STAR+PLUS Handbook


SPH, Section 1000, State of Texas Access Reform Plus (STAR+PLUS) Managed Care

Revision 17-5; Effective September 1, 2017

 

 

1100 Program Overview

Revision 17-5; Effective September 1, 2017

 

The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long-term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living, home modifications, respite (short-term supervision) and personal assistance. These services are delivered through providers contracted with managed care organizations (MCOs).

The STAR+PLUS program provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.

Service coordination, available to all members, is the main feature of the STAR+PLUS program. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members, and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.

The STAR+PLUS Home and Community Based Services (HCBS) program is a program approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility care to receive LTSS in order to be able to live in the community.

Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to the STAR+PLUS program. For a dictionary of acronyms used in the STAR+PLUS Program, refer to Appendix VII, Acronyms.

 

1110 Legal Basis

Revision 17-1; Effective March 1, 2017

 

Statutory basis for the STAR+PLUS program:

 

1120 Values

Revision 17-5; Effective September 1, 2017

 

The principles and practices that form the foundation for the STAR+PLUS Home and Community Based Services (HCBS) program are based on the following values:

 

1130 Service Model

Revision 17-5; Effective September 1, 2017

 

 

 

1131 Service Delivery Model

Revision 17-5; Effective September 1, 2017

 

Individuals enrolled in the STAR+PLUS program may select a delivery model for personal assistance services (PAS) or Community First Choice (CFC) services identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H6516, Community First Choice Assessment, and Form H2060-A, Addendum to Form H2060. Individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services may reside alone, with family members or others at locations of their choice in the community, in adult foster care homes or in licensed assisted living facilities.

The STAR+PLUS HCBS program provides individuals with an array of services, as identified on the individual service plan (ISP), necessary to allow the individual to remain in or return to a community setting. Services are delivered by providers contracted with managed care organizations (MCOs) to provide STAR+PLUS HCBS program services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists to determine financial eligibility for those individuals not already eligible for Supplemental Security Income (SSI) and use financial determinations by the Social Security Administration (SSA) for those individuals already eligible for SSI. (See Section 3110, Medicaid, Medicare and Dual-Eligibles.)

STAR+PLUS members choose to participate in the agency option (AO), consumer-directed services (CDS) option or service responsibility option (SRO) delivery models.

 

1140 Program Services

Revision 17-5; Effective September 1, 2017

 

 

 

1141 Services Available Under STAR+PLUS

Revision 17-5; Effective September 1, 2017

 

If there is a need identified by a service coordinator or a request for additional services from the member, the managed care organization (MCO) assesses the member to determine their needs and to develop an appropriate service plan. Since MCOs are at risk for paying for a range of acute care and long-term services and supports (LTSS), there is an incentive to provide innovative, cost-effective care from the onset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS members who do not have Medicare are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals can choose a specialist to be their PCP and they receive all services, both acute care and LTSS, from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. The STAR+PLUS program does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

The STAR+PLUS program serves as an insurance policy if members have a need for LTSS at a future time. See Section 3110, Medicaid, Medicare and Dual-Eligibles, for additional information on dual-eligible coverage.

Medicaid-only members (those who do not receive Medicare) receive traditional Medicaid acute care services plus an annual check-up. For these members, the cost of acute care services is included in the capitation payment to the MCO. For dual-eligible members, the MCO’s capitation payment does not include the cost of acute care.

 

1142 Long-term Services and Supports

Revision 17-5; Effective September 1, 2017

 

Day Activity and Health Services (DAHS) and Personal Attendant Services (PAS) are available to STAR+PLUS members who meet functional eligibility requirements. Community First Choice (CFC) services are available to STAR+PLUS members who meet an institutional level of care, meet functional eligibility requirements, and who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. Additional services are available under the STAR+PLUS Home and Community Based Services (HCBS) program. For a complete list of services provided under the STAR+PLUS program, refer to the managed care contracts governing the STAR+PLUS program at https://hhs.texas.gov/services/health/provider-information/managed-care-contracts-manuals.

 

1143 STAR+PLUS Services

Revision 17-1; Effective March 1, 2017

 

STAR+PLUS program members have access to medically and functionally necessary services available in the state plan. In addition, some members are eligible for additional services available in the STAR+PLUS Home and Community Based Services (HCBS) program services, in addition to their traditional state plan STAR+PLUS services. See:

 

1143.1 Services Available to STAR+PLUS Members

Revision 17-1; Effective March 1, 2017

 

The Texas Health and Human Services Commission (HHSC) contracts with Medicaid managed care organizations (MCOs) for the provision of STAR+PLUS services. These Medicaid MCOs are responsible for providing a benefit package to members that includes all medically-necessary services covered under the traditional, fee-for-service Medicaid programs, with the exception of non-capitated services provided to Medicaid members outside of the MCO capitation and listed in each managed care contract. (For example, Attachment B-1, Section 8.2.2.8, of the Uniform Managed Care Contract (UMCC).

STAR+PLUS members also receive enhanced benefits compared to the traditional, fee-for-service Medicaid coverage:

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members 18 years of age and over, and prescription drugs.  STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual and the Texas Medicaid Bulletin postings for a more inclusive listing of limitations and exclusions that apply to each Medicaid benefit category. (These documents can be accessed online at: www.tmhp.com.)

The services listed in the managed care contracts (for example, UMCC) are subject to modification based on federal and state laws and regulations and program policy updates.

 

1143.1.1 Services Included Under the MCO Capitation Payment

Revision 17-5; Effective September 1, 2017

 

Services included under the managed care organization (MCO) capitation payment include:

 

1143.1.2 Long-term Services and Support Listing

Revision 17-5; Effective September 1, 2017

 

The following is a non-exhaustive, high-level listing of community-based long-term services and supports included under the STAR+PLUS program:

 

1143.2 Services Available to STAR+PLUS Home and Community Based Services Program Members

Revision 17-5; Effective September 1, 2017

 

Services necessary for the individual to remain in or return to the community are identified from the array of services available through the STAR+PLUS Home and Community Based Services (HCBS) program. STAR+PLUS HCBS program services include:

 

1200 Service Coordination Through the MCO

Revision 17-1; Effective March 1, 2017

 

Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. If a member receives long-term services and supports, has a history of behavioral health issues or substance use disorders, or is dual eligible, the identified MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year. If the member receives STAR+PLUS Home and Community Based Services (HCBS) program, or has a complex medical condition, the identified MCO service coordinator must visit with the member face-to-face at least twice a year. If a member resides in a nursing facility, the MCO service coordinator must meet with the member face-to-face four times per year.

All applicants or recipients of long-term services and supports (LTSS) receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of a service plan with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the member and his/her acute care and LTSS providers to ensure all of a member's medically and functionally necessary services are provided. This includes, but is not limited to, referring and assisting the member in obtaining appointments with specialists, participating in discharge planning for members in hospitals and/or nursing facilities, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving STAR+PLUS HCBS program can be found in Section 3000, Waiver Eligibility and Services, Section 6000, Specific STAR+PLUS Waiver Program Services, Section 5000, Automation and Payment Issues in STAR+PLUS, and Appendices. Service coordination requirements for members receiving Medicaid state plan LTSS can be found in the Uniform Managed Care Contract.

The following sections detail MCO service coordinator responsibilities for members in certain facilities or programs.

 

1210 Service Coordinators and Nursing Facilities

Revision 17-5; Effective September 1, 2017

 

Members residing in a nursing facility (NF), (except members receiving hospice care or living outside the managed care organization (MCO) service delivery area), must receive at least quarterly face-to-face visits for assessment purposes. NF staff should invite MCO service coordinators to their resident care planning meetings or other interdisciplinary team meetings, as long as the resident does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO must maintain and make available upon request documentation verifying the occurrence of required face-to-face service coordination visits, which may coincide with or include participation in care planning or other interdisciplinary team meetings.

Service coordination activities for members residing in an NF include, but are not limited to:

If a member participating in the STAR+PLUS Home and Community Based Services (HCBS) program is admitted to an NF, the NF service coordinator must notify the Program Support Unit (PSU) within three business days of the admission using Form H2067-MC, Managed Care Programs Communication.

 

1220 Service Coordinators and Waivers Serving Members with Intellectual or Development Disabilities

Revision 17-1; Effective March 1, 2017

 

Individuals who have intellectual or developmental disabilities (IDD) and live in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID) or who receive services through one of the following IDD waivers receive their acute care services only through STAR+PLUS and continue to receive their long-term services and supports (LTSS) through the 1915(c) HCBS waivers:

Individuals who receive services through one of these four programs and receive Medicare Part B (dual eligible) are not included in STAR+PLUS.

Members with IDD that meet the above criteria have a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member's or his/her legally authorized representative's personal preference.

These members also have a person(s) outside of the MCO who develops and implements a service plan and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member's waiver case manager or service coordinator. The member's waiver case manager or service coordinator should invite MCO service coordinators to their care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO service coordinator is responsible for the coordination of the member's acute care services.

 

1230 Service Coordinators and Home and Community Based Services - Adult Mental Health Program

Revision 17-1; Effective March 1, 2017

 

The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves individuals who have severe and persistent mental illness (SPMI) and a history of extended (three cumulative or consecutive years of the past five) institutional stays in psychiatric facilities; individuals with SPMI and frequent visits to the emergency department; and individuals with SPMI and frequent arrests and stays in a correctional facility. HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program's population. HCBS-AMH is operated on a fee-for-service basis through the Texas Health and Human Services Commission (HHSC). Each participant is assigned a recovery manager (RM), who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with HHSC. Additional information about HCBS-AMH can be found at: https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

Program Point of Contact

MCO Service Coordination Responsibility

HCBS-AMH may provide transitional planning for individuals who reside in an institution and who are also enrolled in a STAR+PLUS MCO. MCO service coordinators must participate in planning meetings with an RM, telephonically or in-person, during the member's stay.  Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution.  MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR+PLUS MCOs must follow all discharge planning requirements as outlined in Uniform Managed Care Contract, Section 8.3.2.5.

 

1240 Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 17-1; Effective March 1, 2017

 

The Section 811 Project Rental Assistance (PRA) provides subsidized rental housing in coordination with supports to individuals with disabilities. Each tenant in the Section 811 PRA program has a “Section 811 service coordinator.” Managed care organization (MCO) service coordinators are the Section 811 service coordinators for STAR+PLUS members discharging from nursing facilities (NFs).

Once an individual has occupied a Section 811 PRA housing unit, the MCO service coordinator must ensure STAR+PLUS Home and Community Based Services (HCBS) are in place so that the member will be successful in maintaining his or her tenancy.

The Section 811 PRA program relies on Medicaid services and service coordination to provide the supports an individual needs to remain safely in the community. If this activity is not performed by the relocation contractor, the MCO service coordinator is responsible for informing individuals in NFs about the availability of this program and if they are interested, to assist them in submitting an application and required documentation.

The MCO service coordinator must coordinate with the Texas Health and Human Services Commission (HHSC) Section 811 Point of Contact (POC) on an ongoing basis regarding members participating in the Section 811 PRA program. The HHSC Section 811 POC is listed on the Texas Department of Housing and Community Affairs (TDHCA) Section 811 PRA webpage: https://www.tdhca.state.tx.us/section-811-pra/contact.htm. Information on such laws and requirements will be conveyed at training provided by TDHCA and in the Texas Section 811 PRA Program Service Coordinator Manual. Specific responsibilities of the Section 811 service coordinator are listed below:

Once an individual has been accepted for tenancy in a Section 811 PRA program unit, the MCO service coordinator will provide the following support to assist individuals in maintaining their housing:

The MCO must ensure the HHSC Section 811 POC and the TDHCA POC have the means to identify and contact an individual's Section 811 service coordinator within one business day of receiving notice of a concern from the Section PRA program owner, or the owner's designee.

MCO service coordinators serving members exiting a nursing facility or other institution and who are participating in the Section 811 PRA program must comply with the roles and responsibilities assigned to them in the Inter-Agency Partnership Agreement (HHSC Contract No. 529-12-0134-00001) as amended and as applicable, and MCO service coordinators agree to fulfill the obligations assigned to Section 811 service coordinators in accordance with the Texas Section 811 PRA Program Service Coordinator Manual.

MCO Service coordinators serving members who are participating in the Section 811 PRA program may download and read the Texas Section 811 PRA Program Service Coordinator Manual and watch the Section 811 Program Service Coordinator Webinar, available on TDHCA's webpage: hppt://www.tdhca.state.tx.us/section-811-pra/referral-agents.htm.

The 811 POC contact information email is: HHSC_Section811POC@hhsc.state.tx.us.

The TDHCA 811 POC contact information email is: bill.cranor@tdhca.state.tx.us.

 

1250 Service Coordinators and the Medicaid for Breast and Cervical Cancer Program

Revision 17-5; Effective September 1, 2017

 

Individuals eligible for Medicaid through the Medicaid for Breast and Cervical Cancer (MBCC) program are a mandatory population in STAR+PLUS. This program provides Medicaid services including, but not limited to, the treatment of cancer and precancerous conditions for individuals with qualifying diagnoses between the ages of 18 and their 65th birth month. Individuals in MBCC receive their Medicaid services through their STAR+PLUS managed care organization (MCO). The individual will be assigned a named service coordinator and receive at a minimum one telephonic contact and one face-to-face visit annually, unless otherwise requested by the MBCC member.

 

The MCO service coordinator assists the MBCC member with coordinating care. Coordination can include, but is not limited to, assistance with renewing Medicaid eligibility by reminding and assisting with paperwork. Continued participation in MBCC requires a completed MBCC renewal application and physician attestation the individual requires continued, active treatment for her breast or cervical cancer or precancer. The physician attestation and eligibility paperwork must be submitted every six months.

SPH, Section 2000, Legal Requirements

Revision 14-1; Effective March 3, 2014

 

 

2100 Disclosure of Information

Revision 14-1; Effective March 3, 2014

 

 

2110 Confidential Nature of the Case Record

Revision 14-1; Effective March 3, 2014

 

Information collected in determining initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about individual members. The Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify a member.

A member may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

 

2111 Establishing Identity for Contact Outside the Interview Process

Revision 14-1; Effective March 3, 2014

 

Keep all information that the Health and Human Services Commission (HHSC) and the managed care organization (MCO) have about a member or any individual on the member's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing information about a member or any individual on the member's case, take steps to be reasonably sure the individual receiving the confidential information is either the member or an individual the member has authorized to receive confidential information (for example, an attorney or personal representative).

 

2111.1 Telephone Contact

Revision 14-1; Effective March 3, 2014

 

Establish the identity of an individual who identifies himself as a member by using the individual’s knowledge of the member's:

Establish the identity of a personal representative by using the individual's knowledge of the member's:

Establish the identity of attorneys or legal representatives by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the member.

Health and Human Services Commission (HHSC) staff must use established regional procedures to confirm the identity of legislators or their staff. The managed care organization (MCO) must use established Health and Human Services Commission (HHSC) procedures to confirm the identity of legislators or their staff.

 

2111.2 In-Person Contact

Revision 14-1; Effective March 3, 2014

 

Establish the identity of the individual who presents himself as a member or member's representative at a Health and Human Services Commission (HHSC) or managed care organization (MCO) office by using sources such as:

Establish the identity of other HHSC/MCO staff, federal agency staff, researchers or contractors by using sources such as:

Identify the need for other HHSC/MCO staff, federal staff, research staff or contractors to access confidential information through:

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC/MCO staff come to the office without prior notification or adequate identification and request permission to access records.

 

2111.3 Verification and Documentation

Revision 10-0; Effective September 1, 2010

 

If disclosing individually identifiable health information, document how the identity of the person was verified when contact is outside the interview.

Verify the identity of the person who requests disclosure of individually identifiable health information using sources such as:

 

2112 Custody of Records

Revision 14-1; Effective March 3, 2014

 

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain, except as provided by Health and Human Services Commission (HHSC) and managed care organization (MCO) regulations.

Reasonable diligence for employees responsible for records includes keeping records:

 

2113 Disposal of Records

Revision 14-1; Effective March 3, 2014

 

To dispose of documents with member-specific information, Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data. Managed care organizations (MCOs) must follow procedures contained in the Uniform Managed Care Contract.

 

2114 When and What Information May Be Disclosed

Revision 14-1; Effective March 3, 2014

 

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if a member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the member.

Give member addresses or other case information only to a person who has written permission from the member to obtain the information. The member authorizes the release of information by completing and signing:

Note: If the case information to be released includes individually identifiable health information, the document must also tell the applicant or member that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and their survivors.

The Office of the General Counsel at HHSC handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to these offices. MCO staff should contact HHSC’s Managed Care Operations.

 

2115 Confidential Nature of Medical Information — HIPAA

Revision 10-0; Effective September 1, 2010

 

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:

 

2116 Privacy Notice

Revision 14-1; Effective March 3, 2014

 

Health and Human Services Commission (HHSC) and managed care organization (MCO) staff must send each member the Health and Human Services Agencies' Notice of Privacy Practices (links below), upon certification. This notice tells the member about:

Link to printable English PDF
Link to printable Spanish PDF

 

2117 Member Authorization

Revision 14-1; Effective March 3, 2014

 

The member may authorize the release of health information from Health and Human Services Commission (HHSC) and managed care organization (MCO) records by using a valid authorization form. Form 1826-D, Case Information Release, includes all the authorization elements required by Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.

 

2118 Minimum Necessary Information Release

Revision 14-1; Effective March 3, 2014

 

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if a member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the member.

 

2119 Personal Representatives

Revision 14-1; Effective March 3, 2014

 

Only the member's personal representative can exercise the member's rights with respect to individually identifiable health information. Therefore, only a member's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of a member. Exception: Health and Human Services Commission (HHSC) and the managed care organization (MCO) are not required to disclose the information to the personal representative if the member is subjected to domestic violence, abuse or neglect by the personal representative. Consult appropriate legal counsel, as described in Section 2114, When and What Information May Be Disclosed, if it is believed that health information should not be released to the personal representative.

Note: A responsible party is not automatically a personal representative.

 

2119.1 Adults and Emancipated Minors

Revision 10-0; Effective September 1, 2010

 

If the member is an adult or emancipated minor, including married minors, the member's personal representative is a person who has the authority to make health care decisions about the member and includes a:

 

2119.2 Unemancipated Minors

Revision 10-0; Effective September 1, 2010

 

A parent is the personal representative for a minor child except when:

 

2119.3 Deceased Individuals

Revision 10-0; Effective September 1, 2010

 

The personal representative for a deceased member is an executor, administrator or other person with authority to act on behalf of the member or the member's estate. These include:

Consult appropriate legal counsel, as described in Section 2114, When and What Information May Be Disclosed, if you have questions about whether a particular person is the personal representative of an applicant or member.

 

2120 Confidential Information on Notifications

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission (HHSC) is committed to protecting all confidential information supplied by the applicant or individual during the eligibility determination process. This includes inclusion of confidential information by HHSC staff to third parties who receive a copy of a notification of eligibility form.

Staff must ensure they do not include confidential information on the eligibility notice that should not be shared with the service provider or another third party. For example:

In the examples above, revealing specifics of the individual's income or the condition of his home environment is a violation of his right to confidentiality. In all cases, HHSC staff must assess any information provided by the individual to determine if its release would be a confidentiality violation.

 

2130 Correcting Information

Revision 14-1; Effective March 3, 2014

 

A member has a right to correct any information that the Health and Human Services Commission (HHSC) or the managed care organization (MCO) has about the member and any other individual on the member's case.

A request for correction must be in writing and:

If HHSC or the MCO agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the member's request.

Notify the member in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC/MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC or the MCO makes a correction to individually identifiable health information, ask the member for permission before sharing with third parties. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if they may have relied or could rely on it to the disadvantage of the member. HHSC staff must follow regional procedures to contact the HHSC privacy officer for a record of disclosures. MCOs must follow HHSC procedures as stated in the Uniform Managed Care Contract.

Note: Do not follow above procedures when the accuracy of information provided by a member is determined by another review process, such as a:

The decision in that review process is the decision on the request to correct information.

 

2140 Communication with the Managed Care Organization

Revision 14-1; Effective March 3, 2014

 

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member's individually identifiable health information to be shared only with his or her selected managed care organization (MCO). This makes it crucial that when documents containing member information are posted in the incorrect MCO folder in TxMedCentral, they be corrected immediately upon realization an error was made.

Send notification of all posting errors to Arron Michaels (arron.michaels@dads.state.tx.us). Include the document identifying information, the name of the folder in which it was erroneously posted and the name of the folder into which it should have been posted. Include the time the correction was made.

Example: Posted 9F_2067_123456789_ABCD_2S.doc in SUPSPW at 8:54 a.m. on December 20. Should have been posted to MOLSPW. Corrected at 9:22 a.m. December 20.

All emails containing member information must be sent using encryption software. No individually identifiable information may appear in the subject line.

See also:

 

2150 Alternate Means of Communication

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate a member's reasonable requests to receive communications by alternative means or at alternate locations

The member must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the member.

 

2200 Citizenship and Identity Verification

Revision 10-0; Effective September 1, 2010

 

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long-term services and supports (LTSS) members whose financial eligibility is based on a determination from Medicaid for the Elderly and People with Disabilities (MEPD) staff.

This documentation must be provided at the initial determination. Verification of citizenship and identity for eligibility purposes is a one-time activity as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD staff, verification is no longer required even after a break in eligibility.

 

2210 Acceptable Documentation for Both Citizenship and Identity

Revision 10-0; Effective September 1, 2010

 

 

2211 Supplemental Security Income Recipients

Revision 10-0; Effective September 1, 2010

 

The State Data Exchange (SDX) contains the needed information to verify citizenship. For any active Supplemental Security Income (SSI) recipient, Medicaid for the Elderly and People with Disabilities (MEPD) staff are able to use the SDX as verification for both citizenship and identity. For any denied SSI recipient, the SDX can be used as a valid verification source of both citizenship and identity when the denial is for any reason other than citizenship. The SDX printout shows action code N13 if the denial is for citizenship.

 

2212 Medicare Recipients

Revision 10-0; Effective September 1, 2010

 

Active Medicare recipients are exempt from the requirement to provide evidence of citizenship and identity. The Social Security Administration (SSA) documents citizenship and identity for Medicare recipients.

For any individual entitled to or enrolled in Medicare Part A or B and subsequently denied Medicare, use the State On-Line Query (SOLQ) system or Wire Third Party Query (WTPY) system as documentation of both citizenship and identity when the denial is for any reason other than citizenship. If there is an end date listed for Medicare, the individual must provide documentation on the loss of Medicare.

 

2213 All Other Individuals

Revision 14-1; Effective March 3, 2014

 

The primary documents that may be accepted as proof of both identity and citizenship include:

If an individual does not provide one of these primary documents that establish both U.S. citizenship and identity, the individual must provide two documents:

See Evidence of Identity below for a list of documents that are acceptable.

Documents that establish citizenship are divided into second, third and fourth levels based on the reliability of the evidence.

Primary Evidence of Citizenship and Identity
  • U.S. passport.
  • Certificate of Naturalization.
  • Certificate of U.S. Citizenship.
  • State Data Exchange (SDX) for denied Supplemental Security Income (SSI) recipients when the denial reason is for any reason other than citizenship (N13).
  • State On-Line Query (SOLQ)/Wire Third Party Query (WTPY) and documentation on reason for Medicare denial.

Begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

Second Level of Evidence of Citizenship
(Use only when primary evidence is not available.)
  • A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (if born on or after Jan. 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (if born after Nov. 4, 1986). Contact the Bureau of Vital Statistics (BVS) for an individual born in Texas. If an individual's date of birth is earlier than 1903 or if the birth was out of state, accept a legible, non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; and usbirthcertificate.net or their toll-free number, 1-888-736-2692.
  • Report of Birth Abroad of a U.S. Citizen (FS-240).
  • Certification of Birth Abroad (FS 545 or DS-1350).
  • U.S. Citizen Identification card (Form I-179 or I-197).
  • Northern Mariana Identification card (I-873).
  • American Indian card (I-872) issued by the Department of Homeland Security with classification code "KIC".
  • Final adoption decree showing the child's name and U.S. place of birth.
  • Evidence of U.S. Civil Service employment before June 1, 1976.
  • U.S. military record showing a U.S. place of birth (Example: DD-214).

 

Third Level of Evidence of Citizenship
(Use only when primary and second level evidence is not available.)
  • Hospital record of birth showing the U.S. place of birth.
  • Life, health or other insurance record showing the U.S. place of birth.
  • Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual's age at the time the record was made.
  • Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and the name(s) and place(s) of birth of the applicant's/recipient's parents.

 

Fourth Level of Evidence of Citizenship
(Use only when primary, second and third level evidence is not available.)
Any listed documents used must include biographical information, including U.S. place of birth.
  • Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual's age (generally for individuals born 1900-1950).
  • Seneca Indian Tribal census record showing a U.S. place of birth.
  • Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth.
  • Bureau of Indian Affairs Roll of Alaska Natives.
  • U.S. state vital statistics official notification of birth registration showing a U.S. place of birth.
  • Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth.
  • Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth.
  • Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth.
  • Affidavits from two adults regardless of blood relationship to the individual. (Use only as a last resort when no other evidence is available.)

 

Evidence of Identity
  • Driver license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color.
  • School identification card with a photograph.
  • U.S. military card or draft record.
  • Identification card issued by the federal, state or local government with the same information that is included on a driver license
  • Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color.
  • Birth certificate.
  • Hospital record of birth.
  • Military dependent's identification card.
  • Native American Tribal document.
  • U.S. Coast Guard Merchant Mariner card.
  • Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information.
  • Data matches with other state or federal government agencies (Example: Employee Retirement System and Teacher Retirement System).
  • Three or more supporting documents such as a marriage license, divorce decree, high school diploma or employer identification card (use only with second and third level evidence of citizenship).
  • Adoption papers or records.
  • Work identification card with photograph.
  • Signed application for Medicaid (accept signature of an authorized representative or a responsible person acting on the individual's behalf).
  • Health care admission statement.
  • For children under age 16, school records (may include nursery or day care records).
  • For children under age 16, doctor, clinic or hospital records.
  • For children under age 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).
  • For disabled individuals in residential care facilities who cannot provide any document on this list, an affidavit signed by the facility director or administrator attesting the identity of the individual (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).

In the hierarchy of approved documentation sources, some documents listed to verify citizenship are also acceptable to verify identity. When using the hierarchy of approved documentation sources, the same document cannot be the source to verify both citizenship and identity.

If an individual is unable to provide any other documentary evidence of citizenship, an affidavit signed under penalty of perjury is only accepted as a last resort. Medicaid for the Elderly and People with Disabilities (MEPD) staff are required to document the reason another source is not available to verify citizenship. If managed care organization (MCO) or Program Support Unit (PSU) staff are provided an affidavit, ensure the reason the applicant or recipient is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form H1746-A, MEPD Referral Cover Sheet, along with the affidavit. The copies of the affidavit form are to be made available in all Health and Human Services Commission (HHSC) benefits offices. Form H1097, Affidavit for Citizenship/Identity, and Form H1097-S (Spanish), also may be used.

 

2220 Reserved

Revision 10-0; Effective September 1, 2010

 

 

2230 Member Rights and Responsibilities

Revision 12-3; Effective October 1, 2012
 

 

2231 Notifications

Revision 14-1; Effective March 3, 2014

 

 

2231.1 PSU Notification Requirements

Revision 14-1; Effective March 3, 2014

 

The Program Support Unit (PSU) is responsible for preparing and sending notifications to the applicant or member advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant/member of the actions taken regarding STAR+PLUS Waiver services. The form must be completed in plain language that can be understood by the applicant/member. The language preference of the member must be considered.

The applicant or member must be notified on Form H2065-D within two business days of the date a case is certified. The form also includes information on the individual's room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied or a member whose services are terminated. The PSU must notify the applicant on Form H2065-D of the denial of application within two business days of the decision. See also Section 3630, Denial/Termination Procedures.

