Appendices
Appendix I, PSU User Guide for the SK-ISP Form
Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language
Revision 23-2; Effective May 22, 2023
Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix II.
Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.
PSU staff must enter the denial reason in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) associated with the denial reason on Form H2065-D and Form H2065-DS. The denial reason in the TMHP LTCOP associated with the denial reason on Form H2065-D and Form H2065-DS is listed in the TMHP Denial Reason column in the table below.
Denial and Termination Reason Language
The table below contains language PSU staff must enter in the Reason for Denial and Comments field on Form H2065-D and Form H2065-DS for denials and terminations.
PSU staff must enter the associated STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section supporting the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.
| Purpose of Form H2065-D | Reason for Denial in Plain Language | Comments in Plain Language | SKOPH Section | TMHP Denial Reason |
|---|---|---|---|---|
| Unable to Locate | You are not eligible for MDCP because HHSC staff or your health plan cannot locate you to complete the assessment required for the program. Usted no puede recibir servicios del MDCP porque la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa. | PSU staff must not enter comments language. | 6300.6 | Applicant/Member whereabouts are unknown |
| Voluntarily Declined Services | You are not eligible for MDCP because you voluntarily withdrew from the program. Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa. | PSU staff must not enter comments language. | 6300.3 | Applicant: Applicant requested application for services be closed Member: Member requests service termination |
| Enrolled in Another 1915(c) Medicaid Waiver | You are not eligible for MDCP. This is because you are enrolled in another Medicaid waiver program. You can only be enrolled in one Medicaid waiver program at a time. Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito en otro programa con exenciones de Medicaid. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez. | You are not eligible for MDCP. This is because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); Texas Home Living (TxHmL)]. MDCP cannot be authorized. You can only be enrolled in one Medicaid waiver program at a time. Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito actualmente en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Texas para Vivir en Casa (TxHmL)]. No se puede autorizar el programa MDCP. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez. | 6110 | Applicant/Member can only be enrolled in one 1915(c) waiver program at a time |
| Financial Eligibility | You are not eligible for MDCP because you do not meet the financial criteria necessary for the program. Usted no puede recibir servicios del MDCP porque no cumple los criterios financieros necesarios para participar en el programa. | Call 2-1-1 if you have questions about the Medicaid application process. Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid. | 6300.4 | Applicant/Member denied Medicaid eligibility |
| Declined Assessment | You are not eligible for MDCP because you did not let your health plan complete the assessment required for the program. Usted no puede recibir servicios del MDCP porque no permitió que el plan médico realizara la valoración que requiere el programa. | PSU staff must not enter comments language. | 6110 | Applicant/Member failure to provide information |
| Living Arrangement is Not an Allowable Setting | You are not eligible for MDCP because where you live is not an allowable setting to receive services. Code of Federal Regulations at Title 42 CFR Section 441.301(c)(5) describes these settings. Usted no puede recibir beneficios de MDCP porque donde vive no es un entorno adecuado para recibir servicios. Estos servicios están descritos en la sección 441.301(c)(5) del título 42 del Código de Reglamentos Federales (CFR). | PSU staff must not enter comments language. | 6300.2 | Applicant/Member does not reside in an allowable living arrangement |
| Does Not Have an Unmet Need | You are not eligible for MDCP because you do not need services offered through the program. Usted no puede recibir los servicios del MDCP porque no los necesita. | PSU staff must not enter comments language. | 6110 | Applicant and Member: Need for at least one waiver service per individual service plan year |
| Failure to Obtain Physician's Signature | You aren't eligible for MDCP because your doctor didn't tell us you need the level of care provided in a nursing home. Usted no puede recibir los servicios del MDCP porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo. | PSU staff must not enter comments language. | 6300.8 | Applicant/Member failure to provide information |
| Medical Necessity and Level of Care | Reason for denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTOCP). | You are not eligible for MDCP. See the Reason for Denial text box on page 1 of this form and the MDCP Medical Necessity Denial Attachment for more information. Usted no puede recibir servicios del MDCP. Para más información, vea el cuadro “Motivo de la denegación”, en la página 3 de este formulario, y el anexo “Medical Necessity Denial” (denegación por no existir una necesidad médica) del MDCP. | 6300.5 | Applicant and Member: Denied Medical necessity/level of care |
