6100, Description

Revision 22-1; Effective January 31, 2022

This section contains policy for Program Support Unit (PSU) staff when processing:

  • case closure for an individual applying for the Medically Dependent Children Program (MDCP);
  • denials and terminations for an applicant or member; and
  • information regarding adequate notice of an applicant’s or member’s right to due process.

PSU staff must mail Form 2442, Notification of Interest List Release Closure, as notification of an MDCP interest list closure to an individual when the individual does not meet MDCP eligibility. PSU staff must always mail Form 2442 with Appendix XX, MDCP Program Description. Form 2442 does not provide the right to request a state fair hearing. An individual will only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff must mail an applicant or member Form H2065-D when the applicant or member is denied or terminated from MDCP. Form H2065-D provides an applicant or member with the right to request a state fair hearing. An applicant or member will never receive Form 2442.

Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), provides the rules for adverse action for members required by Title 42 Code of Federal Regulations (CFR) Part 431, Subpart E, including requiring that: 

  • the written notice to the member of their right to a hearing must:
    • contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and 
    • be delivered by mail, and postmarked at least 10 business days, before the date the member’s Medicaid eligibility or service is scheduled to be terminated, suspended or reduced, except as provided by Title 42 CFR §431.213 or Title 42 CFR §431.214; and
  • if a hearing is requested before the date a member’s service, including a service that requires prior authorization, is scheduled to be terminated, suspended or reduced, Texas Health and Human Services Commission (HHSC) may not take that proposed action before a decision is rendered after the hearing unless: 
    • it is determined at the hearing that the sole issue is one of federal or state law or policy; and
    • the agency promptly informs the recipient in writing that services are to be terminated, suspended or reduced pending the hearing decision.

Title 42 CFR Part 431, Subpart E, governs fair hearing rights for Medicaid individuals, applicants and members. However, Title 42 CFR §431.213 specifies situations where an adverse action notification period is not required. The agency may mail a notice not later than the date of action if:

  • The agency has factual information confirming the death of an individual, applicant or member; 
  • The agency receives a clear written statement signed by a member that:
    • they no longer want to receive services; or
    • gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information; and
  • The individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
  • The individual’s, applicant’s or member’s whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See Title 42 CFR §431.231(d) of this subpart for procedure if the individual’s, applicant’s or member’s whereabouts become known);
  • The agency establishes the fact that the individual, applicant or member has been accepted for Medicaid services by another local jurisdiction, state, territory or commonwealth;
  • A change in the level of medical care is prescribed by the applicant’s or member’s physician; 
  • The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
  • The date of action will occur in less than 10 days, in accordance with Title 42 CFR §483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30 days’ notice requirements of Title 42 CFR §483.15(b)(4)(i) of this chapter.

6110 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022

An individual, applicant or member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

  • be birth through 20;
  • live in Texas;
  • have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
  • need at least one MDCP service not being addressed by other services and supports;
  • not be 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.

6110.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022

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

  • be under 21 years old; 
  • live 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): 
  • Community Living Assistance and Support Services (CLASS) Program; 
  • Deaf Blind with Multiple Disabilities (DBMD) Program; 
  • Home and Community-based Services (HCS) Program; 
  • Texas Home Living (TxHmL) Program; or 
  • Youth Empowerment Services waiver; 
  • live in: 
  • the person's home; or 
  • an agency foster home as defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and 
  • 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). 

An applicant receiving NF Medicaid is approved for MDCP if the applicant:

  • requests services while residing in a NF; and 
  • meets the eligibility criteria listed above. 

6200, Adverse Action Notification Period

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, to the member no later than 12 business days before the termination effective date. This requirement ensures:

  • the member maintains services while Form H2065-D travels through the mail; and
  • the member has enough time to request a state fair hearing with the option of maintaining continued Medically Dependent Children Program (MDCP) services until a state fair hearing decision is rendered. 

Day zero is the day PSU staff mail Form H2065-D to the member.