Once it is determined that a case action must be taken, Form H2065-D must be prepared and mailed to the member the same date the form is signed. Notification forms must be posted to the managed care organization's XXXSPW folder using the correct naming convention in TxMedCentral on the case action date. The PSU specialist's signature date on Form H2065-D is the case action date.

 

2231.2 MCO Notification Requirements

Revision 10-0; Effective September 1, 2010

 

The managed care organization (MCO) is responsible for notifying the member when a service is either denied or reduced. This is considered an adverse action and the member has a right to appeal. Appeal rights of STAR+PLUS members are in the Uniform Managed Care Manual, which can be found at: https://hhs.texas.gov/services/health/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

 

2232 Notifications with MEPD Involvement

Revision 14-1; Effective March 3, 2014

 

Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff. The Program Support Unit (PSU) must coordinate changes or the denial of waiver services with Medicaid denial decisions made by the MEPD specialist.

Although the MEPD specialist is required to notify the applicant/member of all Medicaid eligibility decisions, the PSU is required to send the HCBS STAR+PLUS Waiver (SPW) applicant/member the notification of denial of waiver services on Form H2065-D, Notification of Managed Care Program Services. PSU staff also send the MEPD specialist a copy of Form H2065-D at initial certification and denial for case actions that involve Medicaid eligibility.

 

2233 Rights and Responsibilities Reference

Revision 10-0; Effective September 1, 2010

 

Member rights and responsibilities are included in the Member Handbook. The required critical elements for member handbooks can be found at:

https://hhs.texas.gov/services/health/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the member at application. This document is shared in the language preference expressed by the applicant/member.

SPH, Section 3000, Waiver Eligibility and Services

Revision 18-1; Effective March 1, 2018

 

 

 

3100 Ancillary Member Resources

Revision 17-1; Effective March 1, 2017

 

 

3110 Medicaid, Medicare and Dual-Eligibles

Revision 17-1; Effective March 1, 2017

 

 

3111 Dual-Eligible Members

Revision 17-5; Effective September 1, 2017

 

Managed care organizations (MCOs) are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member in developing an appropriate plan of care. MCOs are expected to provide innovative, cost-effective care from the beginning in order to prevent or delay unnecessary institutionalization.

STAR+PLUS Medicaid-only members are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These members receive all covered services, both acute care and long-term services and supports (LTSS), from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare eligibility or services. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

 

3112 Medicaid Eligibility

Revision 17-5; Effective September 1, 2017

 

At the time of the initial application for the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. PSU staff must also obtain verification of the applicant's current eligibility for an appropriate type Medicaid program through the Texas Integrated Eligibility Redesign System (TIERS). If there is no existing acceptable coverage type, PSU staff initiate the Medicaid financial eligibility determination process.

Refer to Section 3114, Applicants with Medicaid Eligibility, for Medicaid programs appropriate for STAR+PLUS HCBS program financial eligibility status.

Medicaid eligibility may have already been determined and must be used unless there have been changes in the applicant's financial situation. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200. The PSU staff must check with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding the need for a new Form H1200.

See Appendix V, Medicaid Program Actions, to determine if a program transfer by MEPD will be required. See also Section 3230, Financial Eligibility, for additional information regarding financial eligibility.

Note: The completion or signing of an application for an applicant or member does not automatically authorize a person to receive protected health information from PSU staff or the managed care organization (MCO) regarding that applicant or member. See Section 2119, Personal Representatives, for individuals who may receive or authorize the release of an applicant's or member's individually identifiable health information under Health Insurance Portability and Accountability Act privacy regulations.

 

3113 Transmittal of Form H1200 or Form H1200-EZ

Revision 17-5; Effective September 1, 2017

 

When transmitting Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, to Medicaid for the Elderly and People with Disabilities (MEPD), Program Support Unit (PSU) staff fax Form H1200 or Form H1200-EZ to MEPD. The Texas Health and Human Services Commission (HHSC) retains the original Form H1200 or Form H1200-EZ with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

If HHSC staff are co-housed with MEPD, the original Form H1200 or Form H1200-EZ is hand-delivered to the MEPD specialist and HHSC staff retain a copy of the form in the case record. If unusual circumstances exist in which the original must be mailed to the MEPD specialist after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 or Form H1200-EZ and sending by electronic mail is prohibited.

 

3114 Applicants with Medicaid Eligibility

Revision 17-5; Effective September 1, 2017

 

At the time of the initial intake for the STAR+PLUS Home and Community Based Services (HCBS) program, the Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. The PSU staff must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from Medicaid for the Elderly and People with Disabilities (MEPD) specialist or through inquiry in the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for the STAR+PLUS HCBS program, refer to the mandatory population described in Section 3221, Mandatory Groups.

Note: Individuals who are in Title XIX-approved nursing facilities are potentially eligible for the STAR+PLUS HCBS program through Money Follows the Person (MFP).

Applicants who receive Supplemental Security Income are financially eligible for Medicaid and do not require a financial determination; the Social Security Administration has already made this determination.

Applicants receiving services through Community Attendant Services (TIERS TP14) are not automatically eligible for the STAR+PLUS HCBS program. MEPD specialists must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.

 

3115 Applicants Without Medicaid Eligibility

Revision 17-5; Effective September 1, 2017

 

The Code of Federal Regulations, Section 42 CFR 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas State Plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for Medical Assistance Only (MAO) cases.

Financial eligibility for non-Supplemental Security Income (SSI) STAR+PLUS Home and Community Based Services (HCBS) program is determined exclusively by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Program Support Unit (PSU) staff must not:

If the applicant's individual income exceeds the SSI federal benefit rate (FBR) per month, the applicant applies for Medicaid through HHSC by completing Form H1200, Application for Assistance – Your Texas Benefits, for MAO. If the combined income of the applicant and the spouse exceeds the SSI FBR for a couple, the applicant may apply for MAO with HHSC. See Appendix VIII, Monthly Income/Resource Limits, for the current SSI FBR.

 

3116 Monthly Income Below the Supplemental Security Income Standard Payment

Revision 17-5; Effective September 1, 2017

 

An applicant in the community (with no ineligible spouse) who has income less than the Supplemental Security Income (SSI) federal benefit rate must apply for SSI through the Social Security Administration. The Texas Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except for cases in which the SSI application for disability has been pending for more than 90 days and a decision is made by HHSC Disability Determination Unit staff.

If there is a question whether the applicant should apply for SSI or for Medical Assistance Only (MAO), Program Support Unit (PSU) staff may consult the regional Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

 

3117 Coordination with Medicaid for the Elderly and People with Disabilities Staff

Revision 17-1; Effective March 1, 2017

 

The Program Support Unit (PSU) staff must inform the applicant or member without pre-existing Medicaid coverage and/or his/her authorized representative that the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will complete a financial eligibility (Medicaid) determination. PSU staff must encourage the applicant, member or authorized representative to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by the PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based (HCBS) program according to regional procedures. For those applicants or members already on an appropriate type of Medicaid program, the PSU staff must obtain a copy of the most recent:

An applicant for the STAR+PLUS HCBS program who has medical assistance only (MAO) coverage type Medicaid services may only receive the STAR+PLUS HCBS program after a program transfer to Medicaid waivers is completed by the MEPD specialist. When an applicant for the STAR+PLUS HCBS program has MAO coverage type as indicated in the Texas Integrated Eligibility Redesign System (TIERS), a completed Form H1200 must be sent to the applicant. The completed application must be forwarded to the MEPD specialist for processing.

PSU staff must also send an email to gay.smauley@hhsc.state.tx.us and amanda.hart2@hhsc.state.tx.us  that includes the following information:

The MEPD specialist will make the necessary changes to allow the MA coverage-type Medicaid individual to receive the STAR+PLUS HCBS program.

Identification of MAO Coverage-Type Medicaid

PSU staff can check TIERS to determine a  member’s coverage type. In TIERS, the coverage type on the Search/Summary Screen is displayed with the preface of MAO.

An application form is not required for members receiving Supplemental Security Income (SSI).

If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission's (HHSC’s) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDU staff to make a disability determination, DDU staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, the MEPD specialist is notified.

 

3117.1 Income and Resource Verifications for Medicaid for the Elderly and People with Disabilities

Revision 17-5; Effective September 1, 2017

 

Any information, including information on third-party insurance, obtained by the Program Support Unit (PSU) staff must be shared with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to prevent the applicant or member from having to provide the information twice. Any information obtained by managed care organization (MCO) staff must be immediately forwarded to the PSU staff so it can be passed on to the MEPD specialist.

Inform Medical Assistance Only (MAO) applicants of the importance of providing the most complete packet possible to the MEPD specialist. Explain that failure to submit the required documentation to the MEPD specialist could delay completion of the application or cause the application to be denied.

Ensuring the following items are included greatly facilitates the financial eligibility process:

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program, according to regional procedures. The PSU staff should obtain a copy of the most recent Form H1200, Application for Assistance – Your Texas Benefits, for those applicants/members already on an appropriate type of Medicaid program. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

If a STAR+PLUS HCBS program applicant's/member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Services (DDS) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDS staff to make a disability determination, DDS staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, the MEPD specialist will be notified.

 

3117.2 MAO Applicants Not Previously Certified in TIERS

Revision 17-1; Effective March 1, 2017

 

A new application is defined as an application for a Medicaid for the Elderly and People with Disabilities (MEPD) household not previously certified in either the Texas Integrated Eligibility Redesign System (TIERS).

Once staff determine applicants being referred to MEPD for a financial determination do not have any prior certifications in TIERS, Form H1746-A, MEPD Referral Cover Sheet, and Form H1746-B, Batch Cover Sheet, must be used to send Form H1200, Application for Assistance – Your Texas Benefits, Form H1200-EZ, Application for Assistance – Aged and Disabled, or Form H1010, Texas Works Application for Assistance – Your Texas Benefits, to the Midland Document Processing Center (DPC). Form H1746-B must be attached to the top of each batch containing more than one Form H1746-A being sent to DPC.

 

3117.3 Unsigned Applications

Revision 17-5; Effective September 1, 2017

 

Unsigned applications received by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are returned to the sender. Texas Health and Human Services Commission (HHSC) staff must ensure applications are signed prior to referring to the MEPD specialist; if not, HHSC staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

If the MEPD specialist receives an unsigned application from HHSC with Form H1746-A, MEPD Referral Cover Sheet, MEPD returns the application to HHSC with an annotation on the cover form (Form H1746-A) that the application is unsigned and must be signed before HHSC can establish a file date. Once HHSC staff receive an unsigned application from the MEPD specialist, it is the responsibility of HHSC staff to coordinate with applicants or members in getting applications signed and returned to the MEPD specialist for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to applicants or members.

 

3117.4 Medicaid Eligibility Decisions Pending Past the Program Due Date

Revision 18-1; Effective March 1, 2018

 

For most Medicaid for the Elderly and People with Disabilities (MEPD) applications, eligibility decisions are due by the 45th day. However, applications for individuals under age 65 may require a 90-day time frame to allow the agency to obtain a disability determination. This applies when the person's age is less than 65 and the person does not receive Retirement, Survivors and Disability Insurance (RSDI), Supplemental Security Income (SSI) or Railroad Retirement (RR). A disability determination by the Texas Health and Human Services Commission (HHSC) is required even if the person has received a medical necessity and level of care determination under the STAR+PLUS Home and Community Based Services (HCBS) program eligibility component criteria.

For other case actions (for example, program transfers), the MEPD specialist may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income/resources. Program Support Unit (PSU) staff may contact MEPD once they have been pending more than 45 days.

 

3118 Address Changes for Supplemental Security Income Recipients

Revision 17-5; Effective September 1, 2017

 

Program Support Unit (PSU) staff must not send address change requests for Supplemental Security Income (SSI) recipients to the Document Processing Center (DPC) in Midland. PSU staff must inform the individual or his responsible party to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System (TIERS) after SSA makes the change.

PSU staff must also send an email to the Enrollment Resolution Services (ERS) mailbox at HPO_STAR_PLUS@hhsc.state.tx.us to notify ERS of the request for a change in address.

 

3120 Other Available Services

Revision 17-1; Effective March 1, 2017

 

 

3121 Prescription Drugs

Revision 17-5; Effective September 1, 2017

 

Prescription drugs are not part of the managed care organization's (MCO's) array of services. STAR+PLUS Medicaid-only members continue to have prescriptions filled by any pharmacist participating in the Texas Health and Human Services Commission Vendor Drug Program. They will receive unlimited medically necessary prescriptions instead of the traditional three prescriptions per month limit. Drug coverage through Vendor Drug is limited to the state's formulary and may not cover all of the prescribed medications required for the individual.

Medicare prescription drug coverage (Medicare Part D) is insurance that covers both brand name and generic prescription drugs at participating pharmacies in the member's area. Medicare prescription drug coverage provides protection for people who have very high drug costs. Medicare members are eligible for this coverage, regardless of income and resources, health status or current prescription expenses. Members who are eligible for both Medicaid and Medicare (dual-eligible) receive the majority of their drugs through Medicare Part D.

The MCO must inform individuals requesting the STAR+PLUS program of prescription coverage available through the STAR+PLUS program and the Medicare Part D program. The following information regarding the impact of the Medicare Part D program on members must be explained to the applicant:

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may not be authorized for prescriptions, copayments and costs if the member is eligible for Medicare Part D and chooses private insurance rather than participation in Medicare Part D. Non-covered medications cannot be billed through the STAR+PLUS program as medical supplies or adaptive aids.

Copayments for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through the STAR+PLUS program.

Members who contribute to the cost of their care may be eligible to count Medicare Part D costs as an incurred medical expense if they:

For a member whose current Medicaid identification card does not include the statement "can receive more than three prescriptions," pharmacists may verify the STAR+PLUS program eligibility for more than three prescriptions by calling Pharmacy Billing at 1-800-435-4165.

A list of the STAR+PLUS program enrollments is sent to the Medicaid Vendor Drug Program daily. Vendor Drug staff register the member on the system within two days after the member's enrollment record is registered for STAR+PLUS Program services.

Pharmacists must check the member's Your Texas Benefits Medicaid card monthly to ensure that the member remains eligible for Medicaid.

STAR+PLUS Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs as incurred medical expenses. Refer to Section 3123, Incurred Medical Expenses.

 

3122 Over-the-Counter Drugs

Revision 17-1; Effective March 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

Medications, including over-the-counter drugs not covered through the Texas Health and Human Services Commission (HHSC) Vendor Drug Program, Medicare Part D or other third-party resources, cannot be paid for by the STAR+PLUS HCBS program. Refer to Section 3121, Prescription Drugs, for additional information.

 

3123 Incurred Medical Expenses

Revision 17-5; Effective September 1, 2017

 

Incurred medical expenses (IMEs) are out-of-pocket expenses a Medical Assistance Only (MAO) member can incur for necessary medical services. IMEs include the cost of medically necessary items not covered by Medicaid, such as Medicare Part D premiums.

STAR+PLUS  Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs (such as premiums, enhanced premiums, prescription drug copayments/deductibles, drugs not covered by Medicare Part D, the Texas Health and Human Services Commission (HHSC) Vendor Drug Program and non-formulary drugs) as IMEs if they:

Members who wish to use IMEs to pay for Medicare Part D costs should report these costs to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist so the costs can be included in the calculation of copayment for the STAR+PLUS HCBS program. The member's statement of Medicare Part D expenses is acceptable. No written documentation is required from the member to support the declaration. The arrangement for payment of the prescriptions is between the member and the pharmacist.

Some drugs are not covered by Medicare Part D, Medicaid or private drug coverage. In order for these non-formulary drugs to be considered as IMEs, a member must request an exception from the Medicare Part D plan for the drugs. The member is expected to use the procedure for requesting an exception, as required by his/her Medicare Part D plan. The member can submit the results of the requested exception directly to the MEPD specialist. If an exception is not requested, the non-formulary drugs are not allowable IMEs and the cost will be the responsibility of the member.

The MEPD specialist applies the IME policy during the certification process to all new members who meet the above criteria. MEPD also reviews Medicare costs and IMEs once every six months as part of the regular case monitoring, or whenever the member makes a request to update IME costs. The member or his/her authorized representative may identify and request IMEs by contacting the MEPD specialist.

 

3124 Medical Transportation

Revision 17-5; Effective September 1, 2017

 

STAR+PLUS Home and Community Based Services (HCBS) program members, as recipients of Medicaid, are eligible to use the Medicaid medical transportation system for Medicaid-covered medical appointments. The Medicaid medical transportation system is accessed by calling the local agency whose number is available from the Texas Health and Human Services Commission (HHSC). Day Activity and Health Services (DAHS) providers, Adult Foster Care (AFC) and Assisted Living (AL) providers are responsible for scheduling transportation for the residents.

The local medical transportation contractors have procedures regarding service area limitations, schedules for traveling to certain areas and requirements on the amount of notice required by STAR+PLUS HCBS program members. The AFC/AL provider must provide an escort for the member, if necessary.

There may be questions about eligibility for participants who are living in AFC/AL facilities. In cases of difficulties in scheduling, or questions about eligibility for transportation, participants should contact the managed care organization to intercede on the participant's behalf with the local Medicaid medical transportation system.

 

3125 STAR+PLUS Home and Community Based Services Program Members Requesting Non-Managed Care Services

Revision 17-1; Effective March 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program is required to provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, Community Care for Aged and Disabled services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's service coordinator.

 

3126 STAR+PLUS Members Requesting Non-Managed Care Services

Revision 17-1; Effective March 1, 2017

 

Members receiving STAR+PLUS services are potentially eligible to receive a variety of services from the Texas Health and Human Services Commission (HHSC). For specific information, see:

 

3126.1 Community Care for Aged and Disabled Services

Revision 17-5; Effective September 1, 2017

 

If members meet program requirements, STAR+PLUS Services members are eligible to receive the following Community Care for Aged and Disabled (CCAD) services:

Members may also be eligible for Family Care if the managed care organization (MCO) has denied their request for personal attendant services due to the:

STAR+PLUS members may never receive the following services from the  Texas Health and Human Services Commission (HHSC):

An individual requesting Community Care services should be added to any applicable interest lists at the time of the request, in order to protect the date and time of the request. Prior to processing an application, the CCAD case manager must verify the service array does not include a service equivalent of the Title XX service requested. They may view the STAR+PLUS Program Health Plan Comparison Charts and value-added services on the Health and Human Services (HHSC) website at:  https://hhs.texas.gov/services/health/medicaid-and-chip/programs/starplus/comparison-charts.

Value-added services offered by an MCO are extra services approved by HHSC. Value-added services will vary by MCO. HHSC staff are not required to wait for appeal decisions from MCOs to process requests for Title XX services if the service requested is not a value-added service on the member’s plan. Once released from the Title XX interest list, the CCAD case manager verifies the applicant’s MCO does not offer an equivalent service as a value-added service and proceeds with the eligibility determination for the requested Title XX service.

The member should be asked if he or she has requested the service from the MCO, if the requested service is not a value-added service but is part of the MCO's service array. If the answer to that question is:

Once released from the interest list, Community Care case managers may proceed to determine eligibility. Process applications for individuals who are enrolled in STAR+PLUS Services managed care only if they meet the criteria outlined above. Do not authorize Title XX services for anyone receiving the STAR+PLUS Home and Community Based Services (HCBS) program.

 

3126.2 In-Home and Family Support Program Services

Revision 17-5; Effective September 1, 2017

 

Individuals receiving STAR+PLUS services may receive In-Home and Family Support Program services (IHFSP) if:

Individuals requesting IHFSP should be added to any applicable interest lists at the time of the request in order to protect the date and time of the request. At the time of release from the interest list, the IHFSP case manager must contact the Program Support Unit (PSU). PSU staff will contact the managed care organization (MCO) to ensure IHFSP does not deliver any services already being supplied by the MCO.

Do not authorize IHFSP services for anyone receiving the STAR+PLUS Home and Community Based Services (HCBS) program.

 

3127 Health Insurance Premium Payment Program

Revision 17-1; Effective March 1, 2017

 

The Health Insurance Premium Payment (HIPP) program is a Medicaid program that reimburses eligible individuals for their share of an employer-sponsored HIPP. The state pays for copayments and deductibles for Medicaid-covered services provided by Medicaid providers. HIPP individuals also can receive Medicaid benefits (provided by a Medicaid-enrolled provider) not covered by their employer-sponsored health insurance.

In order to qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The reimbursement may pay for individuals and their family members to receive employer-sponsored health insurance benefits when it is determined the cost of insurance premiums and administration are less than the cost of projected Medicaid expenditures.

Individuals who participate in the HIPP program may participate in STAR+PLUS and remain enrolled in HIPP.

 

3200 Eligibility

Revision 17-1; Effective March 1, 2017

 

 

 

3210 Service Delivery Areas

Revision 17-1; Effective March 1, 2017

 

STAR+PLUS services are currently available statewide in the following service delivery areas:

Bexar Service Area Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties
Dallas Service Area Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwell counties
Harris Service Area Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller and Wharton counties
El Paso Service Area El Paso and Hudspeth counties
Hidalgo Service Area Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy and Zapata counties
Jefferson Service Area Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler and Walker counties
Lubbock Service Area Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher and Terry counties
Medicaid Rural Service Area (RSA) Central Texas Service Area Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell and Washington counties
Medicaid RSA Northeast Texas Service Area Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt and Wood counties
Medicaid RSA West Texas Service Area Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young and Zavala counties
Nueces Service Area Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kennedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties
Tarrant Service Area Denton, Hood, Johnson, Parker, Tarrant, and Wise counties
Travis Service Area Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties

 

3220 Eligible Groups

Revision 17-1; Effective March 1, 2017

 

 

 

3221 Mandatory Groups

Revision 17-5; Effective September 1, 2017

 

The following groups of individuals must receive services through STAR+PLUS. The program designations are used in the following list.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact the Program Support Unit and provide the details for disenrollment from STAR+PLUS.

 

3222 Excluded Groups

Revision 17-1; Effective March 1, 2017

 

For excluded groups, refer to Texas Administrative Code (TAC) §353.603, Member Participation.

 

3223 Hospice Services in STAR+PLUS

Revision 17-1; Effective March 1, 2017

 

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of Hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, Hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF Hospice services can be identified in the Service Authorization System (SAS) as Service Group (SG) 8, Service Code (SC) 31. The NF counter is activated by non-Hospice NF authorizations, which appear in SAS as SG1/SC1 or SG1/SC3.

 

3230 Financial Eligibility

Revision 17-5; Effective September 1, 2017

 

STAR+PLUS Home and Community Based Services (HCBS) program applicants who are not already Medicaid eligible are required to complete Form H1200, Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed application form must be sent to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by close of business of the second business day from receipt. MEPD has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed application form must be sent to the MEPD specialist by close of business of the second business day from receipt. The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Applicants have 30 days from the mail date of the application to complete, sign and return Form H1200. After 30 days, the application must be denied for failure to return the information needed to determine financial eligibility. Before denying the application, Program Support Unit (PSU) staff must check first to make sure the application form was not mailed directly to the MEPD specialist.

If denial is necessary, document "Your application is being denied because you failed to return the application form mailed to you on [date]" in the comments section of Form H2065-D, Notification of Managed Care Program Services.

See Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

 

3231 Income Diversion Trust

Revision 17-5; Effective September 1, 2017

 

An applicant who has a Qualified Income Trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit, if the applicant also meets all other eligibility criteria. Income converted to the trust does not count for purposes of determining financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD) staff; however, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. An applicant may be eligible for services if all other eligibility criteria are met, even if the amount he or she has available for copayment equals or exceeds the total cost of his/her individual service plan (ISP).

Financial eligibility for an applicant with a QIT is determined by the MEPD specialist. He or she is informed that any funds deposited into the trust must be used as copayment for the cost of services delivered. The MEPD specialist calculates the amount of income available from the trust for copayment and provides the amount to the Program Support Unit (PSU). PSU staff notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication.

For an applicant who is financially eligible based on a QIT, the eligibility based on the ISP cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase STAR+PLUS HCBS program services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of STAR+PLUS HCBS program eligibility. A member with a QIT copayment that covers all STAR+PLUS HCBS program costs receives the benefit of contracted rates as opposed to private pay rates.

First, a plan of care is developed by the MCO without consideration of the trust. Then, if the individual is eligible for the STAR+PLUS HCBS program based on the cost limit, the excess funds from the trust (the monthly income in excess of the institutional income limit and allowable deductions for a spouse's needs and medical expenses) are allocated to pay for services identified on Form H1700-1, Individual Service Plan (Pg.1), as the STAR+PLUS HCBS program. The ISP total, and therefore the amount of the authorizations to providers, is reduced by the amount of excess funds. The member must pay the provider directly for the amount of services equivalent to the amount of excess funds. Use of the trust fund is documented on Form H1700-B, Non-STAR+PLUS HCBS Program Services. Continuing Medicaid eligibility through the STAR+PLUS HCBS program is contingent upon payment of the QIT copayment to the provider(s).

Refer to Section 3236, Copayment and Room and Board, and Section 3232, Payments from the Qualified Income Trust, for specific PSU and MCO procedures related to QIT copayments.

 

3232 Payments from the Qualified Income Trust

Revision 17-5; Effective September 1, 2017

 

Applicants or members with a Qualified Income Trust (QIT) are responsible for a copayment in Adult Foster Care (AFC), Assisted Living (AL) or the at-home setting. The managed care organization (MCO) must clearly explain to the applicant or member the funds from the QIT determined to be available for copayment must be used to purchase the STAR+PLUS HCBS program. Payments are made directly to the AFC, AL or other provider.

For applicants or members residing in AFC or AL settings, the copayment amount is usually applied to the cost of AFC or AL first. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other STAR+PLUS HCBS program services, such as nursing, personal assistance services (PAS) or medical supplies. For applicants or members at home, the copayment is first used to purchase PAS, nursing or medical supplies. The MCO calculates the type and amount of payment the applicant or member will make directly to the service provider using the following steps:

 

3233 Available QIT Copayment Amount Exceeds the Daily Rate for Adult Foster Care or Assisted Living

Revision 17-1; Effective March 1, 2017

 

If the available Qualified Income Trust (QIT) copayment amount exceeds the daily rate for Adult Foster Care (AFC) or Assisted Living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment amount remains after the monthly copayment amount is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to Section 3235, Refusal to Pay Qualified Income Trust Copayment.

 

3234 Qualified Income Trust Copayment Agreement

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in Adult Foster Care (AFC) or Assisted Living (AL) settings, the copayment amount is usually applied to the cost of AFC or AL. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase PAS, nursing or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

 

3234.1 Calculation Example and Completion of Form 1578

Revision 17-5; Effective September 1, 2017

 

There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) it equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Next, calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to enter on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization discusses the copayment with the applicant or member and the trustee of the trust. After explaining the requirements, the applicant or member, his responsible party and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant or member and/or his responsible party and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant's or member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.

 

3235 Refusal to Pay Qualified Income Trust Copayment

Revision 17-5; Effective September 1, 2017

 

The trustee of the Qualified Income Trust (QIT) must pay the QIT copayment directly to the provider by the 10th day of the month, or not later than 10 days after STAR+PLUS Home and Community Based Services (HCBS) program services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

If the copayment is not fully paid within 30 days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form H2067-MC.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify the MEPD specialist of the refund.

Refer to Section 7100, Adult Foster Care, for procedures related to failure to pay copayment.

 

3236 Copayment and Room and Board

Revision 17-5; Effective September 1, 2017

 

Members who are determined to be financially eligible based on the special Medical Assistance Only institutional income limit may be required to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for the STAR+PLUS HCBS program.

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the STAR+PLUS HCBS program and specified on the member's individual service plan. The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized STAR+PLUS HCBS program services.