| Exceeding the ISP Cost Limit | You are not eligible for MDCP because the cost of your individual service plan exceeds the maximum amount allowed. Usted no puede recibir servicios del MDCP porque el costo de su plan individual de servicios excede la cantidad máxima permitida. | PSU staff must not enter comments language. | 6300.7 | Applicant and Member: Exceeds cost limit |
| MFP Services Not Authorized Within 24 Hours | You are not eligible for MDCP because services were not authorized within 24 hours of the nursing facility stay. Usted no puede recibir servicios del MDCP porque los servicios no se autorizaron en las 24 horas siguientes a su estancia en el centro de reposo. | PSU staff must not enter comments language. | 2428 | Applicant: PSU staff must contact their supervisor for the appropriate TMHP denial reason. |
| MFP NF Discharge Prior to Eligibility Determination | You are not eligible for the MDCP because you left the nursing facility before HHSC could determine program eligibility. Usted no reúne los requisitos para recibir servicios del MDCP porque abandonó el centro de reposo antes de que la HHSC pudiera determinar si reunía los requisitos del programa. | PSU staff must not enter comments language. | 2001 | Applicant: Failure to Follow Service Plan |
| Institutional Stay Over 90 Days | You are not eligible for MDCP because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR Section 441.301(b)(1). Usted no puede recibir servicios del MDCP porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR). | You are not eligible for MDCP services while an in-patient of a [Select one: hospital; nursing facility; intermediate care facility for persons with intellectual disability]. Usted no puede recibir servicios del MDCP mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; un centro de atención intermedia para personas con discapacidad intelectual]. | 6300.2 | Applicant and Member: Institutional stay |
| Moved Out of State | You are not eligible for MDCP because you are not a Texas resident. Usted no puede recibir servicios del MDCP porque no reside en Texas. | PSU staff must not enter comments language. | 6110 | Applicant/ Member: Member moved out of state |
Over Age 20 and:
| You are not eligible for MDCP because you are 21 or older. Usted no puede recibir servicios del MDCP porque es mayor de 21 años. | PSU staff must not enter comments language. | 6300.9 | Applicant/Member must be age 20 years or younger to be eligible for MDCP services |
| Over Age 20 and Member Transitions to Another Medicaid Waiver | You are not eligible for MDCP because you are 21 or older. Usted no puede recibir servicios del MDCP porque es mayor de 21 años. | PSU staff must not enter comments language. | 6300.9 | Member: Transition to an adult Program |
| Other | PSU staff must contact supervisor. | PSU staff must contact supervisor. | PSU staff must contact supervisor. | Applicant/Member: PSU staff must contact their supervisor for the appropriate TMHP denial reason. |
Approval Language
The table below contains language PSU staff must enter in the Comments field on Form H2065-D and Form H2065-DS for approvals.
| Purpose of Form H2065-D | Reason for Denial in Plain Language | Comments in Plain Language | SKOPH Section | TMHP Denial Reason |
|---|---|---|---|---|
| Medicaid Eligibility Reinstated within Six Months | No reason for denial language should be added. | Your Medicaid was reinstated on [DATE]. Your MDCP services will continue without interruption. Su participación en el programa Medicaid fue restablecida el [DATE]. Usted seguirá recibiendo servicios del MDCP sin interrupción. | N/A | N/A |
| Initial Form H2065-D for MFP to Community | N/A | You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive a second Form H2065-D telling you when your services will begin. Ud. cumple los requisitos del MDCP. Sus servicios no empezarán hasta que usted y su plan médico acuerden una fecha para su salida de la casa de reposo. Permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén vigentes cuando salga de la casa de reposo. Usted recibirá un segundo Formulario H2065-D en el que se le informará cuándo comenzarán sus servicios. | N/A | N/A |
| Initial Form H2065-D for MFP to AFC | N/A | You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive another notice telling you when your MDCP services will begin. We will also send you a notice telling you how much your room and board and copayment will be. Usted cumple los requisitos del programa MDCP. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa MDCP. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago. | N/A | N/A |
| Room and Board and Copayment | N/A | You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility. Ud. tiene que cubrir los gastos de alojamiento y comida y de cualquier copago. Deberá pagarlos cada mes al hogar de acogida o centro de vida asistida en el que se encuentre. | N/A | N/A |
Note: PSU staff must enter “Pending” and “Calculando” in the Copayment fields on the English and Spanish versions of Form H2065-D, if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist has not provided copayment amounts at the time Form H2065-D is generated. This applies to cases where an applicant or member has or will have a copayment.
