hours. However, the MCO must complete investigation and resolution of an internal MCO appeal relating to an ongoing emergency or denial of continued hospitalization:

The member must exhaust the expedited internal MCO appeal process before making a request for an expedited state fair hearing.

Except for an internal MCO appeal related to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited internal MCO appeal may be extended up to 14 days if the member requests an extension or the MCO shows (to the satisfaction of the Texas Health and Human Services Commission (HHSC), upon HHSC’s request) there is a need for additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the internal MCO appeal determination is adverse to the member, the MCO must follow the procedures relating to the notice in the STAR Kids Managed Care Contract, Attachment B-1, Section 8.1.29.5. The MCO is responsible for notifying the member of his or her right to access an expedited state fair hearing. The MCO is also responsible for providing documentation to HHSC and the member, indicating how the determination was made, prior to HHSC’s expedited state fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member, provider or LAR for requesting an expedited internal MCO appeal or an expedited state fair hearing. The MCO must ensure punitive action is not taken against a provider who requests an expedited internal MCO appeal or supports a member’s request.

If the MCO denies a request for an expedited internal MCO appeal, the MCO must:

 

7122 Request for a State Fair Hearing After Exhausting Internal Managed Care Organization Appeals

Revision 18-0; Effective September 4, 2018

A member or legally authorized representative (LAR) may request a state fair hearing only after exhausting the internal managed care organization (MCO) appeal process.

The member must request a state fair hearing no later than 120 days from the date of the expedited internal MCO appeal.

In the case an MCO fails to adhere to the notice and timing requirements in Title 42 Code of Federal Regulations (CFR) §438.408, the member is deemed to have exhausted the internal MCO appeal process and may initiate a state fair hearing.
 

 

7200 State Fair Hearing Procedures for Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018
 

 

 

7201 Timely or Non-timely State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

An applicant, member, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) may request a state fair hearing orally or in writing.

A timely state fair hearing request for a Medically Dependent Children Program (MDCP) eligibility denial is received by Program Support Unit (PSU) staff no later than 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for an MDCP eligibility denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

If a non-timely state fair hearing request is received from the applicant or member, PSU staff create the appeal in the Texas Integrated Eligibility Redesign System (TIERS). If the hearing officer determines there is good cause, the hearing officer will schedule a state fair hearing date. If the hearing officer determines if there is no good cause, the applicant or member is no longer eligible for a state fair hearing.

 

7210 Program Support Unit Staff Procedures for Completing Form H4800

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff may receive a request for a state fair hearing related to Medically Dependent Children Program (MDCP) eligibility from an applicant, member, parent, guardian, or legally authorized representative (LAR) orally or in writing. When a state fair hearing request is received, PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date of the request.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials.

Upon receipt of the state fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. PSU staff send Form H4800 to the data entry representative (DER) and DER supervisor within three days of the request for a state fair hearing. The three-day time frame allows the DER two days to enter the information on Form H4800 in TIERS.

PSU staff must use Form H4800 to record the names of all persons who should attend the state fair hearing.

Depending on the issue being appealed, PSU staff must enter the following staff on Form H4800:

PSU staff should contact the MCO if there is any doubt as to who should be listed on Form H4800.

When PSU staff complete Form H4800, all questions in Section 1 must be answered. PSU staff must always answer “No” to the question, “Appeal requested timely within 10 calendar days of agency action?”, as this question applies only to TW programs. PSU staff must indicate the individual service plan (ISP) begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules.”

PSU staff must indicate the ISP begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800. The begin and end dates must also be mentioned during the state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP denial.

Refer to Form H4800 instructions for more specific directions for form completion and transmittal.
 

7211 Data Entry Representative Procedures for Entering the State Fair Hearing Request

Revision 18-0; Effective September 4, 2018
 
When the data entry representative (DER) receives Form H4800, Fair Hearing Request Summary, from Program Support Unit (PSU) staff, the DER creates a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record to document the state fair hearing request. The HEART case record and Community Services Interest List (CSIL) database record is to remain open until a state fair hearing decision is rendered.

Within two business days of receipt of Form H4800, the DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS). The DER must use the Manage Office Resources (MOR) Search function in TIERS when adding PSU, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP) or Texas Health and Human Services Commission (HHSC) representatives as participants. When entry of all information is complete, TIERS assigns the appeal identification (ID) number. The DER sends a copy of the TIERS generated Form H4800 to PSU staff and uploads to the HEART case record.
 

7212 Generation of the State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018
 
The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet, which is available to state fair hearing participants other than the applicant, member or legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. A partial state fair hearing packet includes:

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing has been scheduled. The alert in TIERS identifies the hearings officer assigned to the state fair hearing and the date and time of the state fair hearing. PSU staff use this information to monitor for the decision of the state fair hearing. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) financial denial.

Once a state fair hearing has been scheduled, TIERS generates a full state fair hearing packet, which the hearings officer mails to the applicant, member or LAR. A full state fair hearing packet includes:

 

7213 State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018
 
Within 10 days, each entity involved in the state fair hearing is responsible for preparing its state fair hearing packet, uploading documents in the Texas Health and Human Services Commission (HHSC) Benefits portal, and mailing the documents to the applicant, member or legally authorized representative (LAR). Refer to Section 7231, Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal, for uploading instructions. Program Support Unit (PSU) staff must ensure documentation on Form H4800, Fair Hearing Request Summary, clearly states this is a state fair hearing for the Medically Dependent Children Program (MDCP). It is crucial that all state fair hearing packets are complete, organized and all pages numbered, in order to support the agency’s action on an appeal.