To determine the room and board amounts for members residing in Adult Foster Care or Assisted Living settings, apply the following post-eligibility calculations:

Some individuals will be responsible for contributing toward the cost of STAR+PLUS HCBS program services. This is referred to as copayment and/or room and board charges. The copayment amount is not a factor in determining the individual's eligibility for services.

The MEPD specialist calculates the copayment and deducts allowable incurred medical expenses for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a Qualified Income Trust (QIT). Refer to Section 3123, Incurred Medical Expenses, and Appendix XXII, §1915(c) Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance, are not required to make a copayment and no copayment calculation is necessary for them. STAR+PLUS HCBS program members who reside in Adult Foster Care (AFC) or Assisted Living (AL) settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the applicant, if it is determined the applicant must pay a monthly copayment that the copayment amount must be paid directly to the AL or AFC provider. All STAR+PLUS HCBS program members, including SSI recipients, are required to pay room and board in AL and AFC settings.

The MCO must also explain to the member that the member is required to pay the AFC or AL provider a room and board charge. If the member fails to pay the agreed-upon room and board charge and/or copayment, the member could be terminated from the STAR+PLUS HCBS program.

Refer to Appendix VI, STAR+PLUS Inquiry Chart, for examples of how to calculate the monthly room and board and monthly amounts available for copayment.

Program Support Unit staff notify the member and MCO of new copayment amounts to be collected on Form H2065-D, Notification of Managed Care Program Services.

Refer to Section 3232, Payments from the Qualified Income Trust, and Section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

 

3237 Determining Room and Board Charges

Revision 17-5; Effective September 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must pay the room and board charges to be eligible for Assisted Living (AL). Room and board cannot be waived, but an AL facility may choose to accept an individual for a lower amount. STAR+PLUS HCBS program policy does not direct the facility to accept or reject the individual.

The room and board charge for an individual is fixed at the amount remaining after subtracting $85 from the Supplemental Security Income (SSI) federal benefit rate (FBR). FBR current amounts are found in Appendix VIII, Monthly Income/Resource Limits, which is updated when the FBR changes.

For couples where both partners are residing in AL or Adult Foster Care (AFC) settings, $170 is subtracted from the couple's income so each member of the couple keeps $85 a month for personal needs and the remainder is the room and board charge for the couple. Due to the difference in income between couples and individuals, the amount of room and board charge for a couple depends on income.

The AL/AFC participant will keep $85 a month for personal needs.

Refer to Appendix VI, STAR+PLUS Inquiry Chart, for instructions about who to contact for information on how to calculate room and board for a partial month.

 

3238 Determining Copayment Amounts

Revision 17-5; Effective September 1, 2017

 

After determining financial eligibility for Medicaid, Medicaid for the Elderly and People with Disabilities (MEPD) specialists determine the amount of money available for copayment. MEPD specialists send Form H2067-MC, Managed Care Programs Communication, or Form H1746-A, MEPD Referral Cover Sheet, and a copy of the completed MEPD Waiver Program Copayment Worksheet to the Program Support Unit (PSU) indicating the amount available for the monthly ongoing copayment. PSU staff forward this information to the managed care organization (MCO) by posting Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral.

 

3239 Copayment Changes

Revision 17-5; Effective September 1, 2017

 

A member's copayment may change during the time he is receiving the STAR+PLUS Home and Community Based Services (HCBS) program, typically due to a change in income or medical expenses. Copayment changes must always be effective on the first day of the month. If the copayment is increasing, Program Support Unit (PSU) staff must send the member and managed care organization (MCO) notification on Form H2065-D, Notification of Managed Care Program Services, and the increase is effective the first day of the month after the expiration of the adverse action period. The MCO is responsible for notifying the provider.

If the first day of the month occurs before the end of the adverse action period, the copayment increase is effective the first day of the subsequent month. Decreases in copayment require Form H2065-D notification, but can be effective the first day of the month after the notification is sent.

Copayments may also change due to other circumstances. Medicaid for the Elderly and People with Disabilities (MEPD) specialists are responsible for calculating and handling fraud referrals. Notices and letters on these issues are prepared by MEPD specialists with copies to PSU staff. MEPD specialists inform PSU staff of fraud referrals and determine whether any corrections are necessary to the member's copayment based on a change in the amount available for copayment. PSU staff post Form H2067-MC, Managed Care Programs Communication, to inform the MCO of any change in the copayment amount.

Underpayments by the member that are not part of a fraud referral, such as those based on reconciliation of variable income, result in the MEPD specialist sending a letter to the member requesting that the member pay the MCO the amount of copayment that was underpaid. PSU staff are not responsible for determining if the underpayment is made to the MCO. The underpayment is not retroactively considered in the copayment calculation. The MEPD specialist notifies PSU staff if the ongoing copayment amount increases. If the amount does increase, PSU staff must post Form H2065-D notifying the MCO of the increase in the monthly copayment amount. The increase in copayment is effective the first day of the month after the expiration of the adverse action period indicated on Form H2065-D.

Refunds due to the member require a new copayment calculation be completed. The copayment may be calculated to allow the refund to be deducted from the member's next copayment amount due to the provider or the member may be given a reimbursement by the Adult Foster Care/Assisted Living (AFC/AL) provider if there are no future copayments. The MCO determines if the AFC/AL provider should submit a negative billing. The effective date of the decrease in copayment is the first of the month after Form H2065-D is sent.

Example: The member's ongoing copayment is $100 per month. The MEPD specialist determines a copayment amount of $75 should have been effective February 1. A refund of $25 per month for the months of February, March, April and May total $100. PSU staff find out about the new amount on May 20 and immediately post Form H2065-D notifying the MCO. The MCO contacts the provider of the member's new copayment amounts: June – $0, July – $50, August – $75, ongoing.

Additional information on copayment and room and board payments is included in Appendix VI, STAR+PLUS Inquiry Chart.

 

3240 STAR+PLUS Home and Community Based Services Program Requirements

Revision 17-5; Effective September 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program is provided by virtue of authority granted to the state of Texas to allow delivery of long-term services and supports that assist members to live in the community in lieu of a nursing facility. To be eligible for services under HCBS, the following criteria must be met:

 

3241 Medical Necessity Determination

Revision 17-5; Effective September 1, 2017

 

A STAR+PLUS Home and Community Based Services (HCBS) program applicant or member must have a valid medical necessity (MN) determination before admission into the STAR+PLUS HCBS program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant's or member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for STAR+PLUS HCBS program applicants or members. TMHP processes MN/LOC Assessments for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility staffing intensity and is used in the STAR+PLUS HCBS program to:

When TMHP processes an MN/LOC Assessment, a three-alphanumeric digit RUG appears in the Level of Service record in the Service Authorization System (SAS) and in the TMHP Long Term Care (LTC) online portal. An MN/LOC Assessment with incomplete information will result with a BC1 code instead of a RUG value. An MN/LOC Assessment resulting with a BC1 code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. Code BC1 is not a valid RUG to determine STAR+PLUS HCBS program eligibility.

The MCO nurse must correct the information on the MN/LOC Assessment within 14 days of submitting the assessment that resulted in a BC1 code. After 14 days, the MCO nurse must inactivate the MN/LOC Assessment and resubmit the assessment with correct information to TMHP.

For applicants or members needing a Medicaid eligibility financial decision, Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the applicant or member meets MN. This notification can be by telephone or may be documented on Form H1746-A, MEPD Referral Cover Sheet, which PSU staff send to the MEPD specialist. The MEPD specialist may view the SAS or LTC online portal to confirm that the applicant or member has met the MN criteria.

 

3241.1 Medical Necessity Determination for Applicants Residing in Nursing Facilities

Revision 17-5; Effective September 1, 2017

 

During the initial contact with the applicant or member, Program Support Unit (PSU) staff must explore the applicant's or member's status in the nursing facility (NF) and determine whether the applicant or member has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. Communication with the NF regarding plans for submittal of the MN/LOC Assessment may be necessary. PSU staff must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary and to avoid duplication of submittal to Texas Medicaid & Healthcare and Partnership (TMHP) for an MN determination.

Approved MNs for individuals residing in NFs may be verified through the Service Authorization System (SAS). In this situation, the MCO must not complete a new MN/LOC Assessment. The MN on record will be accepted as a valid MN. The MCO should ask the NF for a courtesy copy of the Minimum Data Set (MDS) completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.

If an applicant or member is applying for Medicaid as a resident in the NF and is concurrently applying for the STAR+PLUS Home and Community Based Services (HCBS) program, the NF should complete the MDS. The MCO is instructed not to complete a new MN/LOC Assessment with the pre-enrollment assessment. PSU staff must notify the MCO that MN exists by entering the Resource Utilization Group (RUG) and expiration date in Section A, Item 6, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization. If the NF refuses to complete the MDS in a timely manner, PSU staff must authorize the MCO to complete the MN/LOC Assessment on the applicant or member by entering N/A in Section A, Item 6, of Form H3676 and posting to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

A different situation exists when a STAR+PLUS HCBS program applicant or member enters the NF on Medicare. PSU staff must authorize the MCO to complete the MN/LOC Assessment, as described above, to expedite receiving an MN and avoid a delay for the applicant's or member's return to the community.

A denied MN decision resulting from an MN/LOC Assessment the MCO submitted is not used to deny a STAR+PLUS HCBS program applicant who has a current valid NF MDS. The NF MDS and RUG are used in the STAR+PLUS HCBS program eligibility determination.

An MN record must be located in the SAS so the individual service plan (ISP) registration does not suspend. The SAS MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.

 

3241.2 Medical Necessity Determination for Applicants Not Residing in Nursing Facilities

Revision 17-1; Effective March 1, 2017

 

For STAR+PLUS Home and Community Based Services (HCBS) program applicants not living in nursing facilities, the medical necessity determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) doing the pre-enrollment home health assessment.

The MCO must electronically submit the MN/LOC Assessment to TMHP after it has been signed by the physician. A copy of the MN/LOC Assessment is filed in the member's case folder.

 

3242 Individual Cost Limit Requirement

Revision 17-1; Effective March 1, 2017

 

 

3242.1 Maximum Limit

Revision 17-1; Effective March 1, 2017

 

The cost of the STAR+PLUS Home and Community Based Services (HCBS) program cannot exceed 202 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the STAR+PLUS HCBS program applicant must have an individual service plan (ISP) developed that is at or below 202 percent of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.

 

3242.2 Unmet Need for at Least One STAR+PLUS Home and Community Based Services Program Service

Revision 17-5; Effective September 1, 2017

 

The Code of Federal Regulations (CFR) specifies individuals are not eligible to receive  the STAR+PLUS Home and Community Based Services (HCBS) program unless they have a need for at least one STAR+PLUS HCBS program service. Therefore, the Texas Health and Human Services Commission (HHSC) cannot approve any individual service plan (ISP) which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan (Pg. 1). When the Program Support Unit (PSU) receives a service plan from the managed care organization (MCO) with a $0.00 STAR+PLUS HCBS program cost, the following activities occur.

Within two business days:

PSU staff post Form H2067-MC, Managed Care Programs Communication, to the appropriate XXXSPW folder in TxMedCentral, using the appropriate naming convention. This will inform the MCO to verify if the ISP, which has no services, is accurate.

 

3300 Administrative Procedures

Revision 17-5; Effective September 1, 2017

 

A Program Support Unit (PSU) operates in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. The PSU staff provide support necessary for the coordination of long-term services and supports, including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

Responsibilities of PSU staff include:

 

3310 Intake and Enrollment

Revision 17-5; Effective September 1, 2017

 

When Community Care Services Eligibility (CCSE) receives a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

Use the chart below to determine how to process requests for services in STAR+PLUS.

Type of Individual Enrolled with a STAR+PLUS MCO? How does CCSE handle this request?
Full Medicaid recipient applying for the STAR+PLUS HCBS program No. Forward the intake request to the enrollment broker. Supplemental Security Income (SSI) or other full Medicaid program recipients never go on the STAR+PLUS HCBS program interest list, whether they are enrolled with STAR+PLUS or not.

The enrollment broker determines what is preventing MCO enrollment and takes action to resolve the issue, which may include referral to the Health and Human Services Commission (HHSC) or contact with the individual.

Full Medicaid recipient applying for the STAR+PLUS HCBS program Yes. Refer the recipient to the MCO for the STAR+PLUS HCBS program. This individual will never go on the interest list.
Medically Dependent Children Program (MDCP) member who is turning age 21 No. MDCP is excluded from STAR+PLUS. A list of individuals aging out of MDCP is sent from state office to the regional directors 12 months before the individual's 21st birthday. See the procedures for transition from MDCP to the STAR+PLUS HCBS program in Section 3420, Individuals Aging Out of Children's Programs. These individuals never go on the interest list.
Medical Assistance Only (MAO) applicant for the STAR+PLUS HCBS program No. Staff receiving the intake will place the individual on the STAR+PLUS HCBS program interest list.
Nursing facility resident applying for the STAR+PLUS HCBS program Yes. He or she must be referred to the MCO for an upgrade to the STAR+PLUS HCBS program.
Nursing facility resident applying for the STAR+PLUS HCBS program No. All Money Follows the Person (MFP) and MFP Demonstration individuals are placed on the interest list by intake staff and immediately assigned. The community services interest list assignment automatically generates an email notifying PSU of the referral.

When CCSE intake staff determine a request for the STAR+PLUS HCBS program should be forwarded to PSU staff for processing, they must submit the request to the PSU mailbox designated for referrals to this program: StarPlusWaiverInterestList@hhsc.state.tx.us.

The email should contain the following data elements:

If CCSE intake staff are unable to obtain all data elements from the applicant, the referral will still be processed by the PSU state office staff so that access to the STAR+PLUS HCBS program interest list will not be denied. Although CCSE routinely provides the initial four demographic data, there may be times when an individual requesting services is unable to furnish the date of birth. If this information is not included in the referral, PSU staff must obtain it as the date of birth is required for entry to the Community Services Interest List (CSIL) system.

PSU state office staff will monitor the interest list mailbox and process the referrals within three business days by placing the individual on the STAR+PLUS HCBS program interest list, using the original date CCSE referred the request to PSU staff.

Because of member choice issues, MCOs are prohibited from contacting non-members without the authorization from PSU staff to complete required HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS interest list, or MFP and MFP Demonstration initiative individuals, PSU staff:

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake screeners must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.

CCSE intake screeners must be aware of the PACE service areas and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.

 

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 17-1; Effective March 1, 2017

 

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care for Aged and Disabled (CCAD) program. Referrals to CCAD must be made for all full Medicaid recipients. Case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

 

3311.1 Interest List Procedures

Revision 18-1; Effective March 1, 2018

 

Requests from Supplemental Security Income (SSI) or other full Medicaid program recipients must be assigned immediately. The Program Support Unit (PSU) must use the Community Services Interest List (CSIL) as a tracking system for full Medicaid recipients who are not SSI eligible, as well as non-Medicaid individuals who have expressed interest in the STAR+PLUS Home and Community Based Services (HCBS) program. CSIL will record the date and time of the expressed interest. If the individual is first on the list and the service delivery area is releasing names from the interest list, the PSU may immediately release and assign the individual to the appropriate PSU staff.

PSU staff must also use CSIL as a tracking system for nursing facility (NF) residents who are not SSI eligible and express an interest in the STAR+PLUS HCBS program. When PSU staff receive the request for community transition to the STAR+PLUS HCBS program, PSU staff will check CSIL to see if the NF resident is already on the STAR+PLUS HCBS program interest list. If not, and the individual is not SSI eligible, PSU staff will add and immediately release the individual from the STAR+PLUS HCBS program interest list.

PSU staff manage activities related to the STAR+PLUS HCBS program interest list, including:

PSU state office staff are responsible for sending Form H2111, Interest List Notification - HCBS-SPW, or Form H2111-S (Spanish), within three business days of placing individuals on the interest list. Additionally, PSU staff will open a case record in the HHS Enterprise Administrative Report and Tracking System (HEART), upload copies of the completed forms and immediately close the HEART case.

PSU state office staff are required to perform annual contacts for individuals on the STAR+PLUS HCBS program interest list to verify the current address and confirm continued interest in the program. If PSU state office staff are unable to reach the individual by phone during the annual contact, they send Form H2118, STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest, or Form H2118-S (Spanish), to the address on file within one business day of the attempted contact date. If no response is received from the individual within 30 days of the date of the letter, PSU staff remove the individual from the STAR+PLUS HCBS program interest list and close the record in the CSIL database, using "Could Not Locate" as the denial reason.

PSU staff send Form H2053-A, STAR+PLUS Waiver Release Letter, or Form H2053-AS (Spanish), to inform the individual that his name has come to the top of the STAR+PLUS HCBS program interest list. Along with Form H2053-A and H2053-AS, the staff send:

Form H3675 and Form H3675-S are sent to applicants upon release from the STAR+PLUS HCBS program interest list. Actions related to the form depend on whether the member released from the interest list does or does not wish to proceed with the eligibility determination process.

Within 14 days of release from the interest list, PSU staff contact the applicant regarding selection of an MCO as quickly as possible so the selected MCO can conduct the assessment and develop the initial individual service plan. Any delay in selecting an MCO will result in a delay in eligibility determination for the STAR+PLUS HCBS program

If the applicant has not selected an MCO within 30 days of contact by PSU staff, an MCO is assigned on a rotational basis from the list of available MCOs in the service area. The applicant is contacted within three business days and informed that:

See Section 3312, Enrollment, for steps to be taken after an individual is released from the STAR+PLUS HCBS program interest list.

 

3311.2 Interest List Slot Allocations

Revision 17-1; Effective March 1, 2017

 

Members receiving Medicaid services under any of the programs listed in the chart below must receive those services through managed care. This does not impact the STAR+PLUS Services member's right to access non-Medicaid services through the Texas Health and Human Services Commission. STAR+PLUS Home and Community Based Services (HCBS) program members must receive all services through the STAR+PLUS HCBS program, excluding hospice care. Only Medicaid Waivers cases count against regional slot allocations, as the following table illustrates:

Texas Integrated Eligibility Redesign System Type of Assistance (TA) Program Description Counts Against Interest List Slot Allocation?
TP 03 MAO Medicaid – Pickle No
TA 03 Manual Supplemental Security Income (SSI) recipient waivers No
TA 02 SSI recipient waivers No
TP 13 SSI Medicaid No
TA 10 Medicaid waivers Yes
TP 18 Medicaid for disabled adult children No
TP 21 Disabled widows/widowers Medicaid No
TA 01 SSI Denied Child No
TP 22 Early aged widows/widowers Medicaid No
TP 51 Rider 51 waivers No
TP 87 Medicaid Buy-in No

 

3311.3 Earliest Date for Adding a Member Back to the Interest List

Revision 17-5; Effective September 1, 2017

 

The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program (for applicants) or (for STAR+PLUS Home and Community Based Services (HCBS) program members), the first date the applicant or member is no longer eligible for the program denied.

Example 1: The applicant is released from the STAR+PLUS HCBS program CSIL on March 2, 2017. The case manager determines the applicant is not eligible for STAR+PLUS HCBS program on March 28, 2017, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2017.

Example 2: A STAR+PLUS HCBS program member is determined not eligible on March 28, 2017, and PSU staff send notification to the STAR+PLUS HCBS program member of termination of benefits. Termination is effective April 30. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2017.

If the applicant's or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System will cause the name to be removed from the interest list for that program.

Example 3: A member's STAR+PLUS HCBS program services are denied due to medical necessity and end on March 30, 2017. The first date the member can be added back to the STAR+PLUS HCBS program interest list is April 1, 2017.

Example 4: A member's STAR+PLUS HCBS program services are denied and will end March 13, 2017. The first date the member can be added back to the STAR+PLUS HCBS program interest list is March 14, 2017. If the member is already on another interest list, the denial date for the STAR+PLUS HCBS program would not impact the member's original date on the other interest list.

 

3311.4 Updating Community Services Interest List Records

Revision 17-5; Effective September 1, 2017

 

The Community Services Interest List (CSIL) must be updated to reflect accurate information. Program Support Unit (PSU) staff must complete data entry in CSIL for STAR+PLUS Home and Community Based Services (HCBS) program actions within five business days of the date:

For MFP certifications, CSIL is updated when the Service Authorization System (SAS) data entry is completed to register the initial individual service plan. Delaying data entry of the disposition status into CSIL for an applicant certified through MFP provisions prevents removing the individual from the interest list before the actual discharge from the nursing facility is verified.

Staff must ensure CSIL closures are recorded accurately by using the Community Services Interest List (CSIL) User's Guide, available to staff on the intranet.

 

3312 Enrollment

Revision 17-1; Effective March 1, 2017

 

The enrollment broker mails enrollment packets to all Medicaid recipients who are candidates for STAR+PLUS. This packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the recipient can choose. Recipients can return enrollment forms via mail, complete an enrollment form at an enrollment event or presentation, or call the enrollment broker and enroll via telephone.

Recipients have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the recipient will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Recipient assignments to an MCO or PCP are automatic, using a default process. Recipients assigned through the default process may still make a choice about their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, they must receive Medicaid services through the assigned MCO and PCP until they contact the MCO or the enrollment broker at 1-800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity determination is required.

 

3312.1 Enrollment Procedures Following Release from the Interest List

Revision 17-5; Effective September 1, 2017

 

Within 14 days of release from the interest list (see Section 3311.1, Interest List Procedures),  Program Support Unit (PSU) staff take the following steps to ensure candidates are successfully enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

PSU staff contact the applicant or responsible party to:

If the Service Authorization System (SAS) and Texas Integrated Eligibility Redesign System (TIERS) inquiry conducted before release from the interest list indicates an individual does not have pre-existing Medicaid coverage, PSU staff send an application for assistance (Form H1200, Application for Assistance – Your Texas Benefits) to the individual released from the interest list to begin the Medicaid eligibility determination process. Once the form is returned, PSU staff send the signed and completed application form, identifying the action to be taken, within two business days of receipt to Medicaid for the Elderly and People with Disabilities (MEPD) specialists, along with Form H1746-A, MEPD Referral Cover Sheet.

The applicant chooses an MCO and notifies PSU staff verbally or in writing.

Within two business days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post it on TxMedCentral in the MCO's SPW folder, following the naming convention instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance.

The MCO completes:

Note: The Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. The MCO has 45 days per UMCC requirement to complete all assessments and submit the results via Form H3676, Part B, to PSU staff.

The MCO posts the STAR+PLUS HCBS program ISP to TxMedCentral in the MCO's ISP folder, following the naming instructions in Section 5110. The MCO posts Form H3676 to TxMedCentral in the SPW folder, following instructions in Section 5110.

If the MCO does not post an ISP within 45 days after PSU staff posted Form H3676, Part A, PSU staff notify by email the health plan manager assigned to the MCO.

Within five business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff verify eligibility based on Medicaid eligibility, medical necessity and level of care (MN/LOC), and an ISP cost within the individual's assessed cost limit based on the established Resource Utilization Group value.

The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month following receipt of the latter of:

Example: MN/LOC is received at Texas Medicaid & Healthcare Partnership (TMHP) on May 15, the ISP is posted to TxMedCentral on June 2, and Medicaid eligibility is effective May 1. The SOC date is July 1.

The SOC date is the same as the ISP begin date, and will always be the first day of the month. Because individuals are not eligible for any STAR+PLUS HCBS program benefits between the notification form signature date and the ISP begin date, PSU staff must take care in recording the correct date on the notification to the member

For Money Follows the Person Demonstration effective dates, see Section 3500, Money Follows the Person, and the instructions for Form H2065-D, Notification of Managed Care Program Services.

If eligibility is approved, PSU staff complete Form H2065-D, and:

If eligibility is denied, PSU staff complete Form H2065-D and:

PSU staff make Service Authorization System (SAS) entries following procedures in the SAS Help File within five business days of receipt of all required eligibility verification.

After the individual has been determined eligible for the STAR+PLUS HCBS program, ERS updates the member's TIERS record to indicate managed care enrollment.

 

3313 Termination of CCAD Services Upon STAR+PLUS Home and Community Based Services Program Enrollment

Revision 17-5; Effective September 1, 2017

 

Code of Federal Regulations (CFR) §431.213 Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a recipient;

(b) The agency receives a clear written statement signed by a recipient that —

(1) He no longer wishes services; or

(2) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c) The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d) The recipient's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e) The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f) A change in the level of medical care is prescribed by the recipient's physician.

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the CCAD case manager so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service. The STAR+PLUS Home and Community Based Services (HCBS) program member must be encouraged to contact the managed care organization (MCO) to request any services being denied that are not included in the STAR+PLUS HCBS program individual service plan.

The 10-day adverse action prior notice requirement does not apply to individuals transferring from CCAD or other waiver programs to the STAR+PLUS HCBS program.

 

3313.1 Procedure for STAR+PLUS Home and Community Based Services Program Applicants

Revision 17-5; Effective September 1, 2017

 

For individuals just entering the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the waiver or CCAD case manager. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

In-Home and Family Support Program (IHFSP) services are terminated by the IHFSP case manager no later than the day prior to STAR+PLUS HCBS program enrollment, if prior notice is received by the IHFSP case manager. If prior notice is not received, the case manager must initiate denial within three business days of awareness of the transfer to STAR+PLUS.

The case manager must send Form 2065-E, Notification of In-Home Family Support Program Benefits, to initiate denial. It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System.

CCAD services are terminated by the CCAD case manager no later than the day prior to STAR+PLUS HCBS program enrollment. This is crucial since no STAR+PLUS HCBS program individual may receive CCAD and STAR+PLUS HCBS program services on the same day. The CCAD case manager must send:

 

3313.2 Procedure for STAR+PLUS Home and Community Based Services Program Members

Revision 17-5; Effective September 1, 2017

 

If it is determined that an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care for the Aged and Disabled (CCAD) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If In-Home and Family Support Program (IHFSP) services are authorized in the Service Authorization System (SAS), the IHFSP case manager must send Form 2065-E, Notification of In-Home and Family Support Program Benefits, within three business days to initiate denial. It is not necessary to provide an adverse action period prior to closing the authorization in SAS.

If CCAD services are authorized in SAS, the CCAD case manager must immediately send:

 

3314 Managed Care Organization Changes

Revision 17-1; Effective March 1, 2017

 

Members may change managed care organization (MCO) plans as often as monthly by contacting the enrollment broker at 1-800-964-2777. The enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of the month. Depending on which day of the month (before or after the enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834 daily enrollment file notifying the MCO of the new member. The Program Support Unit, when notified by the member, state or an MCO that a member has elected to change MCOs, will update the Service Authorization System to change the previous MCO to the new MCO.

 

3315 STAR+PLUS Home and Community Based Services Program Individuals Requesting Non-Managed Care Services

Revision 17-5; Effective September 1, 2017

 

Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program member. STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

 

3315.1 Requests from Individuals Awaiting Managed Care Enrollment

Revision 17-1; Effective March 1, 2017

 

Individuals awaiting managed care enrollment may be assessed for interim Community Care for the Aged and Disabled (CCAD) services. Texas Health and Human Services Commission case managers may assess all individuals whose managed care enrollment is pending if it appears CCAD services can be approved and delivered prior to enrollment in managed care.

 

3315.2 Requests from STAR+PLUS Home and Community Based Services Program Members

Revision 17-1; Effective March 1, 2017

 

Requirements of the federal 1115 waiver dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

 

3315.3 Requests from STAR+PLUS Services Members

Revision 17-5; Effective September 1, 2017

 

When a STAR+PLUS services managed care member requests non-Medicaid services, Texas Health and Human Services Commission (HHSC) staff must first determine if there is a slot available for the requested service. If not, the individual's name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Members are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.

When a slot is available, or before release from the interest list, HHSC staff consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is a STAR+PLUS member (see Section 5130, Managed Care Data in TIERS). If it is determined that the individual is a STAR+PLUS member, intake staff must contact Program Support Unit (PSU) staff before assignment to a case manager to determine if the managed care organization (MCO) is already delivering the managed care version of the requested service.

