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.

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 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022 

A member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

  • be birth through 20;
  • reside in Texas;
  • have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
  • have a need for at least one MDCP service not being addressed by other services and supports;
  • not enrolled in another waiver program;
  • live in an appropriate living situation;
  • have a STAR Kids individual service plan (SK-ISP) with services under the established cost limit; and
  • have full Medicaid eligibility.

Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an individual, applicant or member.

3210.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022 

A member must meet the following criteria as stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 in order to be eligible for the Medically Dependent Children Program (MDCP):

  • be under 21 years old; 
  • reside in Texas; 
  • meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care as determined by the Texas Health and Human Services Commission (HHSC); 
  • have an unmet need for support in the community that can be met through one or more MDCP services; 
  • choose MDCP as an alternative to NF services, as described in 42 Code of Federal Regulations (CFR) Section 441.302(d)
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs approved by the Centers for Medicaid & Medicare Services (CMS): 
    • the Community Living Assistance and Support Services (CLASS) Program; 
    • the Deaf Blind with Multiple Disabilities (DBMD) Program; 
    • the Home and Community-based Services (HCS) Program; 
    • the Texas Home Living (TxHmL) Program; or 
    • the Youth Empowerment Services waiver; 
  • live in: 
  • be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title (relating to Medicaid Eligibility for the Elderly and People with Disabilities).

3210.2 Reassessment of Medical Necessity Determination

Revision 23-4; Effective Aug. 21, 2023

A Medically Dependent Children Program (MDCP) member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before Program Support Unit (PSU) staff recertifies the member for MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

The managed care organization (MCO) is not required to get a physician’s signature on Form 2601, Physician’s Certification, for reassessments.

The MCO completes and submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care Online Portal (LTCOP) annually. The TMHP nurse or physician processes the SK-SAI and redetermines the member’s Resource Utilization Group (RUG) value and MN.

PSU staff must monitor the TMHP LTCOP every five business days until the MN status updates to one of the final statuses below:

  • MN Approved: The status may change to "MN Approved" if the TMHP physician overturns the denial because more information is received; or 
  • Overturn Doctor Review Expired: The status may change to "Overturn Doctor Review Expired" when the 14-business day period for the TMHP physician to overturn the denied MN has expired, and no additional or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the member, legally authorized representative (LAR), or medical consenter requests a state fair hearing.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, for more information about state fair hearings regarding MN denials.

The MCO must notify PSU staff of a member’s MN denial and request Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. Refer to Section 6000, Denials and Terminations, for more information about processing MN terminations. Refer to Section 3328, Reassessment Notification Requirements, for more information about PSU notification requirements.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the termination of MDCP for STAR Health members.

The MCO uses the SK-SAI to create the member’s reassessment STAR Kids individual service plan (SK-ISP). The SK-ISP lists the member’s services and preferences for care. 

PSU staff do not calculate the SK-ISP cost limit. TMHP LTCOP automatically calculates the cost limit based on the RUG value. PSU staff must verify the member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than the Annual Cost Limit in the TMHP LTCOP SK-ISP.

The MCO must:

  • Track the SK-SAI and SK-ISP renewal dates to ensure all member reassessment activities are completed within 30 days before the SK-ISP expiration date. 
  • Not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the previous SK-SAI. 
  • Submit the SK-SAI in the TMHP LTCOP no earlier than 90 days before or no later than 30 days before the expiration of the member’s current SK-ISP on file. 
  • Upload Form H2067-MC to TxMedCentral documenting any reason for a delay.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox monthly. The ISP Expiring Report details members with SK-ISPs that expire within the next 90 days. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs reported as an MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month]”.

PSU staff are not required to send a follow-up email to PSORT when the MCO submits the following documents for reassessment delinquencies: 

  • Form H2067-MC; 
  • the SK-SAI; or 
  • the SK-ISP.

Refer to Section 3327.1, Process for Reviewing the Individual Service Plan Expiring Report, for more information about the ISP Expiring Report.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must document the HEART case record.
 