The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials.

The following are examples of documentation that must be submitted as evidence and the entity responsible for uploading that information in the HHSC Benefits Portal and mailing documents to the applicant, member, LAR or AR:

If an applicant, member, LAR or AR wants to submit evidence for the state fair hearing, the applicant, member, LAR or AR should fax or mail the evidence to the hearings officer. The hearings officer’s contact information is listed on Form H4803. Any evidence received from an applicant, member, LAR or AR is shared with HHSC.

 

7214 Changes to the State Fair Hearing Request Summary

Revision 18-0; Effective September 4, 2018
 
After the data entry representative (DER) has added information from Form H4800, Fair Hearing Request Summary, in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Woks (TW) financial denials, Program Support Unit (PSU) staff may learn of subsequent changes such as change of address. Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials. When subsequent changes occur, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the DER who will check TIERS to identify if a hearings officer has been assigned to the case. The DER must ensure documentation on Form H4800-A clearly states this is a state fair hearing for Medically Dependent Children Program (MDCP). The appeal identification (ID) number assigned by TIERS must be documented in the designated space on Form H4800-A.

If a hearings officer is assigned, the DER must upload Form H4800-A in the Texas Health and Human Services Commission (HHSC) Benefits Portal as soon as possible, but no later than 10 days of becoming aware of the change.

Delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.
 

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018
 

 

 

7221 Type of Denials

Revision 18-0; Effective September 4, 2018

An applicant, member, parent, guardian or legally authorized representative (LAR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member, or legally authorized representative (LAR) requests a state fair hearing for program denials. PSU staff notify the Centralized Representative Unit (CRU) if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits Portal. PSU staff create all other state fair hearing request in TIERS. The method in which the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

 

7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership

Revision 18-0; Effective September 4, 2018

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN denial, on the “Agency Representative” field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MN denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, PSU staff and the PSU supervisor entered as "Observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.2 Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 18-0; Effective September 4, 2018

If the state fair hearing decision is related to a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial for a medical assistance only (MAO) applicant or member, Program Support Unit (PSU) staff must forward the request to the Centralized Representation Unit (CRU). The CRU is required to attend the state fair hearing to represent Medically Dependent Children Program (MDCP) financial denials.

Within one business day of receipt of the request, PSU staff must create the following:

Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

Once the CRU receives a state fair hearing request, the CRU sends an email reply to PSU staff and the PSU supervisor listed as "Observers" within five days, notifying of the completion of Form H4800 and the appeal identification number (ID). Once PSU staff receives the notification, PSU staff upload the notification in HEART and monitor the appeal until the state fair hearing decision is rendered. PSU staff must not put an applicant or member name back on the MDCP program interest list while an MEPD or TW financial denial are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MEPD or TW financial denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, PSU staff and the PSU supervisor entered as "Observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision 18-0; Effective September 4, 2018

If the action is related to a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA), Program Support Unit (PSU) staff are required to prepare the evidence packet and attend the state fair hearing. Refer to Section 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that must be submitted as evidence and PSU staff are responsible for uploading that information in the Texas Health and Human Services (HHSC) Benefits Portal:

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the PSU staff and PSU supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the “Agency Representative" and “Agency Representative Supervisor” will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an SSI denial, on the "Agency Representative" field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI denials. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the SSI denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "Agency Representative" and “Agency Representative Supervisor” are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.4 Other Denial Reasons

Revision 18-0; Effective September 4, 2018

Other denial reasons include, but not limited to:

If the action is related to other denial reasons, the managed care organization (MCO) staff are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff do not attend state fair hearings related to other denial reasons.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the MCO contact as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to other denial reasons, on the "Agency Representative" field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the data entry representative (DER), PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while other denial reasons are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the other denial reasons state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "Observer” are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

 

 

 

7222.1 Continuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 18-0; Effective September 4, 2018

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for Supplemental Security Income (SSI) denials. For all other denials, MDCP services must continue until the hearings officer issues a decision regarding the state fair hearing of a member, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. If the state fair hearing was requested by the effective date of the action, within three business days, Program Support Unit (PSU) staff must notify:

If the hearings officer’s decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four months or until the state fair hearing decision is rendered. PSU staff do not mail Form H2065-D to the member or LAR notifying of continued eligibility related to the reassessment action taken to continue services until the state fair hearing decision is rendered.

Example: If an ISP expiration date is on December 1 and the state fair hearing decision is on December 15, then a four-month period would end on the last day of April.

If the state fair hearing is initially dismissed and subsequently reopened, the Texas Health and Human Services Commission (HHSC) continues or reinstates services pending the state fair hearing decision, if the member or LAR requests continued services. When the hearings officer sets a date for a new state fair hearing, the hearings officer, in effect, voids the prior state fair hearing decision. Because services are continued until a decision is rendered, and the hearings officer is stating there is still a state fair hearing to be held, HHSC continues or reinstates services again.
 

7222.2 Termination of MDCP Services Due to a Member Not Requesting a State Fair Hearing

Revision 18-0; Effective September 4, 2018

If the state fair hearing is not filed by the effective date of the action, Medically Dependent Children Program (MDCP) services continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If the state fair hearing was not requested by the effective date of the action, Program Support Unit (PSU) staff must process according to the following:

SSI members will remain enrolled in a STAR Kids MCO and are still eligible for State Plan services, which include acute care and long term services and supports (LTSS), such as Community First Choice (CFC), Day Activity and Health Services (DAHS), Emergency Response Services (ERS), and personal assistance services (PAS).