Within two business days of contact by intake staff, PSU staff:

Within five business days of receiving posted Form H2067-MC, the MCO must respond to PSU staff by posting Form H2067-MC to the XXXSPW folder in TxMedCentral using the appropriate naming convention.

Within two business days of receipt of the MCO's response, PSU staff must notify the referring HHSC staff by email or with Form H2067-MC.

If PSU staff determine the requested service is not being delivered by the MCO, the intake must be assigned to a case manager. The case manager processes the application and authorizes services if all eligibility criteria are met.

The PSU staff's response must be included in materials forwarded to the case manager at the time of case assignment. How the case manager proceeds with the eligibility determination process depends on the PSU's documented response.

If PSU staff determine the requested service is already being delivered by the MCO, PSU staff inform the member of the MCO's response. The member is urged to consult the MCO if he/she disagrees or feels the services are not sufficient to meet his/her needs.

See Section 3310, Intake and Enrollment, for additional information on intake and referral procedures.

 

3316 Requests for STAR+PLUS Home and Community Services Program from Participants in 1915(c) Medicaid Waivers

Revision 17-5; Effective September 1, 2017

 

Participants in 1915(c) Medicaid waivers may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program at any time if they:

When a 1915(c) Waiver recipient requests the STAR+PLUS HCBS program through the Texas Health and Human Services Commission (HHSC), a referral is made to Program Support Unit (PSU) staff.

PSU staff are responsible for completing the following activities within 14 days of the initial request for a STAR+PLUS HCBS program assessment. All attempted contacts with the member or encountered delays must be documented. PSU staff:

Within two business days of notification of the MCO selection by the STAR+PLUS HCBS program applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and posts it in the XXXSPW folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

The MCO posts both Form H1701-1 and Form H3676 in the XXXSPW folder on TxMedCentral using the appropriate naming convention. If the packet from the MCO is not received within 45 days after the assessment is authorized, PSU staff email the assigned health plan manager as notification the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff determine STAR+PLUS HCBS program eligibility based upon medical necessity, and an ISP cost within the Resource Utilization Group cost limit.

If eligibility for the STAR+PLUS HCBS program is denied or the applicant decides not to accept the STAR+PLUS HCBS program, PSU staff complete Form H2065-D, Notification of Managed Care Program Services, and:

If eligibility is approved and the individual chooses to accept STAR+PLUS HCBS program services, the individual is enrolled in the STAR+PLUS HCBS program the first day of the next month.

Within two days of determining the start of care date for the STAR+PLUS HCBS program, PSU staff complete Form H2065-D and:

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) Waiver services end the day before enrollment in the STAR+PLUS HCBS program.

 

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 17-1; Effective March 1, 2017

 

 

3321 General Eligibility Issues

Revision 17-5; Effective September 1, 2017

 

At the initial contact, Program Support Unit (PSU) staff must inform the Medical Assistance Only applicant or member and/or his/her authorized representative that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant or member and/or authorized representative to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform MEPD specialists of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by sending a completed Form H1200, Application for Assistance – Your Texas Benefits, within two business days of receipt, according to regional procedures. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

 

3321.1 Disability Determinations

Revision 17-5; Effective September 1, 2017

 

The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have absolutely no role in this process.

If a STAR+PLUS HCBS program applicant's or member's application for Supplemental Security Income (SSI) disability has been pending for over 90 days, the Health and Human Services Commission Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

 

3322 Actions Pending Past the Medicaid for the Elderly and People with Disabilities Due Date

Revision 17-5; Effective September 1, 2017

 

Because Program Support Unit (PSU) staff depend on Medicaid for the Elderly and People with Disabilities (MEPD) staff to determine eligibility for Medical Assistance Only (MAO) applicants, there are times when PSU staff must check with MEPD staff regarding the status of an application or program change.

Before contacting the MEPD specialist, PSU staff must ensure the following:

 

3330 STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program

Revision 17-5; Effective September 1, 2017

 

Medicaid members enrolled in STAR+PLUS qualify for Medicaid eligibility through various program types. Some members who request the STAR+PLUS Home and Community Based Services (HCBS) program may be Medicaid eligible through one of the following Medicaid program types:

Although these Medicaid programs represent full Medicaid eligibility, they do not consider transfer of assets and substantial home equity reviews required to establish financial eligibility for the STAR+PLUS HCBS program. Therefore, these Medicaid types are not eligible for an upgrade and enrollment in the STAR+PLUS HCBS program until Medicaid for the Elderly and People with Disabilities (MEPD) specialists test for the additional criteria.

Managed care organizations (MCOs) must notify the Program Support Unit (PSU) by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within three business days of an upgrade request for a member who has one of these Medicaid program types. PSU staff must contact the member within three business days of the posting date of Form H2067-MC to advise the member Form H1200, Application for Assistance - Your Texas Benefits, must be completed and returned to PSU staff.

Once the member returns Form H1200, PSU staff send the signed and completed application form within two business days of receipt to the MEPD specialist, along with Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken.

The MCO service coordinator must, within 45 days of a STAR+PLUS member's request for the STAR+PLUS HCBS program:

Within five business days of receipt of Form H1700-1 from the MCO, PSU staff review the form to determine if the member meets eligibility criteria for the STAR+PLUS HCBS program.

If medical necessity for a pending upgrade is denied, the MCO must inform PSU staff within three business days by posting Form H2067-MC to TxMedCentral. When this occurs, PSU staff must send Form 1746-A to the MEPD specialist notifying the denial within three business days after receiving it from the MCO.

PSU staff must apply STAR+PLUS Handbook policy regarding upgrades to determine if the member meets the eligibility criteria for the STAR+PLUS HCBS program. This will include not only review of the functional criteria evaluated by the MCO, but also a determination that the member's Medicaid type is eligible for the STAR+PLUS HCBS program. For SSI-denied Medicaid program types referenced in this section, the Medicaid program type verification includes the MEPD certification that the additional required financial criteria have been met.

If not eligible, PSU staff:

If the member is eligible, PSU staff will process the member upgrade by:

 

3400 Transferring Into STAR+PLUS

Revision 17-5; Effective September 1, 2017

 

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services. STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, Section 2230, Interest List Procedures.

Any application for new long-term services and supports from HHSC requires the mandatory member to be sent to his/her MCO first. This must be coordinated through the Program Support Unit (PSU). See Section 3125, STAR+PLUS Home and Community Based Services Program Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants/members, the losing area must inform the gaining area of the GR status. The gaining area must follow the GR process.

 

3410 Transfer Scenarios

Revision 17-1; Effective March 1, 2017

 

 

 

3411 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Delivery Area with Prior Knowledge

Revision 17-5; Effective September 1, 2017

 

When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS area, within two business days, the losing PSU:

Once the gaining PSU receives Form H1700-1, PSU staff follow the usual intake procedures. The process is abbreviated since the member already has a:

The gaining PSU coordinates all appropriate activities between the losing PSU, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

The gaining PSU maintains contact with the member until the move is complete. Within five business days after the move, PSU staff:

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

 

3412 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Delivery Area Without Prior Knowledge

Revision 17-5; Effective September 1, 2017

 

When Program Support Unit (PSU) staff are notified a transfer from one STAR+PLUS service area to another STAR+PLUS area has already occurred, within one business day the losing PSU:

Within two business days of notification from the losing PSU, the gaining PSU:

Upon receipt of Form H2067-MC, the gaining MCO must contact the member within one business day and begin services within two business days.

Once the gaining PSU receives Form H1700-1, staff follow the usual intake procedures. The process is abbreviated since the member already has a:

The gaining PSU coordinates all appropriate activities between the losing PSU, MCOs, the member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

Within two business days after completing the steps above, the gaining PSU:

Within two business days of notification of the move, ERS considers coordination of claims to limit provider impact.

 

3413 STAR+PLUS Home and Community Based Services Program Member Transferring from One MCO to Another Within the Same Service Delivery Area

Revision 17-5; Effective September 1, 2017

 

Once the initial enrollment period of one calendar month is passed, a member is eligible to change managed care organization (MCO) plans. When a member chooses to change from one MCO to another MCO in the same delivery area, the member or responsible party must contact the state-contracted enrollment broker via phone call to 1-800-964-2777, or via written correspondence.

The enrollment broker will ask if the member is in a hospital or residing in a nursing facility. If so, the member cannot change plans until the member has been discharged. The member can change MCOs as many times as the member wants, but not more than once per month.

If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day of the month, the change will take place the first day of the second month following the change request.

Examples:

For more details, see the Uniform Managed Care Manual, Chapter 3.4, Attachment C to the Medicaid Managed Care Member Handbook Required Critical Elements.

Monthly Plan Changes Report

Texas Health and Human Services Commission – Enrollment Resolution Services (ERS) prepares and sends the Monthly Plan Changes report to the Program Support Unit (PSU) and the gaining MCOs. PSU staff receive a full list; the MCO receives a member-specific report. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month. PSU staff must correct the contract number in the Service Authorization System to reflect all MCO changes. See Appendix I-E, Monthly Plan Changes Report.

Within five business days of receiving the list, the gaining MCO must request Form H1700-1, Individual Service Plan — (Pg. 1), and Medical Necessity and Level of Care from the losing MCO. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 14 days of notification of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 30 days of notification of the new member, the gaining MCO must conduct a home visit to assess the member's needs.

 

3420 Individuals Transitioning to an Adult Program

Revision 17-5; Effective September 1, 2017

 

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults. The following services end at the end of the month following the member’s 21st birthday.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

In addition to the programs and services above, individuals for Community First Choice (CFC) services and Personal Care Services (PCS) must transition to an adult program.

Members who receive MDCP, PDN/PPECC, CFC or PCS and transitioning to adult programs may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

 

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving Medically Dependent Children Program or Texas Health Steps Comprehensive Care Program/Private Duty Nursing or Prescribed Pediatric Extended Care Centers

Revision 17-5; Effective September 1, 2017

 

Members may receive a combination of the following services:

 

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 17-5; Effective September 1, 2017

 

Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the CCP Transition Report, which lists members enrolled in STAR Kids/STAR Health and receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including his/her authorized representative, if applicable, to initiate the transition process.

During the face-to-face visit with the member and his/her support person, the MCO must present an overview of STAR+PLUS, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to STAR+PLUS. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids Handbook, or for STAR Health, in the Uniform Managed Care Manual.

The STAR Kids MCO:

The STAR Health MCO:

The UR Transition/High Needs coordinator must:

PSIL staff:

PSU staff:

Note: PSU staff must not post Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder earlier than five months prior to the member’s 21st birthday. 

The following chart outlines the responsibilities for monitoring the CCP Transition Report and contacting members transitioning from STAR Kids/STAR Health who receive MDCP waiver or PDN/PPECC 12 months prior to the member’s 21st birthday.

Twelve Month Transition Chart
Under Age 21 MDCP Waiver Under Age 21 Other Services Received Monitors CCP Report 12-Month Contact

MDCP

CCP/PDN or PPECC

PSU Staff

MCO

MDCP

None

PSU Staff

MCO

Not Applicable

CCP/PDN

PSU Staff

MCO

Not Applicable

CCP/PPECC

PSU Staff

MCO

 

3421.2 Nine Months Prior to the Member's 21st Birthday

Revision 17-5; Effective September 1, 2017

 

Nine months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and Star Health managed care organization (MCO):

PSU staff:

Note: PSU staff must not post Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder earlier than five months prior to the member's 21st birthday.

 
Within 30 days of the enrollment packet mailing, PSU schedules and completes a telephonic contact with the member or the member’s available supports, including his/her authorized representative, to explain the following:

PSU staff will update the case in HEART by noting the due date for the six-month contact.

The following chart outlines the responsibilities for monitoring the CCP Transition Report and contacting members transitioning from STAR Kids/STAR Health and receiving MDCP Waiver or PDN/PPECC nine months prior to the member’s 21st birthday:

Nine Month Transition Chart
Under Age 21 MDCP Waiver Under Age 21 Other Services Received Monitors CCP Transition Report: Nine-Month Contact:
MDCP CCP/PDN or PPECC

PSU Staff

PSU Staff
MDCP None

PSU Staff

PSU Staff
None CCP/PDN

PSU Staff

PSU Staff
None CCP/ PPECC

PSU Staff

PSU Staff

 

3421.3 Six Months Prior to the Member's 21st Birthday

Revision 17-5; Effective September 1, 2017

 

Six months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care (PPECC) services, the following process begins.

Utilization Review (UR) must:

The IDD Waiver/Community Services/Hospice UR:

PSU staff:

Note: PSU staff must not post Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder earlier than five months prior to the member's 21st birthday. 

The following chart outlines the responsibilities for agency referrals and PSU action for members enrolled in STAR Kids/STAR Health and receiving MDCP or PDN/PPECC transitioning six months prior to the member’s 21st birthday.

Six Month Transition Chart
Under Age 21 Current Waiver Under Age 21 Other Services Received PSU Action
MDCP CCP/PDN or PPECC Monitors the CCP report and contacts the member.
MDCP Not Applicable Monitors the CCP report and contacts the member.
Not Applicable CCP/PDN Monitors the CCP report and contacts the member.
Not Applicable CCP/PPECC Monitors the CCP report and contacts the member.
CLASS, DBMD, HCS and TxHmL Not Applicable, CCP/PDN/ PPECC Contacts the member when the referral is received.

 

3421.4 Five Months Prior to the Member's 21st Birthday

Revision 17-5; Effective September 1, 2017

 

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the individual/family by telephone.

If the member/authorized representative receiving MDCP or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

If the member/authorized representative receiving MDCP or CCP/PDN or PPECC has not made an MCO and PCP choice:

Note: Within 14 days of the PSU Form H3676 posting date, the MCO must schedule the initial home visit with the MDCP or CCP/PDN member/authorized representative.

 

3421.5 Within 45 Days of Receiving Notification of a Form H3676 Referral

Revision 17-5; Effective September 1, 2017

 

Within 45 days of receiving email notification of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, the managed care organization (MCO):

 

3421.6 Confirm STAR+PLUS Home and Community Based Services Program Eligibility

Revision 17-5; Effective September 1, 2017

 

Program Support Unit (PSU) staff confirm eligibility within five business days of receipt of all required eligibility documentation from the managed care organization (MCO) and Texas Medicaid & Healthcare Partnership, based on:

PSU staff must request STAR+PLUS HCBS program enrollment from Enrollment Resolution Services (ERS) no later than 60 days prior to the individual's 21st birthdate so MAXIMUS does not send a STAR+PLUS HCBS program enrollment packet to the individual.

If STAR+PLUS HCBS program eligibility is approved, within two business days, PSU staff:

Within five business days of receipt of Form H2065-D from PSU staff, ERS:

Examples:

If STAR+PLUS HCBS program eligibility is denied, HHSC PSU staff:

 

3421.7 Individual Service Plan Cost Exceeds 202 Percent of the Resource Utilization Group Cost Limit

Revision 17-5; Effective September 1, 2017

 

If the individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits the documents below to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

UR may request a clinical review of the case to consider the use of state of Texas General Revenue funds to cover costs exceeding the 202 percent cost limit.

Note: MCOs must not discuss with applicants or members, or request the use of, state of Texas General Revenue funds for services above the cost limit.

 

3422 Transition Policy for Non-Waiver Members Receiving Personal Care Services or Community First Choice Only

Revision 17-5; Effective September 1, 2017

 

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and will need to receive services through programs serving adults. Members must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program.

Depending on eligibility requirements, some members may continue to receive PCS or CFC through STAR Health until age 22. 

MAXIMUS will reach out to the member 30 days prior to the member’s 21st birthday and provide the member with STAR+PLUS enrollment packets (containing the STAR+PLUS managed care organization (MCO) list). Fifteen days is allowed for the member to make an MCO selection. If the member has not made a selection after 15 days, MAXIMUS will select an MCO for the member, as outlined in 1 Texas Administrative Code §353.403(3), Enrollment and Disenrollment.

 

3423 Intrapulmonary Percussive Ventilator

Revision 17-2; Effective March 17, 2017

 

Members who were approved for and are using an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by HHSC's Office of the Medical Director.

 

3500 Money Follows the Person

Revision 17-1; Effective March 1, 2017

 

See Section 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List as a tracking system for Money Follows the Person applications from individuals who are not yet members of a managed care organization.

 

3510 Money Follows the Person and Managed Care

Revision 17-5; Effective September 1, 2017

 

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports. For residents who need the STAR+PLUS Home and Community Based Services (HCBS) program, the managed care organization (MCO) will perform the functional assessment and service planning.

Note: MCOs can use an NF's Medical Necessity/Level of Care (MN/LOC), and Program Support Units can accept an NF’s MN/LOC for MFP applicants as long as the MN/LOCs are approved and have not yet expired. The NF’s MN/LOC may not be used for upgrades. For more information about upgrades, see Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program.

One of the eligibility requirements for MFP is that the individual be approved for the STAR+PLUS HCBS program prior to leaving the NF. Individuals must reside in the NF until a final determination is made indicating approval of the STAR+PLUS HCBS program. Individuals leaving before receiving an approval notification form are denied using Denial Code 39 (Other).

Once the assessment process has been completed and the resident is determined eligible for the STAR+PLUS HCBS program, the MCO must be prepared to initiate the individual service plan (ISP) upon notification of eligibility. Individuals are enrolled in managed care on the first day of the month in which discharge from the NF is planned. This flexible enrollment process only applies to MFP.

See Section 3310, Intake and Enrollment, for more information about MFP.

The MCO participates in community planning groups (for example, the Community Transition Team) and other activities related to the state's Promoting Independence Initiative.

 

3511 Money Follows the Person Procedure

Revision 17-5; Effective September 1, 2017

 

A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility when a nursing facility resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. Intake staff must refer all Money Follows the Person (MFP) requests to Program Support Unit (PSU) staff. Referrals can be made by anyone, including family members, nursing facility staff, relocation specialists and HHSC case managers.

 

3512 Money Follows the Person Applications Pending Due to Delay in Nursing Facility Discharge

Revision 17-5; Effective September 1, 2017

 

In keeping with the Promoting Independence Initiative, the Program Support Unit (PSU) and managed care organizations are obligated to assist the nursing facility (NF) applicant or member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, PSU staff have the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four calendar month timeframe is the guideline used in determining pending or denying requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the member is ready to discharge from the NF.

Examples:

If the applicant has an estimated date of discharge that may or may not go beyond the four calendar month period, PSU staff should keep the request for services open. See Section 3513 below for information about applications pending more than four calendar months.

 

3513 Applications Pending More than Four Calendar Months Due to Delay in Nursing Facility Discharge

Revision 17-5; Effective September 1, 2017

 

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but are not finalized. If the applicant has an estimated date of discharge that goes beyond the four-calendar-month period, PSU staff should keep the request for services open.

Applicants who have not made any living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community should be denied. Deny the request for services by sending Form H2065-D, Notification of Managed Care Program Services, within two business days after the end of the four-calendar-month pending period.

If an Assisted Living (AL) applicant meets eligibility criteria but is on an interest list for a contracted STAR+PLUS HCBS program AL facility, PSU staff verify through the MCO that the applicant is on the list and may leave the service request pending until the slot opens.

 

3514 STAR+PLUS Members Residing in a Facility

Revision 17-5; Effective September 1, 2017

 

When a managed care organization (MCO) receives a request from, or becomes aware of, a STAR+PLUS member who is requesting to transition to the community, the MCO service coordinator must contact the applicant/member within five business days and must meet with the member within 14 business days to explain the process of transitioning to the community.

Within two business days after the MCO has posted Form H2067-MC, PSU staff must:

Within 45 days after becoming aware of a member requesting to transition to the community, the MCO service coordinator must have completed the assessment for the applicant/member for the appropriate services and community settings. The MCO completes the following activities:

Note: PSU staff close the case in HEART if the member will only receive state plan services.

 

3514.1 Transition to Community with STAR+PLUS Home and Community Based Services Program

Revision 17-5; Effective September 1, 2017

 

During the initial 45-day time frame for the assessment, if the member is temporarily suspended from a Texas Health and Human Services Commission (HHSC) 1915(c) waiver, the managed care organization (MCO) service coordinator explains the STAR+PLUS Home and Community Based Services (HCBS) program to the member so he or she can choose between the STAR+PLUS HCBS program or remain in his/her previous HHSC 1915(c) waiver.

Within two business days of receipt of Form H2067-MC from the MCO notifying them of the member’s selection, PSU staff completes the following activities:

For Medicare/Medicaid dually eligible individuals who became members during the nursing facility (NF) stay but have chosen to return to the HHSC 1915(c) waiver, PSU staff notify Enrollment Resolution Services (ERS) at HPO_STAR_PLUS@hhsc.state.tx.us to request disenrollment at the time of discharge.

When the member chooses the STAR+PLUS HCBS program, the MCO coordinates with HHSC relocation contractors and Local Intellectual and Developmental Disability Authority (LIDDA) service coordinators, as needed, to ensure everything required for community living is in place at the time of discharge from the NF. Transition to Life in the Community services must be coordinated between the relocation contractor and HHSC Relocation Services when the relocation contractor determines the member may benefit from Transition to Life in the Community (TLC) services. The MCO is not responsible for obtaining independent housing for the member, but is responsible for identifying assisted living or adult foster care alternatives available in the network.

For all members transitioning into the STAR+PLUS HCBS program, the MCO posts the following information to TxMedCentral:

PSU staff send an email to the appropriate health plan manager if the MCO does not post the above information within 45 days after the member's request to return to the community. PSU staff continue to monitor for receipt of the above information when required. Within five business days after receipt of all required documentation, PSU staff:

Once STAR+PLUS HCBS program eligibility is approved, the MCO, relocation contractor, NF, NF resident and PSU staff collaborate to identify a proposed discharge date. The MCO is the responsible party for notifying PSU staff of the discharge date by posting Form H2067-MC to TxMedCentral. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by posting Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO must respond with the correct scheduled discharge date by posting Form H2067-MC to TxMedCentral within two business days of PSU staff's Form H2067-MC posting date.

Within two business days of the individual's discharge from the NF, the MCO posts Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff complete a second Form H2065-D containing the service effective date and:

Within one business day of mailing the final Form H2065-D to the member, PSU staff create Service Authorization System (SAS) entries documented in Section 9400, Money Follows the Person (MFP) Authorization for a STAR+PLUS HCBS Program Applicant, with the exception of creating a one day STAR+PLUS service authorization for the first day of the month in which an MFP individual is discharged from an NF. It is not necessary to complete a one-day service authorization record for members who discharge mid-month and begin receiving the STAR+PLUS HCBS program.

If the NF records in SAS do not reflect the NF end date within three business days of the individual's discharge date, PSU staff will contact the HHSC Provider Claims department to request closure of the NF service authorization in SAS. The hotline for HHSC Provider Claims is 512-438-2200. Select Option 1 when prompted to do so.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D and:

If a Medicaid eligibility NF Medical Assistance Only member chooses to leave the NF and return to the community before being determined eligible for the STAR+PLUS HCBS program, PSU staff perform the following steps additional to those referenced above:

 

3515 Non-STAR+PLUS Members Residing in a Nursing Facility

Revision 17-5; Effective September 1, 2017

 

For requests to transition to the community for a non-STAR+PLUS member, the Texas Health and Human Services Commission (HHSC) Access and Eligibility staff make a referral to Program Support Unit (PSU) staff. Within two business days of the referral from HHSC, PSU staff:

Within two business days of receipt of the notification of the nursing facility (NF) resident's STAR+PLUS HCBS program selection, PSU staff immediately close the case in HEART if the individual has selected an HHSC 1915(c) waiver program and email the LIDDA indicating PSU staff are closing the case. The LIDDA is responsible for processing the case if the individual chooses the Texas Home Living or Home and Community-based Services waiver. If the individual selects the Community Living Assistance and Support Services or the Deaf Blind with Multiple Disabilities waiver, the LIDDA makes a referral to HHSC for processing. If the individual selects to apply for the STAR+PLUS HCBS program, PSU staff determine the individual's Medicaid status to evaluate for proper coordination with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

When the individual has elected to apply for the STAR+PLUS HCBS program, PSU staff must complete the following activities within two business days of notification of the selection:

PSU staff are responsible for completing the following activities 14  days following the STAR+PLUS HCBS program selection. PSU staff must document in HEART all attempted contacts with the NF resident and any encountered delays. PSU staff:

If, during the 14-day follow-up contact, the NF resident states that he or she, his or her authorized representative, or the NF has already submitted a completed Form H1200, PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to verify Form H1200 has been submitted. If the NF resident communicates Form H1200 has not been submitted, or if TIERS does not have a record Form H1200 has been submitted, PSU staff notify the NF resident to immediately return Form H1200 to PSU staff because the application for the STAR+PLUS HCBS program will be denied for failure to return Form H1200 has been submitted. If the NF resident communicates Form H1200 has not been submitted, or if TIERS does not have a record Form H1200 has been submitted, the PSU notifies the NF resident to immediately return Form H1200 to PSU staff because the application for SPW services will be denied for failure to return the Form H1200 within 45 days from the date the PSU sent the form to the NF resident. Upon receipt of the completed Form H1200, PSU staff make a referral to the MEPD specialist within two business days by completing Form H1746-A, MEPD Referral Cover Sheet, to include submission of the returned Medicaid application.

If Form H1200 is not received within 45 days from the date PSU staff sent Form H1200 to the NF resident, PSU staff deny the application for the STAR+PLUS HCBS program by:

Within two business days from when the NF resident notifies PSU of the MCO selection verbally or in writing, or from when the member is defaulted to an MCO, PSU staff must:

The MCO initiates contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. Within 45 days from receipt of Form H3676, the MCO service coordinator assesses the applicant for the appropriate services and community settings. The MCO completes the following activities

When the MCO has determined the applicant meets the functional eligibility requirements for the STAR+PLUS HCBS program, the MCO coordinates with relocation contractors to ensure everything needed for community living is in place at the time of discharge from the NF. The MCO must coordinate Transition Assistance Services when needed by the applicant as part of the STAR+PLUS HCBS program. The MCO is not responsible for obtaining independent housing for the NF resident, but is responsible for identifying assisted living or adult foster care alternatives available in the network. When the applicant needs Transition to Life in the Community (TLC) services, relocation contractors must coordinate these through HHSC Relocation Services.

As needed, PSU staff collaborate with involved parties throughout the STAR+PLUS HCBS program eligibility determination process to assist with problem resolution and to document any delays. PSU staff track all actions and communications in HEART until all STAR+PLUS HCBS program enrollment activities are complete.

The MCO posts the following information to TxMedCentral:

PSU staff send an email to the appropriate health plan manager if the MCO does not post the above information within 45 days after the NF resident's request to return to the community. PSU staff continue to monitor for receipt of the above-referenced forms. Within two business days of receipt of this information, PSU staff complete and send Form H1746-A, MEPD Referral Cover Sheet, to notify the MEPD specialist of the approved ISP and MN/LOC so the MEPD specialist can complete the Medicaid eligibility determination.

Upon completion of the evaluation for financial eligibility, the MEPD specialist notifies PSU staff of the determination by sending an email to the appropriate mailbox designated for the MEPD specialist to submit communications to PSU staff.

Within five business days after receipt of all MCO documentation required for STAR+PLUS HCBS program eligibility, as well as communication from the MEPD specialist of the applicant's Medicaid eligibility, PSU staff:

The MCO collaborates with the relocation contractor, NF, NF resident and the PSU to identify a proposed discharge date. Once the discharge date has been determined, the MCO must notify the PSU of the discharge date within two business days by posting Form H2067-MC to TxMedCentral. Should any other entity contact the PSU with a discharge date, the PSU must notify the MCO within two business days by posting Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO resolves this discrepancy and must confirm the scheduled discharge date by posting Form H2067-MC to TxMedCentral within two business days of PSU’s Form H2067-MC posting date.