The MDCP termination dates are typically on the last day of the month. PSU staff must manually extend the individual service plan (ISP) record’s end date in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to the last day of the following month if:

  • the 12th business day is beyond the current ISP end date; and
  • the adverse action notification period applies.

See the example chart below for further clarification.

Example Chart:

Form H2065-D SentOriginal ISP End DateAdverse Action Expiration Date: 12th Business DayExtend ISP in TMHP LTCOP for Adverse ActionForm H2065-D Termination DateMember Requests State Fair HearingServices Continue During State Fair Hearing?
6/12/207/31/206/30/20No7/31/207/15/20Yes
6/1/206/30/206/17/20No6/30/207/2/20No
6/25/206/30/207/13/20Yes7/31/207/17/20Yes
6/25/206/30/207/13/20Yes7/31/207/13/20Yes
8/28/208/31/209/15/20Yes9/30/209/14/20Yes

The adverse action notification period does not apply to all member terminations. The adverse action notification period does not apply when: 

  • PSU staff has factual information confirming the death of a member;
  • the member submits a signed written statement waiving their right to the adverse action notification period and understands their services will end;
  • the member is denied Medicaid financial eligibility for MDCP;
  • the member is admitted to an institution for 90 consecutive days where MDCP services cannot be delivered;
  • the member accepts Medicaid services by another jurisdiction, state, territory or commonwealth; or
  • the member chooses to enroll in another Medicaid waiver program. 

6300, Denials and Terminations

Revision 22-1; Effective January 31, 2022

The following sections contain Program Support Unit (PSU) staff procedures for individual case closures, applicant denials and member terminations.

6300.1 Death

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility upon verification an applicant or member is deceased.

PSU staff must process a case closure upon notification that an individual is deceased. PSU staff may receive notification of the individual’s, applicant’s or member’s date of death by:

  • Managed Care Operations;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the legally authorized representative (LAR) or family member;
  • the managed care organization (MCO); or
  • other reliable sources.

PSU staff must verify the individual’s, applicant’s or member’s death in the Texas Integrated Eligibility Redesign System (TIERS). There may be instances where an individual, applicant or member is deceased and information is not updated in TIERS. In those instances, PSU staff must receive verification of death from other sources.

PSU staff must complete the following activities for individuals within two business days of verification of death:

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the individual’s date of death and case closure, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of verification of death:

  • upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX notifying the MCO of the applicant’s date of death and case closure, if applicable;
  • document and close the CSIL record, if applicable;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist if TIERS does not show the applicant is deceased;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of verification of death:

  • upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX notifying the MCO of the member’s date of death and case closure, if applicable;
  • for MAO members, fax Form H1746-A following the instructions in Appendix XV to the MEPD specialist if TIERS does not show the member is deceased;
  • adjust the ISP end date to the date of death and terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload the applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must not mail Form 2442, Notification of Interest List Release Closure, or Form H2065-D, Notification of Managed Care Services, to the individual’s, applicant’s, member’s, LAR’s or family’s address, if applicable. The applicant’s or member’s denial or termination effective date is the date of death and may be a mid-month date.

Example: PSU staff receive notification from the MEPD specialist that the member passed away on 7/26/2021. The member’s termination effective date is 7/26/2021.

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

6300.2 Living Arrangement is Not an Allowable Setting

Revision 22-3; Effective Sept. 9, 2022

Title 42 CFR Section 441.301(c)(5) states the following living arrangements are not an allowable setting for the receipt of the Medically Dependent Children Program (MDCP):

  • a nursing facility (NF);
  • an institution for mental diseases;
  • an intermediate care facility for people with intellectual disabilities;
  • a hospital;
  • any other location that has qualities of an institutional setting, as determined by the U.S. Department of Health and Human Services (HHS) Secretary; or
  • any setting located in a building that is also a publicly or privately operated facility providing inpatient institutional treatment; or 
  • in a building or any other setting:
    • on the grounds of; or
    • immediately next to a public institution that:
      • has the effect of isolating people receiving Medicaid Home and Community Based Services (HCBS) from the broader community of people not receiving Medicaid HCBS;
        • unless the HHS Secretary determines through heightened scrutiny, based on information presented by the state or other parties, that the setting does:
          • not have the qualities of an institution; and 
          • have the qualities of home and community-based settings. 