 

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

 

 

7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal

Revision 18-0; Effective September 4, 2018
 
The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits Portal using the process described below. Refer to Section 7213, State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

Within two business days after receipt of the evidence packet in the HHSC Benefits Portal, the DER must:

If an error is made on the “Agency Representative” screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in “Maintain Appeals.” If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits Portal. The “Agency Action Date” cannot be changed.
 

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 18-0; Effective September 4, 2018

Documentation contained in the evidence packet is not considered in the state fair hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence and summarize what the packet contains. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

MCO Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

The hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the hearings officer explains the reasons for excluding the material. Any documents admitted by the hearings officer are considered when a decision is rendered.
 

7233 State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018
 
After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or legally authorized representative (LAR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, the PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or LAR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or LAR requested continued services during the state fair hearing period, PSU staff follow procedures described in Section 7500, State Fair Hearing Decision Actions.

 

7300 Post State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018
 

 

 

7310 Action Taken on the State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the PSU supervisor and data entry representative (DER). PSU staff must send Form H4807 within the 10-day time frame designated by the hearings officer to allow at least two business days for the DER to enter the information in the Texas Integrated Eligibility Redesign System (TIERS). If the action cannot be taken within the time frame designated by the hearings officer, Form H4807 is completed and sent to the PSU supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on Form H4807; the begin delay date and end delay date must be included. Refer to Form H4807 instructions for more specific directions for form completion and transmittal.
 

7400  Reserved for Future Use

Revision 18-0; Effective September 4, 2018

 

 

 

7500 State Fair Hearing Decision Actions

Revision 18-0; Effective September 4, 2018
 

 

 

7510 Sustained State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018
 
When a hearings officer renders a sustained decision, the denial is upheld. If an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal (request for the state fair hearing), essentially sustaining the action on appeal. Refer to Section 7511, Sustained Decision Termination Effective Date, to determine the correct Medically Dependent Children Program (MDCP) termination effective date to include on forms and notifications.

When the hearings officer’s decision sustains the denial of MDCP, Program Support Unit (PSU) staff must:

PSU staff must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, member authorized representative (AR) or legally authorized representative (LAR) of the sustained denial.
 

7511 Sustained Decision – Termination Effective Date

Revision 18-0; Effective September 4, 2018
 
When Medically Dependent Children Program (MDCP) services are terminated at reassessment because the applicant or member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the termination effective date will vary depending on the following circumstances:

Examples

Example Conditions Original
MN/ISP
Expiration
Date
New Expiration
Date
Hearings Officer
Decision Date
Final
MN/ISP Expiration
Date
1 Hearings officer decision is more than 30 days from the original expiration date. 1/31/18 5/31/18 11/30/17 1/31/18
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/18 5/31/18 1/15/18 2/28/18
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/18 5/31/18 2/15/18 3/31/18
4 Hearings officer decision assigns a specific expiration date. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/15/18. 2/28/18
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/28/18. 2/29/18
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 12/31/17. 1/31/18

 

7520 Reversed State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018
 
When the hearings officer’s decision reverses the denial of the Medically Dependent Children Program (MDCP) for an applicant or member, within two business days Program Support Unit (PSU) staff must:

 
7521 Reversed Decision – Effective Date

Revision 18-0; Effective September 4, 2018
 
When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) eligibility, the effective date for:

When a state fair hearing decision reverses a Program Support Unit (PSU) program denial but PSU staff cannot implement the state fair hearing decision within the required time frame, PSU staff must complete Section C, Implementation Delays, on Form H4807, Action Taken on Hearing Decision. PSU staff must attach and send Form H4807 by email to the data entry representative (DER). Information on Form H4807 must be entered by the DER on the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Refer to Section 7233, State Fair Hearing Decision, and Section 7310, Action Taken on the State Fair Hearing Decision, for the required time frames.

PSU staff may need to coordinate effective dates of reinstatement with the Central Representation Unit (CRU).

PSU staff report the implementation of the state fair hearing decision in TIERS on Form H4807 according to current procedures.
 

7522 New Assessment Required by State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018
 
If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed as a result of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must indicate in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided prior to the first state fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member or LAR requests a state fair hearing due to the lower RUG level, the MCO continues services at the same level services were provided prior to the first state fair hearing.
 

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018
 
An applicant, member or legally authorized representative (LAR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or LAR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or LAR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or LAR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or LAR and must be made to the hearings officer.

If the applicant, member or LAR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or LAR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.
 

7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearings Officer

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) hearings officer:

Administrative review of any hearings officer’s decision provided in the state fair hearings must be initiated by the applicant, member or LAR.

Section 8000, Utilization Management and Review by the State

Revision 18-0; Effective September 4, 2018
 

 

8100 Description

Revision 18-0; Effective September 4, 2018
 
Utilization Review (UR) is a division within the Medicaid and Children’s Health Insurance Program (CHIP) Division of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Title 4 Texas Government Code Section 533.00281 to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of appropriate utilization of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.

STAR Kids managed care organizations (MCOs) must allow UR access to documents, assessments, notes and authorizations contained in the MCO STAR Kids member’s file available upon request. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

Appendices

Appendix I, PSU User Guide for the SK-ISP Form

6-2019

 

Appendix I, PSU User Guide for the SK-ISP Form

Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language

Revision 20-02; Effective July 23, 2020

 

Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment that is not covered in Appendix II.

PSU must enter the associated STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section supporting the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.

Purpose of Form H2065-D Reason for Denial in Plain Language Comments in Plain Language SKOPH Section
Unable to Contact

You are not eligible for MDCP because HHSC staff or your health plan cannot locate you to complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.