Appendix III, LTSS Billing Matrix and Crosswalk
Appendix IV, MDCP Frequently Asked Questions
Appendix V, Time Calculation
Appendix VI, STAR Kids Transition Activities
Appendix VII, SASO Service Group, Service Code and Termination Code
Appendix VIII, RUG IPC Cost Limits
Appendix IX, STAR Kids TxMedCentral Naming Conventions
Appendix X, Income and Resource Limits
Appendix XI, HHSC Benefits Portal and TIERS Reference Guides
Appendix XII, Create an Appeal Task in the HHSC Benefits Portal
Appendix XIII, Long Term Services and Supports
Appendix XIV, State Cutoff Dates
Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet
Appendix XVI, Medicaid Program Actions
Appendix XVII, MDCP Eligibility TAC
Revision 22-3; Effective Sept. 9, 2022
English: 1 Texas Administrative Code Section 353.1155 Medically Dependent Children Program (MDCP)(Word)
Appendix XVIII, STAR Kids HEART Naming Conventions
Revision 23-3; Effective May 22, 2023
This appendix outlines the screenshots Program Support Unit (PSU) staff must upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix IX, STAR Kids TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.
PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2 and the third form sent or received as 1746_3, etc.
PSU staff must upload all screenshots, forms, documents and emails marked as “Yes,” in the “Required” column in the HEART case record. PSU staff must include screenshots, forms, documents and emails marked with an “*” in the “Required” column in the HEART case record if used by PSU staff while completing the case.
Interest List Release (ILR)
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
| SASO Enrollment Screenshot | SASO EN | Yes |
| SASO Service Authorization Screenshot | SASO SA | Yes |
| CSIL Closure Screenshot | CSIL CLOSURE | Yes |
| Form 2442 (English) | 2442 | * |
| Form 2442-S (Spanish) | 2442-S | * |
| Form 2442 Screenshot of Upload to TxMedCentral | Use TxMedCentral Naming Convention | * |
| Form 2602 | 2602 | * |
| Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
| Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| Form H1826 | H1826 | * |
| Form H2053-B | 2053B | * |
| Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | * |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | * |
| Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
| Form H3676-A | Use TxMedCentral Naming Convention | Yes |
| Form H3676-A Upload to TxMedCentral | 3676A TXMED | Yes |
| Form H3676-B | Use TxMedCentral Naming Convention | Yes |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from CCSE | CCSE EMAIL | * |
| Emails to and from CRU | CRU EMAIL | * |
| Emails to and from ERS | ERS EMAIL | * |
| Emails to and from IDD Unit | IDD EMAIL | * |
| Emails to and from ILM Unit | ILM EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | * |
| Emails to and from PSORT | PSORT EMAIL | * |
| MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.
Money Follows the Person (MFP)
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| TIERS Individual- Managed Care Screenshot | TIERS MC | Yes |
| SASO Enrollment Screenshot | SASO EN | Yes |
| SASO Service Authorization Screenshot | SASO SA | Yes |
| CSIL Closure Screenshot | CSIL CLOSURE | Yes |
| Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
| Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| H1826, Case Information Release | H1826 | * |
| Form H2053-B | 2053B | * |
| Form H2065-D Generated in TMHP LTC Online Portal (English and Spanish) | 2065 | Yes |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | Yes |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | Yes |
| Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from CCSE | CCSE EMAIL | * |
| Emails to and from CRU | CRU EMAIL | * |
| Emails to and from ERS | ERS EMAIL | * |
| Emails to and from IDD Unit | IDD EMAIL | * |
| Emails to and from ILM Unit | ILM EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | * |
| Emails to and from PSORT | PSORT EMAIL | * |
| MEPD Communication Tool | MEPD EMAIL | * |
Annual Reassessment
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
| Form 2604 (if received through TMHP LTCOP) | LTCOP ISP | Yes |
| Form 2604 (if received through TxMedCentral) | Use TxMedCentral Naming Convention | Yes |
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| H1826, Case Information Release | H1826 | * |
| Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | Yes |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | Yes |
| Form H2067-MC | Use TxMedCentral Naming Convention | * |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from IDD Unit | IDD EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | * |
| Emails to and from PSORT | PSORT EMAIL | * |
Transition to Adult Programs (MDCP Age-Out)
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page) | 1200 | * |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| H1826, Case Information Release | H1826 | * |
| Form H2053-B | 2053B | * |
| Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | Yes |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | Yes |
| Form H2067-MC | Use TxMedCentral Naming Convention | * |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
| Form H2116 | 2116 | * |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from CCSE | CCSE EMAIL | * |
| Emails to and from ERS | ERS EMAIL | * |
| Emails to and from Higher Needs Coordinator | HN EMAIL | * |
| Emails to and from IDD Unit | IDD EMAIL | * |
| Emails to and from ILM Unit | ILM EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | * |
| Emails to and from STAR+PLUS PSU | PSU EMAIL | * |
| Emails to and from UR | UR EMAIL | * |
| MEPD Communication Tool | MEPD EMAIL | * |
Denials and Terminations
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| CSIL Closure Screenshot | CSIL CLOSURE | * |
| Form 2128 | 120 Day NTCE | * |
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| H1826, Case Information Release | H1826 | * |
| Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | * |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | * |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | * |
| Form H2067-MC | Use TxMedCentral Naming Convention | * |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | * |
| Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants | MN DENIAL ATCH | * |
| Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members | MN DENIAL ATCH | * |
| Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP | ATCH D | * |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from CRU | CRU | * |
| Emails to and from ERS | ERS EMAIL | * |
| Emails to and from IDD Unit | IDD EMAIL | * |
| Emails to and from ILM Unit | ILM EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | * |
| Emails to and from PSU supervisor for 120-day exception request | EXCEPTION REQ EMAIL | * |
| MEPD Communication Tool | MEPD EMAIL | * |
Note: PSU staff uploads Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.