PSU staff may receive notification of the applicant or member’s living arrangement by:

  • managed care operations;
  • enrollment resolution services (ERS) Unit staff;
  • applicant, member, legally authorized representative (LAR) or family member;
  • managed care organization (MCO); or
  • other reliable sources.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant or member has not returned to an allowable living arrangement by the 90th day. 

The MCO will notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, within 14 days following the 90th day that the applicant or member has not returned to an allowable living arrangement. 

PSU staff must email the Managed Care Contracts and Oversight (MCCO) Unit advising that the MCO is not timely in their notification if the MCO fails to meet this notification time frame.

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.

PSU staff must deny the applicant by the end of the month in which the 90th day occurred within two business days of notification by:

  • manually generating Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
    • Note: refer to Form H2065-D instructions for additional information on field entries;
  • mailing Form H2065-D to the applicant or LAR;
  • uploading Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) Medicaid applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • documenting and closing the Community Services Interest List (CSIL) database record, if applicable;
  • invalidating the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • uploading applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • documenting and closing the HEART case record.

Note: Refer to Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials, and Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials, for additional information related to applicants pursing MDCP though the traditional Money Follows the Person (MFP) process.

PSU staff must terminate the member by the end of the month in which the 90th day occurred within two business days of notification by:

  • manually generating Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
    • Note: refer to Form H2065-D instructions for more information on field entries;
  • mailing Form H2065-D to the member or LAR;
  • uploading Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjusting the SK-ISP end date to the termination effective date in the TMHP LTCOP and terminating the SK-ISP record, following the instructions listed in Appendix I;
  • for MAO Medicaid members, complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • for MAO Medicaid members, email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a MDCP termination for Ann Smith would be “MDCP Termination for AS”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (e.g., MDCP eligibility termination);
    • SK-ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

An applicant or member denied or terminated due to an extended stay in a nursing facility (NF) may pursue the Money Follows the Person (MFP) process to reapply for MDCP and return to the community with services. Refer to Section 2400, Money Follows the Person, for procedures for the traditional MFP process and to Section 2420, Money Follows the Person Limited NF Stay Options for Medically Fragile Individual, for procedures for the nursing facility limited stay process.

The process for applicants and members residing in Truman Smith is not applicable to this section. An applicant or member enrolled in STAR Kids who enters the Truman Smith NF or a state veteran’s home is excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied or terminated, as applicable.

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

6300.3 Voluntarily Declined Services

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member no longer wants to receive MDCP services. PSU staff must process a case closure upon notification that an individual voluntarily declines services.

PSU staff may receive notification of the individual’s, applicant’s, member’s or legally authorized representative’s (LAR’s) request to voluntarily decline MDCP from:

  • Managed Care Operations;
  • receipt of Form 2602, Application Acknowledgment, indicating no interest in MDCP;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the individual, applicant, member or LAR;
  • the managed care organization (MCO); or
  • other reliable sources.

PSU staff must complete the following activities for individuals within two business days of notification:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description to the individual or LAR;
  • upload Form H2067-MC, Managed Care Programs Communication, and Form 2442 to TxMedCentral notifying the MCO of case closure following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP.

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for a MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must:

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

Note: See the Uniform Managed Care Manual (UMCM) Chapter 16.2 for procedures for STAR Health individuals.

The medical consenter appointed by the Department of Family and Protective Services (DFPS) is the only person who can accept or decline to pursue MDCP on behalf of the individual, applicant or member.