No additional comment should be added. 2120
Voluntarily Declined Services

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

No additional comment should be added. 2100
Enrolled in Another 1915(c) Medicaid Waiver

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

You are not eligible for MDCP because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); STAR+PLUS HCBS program; Texas Home Living (TxHmL)]. MDCP services cannot be authorized because you can only be enrolled in one Medicaid waiver program at a time.

Usted no puede recibir servicios del MDCP porque actualmente está inscrito en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Servicios en el Hogar y en la Comunidad de STAR+PLUS; Programa de Texas para Vivir en Casa (TxHmL)]. No se pueden autorizar los servicios del MDCP porque usted no puede estar inscrito a la vez en más de un programa con exenciones.

1200
Loss of Medicaid Financial Eligibility

You are not eligible for MDCP because you do not meet the financial criteria necessary for the program.

Usted no puede recibir servicios del MDCP porque no cumple los criterios financieros necesarios para participar en el programa.

No additional comment should be added. 1200
Medicaid Eligibility Reinstated within Four Months No reason for denial language should be added.

Your Medicaid was reinstated on [DATE]. Your MDCP services will continue without interruption.

Su participación en el programa Medicaid fue restablecida el [DATE]. Usted seguirá recibiendo servicios del MDCP sin interrupción.

 
Declined Assessment

You are not eligible for MDCP because you did not let your health plan complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque no permitió que el plan médico realizara la valoración que requiere el programa.

No additional comment should be added. 2200
Living Arrangement is Not an Allowable Setting

You are not eligible for MDCP because your current home is not an allowable setting to receive services. Code of Federal Regulations at Title 42 CFR $ 441.301(c)(5) describes these services.


Usted no puede recibir beneficios de MDCP porque su hogar actual no es un entorno adecuado para recibir servicios. Estos servicios están descritos en la sección 441.301(c)(5) del título 42 del Código de Reglamentos Federales (CFR).

 

No additional comment should be added. 1200
Does Not Have an Unmet Need

You are not eligible for MDCP because you do not need services offered through the program.

Usted no puede recibir los servicios del MDCP porque no los necesita.

No additional comment should be added. 1200
Inability to Obtain Physician Signature

You aren't eligible for MDCP because your doctor didn't tell us you need the level of care provided in a nursing home.

Usted no puede recibir los servicios del MDCP porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.

No additional comment should be added. 1200
Medical Necessity Denial Reason for Denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

You are not eligible for MDCP. See the Reason for Denial text box on page 1 of this form and the MDCP Medical Necessity Denial Attachment for more information.

Usted no puede recibir servicios del MDCP. Para más información, vea el cuadro “Motivo de la denegación”, en la página 3 de este formulario, y el anexo “Medical Necessity Denial” (denegación por no existir una necesidad médica) del MDCP.

1200
Individual Service Plan Exceeds Cost Limit

You are not eligible for MDCP because the cost of your individual service plan exceeds the maximum amount allowed.

Usted no puede recibir servicios del MDCP porque el costo de su plan individual de servicios excede la cantidad máxima permitida.

No additional comment should be added. 1200
Initial Form H2065-D for MAO MFP to Community No Reason for Denial language should be added.

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive a second Form H2065-D telling you when your services will begin.

Usted cumple los requisitos del MDCP. Sus servicios no empezarán hasta que usted y su plan médico acuerden una fecha para su salida de la casa de reposo. Permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén vigentes cuando salga de la casa de reposo. Usted recibirá un segundo Formulario H2065-D en el que se le informará cuándo comenzarán sus servicios.

 
Initial Form H2065-D for MFP to AFC No Reason for Denial language should be added.

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive another notice telling you when your MDCP services will begin. We will also send you a notice telling you how much your room and board and copayment will be.

Usted cumple los requisitos del programa MDCP. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa MDCP. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.

 
MFP Services Not Authorized Within 24 Hours

You are not eligible for MDCP because services were not authorized within 24 hours of the nursing facility stay.

Usted no puede recibir servicios del MDCP porque los servicios no se autorizaron en las 24 horas siguientes a su estancia en el centro de reposo.

No additional comment should be added. 2400
Room and Board and Copayment No Reason for Denial language should be added.

You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility.

Usted tiene que cubrir los gastos de alojamiento y comida y de cualquier copago. Deberá pagarlos cada mes al hogar de acogida o centro de vida asistida en el que se encuentre.

 
Institutional Stay Over 90 Days

You are not eligible for MDCP because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR §441.301(b)(1).

Usted no puede recibir servicios del MDCP porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).

You are not eligible for MDCP services while an in-patient of a [Select one: hospital; nursing facility; intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del MDCP mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; un centro de atención intermedia para personas con discapacidad intelectual].

1200
Moved Out of State

You are not eligible for MDCP because you are not a Texas resident.

Usted no puede recibir servicios del MDCP porque no reside en Texas.

No additional comment should be added. 1200
Over Age 20

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

No additional comment should be added. 1200
Other Contact supervisor. No additional comment should be added. 6300

Appendix III, LTSS Billing Matrix and Crosswalk

Appendix IV, MDCP Frequently Asked Questions

Appendix V, Time Calculation

Appendix VI, STAR Kids Transition Activities

Appendix VII, SASO Service Group, Service Code and Termination Code

Appendix VIII, RUG IPC Cost Limits

Appendix IX, STAR Kids TxMedCentral Naming Conventions

Appendix X, Monthly Income/Resource Limits

Appendix XI, HHSC Benefits Portal and TIERS Inquiry Desk Guide

Appendix XII, Create an Appeal Task in the HHSC Benefits Portal

Appendix XIII, Long Term Services and Supports

Appendix XIV, Reserved for Future Use

Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

Appendix XVI, Medicaid Program Actions

Appendix XVII, Reserved for Future Use

Appendix XVIII, STAR Kids HEART Naming Conventions

Revision 20-3; Effective October 9, 2020

 

This appendix outlines the screenshots Program Support Unit (PSU) staff upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix IX, STAR Kids TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.