3210.3 Texas Administrative Code Medical Necessity Determination Requirements

Revision 22-3; Effective Sept. 9, 2022 

Medical necessity (MN) is the prerequisite for participation in the Medically Dependent Children Program (MDCP). MN exists when an individual, applicant or member meets the conditions described below:

  • The individual must demonstrate a medical condition that: 
    • is sufficient serious that the individual's needs exceed the routine care which may be given by an untrained person; and 
    • requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution. 
  • The individual must require medical or nursing services that: 
    • a physician orders; 
    • are dependent upon the individual's documented medical conditions; 
    • require the skills of a registered or licensed vocational nurse; 
    • are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and 
    • are required on a regular basis.

PSU staff must refer to Section 3210.2, Reassessment of Medical Necessity Determination, for the information about MN redetermination procedures.

3300, Member Service Planning and Authorization

Revision 23-3; Effective May 22, 2023

The managed care organization (MCO) must collaborate with the member and legally authorized representative (LAR) to create and update Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, also known as the STAR Kids individual service plan (SK-ISP). The MCO develops the SK-ISP using a person-centered process with the support of a group of people chosen by the member or LAR. 

The purpose of the SK-ISP is to articulate assessment findings from the STAR Kids Screening and Assessment Instrument (SK-SAI). It includes short and long-term goals, service needs and member preferences. 

The MCO uses the SK-ISP for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the MCO; 
  • documenting services received through third-party sources; 
  • identifying a member's strengths, preferences, support needs, and desired outcomes; 
  • identifying what is essential to the member; 
  • identifying natural supports available to the member and needed supports; 
  • documenting the member's preferences for when and how to receive services; 
  • identifying special needs, requests, or considerations the MCO or providers should know when supporting the member; and 
  • documenting the member's unmet needs. 

The MCO must:

  • write the SK-ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language; 
  • submit the electronic SK-ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, as applicable; 
  • create and update the SK-ISP at least annually, as applicable; 
  • ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility; 
  • provide a printed or electronic copy of the SK-ISP to the member or LAR following any significant update; 
  • retain any amended SK-ISP in an MCO member's case file;
  • provide the Texas Health and Human Services Commission (HHSC) staff with the SK-ISP upon request; 
  • not provide significant change SK-ISPs to Program Support Unit (PSU) staff; and
  • authorize all services identified on the SK-ISP.

The SK-ISP must be within the member's cost limit. PSU staff must not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP SK-ISP Annual Cost Limit field.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

3310 Service Planning

Revision 23-3; Effective May 22, 2023

Form 2603, STAR Kids Individual Service Plan (SK-ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and to develop the SK-ISP. The managed care organization (MCO) is responsible for completing Form 2603. The MCO maintains Form 2603 in the MCO's case file.

At a minimum, Form 2603 must account for the following information:

  • a summary document describing the recommended service needs identified through the SK-SAI;
  • covered services currently received;
  • covered services not currently received but the member may benefit from;
  • a description of non-covered services that could benefit the member;
  • member and family goals and service preferences;
  • natural strengths and supports of the member, including helpful family members, community supports or special capabilities;
  • a description of roles and responsibilities for the member, legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the MCO and the member's school with respect to maintaining and maximizing the health and well-being of the member;
  • a plan for coordinating and integrating care between providers and covered and non-covered services;
  • short and long-term goals for the member's health and well-being;
  • services provided to the member through other third-party resources (TPR) and the sources or providers of those services;
  • plans specifically related to transitioning to adulthood for members 15 and older;
  • a list of Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable;
  • a brief rationale for the services; and
  • any other information to describe strategies to meet service objectives and member goals.

The MCO must include the items listed above in the SK-ISP.

3320 Service Planning for Medically Dependent Children Program Services

Revision 23-3; Effective May 22, 2023

The STAR Kids individual service plan (SK-ISP) contains a list of all the member's services, including Medically Dependent Children Program (MDCP) services. The managed care organization (MCO) lists MDCP services on Form 2603, STAR Kids Individual Service Plan Narrative. The list of MDCP services on Form 2603 must match the services listed on the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

The MCO must submit Form 2604 to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) before the start date of the member's SK-ISP following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MCO must collaborate with the member or legally authorized representative (LAR) to create the SK-ISP including MDCP services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. Program Support Unit (PSU) staff will not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field.