Per Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), the adverse action notification period applies in this situation unless PSU staff receive a clear written statement signed by the member or LAR indicating that the member no longer wants to receive services. The termination effective date is the last day of the current month if the adverse action notification period is waived.

Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.4 Financial Eligibility

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant’s or member’s Medicaid financial eligibility for MDCP is determined by the: 

  • Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients; or 
  • Medicaid for the Elderly and People with Disabilities (MEPD) specialist for:
    • medical assistance only (MAO) Medicaid recipients; or
    • SSI-related Medicaid recipients such as applicants or members who receive:
      • ME-Pickle; or
      • ME-Disabled Adult Child.

The applicant or member may appeal a Medicaid financial denial using SSA or the MEPD fair hearing process, as appropriate.

PSU staff may receive notification of the denial or termination of an applicant or member’s Medicaid financial eligibility from the:

  • Texas Integrated Eligibility Redesign System (TIERS);
  • monthly loss of eligibility (LOE) reports;
  • MEPD specialist; 
  • Enrollment Resolution Services (ERS) Unit;
  • managed care organization (MCO); or
  • other reliable sources.

PSU staff must complete the following activities for applicants within two business days of the denial notification:

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable;
  • verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail the following forms to the applicant or legally authorized representative (LAR): 
    • Form H2065-D;
    • Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
    • Form 2606, Managed Care Enrollment Processing Delay, if applicable;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • document and close the Community Services Interest List (CSIL) database record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record. 

Note: Refer to Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials, and Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials, for additional information related to applicants pursing MDCP though the traditional Money Follows the Person (MFP) process.

PSU staff must complete the following activities for members within two business days of notification of termination:

  • create a new HEART case record, if applicable;
  • verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail the following forms to the member or LAR: 
    • Form H2065-D;
    • Form H1200; and
    • Form 2606; 
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the SK-ISP end date to the Medicaid financial termination date in the TMHP LTCOP, following the instructions in Appendix I;
  • terminate the SK-ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record.

The termination effective date in the TMHP LTCOP must match the TIERS Medicaid/CHIP/CHIP Perinatal History screen end date. This is true even if the TIERS end date is in the past.

The table below depicts examples of PSU staff actions when the MEPD specialist determines a member no longer meets Medicaid financial eligibility.

TIERS Date for Loss of Financial EligibilityDate PSU Informed Eligibility LostCurrent TMHP LTCOP SK-ISP End DateDate Form H2065-D SentForm H2065-D Termination DateTMHP LTCOP Data Entry
12-31-201612-31-20165-31-20171-2-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20161-15-20171-31-20171-17-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20162-5-20175-31-20172-7-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20166-5-20175-31-20176-7-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a state fair hearing prior to the termination effective date.

Notes:

  • The member can resume services if Medicaid financial eligibility is reestablished with a gap of six months or less. The MCO may use the existing SK-ISP and STAR Kids Screening and Assessment Instrument (SK-SAI) if they are still valid. The MCO must conduct a reassessment without penalty if the SK-ISP and medical necessity (MN) have expired.
  • The member must go to the bottom of the interest list to reapply for services if Medicaid financial eligibility is reestablished with a gap greater than six months.

6300.5 Medical Necessity and Level of Care

Revision 22-1; Effective January 31, 2022

Title 26 TAC §554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the Medically Dependent Children Program (MDCP). To verify MN exists, an applicant or member must meet the following conditions described below:

  • The applicant or member must demonstrate a medical condition that: 
    • is of sufficient seriousness that the applicant’s or member’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 applicant or member must require medical or nursing services that: 
    • are ordered by a physician; 
    • are dependent upon the applicant’s or member'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.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant’s or member’s MN does not meet the level of care (LOC) required for a nursing facility (NF). An applicant’s or member’s approval and continued eligibility for MDCP is dependent upon meeting the MN requirements as listed in 26 TAC §554.2401

The tool used to determine MN is the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) completes the SK-SAI and uploads it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP). The TMHP nurse reviews the SK-SAI to determine if the applicant or member meets the MN criteria required for MDCP once the MCO submits it. The TMHP physician will review the SK-SAI if the TMHP nurse cannot approve the SK-SAI. 

