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.