When there is more than one of the same form, or screenshot, uploaded, then add a sequence number after the naming convention. For example, the first Form H1746-A sent or received would be uploaded as 1746, the second form sent or received would be uploaded as 1746_2, 1746_3, etc.

All screenshots, forms, documents and emails marked as “Yes,” in the “Required” column, must be included in the HEART case record. Screenshots, forms, documents or emails marked with an “*” in the “Required” column must be included in the HEART case record if used by PSU staff in the HEART transaction.

 

Interest List Release (ILR)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL Yes
Form 2442 (English) 2442 *
Form 2442-S (Spanish) 2442-S *
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes 
Form H1746-A (form alone or with fax confirmation) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H3676-A Use TxMedCentral Naming Convention Yes
Form H3676-A Upload to TxMedCentral 3676A TXMED Yes
Form H3676-B Use TxMedCentral Naming Convention Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Money Follows the Person (MFP)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual- Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form 3618 3618 Yes
Form H1200 1200 Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTC Online Portal (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Annual Assessment
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from MCCO MCCO EMAIL *

 

Transition to Adult Programs (MDCP Age-Out)
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS Yes
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1200 1200 Yes
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H2116 2116 *
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from Higher Needs Coordinator HN EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
Emails to and from STAR+PLUS PSU PSU EMAIL *
Emails to and from UR UR EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Denials and Terminations
Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
CSIL Closure Screenshot CSIL CLOSURE Yes
Fair Hearing Options for MDCP Denials MN DENIAL ATCH Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from ERS ERS EMAIL Yes
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

 

Fair Hearings
Item HEART Naming Convention Required
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF Yes
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H4800 4800 *
Form H4800-A 4800A *
Form H4803 4803 Yes
Form H4806 4806 *
Form H4807 4807 *
Copy of TAC §353.1155 for SSI and MN denials TAC 353.1155 Yes
Copy of TAC §19.2401 for MN denials TAC 19.2401 Yes
Copy of Section 6240 for SSI denials SKOPH 6240 Yes
Copy of Section 6250 for MN denials SKOPH 6250 Yes
Fair Hearing Options for MDCP Denials MN DENIAL ATCH Yes
Notice of Hearing Officer’s Decision APPEAL DECISION LTR Yes
HHSC Benefits Portal Screenshot of Hearing Officer's Decision TIERS APPEAL DECISION Yes
Emails to and from CRU CRU EMAIL *
Emails to and from ERS ERS EMAIL Yes
MEPD Communication Tool MEPD EMAIL *

Appendix XIX, Mutually Exclusive Services

Appendix XX, MDCP Program Description

Revision 19-6; Effective March 25, 2019
 

English PDF: The Medically Dependent Children Program
Spanish PDF: El Programa para Niños Médicamente Dependientes

Appendix XXI, Reserved for Future Use

Appendix XXII, Instructions and Access to CARE

Appendix XXIII, Community First Choice Support Management

Appendix XXIV, Reserved for Future Use

Appendix XXV, Acronyms

Appendix XXVI, STAR Kids Plan Codes

Appendix XXVII, MDCP Medical Necessity Denial Attachment

Revision 19-4; Effective March 4, 2019

 

English Word: MDCP Medical Necessity Denial

Spanish Word: Denegación de servicios del MDCP, por no existir necesidad médica

Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide

3-2019

 

PDF Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide

 

 

 

Glossary

Revision 18-0; Effective September 4, 2018

 

# A B C D E F G H I K L M N O P Q R S T U V W

Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of an individual. Types of abuse include:

Action — An action is defined as:

An "action" does not include expiration of a time-limited service.

Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.

Acute Care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration.

Adult — A person 18 years of age or older, or an emancipated minor.

Adverse Action — A termination, suspension or reduction of Medicaid eligibility or covered services.

Agency Option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

Appeal — A request for a state fair hearing concerning an HHSC action.

Applicant — A person who has applied for Medicaid benefits.

Authorized Representative (AR) — For medical programs, the individual designated with written consent by an applicant, member or recipient to:

 

# A B C D E F G H I K L M N O P Q R S T U V W

Behavioral Health Service — A covered service for the treatment of mental, emotional, or substance use disorders.

Business Day — A day in which normal business operations are conducted; excluding state holidays.

 

# A B C D E F G H I K L M N O P Q R S T U V W

Capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is responsible for payment.

Capitation Rate — A fixed predetermined fee paid by HHSC to the MCO each month, in accordance with the contract, for each enrolled member in exchange for which the MCO arranges for or provides a defined set of covered services to the member, regardless of the amount of covered services used by the enrolled member.

Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.

Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.

Client — Any Medicaid-eligible recipient.

Code of Federal Regulations (CFR) — The codified federal regulatory law that governs most federal programs, including Medicaid.

Community First Choice (CFC) Option — Personal assistance services (PAS); habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in the Medically Dependent Children Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) program who have received an institutional level of care (LOC) determination.

Community Living Assistance and Support Services (CLASS) — A non-capitated §1915(c) Medicaid waiver which provides home and community-based services to people with intellectual or developmental disabilities other than intellectual disability as an alternative to residing in an intermediate care facility.