Within two business days of the individual's discharge from the NF, the MCO posts Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff complete the final Form H2065-D containing the service effective date and:

Within one business day of sending the final Form H2065-D, PSU staff:

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D, and:

If the applicant chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program, PSU staff fax or email a copy of Form H2065-D to the MEPD specialist. Upon completion of all STAR+PLUS HCBS program actions, PSU staff close the case in HEART

 

3520 Money Follows the Person Demonstration

Revision 17-1; Effective March 1, 2017

 

 

 

3521 Money Follows the Person Demonstration

Revision 17-1; Effective March 1, 2017

 

The Money Follows the Person Demonstration (MFPD) Initiative was implemented in order to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities and receive necessary long-term services and supports (LTSS) in the setting of the individual's choice. Participation in MFPD does not affect the type or amount of services received, or the manner in which they are delivered. Managed care Medicaid waiver services received by the member participating in MFPD are the same as services delivered to other STAR+PLUS Home and Community Based Services (HCBS) program members.

In addition to the STAR+PLUS HCBS program, MFPD participants receive more extensive relocation assistance and follow up. They are also eligible to access Behavioral Health Services (BHS) in the following counties in the Bexar and Travis STAR+PLUS service areas: Travis County, Atascosa County, Bexar County, Guadalupe County and Wilson County.

BHS is designed to assist adults with mental health and substance abuse diagnoses who wish to transition to the community from nursing facilities. Services include Cognitive Adaptation Training (CAT) and adult substance abuse treatment.

CAT provides community-based and in-home assistance to help individuals organize their environment and function independently. The training engages the member in performing self-care and using environmental modifications to facilitate independence. Both substance abuse services and CAT may be provided for participants for up to six months before discharge from the nursing facility as "pre-transition services" and also for one year when participants leave the nursing facility and live in the community.

Substance abuse treatment is provided by STAR+PLUS managed care organizations (MCOs). Individuals will access these services through the MCO.

The state benefits from member participation in MFPD by receiving enhanced funding and more information about LTSS through the participant survey.

 

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

Revision 17-5; Effective September 1, 2017

 

To be eligible for Money Follows the Person Demonstration (MFPD), the applicant must meet current STAR+PLUS HCBS program and MFP policy, and:

For MFPD, an institutional setting is defined as a nursing facility, intermediate care facility for persons with intellectual disability, hospital or state hospital. The 90-day residency rule may be met by a continuous stay in a combination of the settings.

Example: An MFP applicant may have resided continuously in a nursing facility for 30 days, in a hospital for 60 days and then re-entered the nursing facility for another month. This would meet the 90-day institutional residency rule for MFPD.

 

3523 Program Support Unit Responsibilities

Revision 17-1; Effective March 1, 2017

 

Apply the screening criteria, as discussed above, to determine if the individual is potentially eligible to participate in the Money Follows the Person Demonstration (MFPD) Initiative. The requirement that the individual reside continuously in an institutional setting for 90 days need not be met until the actual MFPD eligibility date. The individual does not have to have been in the facility 90 days at the time of referral. The individual meets the screening criteria if it appears likely he/she will have been in the facility at least 90 days by the eligibility date.

To verify MFPD, nursing facility or other institutional residency requirements, staff may:

Communicate to managed care organization (MCO) staff that the individual is potentially eligible for MFPD by completing the MFPD qualifying begin and end dates in Item 20 on Form H3676, Managed Care Pre-Enrollment Assessment Authorization. MCO staff are responsible for presenting the initiative to the member and obtaining his/her signature on the informed consent form.

 

3524 Enrollment in Money Follows the Person Demonstration

Revision 17-5; Effective September 1, 2017

 

Individuals who choose to enroll in and meet the eligibility requirements for Money Follows the Person Demonstration (MFPD) must be designated in the Service Authorization System using the following procedures:

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD period is over or if the member withdraws from MFPD. If a member enters a nursing facility and then re-enters the community setting before the MFPD ISP period is over, the MFPD entitlement period resumes until the end of the ISP or the month of a new ISP period if the 365-day period extends beyond the current ISP period.

The Program Support Unit (PSU) must maintain a list of MFPD participants. This list must contain the participant's:

The member may withdraw from MFPD at any time by completing Form 3632, Withdrawal Confirmation, and sending it to PSU staff. Although MFPD eligibility may end, the member continues to receive the STAR+PLUS HCBS program if all eligibility criteria are met.

 

3525 Money Follows the Person Demonstration Entitlement Period Tracking

Revision 17-5; Effective September 1, 2017

 

Time spent in an institutional setting does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) members receive the full 365-day entitlement period. The entitlement period begins the date the member who agrees to participate in the demonstration is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

In order to assure that the member has been put on the Service Authorization System as an MFPD applicant, Program Support Unit (PSU) staff must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, in the MCO's XXXSPW folder using the most appropriate naming convention, that Fund Code 19MFP has been entered.

Example: The applicant chooses to participate in MFPD and is enrolled in the STAR+PLUS HCBS program effective June 1. If there are no institutional stays during the initial individual service plan (ISP) period, the MFPD period ends on May 31. If the MFPD member is institutionalized for 10 days in April, the MFPD period is extended to June 10, following the ISP end date of May. If the MFPD member is authorized for a new MFPD service during the initial ISP period, the 365-day period would still end on May 31, if there were no institutional stays.

Tracking is required to ensure MFPD members receive the full 365-day entitlement period unless the member withdraws from MFPD. The MCO is responsible for tracking the MFPD entitlement period because PSU staff have no way of knowing when STAR+PLUS HCBS program members are admitted and released from nursing facilities. Once the 365-day period has passed, the MCO is responsible for posting Form H2067-MC, to TxMedCentral to inform PSU staff of the date the member's entitlement period ended. Once received, this information must be forwarded to the regional MFPD reporting coordinator within two business days.

It is essential that complete and accurate records are maintained because MFPD tracking is subject to audit by the Centers for Medicare and Medicaid Services. Staff must follow policy in Section 6412, Maintenance Requirements for Member Information and Forms, which requires a daily backup of TxMedCentral files to compact disk.

 

3526 Documentation of the 90-Day Qualifying Institutional Stay Required for Money Follows the Person Demonstration Eligibility in the STAR+PLUS Home and Community Based Services Program

Revision 17-5; Effective September 1, 2017

 

To be eligible for the Money Follows the Person Demonstration (MFPD) Initiative, members must have resided continuously in an institutional setting for at least 90 days prior to the eligibility date, and be enrolled from a Medicaid-certified facility. The member's date of entry and date of discharge from a hospital, nursing facility (NF) or other institutional setting are included in the number of days the individual is considered to be institutionalized. Check the Service Authorization System (SAS) for verification of residence in qualified institutional settings. This may include stays in a combination of applicable settings, which include:

Form H3676, Managed Care Pre-Enrollment Assessment Authorization, must include documentation of the qualifying stays in Item 20, MFPD Qualifying Dates. Institutional stays for the 90 days prior to the eligibility date must be documented even if it appears the individual does not meet the criteria. If the applicant is currently residing in a qualified institutional setting at the time Form H3676 is sent to the managed care organization, enter the begin date of coverage and use "ongoing" as the end date. For example, Form H3676 for an individual who was admitted to the NF on July 17, 2015, but has not yet discharged from the NF when PSU staff post Form H3676 on Sept. 10, 2015, may include the following:

20. MFPD 90-Day Qualifying Dates

21a. Relocation Referral Made:

22a. Area Code and Telephone No.

Begin Date

End Date

Yes No

123-456-7890

07-17-15 ongoing 21b. Relocation Specialist 22b. Fax Area Code and Telephone No.
    Lisa Simpson 456-789-0123

The example above demonstrates the individual has been in the NF less than 90 days. However, SAS records do not include any possible hospitalizations, which also count toward the 90-day requirement. The managed care organization (MCO) will determine if the individual was in a hospital directly before the period indicated on Form H3676. In this case, the MCO will also determine MFPD eligibility once the discharge, which represents the end date, is known.

Similarly, if the individual has a gap in institutional coverage, as illustrated below, the MCO will evaluate MFPD eligibility by checking for possible hospitalization prior to the NF stay or during the gap period, as well as considering the discharge date from the NF.

20. MFPD 90-Day Qualifying Dates

21a. Relocation Referral Made:

22a. Area Code and Telephone No.

Begin Date

End Date

Yes No

123-456-7890

07-23-15 08-29-15 21b. Relocation Specialist 22b. Fax Area Code and Telephone No.
09-09-15 ongoing Lisa Simpson 456-789-0123

 

3530 High/Complex Needs Members

Revision 17-1; Effective March 1, 2017

 

 

3531 Designation of High Needs Members

Revision 17-1; Effective March 1, 2017

 

The Uniform Managed Care Contract, Attachments A and B-1, Section 8.1.12, specifies the managed care organization (MCO) must develop and maintain a system and procedures for identifying members with special health care needs (MSHCN), including people with disabilities or chronic or complex medical and behavioral health conditions and children with special health care needs (CSHCN).

The MCO must contact members pre-screened by the Texas Health and Human Services Commission (HHSC) Administrative Services contractor as MSHCN to determine whether they meet the MCO's MSHCN assessment criteria, and to determine whether the member requires special services. The MCO must provide information to the HHSC Administrative Services contractor identifying members who the MCO has assessed to be MSHCN, including any members pre-screened by the HHSC Administrative Services contractor and confirmed by the MCO as a MSHCN. The information must be provided in a format and on a time line to be specified by HHSC in the Uniform Managed Care Manual, and updated with newly identified MSHCN by the 10th day of each month. In the event that an MSHCN changes MCOs, the MCO must provide the receiving contractor information concerning the results of the MCO's identification and assessment of that member's needs to prevent duplication of those activities.

CSHCN means a child (or children) who:

MSHCN includes a CSHCN and any adult member who:

 

3532 Determination of High Needs Status for Ongoing Members

Revision 17-1; Effective March 1, 2017

 

If during the individual service plan (ISP) period the managed care organization (MCO) determines the member's subsequent ISP may have the potential to exceed the cost limit, that member is considered to have high needs status. Once designated as having a high needs status, the MCO must initiate in the ninth month of the ISP period plans to bring the ISP at/or under the cost limit.

If it appears the subsequent ISP will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the MCO initiates a request for a staffing with the Texas Health and Human Services Commission to determine whether a request for the use of General Revenue funds is appropriate.

 

3600 Ongoing Service Coordination

Revision 17-5; Effective September 1, 2017

 

Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

 

3610 Revising the Individual Service Plan

Revision 17-5; Effective September 1, 2017

 

It may be necessary to revise the individual service plan (ISP) within the ISP period due to changes in the needs of the member or changes in the services offered or emergency situations. The managed care organization documents revision to the ISP on Form H1700-1, Individual Service Plan (Pg. 1). A revised ISP is not submitted to the Program Support Unit via TxMedCentral, but is kept in the member's case record.

 

3611 MCO Required Notifications from the Provider

Revision 17-1; Effective March 1, 2017

 

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

 

3611.1 Immediate Suspension or Reduction of Services

Revision 17-1; Effective March 1, 2017

 

If the member or someone in the member's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the managed care organization (MCO) and MCO-contracted provider are required to make an immediate referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services and/or the police and suspend services. The MCO must immediately provide written notice of temporary suspension of service to the member, and the right of appeal to a fair hearing must be explained to the member. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference and the right of appeal.

The provider must verbally inform the MCO by the following business day of the reason for the immediate suspension, and follow up with written notification to the MCO within two business days of verbal notification. The MCO must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the STAR+PLUS HCBS program provider may continue providing services to assist in the resolution of the crisis. If the crisis is not satisfactorily resolved, the MCO follows the established denial procedures. Services do not continue during the appeal process.

 

3611.2 Required Notification of Service Denial from the Managed Care Organization

Revision 17-5; Effective September 1, 2017

 

If the managed care organization (MCO) determines that documentation supports initiation of denial, the MCO provides written notification of denial to the member within five business days. The MCO, within five business days, sends Form H2065-D, Notification of Managed Care Program Services, to the member.

Form H2065-D must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal. The MCO forwards a copy of the notification to the provider within two business days.

If the member appeals the notification of denial within the 10-day adverse action period, the MCO must continue the STAR+PLUS Home and Community Based Services (HCBS) program until notification of the decision by the state fair hearings officer. The MCO must not reduce the STAR+PLUS HCBS program until the outcome of the appeal is known.

 

3620 Reassessment

Revision 17-1; Effective March 1, 2017

 

 

3621 Reassessment Procedures

Revision 17-5; Effective September 1, 2017

 

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System (SAS) annually. PSU staff:

The Supplemental Security Income (SSI)-denied Medicaid program types referenced in Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services (HCBS) Program, do not change in the Texas Integrated Eligibility Redesign System (TIERS) either during the initial or annual review by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. As part of reassessment procedures, PSU staff will remain responsible for confirming ongoing Medicaid eligibility, but is not required to request MEPD test an individual for the additional criteria, or request a change in the Medicaid program type.

If the reassessment ISP is being submitted due to the participant's timely appeal of a STAR+PLUS HCBS program denial, staff enter the information from the old ISP, extending the end date an additional four calendar months. Services continue using this ISP until a decision is received from the hearing officer. At that time, changes are made, if necessary, to comply with the hearing officer's decision.

 

3622 Notification Requirements

Revision 17-5; Effective September 1, 2017

 

If the member continues to meet STAR+PLUS Home and Community Based Services (HCBS) program requirements, it is not necessary to send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. If the member does not meet STAR+PLUS HCBS program requirements, Program Support Unit (PSU) staff must, within two business days of notification:

If no appeal is filed, Enrollment Resolution Services (ERS) disenrolls the member from STAR+PLUS effective the date of the action on Form H2065-D.

If the member files an appeal timely, PSU staff, within two business days of notification:

ERS, within 10 days of receiving the fair hearings officer's decision, carries out the decision. See Section 4234, Hearing Decision.

 

3623 STAR+PLUS Home and Community Based Services Program Eligibility Date on Form H2065-D

Revision 17-5; Effective September 1, 2017

 

Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

 

3623.1 Upgrades and Interest List Releases

Revision 17-1; Effective March 1, 2017

 

The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant being released from the interest list or a member requesting/being processed for an upgrade is based on the:

Program Support Unit (PSU) staff determine the effective date based on the later of the above dates. If the date falls on the first day of the month, the effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month. If the date falls between the second and the last day of the month, the effective date is the first date of the following month.

Examples:

Upgrades

Interest List

 

3623.2 Members Transitioning Out of Children's Programs

Revision 17-5; Effective September 1, 2017

 

The effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the 1st of the month following their 21st birthday:

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.  In this scenario, the effective date is the 1st of the month following their 22nd birthday.

 

3623.3 Money Follows the Person/Money Follows the Person Demonstration Nursing Facility Releases

Revision 17-5; Effective September 1, 2017

 

The effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program via the Money Follows the Person (MFP)/MFP Demonstration (MFPD) process is the date of discharge. Service Authorization System (SAS) registration for MFP/MFPD releases from NFs must occur as follows:

 

3630 Denial/Termination Procedures

Revision 17-5; Effective September 1, 2017

 

This section provides information, procedures and references pertaining to denial or termination of the STAR+PLUS Home and Community Based Services (HCBS) program for active members, along with adequate notice of members' rights and opportunities to due process.

The following citation from the Code of Federal Regulations (CFR) specifies situations in which an adverse action period is not required:

CFR §431.213, Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a recipient;

(b) The agency receives a clear written statement signed by a recipient that —

(1) He no longer wishes services; or

(2) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c) The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d) The recipient's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e) The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f) A change in the level of medical care is prescribed by the recipient's physician….

The citation for the following rule, which appears in Texas Administrative Code, Title I, Part 15, Chapter 353, Subchapter G, §353.607, appears on Form H2065-D, Notification of Managed Care Program Services. It is the basis for all STAR+PLUS case action.

"The STAR+PLUS Handbook includes policies and procedures to be used by all health and human services agencies and their contractors and providers in the delivery of STAR+PLUS Program services to eligible members. The STAR+PLUS Handbook can be found on the Texas Health and Human Services Commission website."

 

3631 10-Day Adverse Action Notification

Revision 17-5; Effective September 1, 2017

 

The Code of Federal Regulations (CFR) requires that the Health and Human Services Commission (HHSC) provide a notice to the member at least 10 calendar days before the action effective date. The member must be given the full 10-day adverse action period to give him/her time to file an appeal.

CFR, Subpart E, Sec. 431.230, Maintaining services.

(a) If the agency mails the 10-day or 5-day notice as required under Sec. 431.211 or Sec. 431.214 of this subpart, and the member requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless —

(1) It is determined at the hearing that the sole issue is one of federal or State law or policy; and

(2) The agency promptly informs the member in writing that services are to be terminated or reduced pending the hearing decision.

(b) If the agency's action is sustained by the hearing decision, the agency may institute recovery procedures against the applicant or member to recoup the cost of any services furnished the recipient, to the extent they were furnished solely by reason of this section.

Instructions on how to calculate time periods is provided in §311.014 of the Code Construction Act. It specifies that:

The 10-day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when HHSC offices are officially open, even with limited workforce.

The full adverse action period may be waived if the member signs a statement to waive the adverse action period.

 

3631.1 Denial of Medical Necessity/Level of Care/Individual Service Plan (MN/LOC/ISP)

Revision 17-1; Effective March 1, 2017

 

Date Informed Eligibility Lost Date Form H2065-D Sent Current ISP End Date 10-Day Adverse Action Expiration Date Form H2065-D Termination Date Service Authorization System Action
April 10 April 12 May 31 April 22 May 31 None
May 20 May 21 May 31 May 31 May 31 None
May 20 May 22 May 31 June 1 June 30 ISP must be extended to June 30.
June 5 June 7 May 31 June 17 June 30 ISP must be extended to June 30.
June 22 June 24 May 31 July 4 July 31 ISP must be extended to July 31.

 

3631.2 Denial of Medicaid Eligibility

Revision 17-1; Effective March 1, 2017

 

Actual Date of Medicaid Eligibility Denial Date Informed Eligibility Lost Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Action
December 31 December 31 May 31 January 2 December 31 ISP and Medical Necessity/Level of Care (MN/LOC) must be corrected to December 31.
December 31 October 31 May 31 November 2 December 31 ISP and MN/LOC must be corrected to December 31.
December 31 February 5 May 31 February 7 December 31 ISP and MN/LOC must be corrected to December 31.

Notes:

 

3631.3 Members No Longer in the Service Delivery Area

Revision 17-5; Effective September 1, 2017

 

Actual Date of Move Date Health and Human Services Commission (HHSC) Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Action
December 31 December 31 May 31 January 2 January 31 ISP and Medical Necessity/Level of Care (MN/LOC) must be corrected to January 31.
October 31 December 31 May 31 January 2 January 31 ISP and MN/LOC must be corrected to January 31.
April 22 June 9 May 31 June 11 June 30 ISP and MN/LOC must be corrected to June 30.
May 22 May 22 May 31 May 24 June 30* ISP and MN/LOC must be corrected to June 30.
June 30 June 9 May 31 June 11 June 30 Managed care organization should have submitted an ISP and MN/LOC for June 1. If these forms are not submitted, enter Service Group 19/Service Code 13 for June 1 through June 30.

*The 10-day adverse action period expires after the end of the month.  

 

3631.4 Unable to Locate

Revision 17-1; Effective March 1, 2017

 

Date HHSC Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Action
December 31 May 31 January 2 January 31 ISP and Medical Necessity/Level of Care (MN/LOC) must be corrected to January 31.
May 3 May 31 May 5 May 31 None
May 5 May 31 May 27 June 30* ISP and MN/LOC must be corrected to June 30.
June 9 May 31 June 11 June 30 Managed care organization should have submitted an ISP and MN/LOC for June 1. If these forms are not submitted, enter Service Group 19/Service Code 13 for June 1 through June 30.

*The 10-day adverse action period expires after the end of the month.  

 

3632 Program Support Unit Initiated Denials/Terminations

Revision 17-1; Effective March 1, 2017

 

The following sections contain policy citations that must be included on Form H2065-D, Notification of Managed Care Program Services, when the denial or termination action is initiated by Texas Health and Human Services Commission (HHSC) staff.

 

3632.1 Denial/Termination Due to Death

Revision 17-5; Effective September 1, 2017

 

Upon learning of the death of a member, Program Support Unit (PSU) staff must send to the managed care organization (MCO) within two business days of verification:

Form H1746-A must be sent to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if appropriate. Do not send a notice to the member's address or family. The effective date is the date of death.

If the member was receiving Supplemental Security Income (SSI) and the eligibility records reflect that SSI has been denied, PSU staff must use the same effective date of denial as the SSI denial date. If the eligibility records reflect SSI is still active, PSU staff must contact the Social Security Administration to notify it of the date of the member's death.

If a member's Medicaid eligibility has been denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries must be made to end enrollment in the Service Authorization System.

Services must be denied/terminated once death of the member has been confirmed by PSU staff via:

A 10-day adverse action period is not required for death denials.

 

3632.2 Denial/Termination Due to Residence in a Nursing Facility

Revision 17-5; Effective September 1, 2017

 

Following the 90th day that the member is not returning to the community when a member resides in a nursing facility for 90 days or more, the managed care organization (MCO) or Medicare-Medicaid Plan (MMP) notifies the Program Support Unit (PSU) within 14 days. The MCO sends this notice to PSU staff by posting Form H2067-MC, Managed Care Programs Communication, in TxMedCentral.

PSU staff deny the STAR+PLUS Home and Community Based Services (HCBS) program by the end of the month in which the 90th day occurred by:

 

3632.3 Denial/Termination Due to Member Request

Revision 17-5; Effective September 1, 2017

 

When the Program Support Unit (PSU) has been notified by the Texas Health and Human Services Commission (HHSC) that the member does not want STAR+PLUS HCBS program services or no longer wishes to receive the STAR+PLUS HCBS program, PSU staff must send Form H2065-D, Notification of Managed Care Program Services. Notification must be sent within two business days of notification. PSU staff must not initiate denial/termination until notified by HHSC.

 

3632.4 Denial/Termination of Financial Eligibility

Revision 17-5; Effective September 1, 2017

 

A member's continued receipt of STAR+PLUS services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or Medical Assistance Only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for MAO. The member may appeal the financial denial using SSA or MEPD processes, as appropriate. Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification. Notification can come from:

The chart below describes how to proceed if financial eligibility is denied.

When the individual is denied SSI: When the individual is denied MAO:
  • disenrollment from the STAR+PLUS program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • the right to appeal to SSA is available to the individual.
  • the local Texas Health and Human Services Commission (HHSC) office must be contacted to request other long-term services and supports (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.
  • disenrollment from the STAR+PLUS program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • the right to appeal to the MEPD specialist is available to the individual.
  • the local HHSC office must be contacted to request other long-term services and supports (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.

For SSI members, the termination date must match the SSA termination date.

For MAO members, the termination date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past when PSU staff become aware of the denial.

 

3632.5 Denial/Termination of MN/LOC

Revision 17-5; Effective September 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program must be denied/terminated when the member's Medical Necessity/Level of Care (MN/LOC) Assessment is denied. Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Services, within two business days of notification. Notification can come from:

The MN/LOC Assessment status of "MN Denied" in the Long-term Care (LTC) Portal is the period when the STAR+PLUS HCBS program applicant's or member's physician has 14 days to submit additional information. Once an MN/LOC Assessment status is in "MN Denied" status, several actions may occur:

The PSU staff must not mail Form H2065-D to deny the STAR+PLUS HCBS program case until after 14 days from the date the "MN Denied" status appears in the LTC Portal. The PSU staff must meet initial certification and annual assessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented.

 

3632.6 Denial/Termination Due to Inability to Locate the Member

Revision 17-5; Effective September 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program must be denied/terminated when Program Support Unit (PSU) staff are notified that a member cannot be found. PSU staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification. Notification can come from:

 

3632.7 Denial/Termination Due to Failure to Meet Other STAR+PLUS HCBS Program Requirement

Revision 17-5; Effective September 1, 2017

 

Use this denial citation if the applicant does not meet a STAR+PLUS Home and Community Based Services (HCBS) program requirement mentioned in Section 3632.1 through Section 3632.6. For example, this citation would be used if the applicant applying for services does not require at least one STAR+PLUS HCBS program service. Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification. Notification can come from:

 

3632.8 Denial/Termination for Other Reasons

Revision 17-1; Effective March 1, 2017

 

Use this citation if initiating denial/termination for a reason not covered in Section 3632.1 through Section 3632.7. Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification. Notification can come from:

 

3633 Denial/Termination Initiated by the Managed Care Organization

Revision 17-1; Effective March 1, 2017

 

Section 3633.1 through Section 3633.7 contains policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. After notification by the MCO, Program Support Unit staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification from HHSC.

 

3633.1 Denial/Termination Due to Threats to Health and Safety

Revision 17-5; Effective September 1, 2017

 

The managed care organization (MCO) and provider staff must take special precautions when an applicant's or member's comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant or member, an MCO-contracted provider or an MCO employee. If an applicant exhibits such behavior, the staff member must immediately notify his/her manager.

The Health and Human Services Commission (HHSC) reviews these situations on a case-by-case basis and determines the most appropriate action to be taken. If the applicant's or member's safety may be at risk, the MCO must follow current policy regarding notification to the Department of Family and Protective Services (DFPS). If the staff member believes there is a potential threat to others, HHSC management should determine the best method for notifying the MCO and/or the contracted provider and for addressing the applicant's or member's needs without placing an MCO/provider staff member at risk.

After notification by the MCO, Program Support Unit staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification from HHSC. The 10-day adverse action notification period does not apply in this situation.

 

3633.2 Denial/Termination Due to Hazardous Conditions or Reckless Behavior

Revision 17-1; Effective March 1, 2017

 

When there is no immediate threat to the health or safety of the service provider, but the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, appropriate documentation of denial is essential. For example, a situation where the member has a large dog that may bite if let loose could be resolved if the member or a neighbor or family member will agree to restrain the dog during times of service delivery.

However, if the provider shows up on numerous occasions at the designated time and the dog is loose and the provider has documented a substantial pattern of being unable to deliver services due to this, services could be terminated.

Similarly, if there are illegal drugs in the member's home used by the member or others, the service provider may not be in immediate danger, yet the situation still poses a threat. It is imperative that all available interventions are presented and the opportunity offered for the member to get rid of the illegal drugs and/or users, and agree to refrain and not allow the illegal drug use to resume. A staffing should be held if the illegal drug usage occurs again, and the member must be warned in writing of the potential loss of services for allowing this activity to continue.

After notification by the managed care organization, Program Support Unit staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification from the Texas Health and Human Services Commission. The 10-day adverse action notification period does not apply in this situation.

 

3633.3 Denial/Termination Due to Harassment, Abuse or Discrimination

Revision 17-5; Effective September 1, 2017

 

A substantial demonstrated pattern of verbal abuse or discrimination must be clearly established and documented by the managed care organization (MCO) before services can be denied for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the member and/or his/her family or authorized representative, explaining that the MCO does not condone discrimination, harassment and/or verbal abuse.

Appropriate interventions must be sought. This may include counseling, referral to other case management agencies and possibly changes to the individual service plan (ISP), such as attending Day Activity and Health Services for nursing.

There must be meetings of the Texas Health and Human Services Commission (HHSC) staff that include outside agencies, when appropriate, such as the Department of Family and Protective Services' Adult Protective Services. The results must be documented in letters sent to the member that offer an opportunity to stop the behavior, with clear indication that failure may result in loss of service. Copies of written warnings must be sent to all who attend the meetings and a copy must be retained in the case file.