The MCO conducts:

  • initial SK-SAIs for each applicant;
  • reassessment SK-SAIs annually for each member; and
  • a change in condition (CIC) SK-SAIs for each member, when applicable. 

The MCO must notify PSU staff of an applicant’s or member’s MN denial by uploading either Form H3676, Managed Care Pre-Enrollment Assessment Authorization, or Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, as appropriate.

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 doctor overturns the denial because additional 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 information or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the applicant, member or legally authorized representative (LAR) requests a fair hearing.

On the 15th business day from the date the “MN Denied” status initially appears in TMHP LTCOP, the MN status will update to “Overturn Doctor Review Expired” when no additional information has been provided to reverse the initial MN denial finding. 

PSU staff must complete the following activities for applicants within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP:

  • electronically generate Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTCOP following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language; 
  • mail Form H2065-D and Appendix XXVII, MDCP Medical Necessity Denial Attachment, to the applicant or legally authorized representative (LAR);
  • for Medicaid Assistance Only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) record in the TMHP LTCOP following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP:

  • electronically generate Form H2065-D in the TMHP LTCOP following the instructions in Appendix II; 
  • mail Form H2065-D and Attachment B, Fair Hearing Options for MDCP Denials, to the member or LAR;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D; 
  • email Enrollment Resolution Services (ERS) Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing prior to the termination effective date.

The adverse action notification period applies to MN denials. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.6 Unable to Locate

Revision 22-1; Effective January 31, 2022
 
Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member cannot be located. PSU staff must process a case closure upon notification that an individual cannot be located.

PSU staff may receive notification that an individual, applicant or member cannot be located by:

  • monthly reports;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the managed care organization (MCO); or
  • other reliable sources.

The MCO must conduct the required contact attempts established in the STAR Kids Handbook (SKH) before requesting a denial or termination from PSU staff. PSU staff are not required to verify the MCO’s contact attempts.

PSU staff must complete the following activities for individuals within two business days of notification:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or legally authorized representative (LAR);
  • upload Form H2067-MC, Managed Care Programs Communication, and Form 2442 to TxMedCentral notifying the MCO of case closure, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record. 

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D; and
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

PSU staff must reinstate MDCP using the historical ISP if the member is located within the historical ISP date range. The ISP begin date must be the first day of the month that the member is located. The ISP end date must be the historical ISP end date.

Note: PSU staff must refer to the Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM) for information on processing STAR Health members.

PSU staff must refer to Section 2120, Inability to Contact the Individual, for procedures when unable to contact individuals who have been released from the interest list.

6300.7 Exceeding the ISP Cost Limit

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant’s or member’s individual service plan (ISP) exceeds the cost limit. The intent of MDCP is to serve applicants and members who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems when determining if the ISP meets the needs of the applicant or member. As part of the individual service planning process, the MCO must establish an ISP that does not exceed the applicant’s or member’s cost limit.

The MCO must notify PSU staff when an applicant’s or member’s ISP exceeds the cost limit by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. 

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable; 
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.8 Failure to Obtain Physician’s Signature

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny Medically Dependent Children Program (MDCP) eligibility when the managed care organization (MCO) is unable to obtain a physician’s signature at an initial assessment. The physician’s signature is required to complete the initial STAR Kids Screening and Assessment Instrument (SK-SAI) only. The physician’s signature is not required for the annual SK-SAI. The MCO must notify PSU staff of any delays in processing the assessment by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. 
 
The MCO will notify PSU staff if the MCO is unable to obtain a physician’s signature. The MCO must complete and upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral requesting PSU staff deny the applicant due to the MCO’s inability to obtain a physician’s signature when the MCO’s time frame for obtaining the physician’s signature has expired. 