Complaint — Any dissatisfaction expressed by a complainant, orally or in writing, to the MCO about any matter related to the MCO other than an action. Subjects for complaints may include:

Comprehensive Care Program (CCP) — A package of Medicaid services available to clients based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps (THSteps) benefit for clients under age 21.

Consumer Directed Services (CDS) Employer — A member or legally authorized representative (LAR), parent, or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.

Consumer Directed Services Option — A service delivery option in which a member, AR or LAR employs and retains service providers and directs the delivery of STAR+PLUS HCBS program PAS and respite services. A member participating in the CDS option is required to use a financial management services agency (FMSA) chosen by the member, AR or LAR to provide financial management services.

Continued Benefits — Continuing or restoring benefits to the level authorized immediately before the notice of adverse action.

Co-payment — The amount of personal income a person must pay toward the cost of his or her care. Co-payment was formerly known as applied income.

Covered Services — Unless a service or item is specifically excluded under the terms of the state plan, a federal waiver, a managed care services contract, or an amendment to any of these, the phrase "covered services" means all health care, long term services and supports, or dental services or items that the MCO must arrange to provide and pay for on a member's behalf under the terms of the contract executed between the MCO and HHSC, including:

 

# A B C D E F G H I K L M N O P Q R S T U V W

Day — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

Day Activity and Health Services (DAHS) — Licensed DAHS facilities provide daytime services, up to 10 hours per day, Monday through Friday, to people who live in the community. Services address physical, mental, medical and social needs. People may attend up to five days per week, depending on their eligibility.

Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated §1915(c) Medicaid waiver which provides home and community-based services to individuals who are deaf and blind and have a third disability.

Denial — Closure of an application with a finding of ineligibility.

Designated Representative (DR) — A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the employer. A DR, usually a family member, is not a paid service provider and is at least age 18.

Disability — A physical or mental impairment that substantially limits one or more of an individual's major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, socializing or working.

Dual Eligible — A Medicaid recipient who is also eligible for Medicare.

Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.

 

# A B C D E F G H I K L M N O P Q R S T U V W

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — A federal Medicaid benefit for individuals under 21 years (called THSteps in Texas).

Eligibility Date — The first date all eligibility criteria are met.

Emergency Response Services (ERS) — Services provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure that the appropriate person or service provider responds to an alarm call from an individual.

Emergency Service — A covered inpatient and outpatient service, furnished by a network provider or out-of-network provider that is qualified to furnish such service, that is needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition. For health care MCOs, the term "emergency service" includes post-stabilization care services.

Employee (a.k.a. Service Provider) — An individual who is hired, trained and managed by the employer to provide services authorized by the MCO.

Enrollment — The process by which an individual determined to be eligible for Medicaid is enrolled in a Medicaid MCO serving the service area in which the individual resides.

Enrollment Broker — A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP).

Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of an individual by taking advantage of an individual's disability or impairment.

 

# A B C D E F G H I K L M N O P Q R S T U V W

Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by HHSC.

Family Member — A person who is related by blood, affinity or law to an individual.

Federal Waiver — Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.

Financial Management Services (FMS) —  Services delivered by the FMSA to the member, LAR, or AR who chooses the CDS option, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member, LAR, or AR.

Financial Management Services Agency (FMSA) — An agency that contracts with the MCO to provide FMS to members who choose the CDS option.

Functional Necessity — A member's need for services and supports with activities of daily living or instrumental activities of daily living to be healthy and safe in the most integrated setting possible. This determination is based on the results of a functional assessment.

 

# A B C D E F G H I K L M N O P Q R S T U V W

Guardian — A person appointed as a guardian of the estate or of the person by a court.

 

# A B C D E F G H I K L M N O P Q R S T U V W

Habilitation — Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks based on the individual's person-centered service plan.

Health Information — Any information, whether oral or recorded in any form or medium, that:

Health Maintenance Activity (HMA) — A task that may be exempt from delegation based on registered nurse assessment that enables the member to remain in an independent living environment, and goes beyond activities of daily living because of the higher skill level required to perform.

Health Insurance Portability and Accountability Act (HIPAA) — A federal law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Home and Community-based Services (HCS) — A non-capitated §1915(c) Medicaid waiver which provides home and community-based services to individuals with intellectual or developmental disabilities as cost-effective alternatives to institutional care.

 

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Income — Any item a person receives in cash or in-kind that can be used to meet his or her need for food or shelter. For purposes of determining MEPD financial eligibility, income includes the receipt of any item that can be applied, either directly or by sale or conversion, to meet the basic needs of food or shelter.

Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.

Individual Service Plan (ISP) — An individualized and person-centered plan in which a member enrolled in the STAR+PLUS HCBS program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.

Individual Service Plan (ISP) Service Tracking Tool — This tool is developed at least annually by the member, the MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost limit. This is also known as Form 2604.

Institutional Care — Long-term nursing care, treatment or services received in a Medicaid-certified long-term care facility.

Institutional Setting — A living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under a Home and Community-Based Services waiver program. Formerly known as a vendor living arrangement.

Instrumental Activities of Daily Living (IADLs) — Activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, doing laundry, and using a telephone.

Intellectual and Developmental Disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social, and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.

Interdisciplinary Team (IDT) — All individuals/entities involved in planning the member’s plan of care (POC). This typically includes the member, the member’s authorized representative, the service coordinator, the primary care physician, etc.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) — A Medicaid-certified facility that provides care in a 24-hour specialized residential setting for individuals with an intellectual disability or related condition. An ICF/IID includes a state supported living center and a state center.