The MCO must initiate a reassessment for MDCP to determine and validate the need for continued services listed on the SK-ISP for each member before the end date of the annual STAR Kids Screening and Assessment Instrument (SK-SAI). The MCO must ensure all member reassessment activities, including submitting the SK-ISP to the TMHP LTCOP, are completed no earlier than 90 days and no later than 30 days before the expiration of the member's current SK-ISP on file. Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility. 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 23-3; Effective May 22, 2023

It may be necessary for the managed care organization (MCO) to revise the STAR Kids individual service plan (SK-ISP) within the SK-ISP period due to situations outlined in the STAR Kids Contract, Section 8.1.39.1.

The MCO must retain the amended SK-ISP in the MCO's member case file. 

The MCO must not submit the revised SK-ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to TxMedCentral.

3322 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3323 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3324 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

 

3325 Reserved For Future Use

Revision 23-4; Effective Aug. 21, 2023

 

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:

  • dates during which services are suspended; and
  • reason for suspension.

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 Procedures

Revision 22-3; Effective Sept. 9, 2022

Program Support Unit (PSU) staff must ensure the member’s STAR Kids individual service plan (SK-ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for all SK-ISPs submitted on a daily basis. 

PSU staff must complete the following activities within five business days of receipt of the SK-ISP:

  • verify the member is under 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • verify the member is a Texas resident in TIERS;
  • check the TMHP LTCOP to determine if the managed care organization (MCO) has submitted the member’s SK-ISP before the SK-ISP end date;
  • verify the member has an approved medical necessity (MN) and STAR Kids Screening and Assessment Instrument (SK-SAI) in the TMHP LTCOP;
  • verify the member’s SK-ISP is within the cost limit;
  • confirm ongoing Medicaid financial eligibility and managed care enrollment is active in TIERS; 
  • verify the member has an SK-ISP with a least one Medically Dependent Children Program (MDCP) service;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and 
  • document the HEART case record.

The member’s MDCP services will continue using the existing SK-ISP until a decision is received from the hearings officer if:

  • a member’s reassessment SK-ISP is developed; and
  • not submitted due to the member's timely appeal of an MDCP denial. 

PSU staff and the MCO coordinate the submission of a reassessment SK-ISP to ensure:

  • the SK-ISP records are correct; and 
  • the reassessment SK-ISP processes correctly once the state fair hearing decision is reached.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox each month. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs being reported as a MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month].” 

The assigned PSU staff is not required to send a follow up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

  • Form H2067-MC, Managed Care Programs Communication; 
  • the SK-SAI; or 
  • the SK-ISP. 

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late reassessment activity. 

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

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:

  • PSU staff provide the ISP Expiring Report to the MCO point of contact and to Managed Care Compliance & Operations (MCCO) staff by email five business days prior to the scheduled monthly call. The day of the call is not considered one of the business days.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, completing the columns highlighted in red on the spreadsheet.
  • The MCO must return a completed report to PSU staff within two business days prior to the monthly call.
  • PSU staff review the MCO responses to determine if the MCO needs to provide clarification regarding any member’s ISP status. During the monthly call, only ISP statuses about which PSU staff have questions are reviewed. There is no need to review each member for the status of the ISP if the MCO response is sufficient. PSU staff use the columns in blue on the spreadsheet for internal tracking purposes.

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 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, at reassessment as notification of continuing Medically Dependent Children Program (MDCP) eligibility if the member meets MDCP requirements. 

PSU staff must complete the following activities for an approved MDCP reassessment within five business days from verification that the member continues to meet all MDCP requirements:

  • electronically generate Form H2065-D in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • mail Form H2065-D to the member, legally authorized representative (LAR) or medical consenter; 
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR  Kids HEART Naming Conventions; and 
  • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, if the member does not meet MDCP requirements at reassessment.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, if the member, LAR or medical consenter files a state fair hearing within the adverse action notification time period.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements regarding the termination of MDCP for STAR Health members.