If the situation persists and results in an inability to deliver services, the MCO may request disenrollment from HHSC, as described in the Uniform Managed Care Manual Chapter 11.5. After HHSC approves the disenrollment, HHSC notifies the Program Support Unit (PSU) supervisor via email. PSU staff send Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

PSU staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification from HHSC. The 10-day adverse action notification period does not apply in this situation.

If the denial/termination is being considered due to verbal abuse or harassment of the service provider, HHSC must determine if this behavior is directly related to the member's disability. If the member produces a letter from his physician indicating the behavior stems from the member's disability, services cannot be denied for this reason. Appropriate interventions to ensure service delivery as noted above should still be pursued.

 

3633.4 Denial as a Result of Exceeding the Cost Limit

Revision 17-5; Effective September 1, 2017

 

The managed care organization (MCO) must consider all available support systems in determining if the STAR+PLUS Home and Community Based Services (HCBS) program is a feasible alternative that ensures the needs of the applicant are adequately met. If the STAR+PLUS HCBS program is not a feasible alternative, the MCO must notify Program Support Unit (PSU) staff of the denial and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial is based on the inadequacy of the plan of care, including both the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program services, to meet the needs of the member within the cost limit.

If Form H1700-1, Individual Service Plan (Pg. 1), is over the cost limit, PSU staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of receipt of Form H1700-1 via TxMedCentral.

 

3633.5 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions

Revision 17-5; Effective September 1, 2017

 

If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, services may be denied/terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member's home that prevent determining eligibility, carrying out the service plan or monitoring services. The Texas Health and Human Services Commission (HHSC) will notify Program Support Unit (PSU) staff to send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification.

 

3633.6 Denial/Termination Due to Failure to Pay Room and Board/Copay/Qualified Income Trust

Revision 17-1; Effective March 1, 2017

 

If the member refuses to pay a required copayment, room and board (R&B) payment or Qualified Income Trust (QIT) payment, the STAR+PLUS Home and Community Based Services (HCBS) program must be denied. After notification by the managed care organization, Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification and must provide a 10-day adverse action period.

 

3633.7 Denial/Termination Due to Other Reasons

Revision 17-1; Effective March 1, 2017

 

Use this denial/termination citation if initiating denial for a reason not covered above. After notification by the managed care organization, Program Support Unit staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days of notification.

 

3640 Disenrollment Request Policy

Revision 17-5; Effective September 1, 2017

 

Mandatory STAR+PLUS members may request a case review for disenrollment from STAR+PLUS. Disenrollment of a mandatory member is only approved if a determination is made that a member would be better served under fee-for-service (FFS) than participating in managed care.

Members who request to disenroll from STAR+PLUS must submit a written request with supporting documentation of medical condition and extenuating circumstances. This written request must be submitted to the Texas Health and Human Services Commission (HHSC) at the following address:

Texas Health and Human Services Commission Managed Care
P.O. Box 149030, Mail Code W-516
Austin, TX 78714-9030

HHSC conducts a case review and makes a final determination. The member and Program Support Unit (PSU) staff will be notified in writing of the decision and any available alternatives. If the member is disenrolled, HHSC will make the necessary system adjustments and notify the respective managed care organization and enrollment broker.

The member can only re-enter the STAR+PLUS system and the STAR+PLUS HCBS program using Money Follows the Person (MFP) procedures. See Section 3510, Money Follows the Person and Managed Care, for additional information.

 

3641 Services for Members Disenrolled from STAR+PLUS

Revision 17-5; Effective September 1, 2017

 

In some situations, a STAR+PLUS member or his/her managed care organization may request, and be granted, disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled members can receive available services from the Texas Health and Human Services Commission (HHSC) Medical and Social Services (MSS) Division, if determined eligible. For additional information, see Section 3640, Disenrollment Request Policy.

SPH, Section 4000, Complaint and Appeal Procedures

Revision 15-1; Effective September 1, 2015

 

 

 

4100 Managed Care Organization Procedures

Revision 11-4; Effective December 1, 2011

 

The managed care organization (MCO) must develop, implement and maintain a member complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Code of Federal Regulations 42, §431.200, 42 CFR Part 438, Subpart F, Grievance System, and the provisions of Texas Administrative Code 1, Chapter 357, relating to Medicaid managed care organizations.

The MCO's complaint and appeal systems must include:

 

4110 MCO Complaint Procedures

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission's (HHSC) Uniform Managed Care Contract Terms and Conditions, Attachment A, defines a complaint as:

"an expression of dissatisfaction expressed by a Complainant, orally or in writing to the managed care organization (MCO), about any matter related to the MCO other than an Action. As provided by 43 CFR §438.400, possible subjects for Complaints include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships, such as rudeness of a provider or employee, or failure to respect the Medicaid Member's rights."

The complaint procedure does not apply to situations described in "Appeal Procedures."

When a managed care organization (MCO) member wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide a designated member advocate to assist the member in using the complaint system. The advocate must assist members in writing or filing a complaint, and monitor the complaint throughout the process until the issue is resolved.

If the member is not satisfied with the outcome of the MCO complaint process, he or she sends a written request to HHSC to investigate the complaint. The request is sent to:

Texas Health and Human Services Commission Managed Care Operations – STAR+PLUS Mail Code H-320 P. O. Box 13247 Austin, TX 78711

If a STAR+PLUS member contacts any HHSC employee with a complaint regarding an agency licensed by HHSC, the member is referred to 1-800-458-9858 to file a regulatory complaint.

Members may also call the Medicaid hotline at 1-800-252-8263 to file a complaint not related to licensure issues.

 

4120 MCO Appeal Procedures

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission's Uniform Managed Care Contract Terms and Conditions, Attachment A, defines an appeal as the formal process by which a member or his or her representative requests a review of the managed care organization’s (MCO’s) action. An action is:

The member may file an appeal by contacting the MCO following the procedures specified in the MCO's member handbook. The MCO is contractually required to regard any oral or written expression of dissatisfaction or disagreement as a request to file an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members by monitoring the appeal throughout the process until the issue is resolved.

During the appeal process, the MCO must provide the member a reasonable opportunity to present evidence and any allegations of fact or law in person, as well as in writing. The MCO must inform the member of the time available for providing this information and that in the case of an expedited resolution, limited time will be available.

The MCO must provide the member and his or her representative the opportunity, before and during the appeal process, to examine the member's case file, including medical records and any other documents considered during the appeal process.

As required by 42 CFR §438.420, the MCO must continue the individual's benefits pending the outcome of the appeal if all the following criteria are met:

 

4121 Expedited MCO Appeals

Revision 11-4; Effective December 1, 2011

 

In accordance with 42 Code of Federal Regulations §438.410, and Uniform Managed Care Contract (UMCC) Attachment B-1, Section 8.2.7.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related appeals when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking the time for a standard resolution could seriously jeopardize the member’s life or health. The MCO must follow all appeal requirements for standard member appeals as set forth in UMCC Attachment B-1, Section 8.2.7.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited appeals.

After the MCO receives a request for an expedited appeal, the MCO must notify the member of the outcome of the expedited appeal request within three business days. However, the MCO must complete investigation and resolution of an appeal relating to an ongoing emergency or denial of continued hospitalization:

Members must exhaust the MCO’s expedited appeal process before making a request for an expedited state fair hearing.

Except for an appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Health and Human Services Commission (HHSC), upon HHSC’s request) that there is a need for additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the decision is adverse to the member, the MCO must follow the procedures relating to the notice in UMCC Attachment B-1, Section 8.2.7.5. The MCO is responsible for notifying the member of his/her right to access an expedited fair hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the decision was made, prior to HHSC’s expedited fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his/her representative for requesting an expedited appeal. The MCO must ensure that punitive action is neither taken against a provider who requests an expedited resolution, nor supports a member’s request.

If the MCO denies a request for expedited resolution of an appeal, the MCO must:

 

4200 Appeal Procedures for Program Support Staff

Revision 14-1; Effective March 3, 2014

 

 

4210 PSU Specialist Procedures

Revision 14-1; Effective March 3, 2014

 

When a request for a fair hearing is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the hearings officer within five calendar days from the date of the request. Upon receipt of the fair hearing request, the PSU specialist completes Form 4800-D, DADS Fair Hearing Request Summary. The PSU specialist sends the form to the regional data entry representative (DER) and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the DER two days to enter the information into the Texas Integrated Eligibility Redesign System.

When PSU staff complete Form 4800-D, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

PSU staff must indicate the Individual Service Plan (ISP) or Individual Plan of Care (IPC) begin and end dates, as applicable, in Section 3.D., Summary of Agency Action and Citation. The begin and end dates must also be mentioned during the fair hearing so the hearings officer is aware of when the ISP or IPC year ends when rendering a decision for STAR+PLUS Waiver.

The Form 4800-D format follows the data entry screens. See the Form 4800-D instructions for more specific directions for completion and transmittal.

 

4211 Designated DER Procedures

Revision 14-1; Effective March 3, 2014

 

Within two calendar days of receipt of Form 4800-D, DADS Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Fair Hearings and Appeals system in the Texas Integrated Eligibility Redesign System. When entry of all information is complete, the system assigns the appeal identification (ID) number. The DER notes the appeal ID number on the bottom of the form and in the designated space on the front of the form, and sends a copy back to the PSU specialist and his supervisor.

When an applicant or member requests a fair hearing, the burden of proof to uphold the PSU decision rests with the PSU. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency’s decision.

 

4212 Fair Hearings and Appeals Procedures

Revision 14-1; Effective March 3, 2014

 

The Texas Integrated Eligibility Redesign System generates a hearing packet, which includes:

The Program Support Unit (PSU) coordinator and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the fair hearings officer assigned to the appeal and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

 

4213 Hearing Packet

Revision 15-1; Effective September 1, 2015

 

Use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the fair hearings officer. Be sure documentation on the form clearly states this is a STAR+PLUS Program appeal. The appeal identification number assigned by the Texas Integrated Eligibility and Redesign System must be written on the top of Form H4800-A.

Use Form 4800-D, DADS Fairs Hearing Request Summary, to record the names, titles, addresses and telephone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup. Program Support Unit (PSU) staff should contact the MCO if there is doubt as to who should be listed on Form 4800-D.

Depending on the issue being appealed, the following staff must attend:

All related documentation necessary to support the decision taken on an Home and Community-based (HCBS) STAR+PLUS Waiver (SPW) case must be sent to the fair hearings officer within 10 business days prior to the hearing. Each entity involved in the fair hearing is responsible for preparing its packet and forwarding it to both the hearings officer identified on Form H4803, Notice of Hearing, and the appellant. Be sure documentation on the form clearly states this is a STAR+PLUS Waiver Program appeal. All documentation must be neatly and logically organized, and all pages numbered.

Examples of additional information and who is responsible for submitting that information to the state fair hearings office include, but are not exclusively limited to:

After the data entry representative (DER) has added information from Form 4800-D into the Texas Integrated Eligibility Redesign System (TIERS), PSU may learn of subsequent changes such as address changes, withdrawal forms or additional supporting documents needed for a fair hearing. When this occurs, PSU staff complete Form H4800-A with the updated information and submit it to the designated DER who will check TIERS to identify if a fair hearings officer has been assigned to the case. In the event the participant updates need to be communicated to the fair hearings officer, PSU staff complete and forward Form 4800-D to the DER.

If a fair hearings officer is not yet assigned, the DER must wait until one is assigned to send the additional information. When sending information, the DER completes the following activities according to the situation:

PSU staff and the DER must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

 

 

4220 Special Procedures for Cases MEPD or TW Determined Financial Eligibility

Revision 14-1; Effective March 3, 2014

 

 

4221 Centralized Representation Unit

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) maintains a Centralized Representation Unit (CRU) to handle all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works (TW) staff. CRU replaces the MEPD specialist in specific steps related to the denial of MEPD applications and ongoing cases. CRU:

PSU staff must coordinate all appeals involving TW/MEPD-related eligibility with CRU. This includes HCBS STAR+PLUS Waiver (SPW) cases. The procedures in Section 4222, Centralized Representation Unit Procedures, must be used to coordinate appeal actions with CRU in cases for which MEPD staff determine financial eligibility.

Staff must remember CRU replaces the local TW/MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

 

4222 Centralized Representation Unit Procedures

Revision 14-1; Effective March 3, 2014

 

Applicants/members may appeal a decision orally, in person or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, DADS Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a fair hearing. The method in which the form is completed depends on the action being appealed. Staff must determine if the appealed action is:

If the appealed action is related to a waiver/service denial, PSU staff complete Form 4800-D, entering the managed care organization contact as the Agency Representative. In the Other Participants field, PSU staff enter the Centralized Representation Unit (CRU) supervisor and CRU administrative assistant. The CRU supervisor and assistant names must be entered by using the Model Office Resources (MOR) Search function. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System (TIERS) and CRU staff will receive the notice of the appeal. Supplemental Security Income recipient appeals are not handled by CRU.

If the appealed action is a TW/MEPD financial denial, staff complete Form 4800-D and enter the name of the CRU supervisor as the agency representative. This information must be entered through the MOR Search function for CRU to receive the hearing information. List the PSU staff name and title in the Other Participants section. The name of the local TW/MEPD specialist is not entered by staff on Form 4800-D for TW/MEPD financial appeals. PSU staff must include staff title, such as PSU specialist or supervisor. Enter the staff email address and include the CRU administrative assistant in Other Participants. Her information must be entered through the MOR Search function.

If this is a TW/MEPD-related appeal, select "Yes" to the question in Section 6 which asks: "Are you an OES Texas Works or MEPD employee?" You are actually responding to this question on behalf of Kristi Rojas, so "Yes" is the correct response. On the Agency Representative page, select "Yes" in the drop-down menu. Failure to answer "Yes" to this item will result in CRU not being notified of the hearing. This paragraph only applies to TW/MEPD financial denials.

When Form 4800-D is sent to the designated data entry representative, PSU staff send an email notification regarding the request for an appeal to CRU. PSU staff will send the email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, staff must also include a copy of the notification form sent to the applicant or member.

The email must include:

For example, the financial case may need to remain open pending an appeal decision regarding medical or functional eligibility. PSU staff must notify CRU to keep the TW/MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU requests the TW/MEPD evidence packet from the local TW/MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent TW/MEPD at the hearing, if required, and takes steps to ensure the appropriate TW/MEPD financial case action is taken once a fair hearings officer's decision is rendered.

When a waiver/service denial hearing decision is rendered by the fair hearings officer, the PSU staff entered as "Agency Representative" is notified via email of the decision by the fair hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver/services according to program-specific time frames. For more information, refer to Section 4500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. PSU staff report the implementation of the hearing decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

The local TW/MEPD specialist notifies PSU staff if an appeal is filed by TW/MEPD regarding a financial eligibility decision, and refers the TW/MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, staff determine the appropriate action for the waiver/service. The email sent by CRU includes:

Staff must not put an applicant/member back on waiver/service-specific interest lists while a TW/MEPD denial is in the appeal process. PSU staff must take appropriate action to certify or deny the case, or resume services once the TW/MEPD hearing decision is rendered. The individual may choose to be added back to the waiver/service-specific interest list once staff deny the waiver/service.

 

4230 Regional Responsibilities

Revision 14-1; Effective March 3, 2014

 

 

4231 Uploading the Appeals Evidence Packet into the TIERS Application

Revision 14-1; Effective March 3, 2014

 

All evidence packets must be scanned into the Texas Integrated Eligibility Redesign System (TIERS) Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation (also referred to as the appeals packet) to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 business days prior to the fair hearing date, the case manager or Program Support Unit (PSU) specialist must:

Within two business days after receipt, the DER must:

Users who make mistakes they are unable to reverse may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

 

4232 Presentation of the Hearing Packet

Revision 14-1; Effective March 3, 2014

 

The Texas Integrated Eligibility Redesign System generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The Program Support Unit (PSU) specialist and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

 

4233 Presentation of the Evidence

Revision 14-1; Effective March 3, 2014

 

Documentation contained in the fair hearing packet is not considered in the case decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Ned Flanders. Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the STAR+PLUS Handbook that relates directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant on March 2, 2011."

The fair hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the fair hearings officer explains the reasons for excluding the material. Any documents admitted by the fair hearings officer are considered when a decision is rendered.

 

4234 Hearing Decision

Revision 14-1; Effective March 3, 2014

 

After the hearing is held, the fair hearings officer sends a decision letter to the appellant and copies to the Program Support Unit (PSU) specialist and his/her supervisor. If the decision is sustained, the PSU specialist takes the appropriate action. If the member requested continued services during the appeal period, follow procedures as described in Section 4500, Hearing Decision Actions.

If the action is reversed, the fair hearings officer also sends Form H4807, Action Taken on Hearing Decision. The fair hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The PSU specialist actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System within the 10-day time frame designated by the hearings officer.

 

4300 Post Hearing Actions

Revision 14-1; Effective March 3, 2014

 

 

4310 Action Taken on the Hearing Decision

Revision 14-1; Effective March 3, 2014

 

The Program Support Unit (PSU) specialist completes Form 4807-D, DADS Action Taken on Hearing Decision, recording case actions taken and sends it to his/her supervisor and the designated data entry representative (DER). The PSU specialist must send Form 4807-D within the time frame to allow at least two days for the DER to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, Form 4807-D is completed and sent to the supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on the form; the begin delay date and end delay date must be included. See the instructions for Form 4807-D for detailed information on completion of the form.

 

4400 Continuation of Services

Revision 14-1; Effective March 3, 2014

 

 

4410 Continuation of STAR+PLUS Waiver Services During an Appeal

Revision 15-1; Effective September 1, 2015

 

HCBS STAR+PLUS Waiver (SPW) services must continue until the hearings officer makes a decision regarding the appeal of an active SPW member, if the appeal is filed by the effective date of the action pending the appeal. If an appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO).

SPW services must continue to be provided until the hearings officer renders a decision by posting to TxMedCentral Form H2067-MC, Managed Care Programs Communication.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four calendar months or until the outcome of the appeal is determined. PSU does not extend the medical necessity/level of care records in the Service Authorization System (SAS). Do not send Form H2065-D, Notification of Managed Care Program Services, to the member notifying of continued eligibility related to the reassessment action taken to continue services until the appeal decision is made.

If an appeal is initially dismissed and subsequently re-opened, the Health and Human Services Commission (HHSC) continues/restarts services pending the appeal outcome, if the member requests continued services. When the hearing officer sets a date for a new hearing, he/she, in effect, voids the prior decision. Because services are continued until a decision is rendered, and the hearing officer is stating there is still a hearing to be held, HHSC continues/re-starts services again.

 

4420 Discontinuation of HCBS STAR+PLUS Waiver Services During an Appeal

Revision 14-1; Effective March 3, 2014

 

If the appeal is not filed by the effective date of the action, HCBS STAR+PLUS Waiver (SPW) services continue until the effective date of denial notated on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If an appeal was not requested by the effective date of the action, the Program Support Unit must complete Form H2067-MC, Managed Care Programs Communication.

SSI members are still enrolled in STAR+PLUS services and are still eligible for State Plan services, which include acute care and long-term services and supports, such as Primary Home Care and Day Activity and Health Services.

 

4500 Hearing Decision Actions

Revision 14-1; Effective March 3, 2014

 

 

4510 Sustained Appeal Decisions

Revision 14-1; Effective March 3, 2014

 

When the hearings officer’s decision sustains the denial of HCBS STAR+PLUS Waiver (SPW) services, Program Support Unit (PSU) staff must:

PSU must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the member of the sustained denial.

 

4511 Sustained Decisions – Termination Effective Dates

Revision 12-3; Effective October 1, 2012

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the appeal decision is known, the HCBS STAR+PLUS Waiver (SPW) termination effective date will vary depending on the circumstances:

Examples

Example Conditions Original MN/ISP Expiration Date New Expiration Date Hearings officer Decision Date Final MN/ISP Expiration Date
1 hearings officer decision is more than 30 days from the original expiration date. 1/31/10 5/31/10 11/30/09 1/31/10
2 hearings officer decision is less than 30 days from the original expiration date. 1/31/10 5/31/10 1/15/10 2/28/10
3 hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/10 5/31/10 2/15/10 3/31/10
4 hearings officer decision assigns a specific expiration date. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 2/15/10. 2/28/10
5 hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 2/28/10. 2/28/10
6 hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 12/31/09. 1/31/10

 

4520 Reversed Appeal Decisions

Revision 14-1; Effective March 3, 2014

 

When the hearings officer’s decision reverses the denial of an HCBS STAR+PLUS Waiver (SPW) applicant or member, Program Support Unit staff must:

 

4521 Reversed Decisions – Effective Dates

Revision 14-1; Effective March 3, 2014

 

When the hearings officer’s decision reverses the denial of HCBS STAR+PLUS Waiver (SPW) eligibility, the SPW effective date for:

When a fair hearing decision reverses a Program Support Unit (PSU) action but PSU staff cannot implement the fair hearing decision within the required time frame, PSU staff must complete Section C, Implementation Delays, on Form 4807-D, DADS Action Taken on Hearing Decision. Form 4807-D must be submitted within the required time frame.

 

4522 New Assessment Required by Fair Hearing Decision

Revision 14-1; Effective March 3, 2014

 

If the hearings officer’s final decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Medical Necessity and Level of Care (MN/LOC) Assessment, the hearing is closed as a result of this ruling. Program Support Unit (PSU) staff must notify the member of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. The member may appeal the results of the new assessment. If the member chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, of Form 4800-D, DADS Fair Hearing Request Summary, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision.

If the member requests an appeal of the new assessment and services are continued, the managed care organization (MCO) continues services until the second fair hearing decision is implemented. For example, a STAR+PLUS Waiver (SPW) member is denied medical necessity (MN) at an annual reassessment and requests a fair hearing and services are continued. The MCO would continue services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN/LOC Assessment which results in another MN denial. PSU staff send a notice to the member informing him of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO would continue services at the same level services were continued prior to the first fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member requests a fair hearing due to the lower RUG level, the MCO would continue services at the same level services were continued prior to the first fair hearing.

 

4523 Request to Withdraw an Appeal

Revision 14-1; Effective March 3, 2014

 

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. Program Support Unit (PSU) staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts PSU staff regarding the withdrawal, PSU staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to PSU staff, PSU staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on a PSU decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify PSU by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System and a written notice will be sent to participants informing them of the fair hearing cancellation.

 

4600 Roles and Responsibilities of HHSC Fair Hearings Officers

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission fair hearings officer:

Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant (applicant/member). Program staff may disagree with the decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to the regional attorney.

 

4700 Fair Hearings for MCO Decisions

Revision 14-1; Effective March 3, 2014

 

If an applicant wishes a fair hearing with the state of Texas regarding an HCBS STAR+PLUS Waiver (SPW) eligibility denial, he or she must contact the Program Support Unit (PSU) as instructed in the denial notification.

In addition to appealing an adverse action not related to eligibility, the SPW member may also request a fair hearing by contacting PSU.

SPH, Section 5000, Automation and Payment Issues in STAR+PLUS

Revision 17-1; Effective March 1, 2017

 

 

 

5100 TxMedCentral

Revision 17-1; Effective March 1, 2017

 

 

5110 TxMedCentral Naming Convention and File Maintenance

Revision 17-1; Effective March 1, 2017

 

TxMedCentral is a secure Internet bulletin board that the state and managed care organizations (MCOs) use to share information. TxMedCentral uses specific naming conventions only for documents listed below. Staff must follow these conventions any time one of the following documents is filed in TxMedCentral.

Form H1700-1, Individual Service Plan — SPW (Pg. 1)

The following forms may be used, if appropriate, in development of the individual service plan (ISP). Only Form H1700-1 and Form H1700-2 are posted to MCO's ISPXXX folder in TxMedCentral and should not be posted in any other folder:

Two-Digit Plan Identification (ID) Form Number (#) Member ID, Medicaid # or Social Security Number (SSN) Member Last Name (first four letters) Page Number of Form H1700 Sequence Number of Form
## 1700 123456789 ABCD 1 2

This file would be named ##_1700_123456789_ABCD_1_2.doc.

Form H1700-1, completed for non-members, age-outs, and nursing facility residents transitioning to the STAR+PLUS Home and Community Based (HCBS) program, continues to be posted to TxMedCentral.

Form H1700-1, completed for members in the community, is submitted to the Long Term Care (LTC) portal.

Form H3676, Managed Care Pre-Enrollment Assessment Authorization

This form is posted to the STAR+PLUS Waiver (SPW) folder and should not be posted in any other folder.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 3676 123456789 ABCD A 2

This file would be named ##_3676_123456789_ABCD_A_2.doc.

Form H2065-D, Notification of Managed Care Program Services

This form is posted to the SPW folder and should not be posted in any other folder.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2065 123456789 ABCD D 2D or 2A

If a member has an ISP which is electronically generated, Form H2065-D is available in the "LETTERS" tab of the LTC portal when the member's ISP is selected. Form H2065-D is posted to TxMedCentral only for individuals without electronic ISPs.

MCOs must check the LTC portal to check for updates and notifications electronically generated by the Program Support Unit (PSU).

Form H2067-MC, Managed Care Programs Communication

This form is posted to the SPW folder and should not be posted in any other folder. An "M" or "S" is added to the sequence number to indicate whether the MCO or PSU posted the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 2M

This file would be named ##_2067_123456789_ABCD_2M.doc.

Additional to the standardized naming convention for Form H2067-MC, a separate naming convention has been developed to address use of Form H2067-MC for nursing facility residents who request transition to the community under the STAR+PLUS Home and Community Based Services (HCBS) program. These individuals are considered expedited cases for application to the STAR+PLUS HCBS  program. For this reason, staff from both the MCO and PSU must be able to readily identify communications specific to these cases.

An "M" or "S" continues to be added to the sequence number to denote, respectively, whether the MCO or PSU has posted the form. The new naming convention for posting Form H2067-MC, on both member and non-member cases in a nursing facility, is expanded as follows:

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 1M or 1S MFP

This form file posted by the MCO would be named ##_2067_123456789_ABCD_1M_MFP.doc.

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all STAR+PLUS HCBS program related postings. Each MCO has two folders with three-letter identifiers:

Primary Folder: MCO Three-Letter Identifiers Secondary Folder: TxMedCentral Folders by Plan
AMC — Amerigroup MCO AMCISP AMCSPW
EVR — United Healthcare Community Plan MCO EVRISP EVRSPW
MOL — Molina MCO MOLISP MOLSPW
SUP — Superior MCO SUPISP SUPSPW
BRV — Cigna-HealthSpring MCO BRVISP BRVSPW

File Maintenance

Due to the volume of forms being posted to TxMedCentral, it is mandatory to purge older documents from time to time. The PSU must electronically back up documents from the XXXISP and XXXSPW on a daily basis to prevent loss of Form History. Documents must be easily accessible to staff whenever needed. The state requires these backup documents be maintained for five years.

 

5120 Maintenance Requirements for Member Information and Forms

Revision 17-1; Effective March 1, 2017

 

The Program Support Unit (PSU) must establish and maintain a case record for each STAR+PLUS Home and Community Based Services (HCBS) program member. Staff must not work directly with member files posted to TxMedCentral. TxMedCentral files must be backed up daily on a compact disc (CD) before they are accessed, organized or member forms printed.

 

5130 Managed Care Data in TIERS

Revision 17-1; Effective March 1, 2017

 

 

5130.1 County Code Issues Affecting Enrollment

Revision 17-1; Effective March 1, 2017

 

The Service Authorization System (SAS) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Therefore, if the county code is incorrect in TIERS, it must be changed to ensure the correct code appears in SAS. Incorrect county records in TIERS can cause enrollment problems for applicants/members in STAR+PLUS.