Interest List — A list of people who have contacted HHSC and expressed an interest in receiving waiver services, but who have not applied for or been determined eligible for services.

 

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Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of an member, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code §752.

Level of Care (LOC) — The type of care a person is eligible to receive in an ICF/IID based upon an assessment of the person's need for care.

Local Intellectual and Developmental Disability Authorities (LIDDAs) — Authorities that serve as the point of entry for publicly funded intellectual and developmental disability (IDD) programs, whether the program is provided by a public or private entity. LIDDAs:

Long Term Services and Supports (LTSS) —  A service provided to a qualified member in his or her home or other community-based setting necessary to allow the member to remain in the most integrated setting possible; assist members in living in the community as opposed to a institutionalized setting. LTSS includes services provided under the Texas State Plan as well as services available to persons who qualify for STAR+PLUS HCBS or §1915(c) Medicaid waiver services. LTSS available through an MCO in STAR+PLUS, STAR Health, and STAR Kids varies by program model.

 

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Managed Care Compliance & Operations (MCCO) — A unit within the Medicaid/Children's Health Insurance Program (CHIP) Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.

Managed Care Organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with §843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.

Medicaid — A program administered by the federal Centers for Medicare and Medicaid Services (CMS), and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.

Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.

Medicaid Estate Recovery Program (MERP) — A program that requires HHSC, as the State Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients.

Medicaid for the Elderly and People with Disabilities (MEPD) — A public assistance program providing medical assistance, institutional and community-based health-related care, and Medicare cost-sharing assistance for the elderly and people with disabilities. MEPD does not provide cash assistance.

Examples of MEPD services and programs are:

Medical Assistance Only (MAO) — A person who qualifies financially and functionally for Medicaid assistance but does not receive SSI benefits, as defined in Title 1 TAC §358, §360, and §361 (relating to MEPD, Medicaid Buy-In Program and Medicaid Buy-In for Children Program).

Medical Necessity (MN) — The medical criteria a person must meet for admission to a Texas nursing facility (NF), as defined in Title 40 Texas Administrative Code (TAC) §19.2401.

Medically Dependent Children Program (MDCP) — A §1915(c) Medicaid waiver program that provides LTSS home and community-based services to help the primary caregiver care for an individuals with a nursing facility level of need and their families in the community.

Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease (ESRD).

Member — An individual who is enrolled in and receiving services through a STAR Kids or STAR+PLUS MCO.

Money Follows the Person (MFP) — A process whereby the funds used for payment of institutional care follows the person when transitioning; used when a member in a Medicaid-certified NF who requests to move to the community is Medicaid-eligible and approved for the MDCP or STAR+PLUS HCBS program before leaving the NF.

Mutually Exclusive Services — Two or more services that may not be authorized for the same individual during the same time period.

 

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Neglect — The failure to provide an individual the reasonable care required, including but not limited to:

Non-capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is not responsible for payment.

Non-institutional Setting — A living arrangement in which a person applying for or receiving Medicaid does not live in a long-term care facility or receive services under an HCBS waiver program. Formerly known as a non-vendor living arrangement.

Nursing Facility (NF) — A residential institution that primarily provides:

 

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Person-centered Planning — A documented service planning process that includes people chosen by the individual, is directed by the individual to the maximum extent possible, enables the individual to make choices and decisions, is timely and occurs at times and locations convenient to the individual, reflects cultural considerations of the individual, includes strategies for solving conflict or disagreement within the process, offers choices to the individual regarding the services and supports they receive and from whom, includes a method for the individual to require updates to the plan, and records alternative settings that were considered by the individual.

Personal Assistance Services (PAS) — A range of services provided by one or more persons designed to assist an individual with a disability to perform daily living activities on or off the job that the individual would typically perform without assistance if the individual did not have a disability.

Personal Care Services (PCS) — Services that include bathing, dressing, preparing meals, feeding, grooming, taking self-administered medication, toileting, ambulation, and assistance with other personal needs or maintenance.

Personal Identifiable Information (PII) — Information that is a subset of health information, including demographic information collected from an individual, and:

Plan of Care (POC) — A care plan the MCO develops for its members that includes acute care and LTSS. The POC is not the same as the ISP.

Primary care provider (PCP) — A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

Program Support Unit (PSU) Staff — An HHSC unit of with staff who support and handle certain aspects of the STAR Kids program and STAR+PLUS program.

Protected Health Information (PHI) — The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

 

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Qualified Income Trust (QIT) (a.k.a. Miller Trust) — An irrevocable trust specially designed to legally divert an individual or married couple’s income into a trust resulting in the income being excluded for purposes of determining eligibility for nursing home (“institutional”) Medicaid and §1915(c) home and community-based Medicaid waiver services.

 

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Respite Services — Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Responsible Adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.

Responsible Party — An individual who:

 

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Service Area (SA) — The counties included in any HHSC-defined service area as applicable to each MCO.

Service Coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR+PLUS members.

Service Provider (a.k.a. Employee) — An individual who is hired, trained and managed by the employer to provide services authorized by the MCO.

Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing PAS. The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

Social Security Administration (SSA) — A federal agency that administers the social insurance programs in the U.S and authorizes Medicaid and waiver services.

Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.

State of Texas Access Reform (STAR) — STAR managed care program that operates under a federal waiver and primarily provides, arranges for, and coordinates preventive, primary, acute care, and pharmacy services for low-income families, children, and pregnant women.

STAR Health — The managed care program that operates under the Medicaid state plan and primarily serves:

STAR Kids — Authority granted to the state of Texas to allow delivery of LTSS and acute care services to children and young adults with disabilities under the age of 21. The STAR Kids program assist members to live in the community in lieu of an NF.