3400, Member Transfers

3410 Transfer from One MCO to Another

Revision 22-3; Effective Sept. 9, 2022

A member or legally authorized representative (LAR) can request to change managed care organization (MCO) plans as often as they want, but the change cannot be made more than once per month. A member can only be enrolled with one MCO for a given month.  
A member or LAR who wants to change from one MCO to another MCO must contact the state-contracted enrollment broker by: 

  • phone: 800-964-2777;
  • fax: 855-671-6038; or
  • mail: 
    HHSC 
    P.O. Box 149023 
    Austin TX 78714-9023

Note: Adoption Assistance or Permanency Care Assistance (AAPCA) members must contact the state’s enrollment broker to request transfer.

MCO enrollment changes become effective based on the date the MCO change is requested and processed in relation to state cutoff. 

Refer to Appendix XIV, State Cutoff Charts, for more information on for additional information on current cutoff dates.

Monthly Plan Changes Report

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. The report gives a full list of all Medically Dependent Children Program (MDCP) members who have changed MCOs from the previous month. PSU staff are not required to provide the Plan Change Report to the MCOs. MCOs receive the plan change report for their members only through an automated process in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP).

The losing MCO and the gaining MCO must coordinate and share applicable member information in order to prevent a gap in services during the transfer. In cases where this does not occur, the HHSC Managed Care Contracts and Oversight (MCCO) Unit staff must request PSU staff intervention. Within two business days of notification from MCCO Unit staff, PSU staff must assist with the transfer of information from the losing MCO to the gaining MCO.

The gaining MCO will have access to current and historical STAR Kids Screening and Assessment Instruments (SK-SAIs) and STAR Kids - Individual Service Plans (SK-ISPs) in the TMHP LTCOP once the member is enrolled with them. 
The gaining MCO is responsible for service delivery from the first day of enrollment. The gaining MCO must provide services and honor authorizations included in the prior SK-ISP until the member receives a new SK-SAI. 

3420 Transfer from Another Medicaid Waiver Program to Medically Dependent Children Program

Revision 21-10; Effective October 25, 2021

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 Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by a member.

Individuals in the following Intellectual and Developmental Disabilities (IDD) waiver programs may be on the interest list for MDCP:

  • Community Living Assistance and Support Services (CLASS);
  • Home and Community-based Services (HCS);
  • Deaf Blind with Multiple Disabilities (DBMD); or
  • Texas Home Living (TxHmL).

Program Support Unit (PSU) staff will receive a Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) interest list release (ILR) case record assignment from Interest List Management (ILM) Unit staff when an individual in another IDD waiver program comes to the top of the MDCP interest list and requests MDCP. PSU staff may also receive notification from IDD waiver program staff.

PSU staff must complete the following activities within three business days of the receipt of the MDCP ILR case record assignment in HEART or notification from IDD waiver program staff:

  • Create a case record in HEART, if applicable;
  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid eligibility;
  • Verify that individual has an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the TxHmL or HCS waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the CLASS (Service Group 2) and DBMD (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
    • Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income;
    • Form 2602 , Application Acknowledgement;
    • Appendix IV, MDCP Frequently Asked Questions;
    • Appendix XX, MDCP Program Description; and
    • a postage-paid envelope.

PSU staff must contact the individual or LAR within 14 days from the mail date of the above enrollment packet to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Give a general description of MDCP services; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual or LAR did not express interest in MDCP.

PSU staff can accept the individual’s or LAR’s verbal statement of interest in MDCP. PSU staff must document all attempted contacts with the individual, LAR and IDD waiver program staff and any delays in the HEART case record.

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

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP services.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain confirmed interest in MDCP, if PSU have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual or LAR does not express interest in MDCP.

PSU must document all contact attempts in the HEART case record.

The individual or LAR is not required to select a managed care organization (MCO) since the individual is already enrolled with a STAR Kids MCO. PSU staff can accept the individual or LAR’s verbal statement of interest in MDCP.