Supplemental Security Income Cases

If the individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential ZIP code provided by the Social Security Administration (SSA). Two problems could arise:

Non-SSI Cases

If the individual has any TP other than 12 or 13, TIERS contains the county code entered by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Two problems could arise:

What to Do

  1. Perform an inquiry into TIERS or the Financial Wizard in SAS and determine the TP.
  2. If the TP is anything but 12 or 13 and the residence county is incorrect, refer the matter to the MEPD specialist to correct the residence county field.
  3. If the TP is 12 or 13:
    • Determine the residence ZIP code recorded in TIERS.
    • If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.
  4. If the residence ZIP code in TIERS is correct but the county is incorrect, use Form H1270, Data Integrity SAVERR Notification, to send the following information to the Data Integrity Unit:
    • individual's name as recorded in TIERS;
    • individual's number;
    • residence ZIP code; and
    • residence county as it should be reflected in TIERS.

The Data Integrity Unit can force correct the problem in TIERS. The correction will take place during the next TIERS cutoff process, usually around the 20th day of the month. SAS should reflect the corrected county during the first TIERS-to-SAS reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

 

5130.2 Service Interruptions Resulting from County Code Mismatches in the Texas Integrated Eligibility Redesign System

Revision 17-1; Effective March 1, 2017

 

Because participation in managed care programs is based on an individual's residence county code as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when TIERS records show the wrong residence county code.

The Service Authorization System (SAS) reflects the residence county as recorded in TIERS and is updated through monthly interfaces. Therefore, incorrect county code data in SAS must be corrected in TIERS. The manner in which this correction occurs depends on the individual's Type Program (TP). If a residential county code is incorrect and the individual receives services under:

 

5131 Identifying Managed Care Members in the Texas Integrated Eligibility Redesign System

Revision 17-1; Effective March 1, 2017

 

The Individual-Summary screen in the Texas Integrated Eligibility Redesign System (TIERS) contains a managed care segment for any individual who is currently or has been enrolled in managed care. From the Individual-Search window, enter the individual's information and select Search. The individual's managed care status is shown on this window in the managed care section of the Individual-Summary screen.

Specific managed care information is located under Individual Managed Care History. The data elements across the bottom of the screen are: Provider – Plan – Program – County – Begin Date – End Date – Status – Eligibility – Candidature.

These fields contain the following information:

Provider — Contains the name of the provider contracted by the managed care organization (MCO) to deliver services to members.

Plan — Contains the name of the MCO providing Medicaid services to the member.

County — Individual's county of residence.

Program — For managed care members, "STARPLUS" will appear in this field.

Begin Date — Date enrollment began under this plan.

End Date — Date enrollment ended under this plan.

Status — Describes the type of action.

Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).

Candidature — Describes the individual's status.

STAR+PLUS Plan Codes

Service Area Plan Name Plan Codes Plan Codes Dates
Bexar Amerigroup 45 Sept 1, 2011
Molina 46 Sept 1, 2011
Superior 47 Sept 1, 2011
Dallas Molina 9F March 1, 2012
Superior 9H March 1, 2012
El Paso Amerigroup 34 March 1, 2012
Molina 33 March 1, 2012
Harris Amerigroup 7P Sept 1, 2011
United Healthcare 7R Sept 1, 2011
Molina 7S Sept 1, 2011
Hidalgo Cigna-HealthSpring H7 March 1, 2012
Molina H6 March 1, 2012
Superior H5 March 1, 2012
Jefferson Amerigroup 8R Sept 1, 2011
United Healthcare 8S Sept 1, 2011
Molina 8T Sept 1, 2011
Lubbock Amerigroup 5A March 1, 2012
Superior 5B March 1, 2012
Medicaid Rural Service Area (RSA) West Texas Amerigroup W5 Sept 1, 2014
Superior W6 Sept 1, 2014
Medicaid RSA Northeast Texas Cigna-HealthSpring N3 Sept 1, 2014
United Healthcare N4 Sept 1, 2014
Medicaid RSA Central Texas Superior C4 Sept 1, 2014
United Healthcare C5 Sept 1, 2014
Nueces United Healthcare 85 Sept 1, 2011
Superior 86 Sept 1, 2011
Tarrant Amerigroup 69 Sept 1, 2011
Cigna-HealthSpring 6C Sept 1, 2011
Travis Amerigroup 19 Sept 1, 2011
United Healthcare 18 Sept 1, 2011

 

5200 Service Authorization System

Revision 17-1; Effective March 1, 2017

 

 

5210 Managed Care Data in the Service Authorization System

Revision 17-1; Effective March 1, 2017

 

The STAR+PLUS Home and Community Based Services (HCBS) program is authorized by the managed care organization (MCO) and registered by Program Support Unit (PSU) staff in the Service Authorization System (SAS) with a Service Group (SG) 19 and a service code (SC). If the member's individual service plan (ISP) is electronic, the Long Term Care (LTC) portal registers the appropriate SG/SC combination, which is verified by the PSU. Service codes are based on the following:

Example: A reassessment ISP is received on June 5, 2017, for an ISP that ended May 31, 2017. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2017, and an end date of June 30, 2017. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2017, and an end date of May 31, 2018.

Example of automatic registration: A reassessment ISP is submitted to the LTC portal on June 5, 2017, for an ISP that ended May 31, 2017. One service authorization record with "Service Code 13 — Nursing" will be system-generated with a begin date of June 1, 2017, and an end date of June 30, 2017. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2017, and an end date of June 30, 2018.

 

5220 Closing Institutional Service Records in the Service Authorization System

Revision 17-1; Effective March 1, 2017

 

For individuals being discharged from a nursing facility who are to begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program and still have active Category 1 services open in the Service Authorization System (SAS), Provider Claims Services has established a hotline to assist Program Support Unit (PSU) staff in closing the nursing facility authorization. The hotline is 512-438-2200. Select Option 1 when prompted to do so.

PSU staff should call the hotline directly to request the nursing facility record in SAS be closed so non-institutional services can be authorized. Staff must confirm the member has been discharged from the facility and community services are negotiated to begin on or after the date of discharge.

When calling the hotline, the PSU staff must identify himself/herself as a Health and Human Services Commission (HHSC) employee and report the member has been discharged from the nursing facility, providing the discharge date. The Provider Claims Services representative will close all Group 1 service authorizations and enrollment records in SAS, including the Service Code 60 record. This procedure applies whether or not the individual is leaving the facility using the Money Follows the Person (MFP) option.

 

5230 Money Follows the Person Demonstration Entitlement Tracking and Service Authorization System Data Entry

Revision 17-1; Effective March 1, 2017

 

Time spent in a nursing facility does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) individuals receive the full 365-day entitlement period. The entitlement period begins the date the individual who agrees to participate in the demonstration is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The tables below are intended to assist Program Support Unit (PSU) staff in making accurate entries in the Service Authorization System (SAS).

Example 1 — No institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the nursing facility (NF). The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the managed care organization (MCO) capitation payment. SAS record entered by PSU. Blank
06-15-18 06-14-19 19 12 PSU enters SAS record and enters fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU enters the remaining individual service plan (ISP) period without the 19MFP fund code. Blank

Example 2 — Institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SAS record entered by PSU. Blank
06-15-18 06-14-19 19 12 PSU enters SAS record and enters fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU enters the remaining ISP period without the 19MFP fund code. Blank

The MCO has notified PSU this member spent a total of 15 calendar days in the hospital during the MFPD period. PSU must correct SAS as follows:

06-15-19 06-29-19 19 12 PSU enters the MFPD period for the 15 calendar days the member was in the hospital. 19MFP
06-30-19 06-30-19 19 12 MFPD period reached the 365th day on 06-29-10. ISP had one day remaining. Blank

Example 3 — Institutionalization during the 365-day period

Begin Date

End Date

Service Group

Service Code

Comments

Fund Code

02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SAS record entered by PSU. Blank
06-15-18 06-14-19 19 12 PSU enters SAS record and enters fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU enters the remaining ISP period without the 19MFP fund code. Blank
07-01-19 06-30-20 19 12 PSU enters reassessment ISP. Blank

The MCO has notified PSU this member spent a total of 25 calendar days in the hospital during the MFPD period. PSU must correct SAS as follows:

06-15-19 06-30-19 19 12 PSU enters the MFPD period for the 16 of the 25 days the member was in the hospital. 19MFP
07-01-19 07-09-19 19 12 PSU enters the MFPD period for the last 9 of the 25-day period in which the member was in the hospital. 19MFP
07-10-19 06-30-20 19 12 PSU enters the remainder of the reassessment ISP period. Blank

Example 4 — Institutionalization in NF during MFPD period

(The difference between Example 2 and Example 4 is that for NF stays, the PSU has to correct STAR+PLUS HCBS program/NF overlaps.)

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-17 06-15-18 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-18 06-01-18 19 12 One-day registration to set the MCO capitation payment. SAS record entered by PSU. Blank
06-15-18 06-14-19 19 12 PSU enters SAS record and enters fund code as 19MFP for the entire period. 19MFP
06-15-19 06-30-19 19 12 PSU enters the remaining ISP period without the 19MFP fund code. Blank
08-15-18 08-29-18 1 1 The NF begin and end dates are derived from forms submitted by NFs. Blank

The PSU becomes aware this member spent a total of 15 calendar days in the nursing facility during the MFPD period. PSU must correct SAS as follows:

06-15-18 08-14-18 19 12 PSU must correct STAR+PLUS HCBS program/NF overlap. 19MFP
08-30-18 06-14-19 19 12 PSU completes overlap entries. 19MFP
06-15-19 06-29-19 19 12 PSU enters the MFPD period for the 15 calendar days the member was in the nursing facility. 19MFP
06-30-19 06-30-19 19 12 MFPD period reached the 365th day on 06-29-10. ISP had one day remaining. Blank

 

 

5300 Long Term Care Portal

Revision 17-1; Effective March 1, 2017

 

 

5310 Using the Long Term Care Portal

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Long-Term Care (LTC) Portal to process a determination of MN and reimbursement rates. MCOs submit the MN/LOC Assessment as an:

The MCO has the ability to correct or inactivate assessment forms submitted within specific time frames. Corrections are completed when data submitted incorrectly is updated; inactivation is completed when data needs to be removed from the LTC Portal system.

The MCO is given access to the LTC Portal to:

More information about submitting Form H1700-1 through the LTC portal is available in Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations.

Staff with access and responsibility to manage workflows related to their job duties include Claims Management System (CMS) coordinators, Provider Claims Services (PCS) coordinators and the Program Support Unit (PSU).

Submittal of the MN/LOC Assessment through the LTC Portal creates MN, Level of Service (LOS) and Diagnosis (DIA) records in the Service Authorization System (SAS). The RUG value is located in the LOS record.

Status messages appear in the LTC Portal workflow folder when an MN/LOC Assessment is submitted and certain requirements in Texas Medicaid & Healthcare Partnership (TMHP) processing cannot be completed. Status messages may be generated when:

This list is not all inclusive.

Messages will appear in the workflow folder to indicate whether or not the LTC Portal action was processed as complete. In some situations, MN, LOS and Diagnosis records will not be generated to SAS; in other situations, SAS records will be generated but messages may still appear in the workflow for required action.

MCO and CMS coordinators:

Enrollment Resolution Services may:

 

5400 Administrative Payment Process

Revision 17-1; Effective March 1, 2017

 

When an individual is aging out of the Texas Health Steps Comprehensive Care Program, Medically Dependent Children Program (MDCP) or has been approved for a nursing facility diversion slot, the managed care organization (MCO) must authorize services to start on the day of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program, which may not be the first of the month. If the eligibility date is not the first of the month, the MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date. The administrative payment process must be used for the state to issue payment to the MCO and for the MCO to pay the provider.

Once the MCO authorizes services, the provider:

Within five business days of receiving Form 1500, the MCO verifies the provider was authorized to deliver the services billed on Form 1500, the information on Form 1500 meets the clean claim requirements as defined in the Uniform Managed Care Manual, Chapter 2.0, and the claim met the 95-day filing deadline. Once the MCO verifies this information, the MCO:

Within two business days of receiving Form 1500, the PSU:

Within two business days from the receipt of the PSU email, the assigned ERS staff person:

If the decision is to approve to pay the administrative payment, the ERS staff person:

If the decision is to deny the administrative payment, the ERS staff person notifies by email the PSU staff person who emailed the request that the administrative payment has been denied and the reason for the denial.

If the decision is to approve the administrative payment, the following also occurs:

Within two business days of receipt of email from the ERS, the PSU staff person who submitted the request for administrative payment:

 

5500 Safeguard Procedures for Wire Third Party Query and State Online Query

Revision 17-1; Effective March 1, 2017

 

The Social Security Administration (SSA) clarified the treatment of printed copies of Wire Third Party Query (WTPY) and State Online Query (SOLQ) responses. Federal guidelines require states to comply with the same safeguard procedures addressed in the Internal Revenue Service (IRS), Publication 1075, "Tax Information Security Guidelines for Federal, State, and Local Agencies and Entities," although Program Support Unit (PSU) staff rarely have need to access or document the information discussed below. In keeping with SSA's guidance, the STAR+PLUS program will follow IRS safeguard procedures for printed copies of WTPY and SOLQ in those rare instances in which printing an SSA document is necessary.

Guidelines for Printing WTPY and SOLQ Inquiry Screens

Printing WTPY/SOLQ inquiry screens is not specifically prohibited; implement the following requirements when WTPY/SOLQ inquiry screens must be printed:

The office must keep each destruction log for five years from the date of the last entry. PSU staff should not place WTPY/SOLQ print outs in agency confidential trash bins without being shredded. Copies of the inquiry screen can never be transferred to any off-site storage or destruction facility.

These requirements do not apply to print outs from the Texas Integrated Eligibility Redesign System or the System for Applications, Verifications, Eligibility, Reports and Referral. Staff can access IRS Publication 1075 on the Internet by going to www.irs.gov and searching for Publication 1075.

SPH, Section 6000, Specific STAR+PLUS Waiver Services

Revision 18-1; Effective March 1, 2018

 

 

 

6100 Home and Community Support Services

Revision 16-1; Effective March 1, 2016

 

 

6110 Program Overview

Revision 16-1; Effective March 1, 2016

 

 

6111 Service Introduction

Revision 16-1; Effective March 1, 2016

 

The service array under the Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities. Eligible members receive services according to their specific needs, as defined by an assessment process, based on informed choice and through a person-centered process.

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 6113, General Requirements for MCOs, and in accordance with the ISP.

 

6112 Service Locations for HCBS STAR+PLUS Waiver (SPW)

Revision 16-1; Effective March 1, 2016

 

All Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) services, except minor home modifications, can be provided to members in locations of their choice. Nursing services, therapy services, adaptive aids (including dental) and medical supplies may be provided to an SPW member residing in an assisted living facility contracted to provide SPW services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, Section 441.530(a)(2), the following locations are excluded from HCBS SPW service locations, with the exception of out-of-home respite care:

 

6113 General Requirements for MCOs

Revision 16-1; Effective March 1, 2016

 

The managed care organization (MCO) must coordinate and authorize the array of services in accordance with Form H1700-1, Individual Service Plan — SPW (Pg. 1). Services include:

The MCO must identify, coordinate and when applicable, authorize available value added services, Medicare and other third-party resources before authorizing those services on the member's individual service plan (ISP).

 

6114 Service Plan

Revision 16-2; Effective June 1, 2016

 

The managed care organization (MCO) must authorize all services identified on the individual service plan (ISP). When sending an authorization to a provider, the MCO may send the following:

The MCO must send any of the above documentation when requested by the provider and if improvement of member outcome is expected. The MCO will post both Form H1700-1 and the signed Form H1700-2 to the XXXISP folder in TxMedCentral using the appropriate naming convention. All other forms are maintained in the member's file folder. If Form H1700-1 is electronic, the MCO will submit Form H1700-1 only through the Long Term Care Online Portal.

The MCO registered nurse (RN) service coordinator or MCO contracted RN service coordinator must sign Form H1700-2 prior to the start date of the ISP to certify the proposed ISP accurately reflects the needs of the member.

Verbal signatures are permitted for ISP changes, as long as the name of the person who verbally signed, and the date the verbal signature was given, are included on the signature line. The proposed ISP should be presented to the member following development of the proposed ISP and the member should sign Form H1700-2 to indicate acceptance.

 

6115 Individual Agreement for Services

Revision 16-1; Effective March 1, 2016

 

Managed care organizations (MCOs) may choose to provide services through other pay arrangements with individuals awaiting determination of Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) eligibility. MCOs will not be reimbursed for services delivered prior to the determination of the SPW eligibility.

The provider cannot be held responsible for deficits or failure in areas not included in the provider’s portion of the member's individual service plan when gratuitous care or care by other resources is being provided.

 

6116 Refusal to Serve Members

Revision 16-1; Effective March 1, 2016

 

If a provider refuses to serve a member, the reason the provider cannot adequately meet the needs of the member must be stated in writing to the member’s managed care organization. The reason for provider refusal must be related to the provider’s limitation and not previous experience with the member or discriminated against because of age, disability or gender, etc.

 

6117 Service Planning

Revision 16-1; Effective March 1, 2016

 

Services and care provided, as identified and authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1), must assist the member to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Services provided are tailored to meet the member's goals and needs based upon his/her medical condition, mental and functional limitations, ability to self-manage, and availability of family and other support.

The managed care organization (MCO) must assure the member's informed choice and convenience are incorporated into the planning and provision of the member's care by involved professionals. Members must be encouraged and allowed to play an active role in determining their ongoing plan of care.

MCOs must recognize and support the member's right to a dignified existence, privacy and self-determination.

 

6118 Personal Assistance Services

Revision 16-1; Effective March 1, 2016

 

Personal Assistance Services (PAS) provide assistance to members in performing the activities of daily living based on the member’s service plan. PAS includes assistance with the performance of the activities of daily living and instrumental activities of daily living necessary to maintain the home in a clean, sanitary and safe environment. PAS is provided to the member, as authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1).

 

6118.1 Description of Personal Assistance Services

Revision 16-1; Effective March 1, 2016

 

Shopping

Neither the provider nor the attendant can charge the member for transportation costs incurred in the performance of this task.

Ambulation

Ambulation is a personal care task that involves non-skilled assistance with walking/transferring while taking the usual precautions for safety (that is, standby assistance, gentle support of an elbow for balance or assuring balance of a walker). This does not involve nursing intervention. No special precautions are needed other than for safety measures.

To facilitate safe member ambulation or movement, the attendant may need to ensure safe pathways throughout the home for the member. Examples include those who use wheelchairs, walkers or crutches, or for members with visual impairment. The attendant care provider or member (or member's representative) addresses this activity during orientation and on an ongoing basis for an attendant who provides services to a member needing assistance.

The member’s primary care provider (PCP) may request specific ambulation orders. If ambulation is authorized as a nursing task, the service coordinator must not authorize ambulation as a non-skilled task on Form H2060 and any addendums to Form H2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form H2060 and any addendums to Form H2060, the service coordinator must consider the individual's need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the service coordinator must document in the case record why and how the member requires both. The service coordinator can approve both if there is no duplication.

Escort

Escorting is for healthcare-related appointments and does not include the direct transportation of the member, or the communication of the member’s health information, by the attendant. Transportation for Medicaid recipients is available in every county through the Medical Transportation Program. Transportation is not included as an activity in the escort task. See Section 8200, Consumer Directed Services, for information.

Protective Supervision

The purpose of protective supervision is to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness. Protective supervision is authorized by the MCO, and assures supervision of the member during instances in which the member’s informal support is unavailable.

Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to his/her cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn himself/herself, or try to walk and then fall. Protective supervision is not routinely authorized for members who can safely live on their own, nor is it intended to provide 24-hour care.

Exercise

A member may request, or a physician may order, assistance with walking as a form of exercise. A member must be ambulatory for exercise to be an authorized PAS activity.

Therapy Extension

Licensed therapists may choose to instruct the attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance/support provides reinforcement of instruction and aids in the rehabilitative process. Therapy extension is documented on Form H2060-A.

 

6118.2 Personal Assistance Services Attendants

Revision 16-1; Effective March 1, 2016

 

Personal assistance services (PAS) are performed by personal care attendants who:

 

6200 Nursing Services

Revision 16-1; Effective March 1, 2016

 

Nursing services are services that are within the scope of the Texas Nursing Practice Act and are provided by a registered nurse (or licensed vocational nurse under the supervision of a registered nurse) licensed to practice in the state. In the Texas State Plan, nursing services are provided only for acute conditions or exacerbations of chronic conditions lasting less than 60 days. Nursing services provided in the waiver cover ongoing chronic conditions such as medication administration and supervising delegated tasks. This broadens the scope of these services beyond extended State Plan services. Extended State Plan services are those services provided which exceed what are allowable benefits under the State Plan.

Nursing services purchased through Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) can be skilled or specialized in nature and do not replace a member's acute care benefit. Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing or vocational nursing in Texas, or licensed in a state that has adopted the Nurse Licensure Compact. Proof of valid licensure can be verified by viewing the nurse's license at the Texas Board of Nursing website at https://www.bon.texas.gov/.

To assure quality of care for members in the HCBS SPW, the managed care organization (MCO) is responsible for identifying significant changes in the member's condition by performing interim assessments on current SPW members contingent on changes in the member's health condition, and initiating appropriate interventions on a timely basis.

 

6210 Settings

Revision 16-1; Effective March 1, 2016

 

Nursing services can be delivered in a member's own home/family home, in a personal care facility, assisted living facility or an adult foster care setting. Nursing services purchased through Home and Community Based Services STAR+PLUS Waiver may not be provided in the following settings as defined in 42 Code of Federal Regulations, Section 441.530(a)(2):

 

6220 Nursing Services to Meet Member Needs

Revision 16-1; Effective March 1, 2016

 

All Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) members meet Medical Necessity (MN) and therefore have a need for one or more nursing tasks. It is the responsibility of the managed care organization (MCO) service coordinator to identify and document in the plan of care (POC) how the member's nursing need(s) will be met.

The member's nursing needs may be met by direct or delegated nursing, health maintenance activity (HMA) or informal support as described below:

For information about delegation and HMAs, refer to the Texas Administrative Code for Texas BON, Title 22, Part 11, Rules 224 and 225.

 

6230 Nursing Services in Assisted Living Facilities

Revision 16-1; Effective March 1, 2016

 

Assisted living facilities must have sufficient staff to assist with member medication regimens. Therefore, nursing for this task must not be included on the individual service plan. Licensed nurses may directly deliver medication administration to members residing in assisted living facilities, but are not required to do so. In this setting, delegation of nursing tasks to facility attendants is not allowed by licensure. See Section 7200, Assisted Living Services, Section 7224, Personal Care 3, and Section 7230, Other Services Available to Members.

Facility employees may not deliver services other than personal care services and/or administration of medications. If a resident needs additional services, the resident may contract with a Home and Community Support Services Agency or an independent health care provider.

Personal care services, also called personal assistance services, are defined as assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in the facility; or who needs assistance to manage his or her personal life, regardless of whether a guardian has been appointed for the person.

 

6240 Nursing Services in Adult Foster Care Homes

Revision 16-1; Effective March 1, 2016

 

Based upon the managed care organization’s (MCO’s) registered nurse (RN) service coordinator's assessment, the RN service coordinator determines a member’s classification level for Adult Foster Care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member. Nursing services may be purchased through the waiver, depending on the member's assessed need and the AFC home classification. See Section 7133 Classification Levels, for additional information.

 

6250 Specialized Nursing

Revision 16-1; Effective March 1, 2016

 

Specialized nursing services delivered by a registered nurse or licensed vocational nurse are available through the Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) program. Specialized nursing services may be used when a member requires, as determined by a physician, daily skilled nursing to:

 

6300 Therapy Services

Revision 16-1; Effective March 1, 2016

 

Therapy services purchased through the Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) are long term services and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional, cognitive, speech and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of his/her state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic. If the therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing his/her own transportation or accessing the Medicaid medical transportation system.

If the therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. If a member resides in an adult foster care or an assisted living setting and therapy is provided in an outpatient center or clinic (see Section 6112, Service Locations for HCBS STAR+PLUS Waiver (SPW), the assisted living provider or foster care provider is responsible for arranging for transport or directly transporting the member.

Occupational therapy, physical therapy, speech therapy and cognitive rehabilitative therapy services are covered by the HCBS SPW only after the member has exhausted his therapy benefit under Medicare, Medicaid or other third-party resources. Providers contracted with the managed care organization must provide the occupational therapy, physical therapy, speech therapy and cognitive rehabilitation therapy services as identified on the member's individual service plan. Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider or through the Consumer Directed Services Option.

Physical therapy is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed physical therapy assistant directly supervised by a licensed physical therapist. Physical therapy is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents (such as mechanical devices, heat, cold, air, light, water, electricity and sound) in the aid of diagnosis or treatment.

Occupational therapy consists of interventions and procedures to promote or enhance safety and performance in activities of daily living, instrumental activities of daily living, education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified occupational therapy assistant directly supervised by a licensed occupational therapist.

Speech therapy in HCBS SPW is defined as evaluation and treatment of impairments, disorders or deficiencies related to an individual's speech and language. The scope of speech, hearing and language therapy services offered to HCBS SPW participants exceeds the State Plan as the service in this context is available to adults. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist.

 

6310 Initiation of Assessment and Therapy

Revision 16-1; Effective March 1, 2016

 

Upon member request or recommendation from the nurse, primary care provider or service coordinator for a therapy assessment, the managed care organization authorizes appropriate hours based on physician orders on the service plan.

 

6320 Responsibilities of Licensed Therapists in SPW

Revision 16-1; Effective March 1, 2016

 

Responsibilities of the licensed therapists include, but are not limited to, the following:

 

6330 Cognitive Rehabilitation Therapy

Revision 16-1; Effective March 1, 2016

 

Cognitive rehabilitation therapy is a service that assists a member in learning or relearning cognitive skills lost or altered as a result of damage to brain cells/chemistry in order to enable the member to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Qualified providers include:

 

6400 Adaptive Aids and Medical Supplies

Revision 16-1; Effective March 1, 2016

 

Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their abilities to perform activities of daily living, or to perceive, control or communicate with the environment in which they live. Adaptive aids and medical supplies are reimbursed with waiver funds, when specified in the individual service plan, with the goal of providing individuals a safe alternative to nursing facility (NF) placement.

This service also includes items necessary for life support, ancillary supplies, and equipment necessary to the proper functioning of such items; and durable and non-durable medical equipment not available under the Texas State Plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

The annual cost limit of this service is $10,000 per waiver plan year. The $10,000 cost limit may be waived by the Texas Health and Human Services Commission upon request from the managed care organization.

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be his/her provider for this service if the relative or legal guardian meets the requirements for this type of service.

Adaptive aids and medical supplies are limited to the most cost-effective items that:

 

6410 List of Adaptive Aids and Medical Supplies

 

Revision 16-1; Effective March 1, 2016

 

Adaptive aids and medical supplies are covered by the Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) only after the member has exhausted State Plan benefits and any third-party resources, including product warranties or Medicare and Medicaid home health the member is eligible to receive. Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of but are not limited to following:

If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, the MCO contracted provider must:

Other types of supplies include:

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare/Medicaid can cover hospital beds and specialty mattresses. Specialty sheets, such as hospital bed sheets, may be covered.

SPW will pay for a Geri-chair if the member is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and SPW does not pay for restraints.