Fair Hearings
| Item | HEART Naming Convention | Required |
|---|---|---|
| Form 2606 | 2606 | * |
| Form 2606-S | 2606-S | * |
| Form 4801 | FH COVER LTR | Yes |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| H1826 | H1826 | * |
| Form H2065-D Generated in TMHP LTCOP (English and Spanish) | 2065 | Yes |
| Form H2065-D Generated Manually (English and Spanish) | Use TxMedCentral Naming Convention | Yes |
| Form H2065-D Screenshot of Upload to TxMedCentral | 2065 TXMED | Yes |
| Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
| Form H4800 | 4800 | * |
| Form H4800-A | 4800A | * |
| Form H4803 | 4803 | Yes |
| Form H4806 | 4806 | * |
| Form H4807 | 4807 | * |
| Copy of Handbook Section Referenced on Form H2065-D | SKOPH [####] | Yes |
| Appendix XVII, MDCP Eligibility TAC | ELIGIBILITY TAC | Yes |
| Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants | MN DENIAL ATCH | * |
| Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members | MN DENIAL ATCH | * |
| Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP (English) | ATCH D | * |
| Notice of Hearing Officer’s Decision | APPEAL DECISION LTR | Yes |
| HHSC Benefits Portal Screenshot of Hearing Officer's Decision | TIERS APPEAL DECISION | Yes |
| Emails to and from CRU | CRU EMAIL | * |
| Emails to and from ERS | ERS EMAIL | * |
| MEPD Communication Tool | MEPD EMAIL | * |
Disenrollment
| Item | HEART Naming Convention | Required |
|---|---|---|
| TIERS Individual - Medicaid History Screenshot | TIERS ME | Yes |
| TIERS Individual - Managed Care Screenshot | TIERS MC | Yes |
| TMHP LTCOP ISP Termination Screenshot | DISENISP | * |
| Form H1746-A (form alone or with fax confirmation page) | 1746 | * |
| Form H1746-A Fax Confirmation (if confirmation page only) | 1746 CONF | * |
| Form H2067-MC | Use TxMedCentral Naming Convention | Yes |
| Form H2067-MC Screenshot of Upload to TxMedCentral | 2067 TXMED | Yes |
| Medicaid Managed Care Member Disenrollment Form | DISENFORM | Yes |
| Emails for PSU QA Process | QA EMAIL | * |
| Emails to and from MCCO | MCCO EMAIL | Yes |
| MEPD Communication Tool | MEPD EMAIL | * |
Appendix XIX, Mutually Exclusive Services
Appendix XX, MDCP Program Description
Revision 19-6; Effective March 25, 2019
English PDF: The Medically Dependent Children Program
Spanish PDF: El Programa para Niños Médicamente Dependientes
Appendix XXI, Creating an Appeal in TIERS
Appendix XXII, Instructions and Access to CARE
Appendix XXIII, Community First Choice Support Management
Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials - Members
Revision 23-4; Effective Aug. 21, 2023
English: Fair Hearing and Interest List Options for MDCP Denials - Members (PDF)
Spanish: Fair Hearing and Interest List Options for MDCP Denials - Members (PDF)
Appendix XXV, Acronyms
Appendix XXVI, STAR Kids Plan Codes
Appendix XXVII, Fair Hearing Options for MDCP Denials - Applicants
Revision 23-4; Effective Aug. 21, 2023
English: Fair Hearing Options for MDCP Denials – Applicants (PDF)
Spanish: Fair Hearing Options for MDCP Denials - Applicants (PDF)
Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide
Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP
Revision 23-4; Effective Aug. 21, 2023
English: Fair Hearing and Interest List Options for Aging Out of MDCP (PDF)
Spanish: Fair Hearing and Interest List Options for Aging Out of MDCP (PDF)