PSU staff must complete the following activities within two business days from the date the individual or LAR expressed interest in MDCP:

  • Complete Form H3676 , Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) within a total of 30 days from the date PSU staff uploaded Form H3676, Section A to TxMedCentral. The SK-SAI is considered “complete” when the MCO has obtained a physician’s signature on Form 2601, Physician’s Certification.

The MCO must submit the complete SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral. PSU staff must monitor the TMHP LTCOP for receipt of the completed SK-SAI.

The MCO must submit the following documents within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The STAR Kids Individual Service Plan (SK-ISP) to the TMHP LTCOP; and
  • Form H3676, Section B to TxMedCentral.

PSU staff must monitor TxMedCentral for receipt of Form H3676, Section B. PSU staff must monitor the TMHP LTCOP for receipt of the SK-ISP.

PSU staff must email Managed Care Compliance & Operations (MCCO) Unit staff at PSU_Past_Due_Assessments@hhsc.state.tx.us to advise if the MCO has not completed and submitted the following items within 60 days of the date of PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The completed SK-SAI;
  • The completed SK-ISP or
  • Form H3676, Section B.

PSU staff must contact and coordinate with IDD waiver program staff, the applicant, LAR and MCO as appropriate, ensuring the applicant’s current Medicaid waiver program services end one day before enrollment in MDCP.

PSU staff must complete the following activities within two business days of receipt of all required MDCP eligibility documentation:

  • Confirm MDCP eligibility by verifying the applicant:
    • is under age 21 in TIERS;
    • is a Texas resident in TIERS;
    • has a compatible Medicaid eligibility for MDCP in TIERS;
    • has an approved medical necessity (MN) in the TMHP LTCOP;
    • has an SK-ISP with a least one MDCP service; and
    • has an SK-ISP within the applicant’s cost limit.

PSU staff must approve the applicant’s enrollment in MDCP the first day of the following month after verifying all MDCP eligibility criteria are met. PSU staff must complete the following activities within two business days of determining the start of care (SOC) date for MDCP:

  • Generate Form H2065-D, Notification of Managed Care Program Services, following the instructions Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, in the TMHP LTCOP;
  • Mail Form H2065-D to the member or LAR;
  • Email Enrollment Resolution Services (ERS) Unit at ManagedCareEligibilityEnrollment@hhsc.state.tx.us. The email to the ERS Unit must include the following information:
    • an email subject line that reads: “Waiver Transfer for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for a waiver transfer for Ann Smith would be “Waiver Transfer for ANN.SMI”;
    • member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., waiver transfer);
    • MN approval date;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO;
    • effective date of enrollment; and
    • Form H2065-D; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII;
  • Document all contacts with the IDD waiver program staff, member, LAR or MCO and any delays; and
  • Close the HEART record.

PSU staff must complete the following activities for an individual whose MDCP eligibility is denied or who declined MDCP:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, notifying the MCO that the individual is not eligible for MDCP;
  • Upload all applicable documents to the HEART case record. following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

The MCO must upload Form H3676, Section B, to TxMedCentral within two business days if the applicant fails to meet any MDCP eligibility criteria other than Medicaid financial eligibility. PSU staff must complete the following activities for an applicant whose MDCP eligibility is denied or who declined MDCP:

  • Electronically generate Form H2065-D if the applicant is denied due to not meeting MN;
  • Manually generate Form H2065-D if the applicant is denied for reasons other than MN;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral if manually generated;
  • Fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist for medical assistance only (MAO) members;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record. 

3430 Transfer from MDCP to Another Medicaid Waiver Program

Revision 23-4; Effective Aug. 21, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(F) states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if a member may receive two services simultaneously.
MDCP members may be on an interest list for an Intellectual and Developmental Disabilities (IDD) waiver 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).

Program Support Unit (PSU) may receive notification from IDD waiver program staff or the MDCP member’s managed care organization (MCO) that the MDCP member:

  • has come to the top of an IDD waiver program interest list;
  • chooses to transfer to the IDD wavier program; or
  • is already enrolled with an IDD waiver program.