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D notifying the MEPD specialist of the denial, if applicable; 
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable; 
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

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

6300.9 No Longer Meets the Age Requirement for MDCP

Revision 23-3; Effective May 22, 2023

A Medically Dependent Children Program (MDCP) individual, applicant or member must be under 21 years old to be eligible for MDCP per Title 1 Texas Administrative Code (TAC) Section 353.1155.

Program Support Unit (PSU) staff may receive notification that an individual, applicant or member no longer meets the age requirement for MDCP by:

  • the MDCP PDN Transition Report;
  • the managed care organization (MCO); 
  • the individual, applicant, member or legally authorized representative (LAR); or 
  • other reliable sources.

PSU staff must complete the following activities for an individual within two business days from notification:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • upload Form 2442 to TxMedCentral notifying the MCO of case closure, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for an applicant within two business days from notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must process a case termination notification for an MDCP member no earlier than 45 days and no later than 30 days before the last day of the month the member turns 21. The member will no longer receive MDCP services beginning the last day of the member’s 21st birth month.

PSU staff must complete the following activities no earlier than 45 days and no later than 30 days before the last day of the month the member turns 21:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D and Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • complete the following tasks in the TMHP LTCOP:
    • adjust the SK-ISP end date and the MDCP Enrollment Form end date to the last day of the member's 21st birth month following the instructions in Appendix I, and Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide;
    • terminate the SK-ISP and MDCP Enrollment Form using the applicable denial reason indicated in Appendix II;
  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist indicating the member aged out of MDCP and the termination effective date; 
  • email the appropriate Intellectual and Developmental Disability (IDD) waiver staff to advise of the MDCP termination date as the last day of the member’s 21st birth month if the member is transitioning from MDCP to an IDD waiver;
  • upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Adverse action is not required when an MDCP member transitions to another waiver.

6300.10 Other Reasons

Revision 23-3 Effective May 22, 2023

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an individual, applicant or member may need a case closure or to be denied or terminated for other reasons not listed in Section 6300.1 through Section 6300.9.

The PSU supervisor will notify PSU staff if: 

  • the case closure, denial or termination can be processed; and
  • what denial reason to use.

PSU staff must complete the following activities for individuals within two business days from PSU supervisor approval to proceed with case closure:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description to the individual or legally authorized representative (LAR);
  • upload Form 2442 to TxMedCentral notifying the MCO of case closure following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days from PSU supervisor approval to deny the applicant:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable; 
  • document and close the CSIL record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

Note: PSU staff must refer to one of the following sections for more information about traditional Money Follows the Person (MFP) individual and applicant denials, as appropriate:

  • Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials.
  • Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials.

PSU staff must complete the following activities for members within two business days from PSU supervisor approval to terminate the member:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the SK-ISP end date to the termination effective date in the TMHP LTCOP;
  • terminate the SK-ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • for MAO members, complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • for MAO members, notify the Enrollment Resolution Services (ERS) Unit by email. The email to the ERS Unit must include the following information:
    • an email subject line that reads: “MDCP Termination for XX [first letter of the member's first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for AS;”
    • the member’s name;
    • Medicaid (identification) ID number;
    • the type of request (e.g., MDCP eligibility termination);
    • SK-ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document the HEART case record.

The applicability of the adverse action notification period is scenario specific.

PSU staff must refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, if an MAO Medicaid member requests a state fair hearing with continued benefits within the adverse action notification period.

PSU staff is not required to notify the PSU supervisor for the following denial or termination reasons:

  • does not have an unmet need;
  • moved out of state; or
  • declined assessment.

6400, Disenrollment Request Policy

Revision 22-1 Effective January 31, 2022

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of non-compliance listed in Texas Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5. These reasons for noncompliance include:

  • misusing or loaning the member’s MCO membership card to another person to obtain services;
  • disruptive, unruly, threatening or uncooperative behavior unrelated to a physical or behavioral health condition to the extent that the member’s membership seriously impairs the MCO’s ability to provide services to the member or to obtain new members; or 
  • steadfast refusal to comply with managed care restrictions (e.g., repeatedly using emergency room in combination with refusing to allow the MCO to treat the underlying medical condition).

