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 STAR+PLUS Home and Community Based Services (HCBS) program; 
• 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 mail Form 2442, Notification of Interest List Release Closure, as notification of STAR+PLUS HCBS program interest list closure to an individual when the individual does not meet STAR+PLUS HCBS program eligibility. PSU staff must always mail Form 2442 with Appendix XII, STAR+PLUS HCBS Program Description. Form 2442 does not provide the right to request a state fair hearing. Individuals only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff mail an applicant or member Form H2065-D when denied or terminated from the STAR+PLUS HCBS program. Form H2065-D provides the applicant or member with the right to request a state fair hearing. Applicants and members 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 the adverse action notification period 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 §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:

1. The agency has factual information confirming the death of an individual, applicant or member;
2. The agency receives a clear written statement signed by a member that:
   1. They no longer want to receive services; or
   2. Gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information;
3. The  individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
4. 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);
5. 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;
6. A change in the level of medical care is prescribed by the applicant’s or member’s physician; or
7. The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act;
8. 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 STAR+PLUS HCBS Program Eligibility Requirements

Revision 22-1; Effective January 31, 2022

An individual, applicant or member must meet the following criteria as stated in Title 1 Texas Administrative Code (TAC) §353.1153(a)(1) in order to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:

• be 21 years of age or older;
• reside in Texas;
• meet the medical necessity (MN) for a nursing facility (NF) level of care (LOC) as determined by Texas Health and Human Services Commission (HHSC);
• have an unmet need for support in the community that can be met through one or more of the STAR+PLUS HCBS program services;
• choose the STAR+PLUS HCBS program as an alternative to NF services, as described in Title 42 Code of Federal Regulations (CFR) §441.302(d);
• not be enrolled in another Medicaid HCBS waiver program approved by Centers for Medicaid & Medicare Services (CMS); and
• be determined by HHSC to be financially eligible for Medicaid, as described in Title 1 TAC §358 (relating to Medicaid Eligibility for the Elderly and People with Disabilities) and Title 1 TAC §360 (relating to Medicaid Buy-In Program).

Revision 22-2; Effective March 4, 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 prior to 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 STAR+PLUS Home and Community Based Services (HCBS) program services until a state fair hearing decision is rendered. 

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

The STAR+PLUS HCBS program termination dates are typically on the last day of the month. PSU staff must manually extend the end date all service group (SG) 19 records in the Service Authorization System Online (SASO) 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

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 the STAR+PLUS HCBS program;
• the member is admitted to an institution for 90 consecutive days where STAR+PLUS HCBS program 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. 

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 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility upon verification an applicant or member is deceased. PSU staff must take similar action upon verification that an individual is deceased.

PSU staff may receive notification of an individual, applicant or member’s date of death by:

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

PSU staff must verify the individual, applicant 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 the MCOHub 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; 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 the MCOHub 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, 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) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• upload applicable documents to the HEART case record; 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 the MCOHub notifying the MCO of the member’s date of death and case closure, if applicable;
• for MAO members, fax Form H1746-A to the MEPD specialist if TIERS does not show the member is deceased;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload the applicable documents to the HEART case record; 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, applicant or member’s address or family’s address. The applicant 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 July 26, 2021. The member’s termination effective date is July 26, 2021.

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

6300.2 Institutional Stay

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not live in an allowable living situation. Title 42 CFR Section 441.301(c)(5) states the following settings are not allowed for the STAR+PLUS HCBS program:

• a nursing facility (NF);
• an institution for mental diseases;
• an intermediate care facility for individuals 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 on the grounds of, or immediately adjacent to, a public institution; or
• any other setting with the effect of isolating individuals receiving Medicaid Home and Community Based Services (HCBS) from the broader community of individuals not receiving Medicaid HCBS is presumed to be a setting with the qualities of an institution; 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 that the setting does 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;
• the applicant, member, legally authorized representative (LAR) or family member;
• the managed care organization (MCO); or
• other reliable sources.

The MCO must notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub within 14 days following the 90th day that the applicant or member has not returned to an allowable living arrangement. PSU staff must email Managed Care Compliance Operations (MCCO) if the MCO is not timely in their notification.

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;
• mailing Form H2065-D to the applicant;
• uploading Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• documenting and closing the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• uploading all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• documenting and closing the HEART case record.

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;
• mailing Form H2065-D to the member;
• uploading Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• uploading applicable documents to the HEART case record; and
• documenting the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing prior to the termination effective date.

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, procedures outlined in Section 3500, Money follows the Person, to reapply for the STAR+PLUS HCBS program and return to the community with services.

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

6300.3 Voluntarily Declined Services

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member no longer wants to receive STAR+PLUS HCBS program services. PSU staff must take similar action upon notification that an individual voluntarily declines services.