PSU staff must complete the following activities within three business days from notification:

  • create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART), if applicable;
  • contact and coordinate with IDD waiver program staff by email to determine an MDCP termination date and a start of care (SOC) date for the IDD waiver program;
    • The MDCP termination date must be the last day of the month before the IDD waiver SOC date.
  • terminate the STAR Kids Individual Service Plan (SK-ISP) and the Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to the last day of the month before the IDD waiver SOC date. 
  • manually generate Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral;
  • mail Form H2065-D to the member, legally authorized representative (LAR) or medical consenter;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the MDCP termination date and the enrollment effective date for the new Medicaid waiver program; 
  • upload all applicable documents to the HEART case record;
  • document all contacts with the IDD waiver program staff, member, LAR, medical consenter or MCO and any delays; and
  • close the HEART case record. 

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 23-3; Effective May 22, 2023

All STAR Kids members begin transition activities at age 15 and periodically meet with a transition specialist to plan their transition to an adult program.

A person receiving Medically Dependent Children Program (MDCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC): 

  • is no longer eligible for these services at 21 years old; 
  • must transition to an adult program; and
  • may choose to transition to the STAR+PLUS Home and Community Based Services (HCBS) program.

Each quarter, Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the MDCP PDN Transition Report to: 

  • Program Support Unit (PSU) supervisors and managers; and
  • UR unit for the Intellectual and Developmental Disability (IDD) 1915(c) waivers.

The report lists members enrolled in STAR Kids: 

  • receiving MDCP, PDN or PPECC services; and
  • who may transition to STAR+PLUS or the STAR+PLUS HCBS program in the next 12 months.

PSU staff must refer to Appendix VI, STAR Kids Transition Activities, for more information about managing this report, including time frames.

3510 Twelve Months Before the Member's 21st Birthday

Revision 23-3; Effective May 22, 2023

The member’s STAR Kids managed care organization (MCO) identifies all members turning age 21 within the 12 months before the member's 21st birthday. The STAR Kids MCO schedules a face-to-face visit with the member and the member's available supports to initiate the transition process to:

  • provide an overview of the STAR+PLUS Home and Community Based Services (HCBS) program; and
  • discuss the changes that will occur in the first month following the member's 21st birthday.

The STAR Kids MCO follows up with the member or legally authorized representative (LAR) every 90 days during the year before the member turns 21. This is to ensure the MCO completes all transition activities.

The enrollment broker (EB) will contact the member 30 days before the member’s 21st birthday and mail the STAR+PLUS HCBS enrollment packet. EB will select an MCO for the member if no selection has been made within 15 days, as outlined in Title 1 Texas Administrative Code (TAC) Section 353.403(3).  

The member’s selected or defaulted STAR+PLUS MCO conducts the Medical Necessity and Level of Care (MN/LOC) Assessment for those receiving the Medically Dependent Children Program (MDCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) to determine eligibility for the STAR+PLUS HCBS program before 21.

Members who meet the STAR+PLUS HCBS program enrollment criteria will transition to the STAR+PLUS HCBS program on the first of the month following their 21st birthday. MDCP eligibility terminates on the last day of the month when the member's 21st birthday occurs.

Program Support Unit (PSU) staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for PSU staff denial procedures for MDCP members transitioning out of MDCP due to turning 21.

PSU staff must refer to the following resources for more detailed information about STAR Kids transition activities, as applicable: 

  • Appendix VI, STAR Kids Transition Activities;
  • the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH); and 
  • the STAR+PLUS Handbook (SPH). 

3520 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only

Revision 21-10; Effective October 25, 2021

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the non-waiver program individual’s or applicant’s 21st birthday occurs. The non-waiver program individual or applicant with STAR Kids or STAR Health must receive services through programs serving adults beginning the first day of the month following the non-waiver program individual’s or applicant’s 21st birthday.

Individuals or applicants with STAR Kids and STAR Health must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program. Some individuals or applicants with STAR Kids and STAR Health may continue to receive PCS or CFC through STAR Health until age 22 depending on eligibility requirements.

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