A member may also request to be disenrolled from managed care. Disenrollment from managed care means the member wants to remove themselves from managed care and receive services via fee-for-service (FFS) only. The member must receive approval from HHSC to disenroll from managed care. 

Disenrollment is not the same as voluntarily withdrawing from the program. A member may voluntarily withdraw from MDCP without HHSC approval. Examples of scenarios where a member may request to voluntarily withdraw from MDCP include:

  • The member’s name came to the top of another Medicaid waiver program’s interest list, and the member chose to pursue the other Medicaid waiver program and withdraw from MDCP; or
  • The member states they no longer want MDCP because they do not use any MDCP services.

Refer to the HHSC UMCM Chapter 16.2, STAR Health Medically Dependent Children Program (MDCP), for specific requirements for STAR Health members.

Members who receive HHSC approval to disenroll from managed care and maintain Medicaid eligibility, such as Supplemental Security Income (SSI) or SSI-related Medicaid, may continue receiving non-waiver services available through FFS Medicaid. Medical assistance only (MAO) members will lose Medicaid eligibility as well as waiver services. 

Program Support Unit (PSU) staff must refer a member who requests disenrollment from managed care to HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 to request to disenroll. 

PSU staff must refer MCOs requesting a member be disenrolled from managed care to follow the policy outlined in UMCM Chapters 11.5 and 11.6

PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Compliance & Operations (MCCO) Unit staff and the HHSC Disenrollment Committee will review each member and MCO request to disenroll. MCCO Unit staff will notify Program Enrollment & Support (PES) state office staff of an approved disenrollment request. PES state office staff will notify the appropriate PSU supervisor and request disenrollment. The notification will include the Medicaid Managed Care Member Disenrollment Form and the disenrollment date. 

The PSU supervisor will email the disenrollment request to the assigned PSU staff for processing. PSU staff must complete the following activities within two business days of PSU supervisor assignment:

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record selecting “Disenrollment” in the Action Type field;
  • select “Disenrollment. HPM Request. Add Never Not” as the Issue Type in the HEART case record;
  • terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the effective date provided by the MCCO Unit and the termination reason, “Member requests service termination”; 
  • for MAO members, complete Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid the Elderly and People with Disabilities (MEPD) specialist requesting Medicaid termination effective the date of disenrollment provided by the MCCO Unit;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions;
  • document that the member disenrolled in the HEART case record; and
  • close the HEART case record. 

PSU staff must not generate Form H2065-D, Notification of Managed Care Program Services, for an approved disenrollment. PSU staff are not required to notify Enrollment Resolution Services (ERS) Unit staff or the member of the approved disenrollment. MCCO Unit staff will send a Notice of Ineligibility to the member and work with ERS Unit staff to disenroll the member from managed care.

6500, ISPs Invalidated or Terminated in Error

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must notify the PSU supervisor by email if an individual service plan (ISP) record is invalidated or terminated in error in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The email must include the following:

  • an email subject line that reads: “TMHP ISP Restart Requested for XXX.XXX [first three letters of the applicant or member’s first and last name].” For example, the email subject line for a restart request for Ann Smith would be “TMHP ISP Restart Request for ANN.SMI”;
  • applicant’s or member’s name; 
  • Medicaid identification (ID) number or Social Security Number (SSN); 
  • the ISP record’s document locator number (DLN) number; and 
  • an explanation of the error and reason for restart request. The explanation of the restart request must include the correct termination date if the ISP record was terminated on an incorrect date. 

Refer to Appendix I, PSU User Guide for the SK-ISP Form, for additional direction on moving an ISP record into an invalidated or terminated status in the TMHP LTCOP.