PSU staff may receive notification of the individual, applicant, member or authorized representative’s (AR’s) request to voluntarily decline the STAR+PLUS HCBS program from:

• Managed Care Operations;
• receipt of Form H3675, Application Acknowledgment, indicating no interest in STAR+PLUS HCBS program services;
• Enrollment Resolution Services (ERS) Unit staff;
• the individual, applicant, member or AR;
• 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 XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of 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; 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;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the CSIL record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• upload applicable documents to the HEART case record; 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;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

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 AR 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, if the adverse action period is not waived.

6300.4 Financial Eligibility

Revision 22-3; Effective Sept. 27, 2022

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant’s or member’s Medicaid financial eligibility for the STAR+PLUS HCBS program is determined by the:

• Social Security Administration (SSA) for Supplemental Security Income (SSI); or  
• Medicaid for the Elderly and People with Disabilities (MEPD) specialist for:
  • medical assistance only (MAO) (type assistance (TA) 10);  
  • Pickle Amendment Group (type program (TP) 03); and
  • Disabled Adult Children (DAC) (TP 18).

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

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

• the Texas Integrated Eligibility Redesign System (TIERS);
• the monthly loss of eligibility (LOE) reports;
• MEPD specialist; 
• Enrollment Resolution Services (ERS) Unit staff;
• the 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 Record 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 IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language;
• mail the applicant:
  • 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 XXXIV, STAR+PLUS HCBS Program TxMedCentral Naming Conventions;
• document and close the Community Services Interest List (CSIL) database record, if applicable;
• upload applicable documents to the HEART case record following the instructions in Appendix XXXIII, STAR+PLUS HCBS Program 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 of termination:

• 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 IV;
• mail the member:
  • Form H2065-D;
  • Form H1200; and
  • Form 2606;
• upload Form H2065-D on TxMedCentral following the instructions in Appendix XXXIV;
• manually close all service group (SG) 19 records in Service Authorization System Online (SASO) to align with the date of termination, using the appropriate termination code listed in Appendix IV;
• upload applicable documents to the HEART case record following the instructions in Appendix XXXIII; and
• document and close the HEART case record.  

The adverse action notification period does not apply in this situation. The member’s STAR+PLUS HCBS program termination effective date must match the TIERS Medicaid/CHIP/CHIP Perinatal History segment end date 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.

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing prior to the termination effective date.

Notes:

• The member can resume services if the Medicaid is reestablished with a gap of six months or less. The MCO may use the existing ISP and Medical Necessity and Level of Care (MN/LOC) Assessment if they are still valid. The MCO must conduct a reassessment without penalty if the ISP and MN/LOC have expired.
• The member must go to the bottom of the interest list to reapply for services if Medicaid is reestablished with a gap greater than six months.

6300.5 Medical Necessity and Level of Care

Revision 23-4; Effective Dec. 7, 2023

Title 26 TAC Section 554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the STAR+PLUS Home and Community Based Services (HCBS) program. 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 STAR+PLUS HCBS program eligibility when an applicant or member’s MN does not meet the level of care (LOC) required for a nursing facility (NF). An applicant or member’s approval and continued eligibility for the STAR+PLUS HCBS program is dependent upon meeting the MN requirements as listed in 26 TAC Section 554.2401. The tool used to determine MN is the Medical Necessity and Level of Care (MN/LOC) Assessment. The managed care organization (MCO) completes the MN/LOC Assessment and uploads it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP nurse and physician review the MN/LOC Assessment to determine if the applicant or member meets the MN criteria required for the STAR+PLUS HCBS program.

The MCO conducts:

• an initial MN/LOC Assessment for each applicant;
• a reassessment MN/LOC Assessment annually for each member; and
• a change in condition (CIC) MN/LOC Assessment for each member, when applicable.

The MCO must notify PSU staff of an applicant or member’s MN denial by uploading:

• Form H3676, Managed Care Pre-Enrollment Assessment Authorization, for applicants; or
• Form H2067-MC, Managed Care Programs Communication, for members, to the MCOHub.

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 authorized representative (AR) requests a fair hearing.