STAR+PLUS Home and Community Based Services (HCBS) Program — Authority granted to the state of Texas to allow delivery of community-based LTSS to adults with disabilities over the age of 21. The STAR+PLUS program assist members to live in the community in lieu of an NF.

STAR+PLUS Program — The STAR+PLUS Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange, and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program. Children under age 21, who qualify for Medicaid through the SSI program, may voluntarily participate in the STAR+PLUS program. The STAR+PLUS program is the umbrella designation that includes both the STAR+PLUS services and STAR+PLUS HCBS program.

STAR+PLUS Program Specialist — The staff person responsible, along with MCCO, for STAR+PLUS policy development.

State Plan — The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.

Supplemental Security Income (SSI) — A federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter.

Support Advisor — An employee who provides support consultation to an employer, a DR, or a member receiving services through the CDS Option.

Support Consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.

 

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Transition Assistance Services (TAS) Agency — An agency that provides a one-time service to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the NF into the community.

Termination — Closure of an ongoing case due to a finding of ineligibility.

Texas Administrative Code (TAC) — A compilation of all the state rules in Texas that implement state programs and services.

Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code §531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.

Texas Home Living (TxHmL) — The Texas Home Living Program, operated by HHSC and approved by CMS in accordance with §1915(c) of the Social Security Act, that provides community-based services and supports to eligible individuals who live in their own homes or in their family homes.

Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service (FFS) claims processing. TMHP is responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for Medicaid waiver programs.

Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved state Medicaid plan, or as part of their caregiving arrangement without pay.

Texas Health Steps (THSteps) — The EPSDT benefit in Texas.

Texas Health Steps-Comprehensive Care Program (THSteps-CCP) — Texas Health Steps is also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. Texas Health Steps is dedicated to:

TxMedCentral — A secure internet bulletin board the state and MCOs use to share personal identifiable information (PII) and protected health information (PHI).

 

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Unlicensed Assistive Person (UAP) — A paraprofessional who assists individuals with physical disabilities, mental impairments, and other health care needs with their ADLs, and provides bedside care. A UAP may perform nursing tasks only in specific situations, as governed by the Title 22 Texas Administrative Code (TAC) §224 and Title 22 TAC §225.

Upgrade — An existing STAR+PLUS member who requests STAR+PLUS HCBS program services, or if the MCO determines the member would benefit from the STAR+PLUS HCBS program, is granted services after meeting waiver eligibility criteria.

Utilization Review (UR) — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.

 

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Value-added Service — A service provided by an MCO that is not "medical assistance," as defined by Title 2 Texas Human Resources Code §32.003.

Forms

ES = Spanish version available.

Form Title  
1579 Referral for Relocation Services ES
1580 Texas Money Follows the Person Demonstration Project Informed Consent for Participation ES
1581 Consumer Directed Services Overview ES
1582 Consumer Directed Services Responsibilities ES
1582-SRO Service Responsibility Option Roles and Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1585 Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
1586 Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1826-D Case Information Release  
2406 Physician Recommendation for Length of Stay in a Nursing Facility ES
2416 Minor Home Modifications and Adaptive Aids Service Authorization  
2442 Notification of Interest List Release Closure ES
2601 Physician Certification ES
2602 Application Acknowledgment ES
2603 STAR Kids Individual Service Plan (ISP) Narrative ES
2604 STAR Kids Individual Service Plan - Service Tracking Tool ES
2606 Managed Care Enrollment Processing Delay ES
3618 Resident Transaction Notice  
H0003 Agreement to Release Your Facts ES
H1097 Affidavit for Citizenship/Identity ES
H1746-A MEPD Referral Cover Sheet  
H1746-B Batch Cover Sheet  
H2053-B Health Plan Selection ES
H2065-D Notification of Managed Care Program Services ES
H2067-MC Managed Care Programs Communication  
H1200 Application for Assistance – Your Texas Benefits  
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES
H3676 Managed Care Pre-Enrollment Assessment Authorization  
H4800 Fair Hearing Request Summary  
H4800-A Fair Hearing Request Summary (Addendum)  
H4803 Notice of Hearing  
H4807 Action Taken on Hearing Decision  

Revisions

20-3, Appendix XVIII Changes

Revision Notice 20-3; October 9, 2020

 

The following change(s) were made:

Section Title Change
Appendix XVIII STAR Kids HEART Naming Conventions Revises the documents to upload to the HHS Enterprise Administrative Report and Tracking System (HEART) and other miscellaneous changes.

20-2, Appendix II Change

Revision Notice 20-2; July 23, 2020

 

The following change(s) were made:

Section Title Change
Appendix II Form H2065-D MDCP Reason for Denial and Comments Language Revises “Inappropriate Living Situation” language, now listed as “Living Arrangement is Not an Allowable Setting.”

20-1, Appendix XVIII Changes

Revision Notice 20-1; June 8, 2020

 

The following change(s) were made:

Section Title Change
Appendix XVIII STAR Kids HEART Naming Conventions Revises the appendix to clarify the naming conventions when uploading to HEART.

19-13, Appendix Deleted

Revision Notice 19-13; September 5, 2019

 

The following change(s) were made:

Section Title Change
Appendix XVII Reserved for Future Use Deletes the Program Transfer with Form H1200 Guide.

Policy Updates

Release Date Title
   

Contact Us

For questions about the STAR Kids Program Support Unit Operational Procedures Handbook, email: HHSC_MCD_PSU_Policy@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us