On the 15th business day from the date the “MN Denied” status initially appears in the 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;
• mail Form H2065-D and the Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment, to the applicant;
• for Medicaid Assistance Only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) in the TMHP LTCOP, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; 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;
• mail Form H2065-D and Appendix XI to the member;
• terminate the ISP in the TMHP LTCOP using the existing ISP end date as the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email Enrollment Resolution Services (ERS) Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before 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 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member cannot be located. PSU staff must take similar action 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+PLUS Handbook (SPH), Section 3632.7, Denial/Termination Due to Inability to Locate the Member, 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 XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

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

• upload Form H2067-MC to the MCOHub notifying the MCO of case closure;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• document and close the CSIL record, if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

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

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the CSIL record, if applicable;
• invalidate the ISP in the TMHP LTCOP, if applicable;
• upload applicable documents to the HEART case record; 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;
• mail Form H2065-D to the member;
• upload Form H2065-D to MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• manually close the following service group (SG) 19 records in the Service Authorization System Online (SASO), if applicable, and ensuring the closure date aligns with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

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 complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].”
  • the member’s name;
  • Medicaid ID number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

PSU staff must reinstate the STAR+PLUS HCBS program 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.

6300.7 Exceeding the ISP Cost Limit

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member’s individual service plan (ISP) exceeds the cost limit. The intent of the STAR+PLUS HCBS program 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 the MCOHub.

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;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) 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; 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;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS 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 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny STAR+PLUS Home and Community Based Services (HCBS) program eligibility when the managed care organization (MCO) is cannot get a physician’s signature at an initial assessment. The physician’s signature is required to complete the initial Medical Necessity and Level of Care (MN/LOC) Assessment only. The physician’s signature is not required for the annual MN/LOC Assessment.

The MCO must make at least three more attempts to get the physician’s signature if the MCO does not receive a signed copy of the physician’s signature page within five business days of the first request to the applicant or member’s physician. The MCO must contact the applicant or member for help getting the physician’s signature if the MCO is unsuccessful getting the signature from the physician.

The MCO must notify PSU staff if the MCO is cannot get a physician’s signature within two business days of the 45-day time frame for completing all initial assessment activity expiring. The MCO must notify PSU staff by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub notating that the MCO could not get a physician’s signature and the MCO is requesting the applicant be denied.

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;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
• invalidate the individual service plan (ISP) 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; and
• document and close the HEART case record.

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

6300.9 Failure to Meet Other Program Requirements

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an applicant or member fails to meet other program requirements not listed in Section 6200.1 through Section 6200.8. The PSU supervisor will notify PSU staff if the denial or termination can be processed. PSU staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet the eligibility requirements as noted in Title 1 Texas Administrative Code (TAC) Section 353.1153.

PSU staff may receive notification that an individual, applicant or member does not meet other program requirements by:

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

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

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
• document and close the Community Services Interest List (CSIL) database record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

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

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) Medicaid applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
• document and close the CSIL database record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

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

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• for MAO Medicaid members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO Medicaid members, email ERS Unit staff the following information:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request such as STAR+PLUS HCBS program eligibility termination
  • individual service plan (ISP) end date;
  • effective date of termination;
  • Form H2065-D;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to 7222.1, Continuation of STAR+PLUS HCBS 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.

Refer to 6200, Adverse Action Notification Period, for additional information on determining the termination effective date if the PSU supervisor determines the adverse action notification period is applicable.

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

• does not have an unmet need;
• moved out of the state of Texas;
• declined assessment; and
• under 21.

6300.10 Other Reasons

Revision 24-1; Effective Feb. 22, 2024

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 
• be denied or terminated for reasons not listed in Section 6200.01 through Section 6200.09.

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 XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of 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; and
• document and close the HEART case record.

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

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• complete 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 for medical assistance only (MAO) applicants, when applicable;
• document and close the CSIL record, if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

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

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• manually close all service group (SG) 19 records in Service Authorization System Online (SASO) to align with the date of termination;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, complete Form H1746-A and fax to the MEPD specialist along with Form H2065-D;
• for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
  • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name]”;
  • the member’s name;
  • Medicaid ID number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and 
• document and close the HEART case record.

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

The applicability of the adverse action notification period is scenario-specific. Refer to 6200, Adverse Action Notification Period, for more information on determining the termination effective date if the supervisor determines the adverse action notification period is applicable.

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; 
• declined assessment; or 
• under 21.
   

Revision 24-1; Effective Feb. 22, 2024 

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of noncompliance listed in the Texas Health and Human Services Commission (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5 (PDF). 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 get new members;
• steadfast refusal to comply with managed care restrictions such as repeatedly using the emergency room along with refusing to allow the MCO to treat the underlying medical condition; or 
• a member’s failure to pay room and board (R&B) or copayment charges.

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 by 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 the STAR+PLUS Home and Community Based Services (HCBS) program without HHSC approval. Examples where a member may request to voluntarily withdraw from the STAR+PLUS HCBS program voluntarily 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 the STAR+PLUS HCBS program; or
• member states they no longer want the STAR+PLUS HCBS program because they do not use any STAR+PLUS HCBS program services.

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 the 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;
• manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) 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 and fax to the Medicaid for 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 HEART case record;
• 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.