Gloves

Gloves may be purchased through SPW for family caregiver use in the care of an incontinent member, if the member has an active infectious disease that is transmitted through urine (if incontinent of urine) or stool (if incontinent of stool). Examples of active infectious diseases that qualify are Methicillin-Resistant Staphylococcus Aureus (MRSA) and hepatitis. Gloves may be purchased for family caregiver use to provide wound care to protect the member. Documentation by the MCO-contracted provider must support the need of gloves to be left at the residence and for family caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his/her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using SPW funds. These items include, but are not limited to:

Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

 

6420 Approval of Adaptive Aids and Medical Supplies

Revision 16-1; Effective March 1, 2016

 

In the initial pre-enrollment assessment, the managed care organization (MCO) nurse identifies the basic needs of the member for adaptive aids and HCBS STAR+PLUS Waiver medical supplies along with the estimated costs on Form H1700-1, Individual Service Plan — SPW (Pg. 1). The MCO must provide documentation supporting the medical need for all adaptive aids and medical supplies. The documentation must be provided by the physician, physician assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist or speech pathologist. The service coordinator must use Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services, to document medical need and the rationale for purchasing the item(s).

Adaptive aids and medical supplies are approved for purchase as a waiver service by the MCO only if the documentation supports the requested item(s) as being necessary and related to the member's disability or medical condition.

The MCO determines if the documentation submitted is adequate, and makes the decision as to whether an adaptive aid or medical supply is needed and related to the member's condition. The MCO makes the final decision if the purchase is necessary and will be authorized on the individual service plan (ISP).

If the member's request for a particular adaptive aid or medical supply is denied, the member must receive written notification of the denial of the specific item following the requirements outlined in the Uniform Managed Care Manual, Chapter 3.21.

If the member requests an item the MCO deems is not medically necessary or related to the member's disability or medical condition, the MCO sends an adverse determination notice to the member.

For situations in which the member requests an adaptive aid or medical supply, and the item(s) are documented by the nurse or other medical professional to be medically necessary, the MCO has the option of approving the item(s). If not approved, the MCO sends the adverse determination notice to the member.

The member may appeal the denial by filing an appeal with the MCO. The member does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP. The cost of the item is reflected in the ISP in effect at the time of the appeal.

Service plans should be individualized to the member. All items must be related to the member's disability or medical condition.

If the provider cannot deliver the adaptive aids by the appropriate time frames, the provider must notify the MCO via Form H2067-MC, Managed Care Programs Communication, and include the reasons the adaptive aid will be late. The MCO reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the MCO to discuss the reasons for the delayed delivery with the member and provider staff.

If the adaptive aid requested will not be delivered in the current ISP, the item must be transferred to the new ISP. If the authorization on the new ISP causes the service plan to exceed the annual cost limit, the nurse may authorize it using the date the item was ordered by the provider as the date of service delivery and the provider may bill against the previous ISP.

 

6421 Lift Chair Approvals

Revision 16-1; Effective March 1, 2016

 

Lift chairs may be authorized as adaptive aids as part of the Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) service array. Use the following procedures if attempting to purchase the lift chair using Medicare funding.

Once the managed care organization (MCO) determines a lift chair may be needed or is requested by the member, the MCO assesses the individual to determine if the individual meets all of the following criteria required for Medicare to pay for the lift mechanism:

Individual Does Not Meet All Criteria

If the individual does not meet all of the Medicare criteria, the MCO completes Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services. The MCO should state the following on Form H1700-A, Section 4, "Lift Chair: Plus Mechanism." Along with Form H1700-A, the MCO must obtain a:

The MCO approves the cost of the lift chair plus the mechanism if the request meets all criteria and the above documentation is received.

Individual Meets All Criteria

If the MCO determines the individual meets all of the criteria for Medicare to pay for the lift mechanism, the MCO:

If a request for a lift chair minus the mechanism is approved by the MCO, but the provider later requests additional funds for the mechanism denied by Medicare, the MCO may approve the request if it meets all SPW criteria. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

 

6430 Effects of Changing MCOs on Adaptive Aids Procurements

Revision 16-1; Effective March 1, 2016

 

If a member changes to another managed care organization (MCO) while an adaptive aid is on order or in the process of being delivered, the losing MCO is responsible for payment and delivery of the adaptive aid.

 

6440 Temporary Lease and Equipment Rental

Revision 16-1; Effective March 1, 2016

 

Rental of equipment allows for repair, purchase or replacement of the equipment, or temporary usage of the equipment. The length of time for rental of equipment must be based on the individual circumstances of the member. If the medical professional and/or the member is not certain the medical equipment will be useful, the equipment should be rented for a trial or short-term period before purchasing the equipment.

The cost of renting equipment versus purchasing equipment may be explored, if you are currently renting the equipment. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment may be considered in the decision to rent or purchase. It may be more cost-effective, after renting for a period of time, to purchase the equipment instead of continuing to rent.

If the member prefers to buy the rented equipment, the managed care organization must document the equipment functions properly and is appropriate for the member, so waiver funds may be expended.

 

6450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 16-1; Effective March 1, 2016

 

 

6451 Time Frames for Adaptive Aids

Revision 16-1; Effective March 1, 2016

 

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) form or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO must document the reason for the delay.

The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered.

 

6452 Time Frames for Medical Supplies

Revision 16-1; Effective March 1, 2016

 

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Waiver (SPW) services. The provider must deliver medical supplies within five business days from the start date on the individual service plan (ISP). The member’s current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) before the fifth day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time.

Stockpiling of medical supplies must not occur. Supplies, such as incontinence and wound care supplies not covered through Medicaid Home Health and needed on an ongoing basis, should be delivered so there is no more than a three-month supply in the member's home at a time.

 

6460 Co-Insurance and Deductibles

Revision 16-1; Effective March 1, 2016

 

Reimbursement for the cost of co-insurance for the purchase or rental of adaptive aids or the purchase of medical supplies reimbursed by Medicare or private health insurance is available if the following conditions are met:

Reimbursement for the co-insurance amount to Medicare or private health insurance for therapy services or the rental of any adaptive aids is a cost-effective way to utilize third-party resources. The cost of any co-insurance payment must be billed under adaptive aids.

For instances in which a member is not covered under the QMB or MQMB programs and cannot pay his/her premium deductible under a third-party resource for items covered under the waiver, the deductible can be listed under adaptive aids on Form H1700-1, Individual Service Plan — SPW (Pg. 1), for payment.

 

6470 Bulk Purchase of Medical Supplies

Revision 16-1; Effective March 1, 2016

 

The managed care organization may choose to buy medical supplies in bulk. The cost of storing supplies can be reported on the annual cost report as an allowable expense. The medical supply is billed at the unit rate based on the invoice cost of the bulk purchase divided by the number of units purchased.

 

6500 Dental Services

Revision 16-1; Effective March 1, 2016

 

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership. The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Waiver (SPW) members with licensed and enrolled dentists.

The MCO must discuss with the SPW member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through SPW. If dental services are on the individual service plan, the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.

 

6510 Allowable Dental Services

Revision 18-1; Effective March 1, 2018

 

Allowable dental services include:

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by STAR+PLUS HCBS program when no other financial resource for such services is available and when all other available resources, with the exception of value-added services (VAS). VAS are not required to be used prior to waiver services. VAS vary by MCO.

The state allows a member to select a relative or legal guardian, other than a spouse, to be his/her provider for this service if the relative or legal guardian meets the requirements to provide this service. Payments for dental services are not made for cosmetic dentistry.

The annual cost cap of this service is $5,000 per waiver plan year. The $5,000 cap may be waived by the MCO upon request of the member only when the services of an oral surgeon are required. Exceptions to the $5,000 cap may be made up to an additional $5,000 per waiver plan year when the services of an oral surgeon are required.

 

6520 Documentation of Dental Services by a Dentist

Revision 16-1; Effective March 1, 2016

 

The managed care organization (MCO) must ensure all requests for dental treatments include documentation by a professional dentist of the need for dental services. A dentist must determine the medical necessity for dental treatment and submit a detailed treatment plan to the MCO to document the medical necessity and all specific dental procedures to be completed. The dentist may not bill the HCBS STAR+PLUS Waiver (SPW) member for the remainder of the cost over the approved amount.

Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services, must be completed by the MCO to document the medical need for requested SPW items/services. Medical necessity for dental services is completed by the dental professional, as described above. Form H1700-A may be submitted in lieu the process described above, if the information is sufficient to describe the medical need for the dental services.

 

6530 Time Frames for Initiation of Dental Services

Revision 16-1; Effective March 1, 2016

 

The managed care organization (MCO) must send an authorization to the dentist within seven days of receipt of the dental treatment plan. Services must be initiated within 90 days of treatment plan development unless the member or dentist has a documented preference for a later initiation date. Prior to authorizing dental on the individual service plan, the member must exhaust all value-added services.

 

6600 Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

Minor home modifications are those physical adaptations to a member’s home, required by the service plan, that are necessary to ensure the member's health, welfare and safety, or that enable the member to function with greater independence in the home. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies necessary for the member’s welfare. Excluded are those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the member, such as carpeting, roof repair, central air conditioning, etc. Adaptations that add to the total square footage of the home are excluded from this benefit.

All services are provided in accordance with applicable state or local building codes. Modifications are not made to settings that are leased, owned or controlled by waiver providers. The state allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this service.

 

6610 Responsibilities Pertaining to Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

In order to ensure cost-effectiveness in the purchase of minor home modifications (MHMs), the managed care organization (MCO) must:

The MCOs have their own policies and procedures in regards to bidding, awarding contracts, doing inspections and completing MHMs.

 

6620 List of Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

The following minor home modifications include the installation, maintenance and repair of approved items not covered by warranty:

Ramps may be installed for improved mobility for use with scooters, walkers, canes, etc., or for individuals with impaired ambulation, as well as for wheelchair mobility. In some instances and according to supporting documentation, multiple modifications may be needed for accessibility and mobility, such as ramps and hand rails for individuals with impaired ambulation. There is no limit to the number of wheelchair ramps that can be authorized, provided the total cost does not exceed the cost ceiling, but documentation must support the justification for additional ramps as related to medical need or health and safety of the individual.

Carbon monoxide detectors cannot be purchased under STAR+PLUS Waiver as a "fire safety adaptation and alarm."

Requests for items (or repair of items) or service calls that are considered routine home maintenance and upkeep cannot be approved.

Items that cannot be approved by the service coordinator include:

Heating and cooling equipment may be approved as an adaptive aid. Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms are considered as an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as a minor home modification.

Flooring applications, including vinyl and industrial carpet, may not be authorized for adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the individual.

 

6630 Home Modification Service Cost Lifetime Limit

Revision 16-1; Effective March 1, 2016

 

There is a lifetime limit of $7,500 per member for this service and $300 yearly for repairs. To request approval to exceed the service cost cap for minor home modifications, the managed care organization (MCO) must send a written request to the Texas Health and Human Services Commission (HHSC), along with appropriate documentation which must include the cost estimate and an assurance that the individual service plan (ISP) is within the member's overall cost ceiling and adequate to meet the needs of the member. Once the $7,500 cap or a higher amount approved by HHSC is reached, only $300 per year per member, excluding associated fees, will be allowed for repairs, replacement or additional modifications. The MCO is responsible for obtaining cost-effective modifications authorized on the member's ISP.

If a member changes MCOs, the losing MCO must provide documentation to the gaining MCO related to any minor home modification expenditures. See Uniform Managed Care Terms and Conditions (UMCC), Section 5.06, Span of Coverage, for payment responsibilities.

 

6640 Landlord Approval for Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

When the member has a landlord or when the owner of the home is not the member, written approval prior to the initiation of any requested modification must be obtained.

 

6700 Employment Services

Revision 16-1; Effective March 1, 2016

 

 

6710 Employment Assistance

Revision 16-1; Effective March 1, 2016

 

Employment assistance is provided to an individual to help the individual locate paid employment in the community and includes:

In the state of Texas, this service is not available to individuals receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the individual’s record that the service is not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).

An employment assistance service provider must satisfy one of these options:

Option 1:

Option 2:

Option 3:

 

6720 Supported Employment

Revision 16-1; Effective March 1, 2016

 

Supported employment is assistance provided, in order to sustain competitive employment, to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed. Supported employment includes adaptations, supervision, training related to an individual's assessed needs and earning at least minimum wage (if not self-employed). In the state of Texas, this service is not available to individuals receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the individual’s record that the service is not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).

A supported employment service provider must satisfy one of these options:

Option 1:

Option 2:

Option 3:

 

SPH, Section 7000, Waiver Program Services

Revision 15-1; Effective September 1, 2015

 

 

 

7100 Adult Foster Care

Revision 15-1; Effective September 1, 2015

 

 

7110 Introduction

Revision 15-1; Effective September 1, 2015

 

Adult Foster Care (AFC) provides 24-hour living arrangements and personal care services and supports for persons who, because of physical or behavioral conditions, are unable to live independently. Services and supports may include assistance and/or supervision with daily living, including meal preparation, housekeeping, companion services, personal care, nursing tasks and provision of, or arrangement for, transportation. The Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) applicant or member who chooses AFC must reside with a contracted HCBS SPW AFC home provider that meets the minimum standards and licensure requirements found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

AFC home providers must be contracted either directly with the member’s managed care organization (MCO) or with an AFC provider agency contracted with the member’s MCO. The individual qualified to provide AFC (AFC home provider) must be the primary caregiver. AFC home providers must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. AFC home providers may serve up to three adult residents in a qualified AFC home without being licensed as a personal care home or assisted living facility, and may be the AFC home provider’s home or the HCBS SPW member’s home. AFC home providers with four or more residents, who are also contracted with the Department of Aging and Disability Services (DADS), are required to have a Type C Personal Care Home license. AFC homes with four or up to eight more AFC residents who are only contracted with a STAR+PLUS MCO must be licensed as an assisted living facility, with limitations on the number of residents at each level who may reside in one home. The three levels of eligibility for AFC are explained in Section 7133, Classification Levels of Adult Foster Care Members. Assisted living licensure requirements are found in 40 Texas Administrative Code (TAC), Chapter 92.

Any reference to “resident” includes members receiving HCBS SPW AFC and private pay individuals. AFC home providers may serve a combination of HCBS SPW members and private pay individuals in a qualified or licensed AFC home as long as the AFC home provider continues to meet the minimum standards specified in Appendix XXIV, and additional other standards may be specified by the MCO.

When the AFC home provider moves in with the HCBS SPW member receiving AFC in the member’s home, the AFC home enrollment requirements indicated with an asterisk in Appendix XXIV may be waived at the discretion of the MCO or the MCO-contracted AFC provider agency, as appropriate. Other minimum standards, excluding home safety requirements, may be waived at the discretion of the MCO, or upon the recommendation by the MCO-contracted AFC provider agency as long as the MCO-contracted AFC provider agency has completed a home assessment and concluded the member’s needs can be appropriately met through the HCBS SPW and AFC-specific services. Such conclusions must be documented by the MCO-contracted AFC provider agency and approved by the MCO.

The MCO is responsible for ensuring the AFC member receives all necessary AFC services, including the authorization of other needed services and nursing tasks.

HCBS SPW AFC members are required to pay for their own room and board costs and, if able, contribute to the cost of AFC services through a copayment to the AFC home provider. The only time room and board is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home. Room and board arrangements must be documented in the member’s case file by the MCO or by the MCO-contracted AFC provider agency.

If an AFC home is contracted with DADS to provide services to an individual receiving AFC through DADS, the MCO or the MCO-contracted provider agency may request a copy of the AFC home and AFC home provider qualification documents from DADS, if applicable. These documents contain DADS findings regarding the qualifications of the AFC home and AFC home provider.

 

7111 Purpose

Revision 15-1; Effective September 1, 2015

 

The purpose of Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) is to promote the availability of appropriate services in a home-like environment for individuals who are aging and who have disabilities to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of a member.

The HCBS SPW requires each AFC member to have enough living space to guarantee their privacy, dignity and independence.

 

7112 MCO Contracting Options

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) provides Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) through one of the two contracting methods:

If the MCO contracts with an AFC provider agency, the MCO has oversight over the AFC provider agency. The MCO retains responsibility for its member(s).

 

7113 Adult Foster Care Services

Revision 15-1; Effective September 1, 2015

 

The Adult Foster Care (AFC) home provider must provide services, supports and supervision, as needed, around the clock in an AFC home that has either been qualified based on the minimum standards or licensed by the Department of Aging and Disability Services (for homes serving four or more residents). Services may include:

Personal assistance — Help with activities related to the care of the member's physical health that includes but is not limited to bathing, dressing, preparing meals, feeding, exercising, grooming (routine hair and skin care), toileting and transferring/ambulating.

A Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) member may not receive HCBS SPW Personal Assistance Services (PAS) while the member is a resident in an HCBS SPW AFC home. Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and any addendums to Form H2060 are completed by the managed care organization (MCO) to determine the needed tasks for completion by the AFC home provider. The MCO must provide a copy of the required PAS tasks to the AFC home provider and to the MCO-contracted AFC provider agency, if applicable.

Transportation — Arrangement of and/or direct transport of members to meet their basic needs for food, clothing, toiletries, medications, medical care and necessary therapy.

Supervision — Periodic checks or visits by the provider to the member throughout the 24-hour period to assure the member is well and safe. For some members with more intensive medical needs or behavior problems, more frequent supervision is required.

Meal preparation — Preparation or provision of meals adequate to meet the needs of the member.

Housekeeping — Activities related to housekeeping that are essential to the member's health and comfort, such as changing bed linens, housecleaning, laundry, shopping, arranging furniture, washing dishes and storing purchased items.

AFC services, with the exception of 24-hour supervision that is provided to all HCBS SPW AFC members, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. For example, HCBS SPW AFC members may not need assistance with medication or help with transportation, but the services are available to all HCBS SPW members in AFC homes. PAS tasks must be provided as identified on Form H2060 and any addendums to Form H2060. The AFC home provider may provide more services for the member than are authorized, as the changing needs of the member may warrant, but may not reduce or discontinue services without prior consultation with the MCO.

HCBS SPW members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to non-emergency medical transportation is available to members through the Medical Transportation Organization.

 

7114 Other Long Term Services and Supports Available to Adult Foster Care Members

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) may provide or arrange for the provision of the following services.

Adaptive Aids and Medical Supplies — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live.

Nursing Services — Services for members may be provided through the Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW). Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing or vocational nursing by the Texas Board of Nursing or licensed in a state that has adopted the Nurse Licensure Compact.

Minor Home Modifications — Services that assess the need, arrange for, and provide modifications and/or improvements to a residence to enable the member to reside in the community and to ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the individual service plan (ISP).

If the Adult Foster Care (AFC) home is the member’s home, the member must agree to have modifications made to the home. If the AFC home provider is the owner of the home, the AFC home provider must agree to have modifications made to the home. If the AFC home provider is the lessee of the home, the owner must be contacted and apprised of the needed modifications. Permission to make the modifications must be obtained from the home owner in writing and kept with Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services.

When the AFC home provider and member or HCBS SPW applicant meet to interview each other and complete Form 2327, Individual/Member and Provider Agreement, the minor home modifications must be listed in "Miscellaneous Arrangements" if the AFC home is not the member’s home. Both the member and the AFC home provider must sign the form agreeing to all included information and stipulations.

To save the member from spending his/her allocation for minor home modifications unnecessarily, a minimum grace period of 30 calendar days must be allowed for the individual to adjust to the AFC placement before any modifications are begun. If the health or safety of the member is jeopardized without the necessary modifications upon entry into the AFC home, a waiver of the 30 calendar days can be made based on the recommendations of the interdisciplinary team and approved by the MCO.

Minor home modifications remain in an HCBS SPW AFC home even if the member for whom the modifications were made permanently leaves the home.

Dental Services — Services provided by a licensed dentist to preserve teeth and meet the medical need of the member.

Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. Services consist of the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist and within the scope of his/her state licensure.

Physical Therapy — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculoskeletal systems. Services consist of the full range of activities provided by a physical therapist or a licensed physical therapist assistant under the direction of a licensed physical therapist and within the scope of his/her state licensure.

Speech Pathology Services — The evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by a speech and language pathologist under the scope of the pathologist's state licensure.

Cognitive Rehabilitation Therapy — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Employment Assistance Services — Services that assist the member with locating competitive employment or self-employment.

Supported Employment Services — Services that assist the member with sustaining competitive employment or self-employment.

Day Activity and Health Services (DAHS) — Includes nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed or certified by the Texas Department of Aging and Disability Services.

Each of the above services is provided according to the needs of the member as identified on the ISP, with the exception of DAHS, which is not included on the ISP. The MCO makes referrals for DAHS, coordinates delivery and advises the AFC home provider or MCO-contracted provider agency of any updates to the ISP or referrals for DAHS. Members who have nursing needs may be able to obtain nursing services at a DAHS facility. The MCO service coordinator will work with the AFC home provider or provider agency, if applicable, and the member to determine where the member’s needs can be most appropriately met. SPW members residing in an AFC home without an RN as the AFC home provider may receive up to 10 units of DAHS per week. For Level III AFC homes, see Section 7133.2, AFC Homes Corresponding to AFC Member Levels, for DAHS eligibility.

 

7120 Minimum Standards for All Adult Foster Care Homes and Home Providers

Revision 15-1; Effective September 1, 2015

 

All Adult Foster Care (AFC) homes and AFC home providers must be qualified initially and annually thereafter in accordance with the minimum standards outlined in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

 

7121 AFC Homes with Four or More Residents and Members

Revision 15-1; Effective September 1, 2015

 

An Adult Foster Care (AFC) home provider must obtain an Assisted Living (AL) license if the AFC home provider wants to serve four or more private pay residents and/or members. The AFC home provider may apply for an AL license from the Department of Aging and Disability Services (DADS) Regulatory Services division. The license must be renewed annually and requires an annual fee. Licensing standards for various types of AL facilities are found in 40 Texas Administrative Code (TAC), Chapter 92.

The AFC home provider must submit a copy of the AL license to the managed care organization (MCO) or MCO-contracted AFC provider agency before being credentialed and upon renewal. The AFC home provider must report to the MCO or MCO-contracted AFC provider agency any problem(s) identified by DADS Regulatory Services. AFC home providers must meet all applicable requirements in the minimum standards for AFC. AFC home providers with an AL license must serve no more than a total of eight adult residents in a small group home.

AFC homes of four or more residents, without a DADS contract, are also subject to the following two sets of regulations:

The stricter requirements apply when requirements of the two sets of regulations conflict. For example, an AFC home licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of members currently residing in the facility.

If the MCO uses a contracted AFC provider agency, the contracted AFC provider agency must provide copies of any licenses for AFC homes of four or more residents when the MCO requests them.

 

7122 Small Homes for One to Three Residents and Members

Revision 15-1; Effective September 1, 2015

 

An Adult Foster Care (AFC) home provider who serves up to three residents, including Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) members, may be a member's relative, excluding the spouse. While these small homes do not require licensure, AFC homes and AFC home providers must meet the standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers. As outlined in Section 7110, Introduction, if the AFC home provider moves into the AFC member's home, AFC home requirements in Appendix XXIV may be waived at the discretion of the managed care organization (MCO) or MCO-contracted AFC provider agency.

 

7123 MCO Responsibilities

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) responsibilities include:

An MCO may also choose to contract with an AFC provider agency to facilitate AFC home and home provider management on behalf of the MCO. When this occurs, the contracted AFC provider agency is responsible for provisions stipulated in its contract with the MCO. However, the MCO retains overall responsibility for all requirements related to AFC service delivery and oversight of the MCO-contracted AFC provider agency and the member.

 

7130 Adult Foster Care Eligibility

Revision 15-1; Effective September 1, 2015

 

To be eligible for Adult Foster Care (AFC), applicants and members must meet basic eligibility requirements for Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) services as well as specific requirements related to AFC. Basic eligibility requirements for HCBS SPW can be found in Section 3230, Financial Eligibility, and Section 3240, Waiver Requirements. AFC applicants or members are identified for HCBS SPW AFC based on their assessed needs for care. Refer to Section 7133, Classification Levels of Adult Foster Care Members.

 

7131 AFC Intake, Assessment and Response to Request for Services

Revision 15-1; Effective September 1, 2015

 

Adult Foster Care (AFC) is appropriate for individuals who, because of physical, mental or behavioral conditions, are unable to live independently and who need and desire the support and security of family living. AFC may be appropriate for individuals who are:

When discussing AFC as an option for applicants or members, the managed care organization (MCO) or MCO-contracted AFC provider must explain the room and board requirements and ensure the applicant or member understands that he or she must pay a portion of his or her monthly income for room and board. If the AFC home provider moves into the member’s home, payment for room and board does not apply. The MCO must also explain that some members residing in an AFC home are additionally required to contribute to the cost of their AFC services by paying a copayment, regardless of whether the AFC home is the member's home. Refer to Section 7152, Copayment and Room and Board Requirements, for additional information.

 

7132 Assessing Potential Adult Foster Care Homes

Revision 15-1; Effective September 1, 2015

 

If the applicant/member appears to meet eligibility criteria, the managed care organization (MCO) or MCO-contracted provider agency provides information to the applicant/member about Adult Foster Care (AFC) services, including potential AFC home providers and AFC homes. The MCO or MCO-contracted AFC provider agency can arrange visits to appropriate AFC homes or, if the applicant or member is capable or has family/supports available, the applicant/member and family may make the arrangements to visit potential AFC homes.

The purpose of the visits to potential AFC homes is to let the applicant/member assess the home and let the AFC home provider assess if the applicant/member will be an appropriate resident for the AFC home. The MCO or MCO-contracted AFC provider agency may contact the AFC home provider and share information about the applicant/member, including the applicant's/member’s particular needs and characteristics, to ensure the potential AFC home provider is fully aware of the responsibilities involved in caring for the applicant/member and to prevent a potential mismatch of the applicant/member and the AFC home provider.

As part of the assessment, MCO service coordinators must determine if the applicant/member can be left alone for up to three hours and document this on Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services. The MCO service coordinator must inform the AFC home provider directly of this or through the MCO-contracted AFC provider agency, if applicable. If the applicant/member cannot be left alone, the AFC home provider will be responsible for providing or arranging for 24-hour supervision.

To guide the applicant/member in the selection of the AFC home, the MCO or MCO-contracted AFC provider agency relies on the recommendation of the registered nurse completing the HCBS SPW assessment regarding the needs of the applicant/member. Refer to Section 7133 below. If the MCO is not contracting with an AFC provider agency, the MCO’s registered nurse must also assess the ability of the applicant/member to safely evacuate the AFC home.

 

7133 Classification Levels

Revision 15-1; Effective September 1, 2015

 

Classification (payment levels) for Adult Foster Care (AFC) members are used for identification of potential AFC applicant/member appropriateness, and are based on the member’s assessed needs for care as determined through the required face-to-face assessments for Home and Community-based Services STAR+PLUS Waiver services and the individual service plan completed by the managed care organization (MCO) service coordinator. Determine and document whether an applicant/member is appropriate for AFC based on the applicant’s/member’s condition and behavior. Develop a service plan appropriate to the applicant’s/member’s needs and specific to a given AFC home provider, taking into consideration the AFC home provider’s capabilities. The MCO-contracted AFC provider agency, if applicable, would be involved in a determination of AFC home provider capabilities.

 

7133.1 Levels of Adult Foster Care Members

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) will use the Medical Necessity and Level of Care (MN/LOC) assessment, Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums. The registered nurse service coordinator determines a member’s classification level for Adult Foster Care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) (transferring, walking, dressing, eating, toileting, bathing), and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member.

Below are the classification levels of a member’s daily assistance and/or supervision requirements.

Level I AFC Member

A member who needs assistance with identified needs including a minimum of:

Level II AFC Member

A member who needs assistance with identified needs including a minimum of:

Level III AFC Members

A member who needs assistance with identified needs including a minimum of:

 

7133.2 AFC Home Provider Corresponding to AFC Member Levels

Revision 15-1; Effective September 1, 2015

 

The Adult Foster Care (AFC) home provider must be able to meet the member’s needs in the AFC setting in conjunction with Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) and other available supports. If the member’s needs for care exceed the capability of the AFC home provider, the MCO service coordinator must reassess the member and offer alternate care options.

The AFC home provider who is a licensed registered nurse (RN) and the AFC home provider RN substitute must provide proof of current licensure to the MCO or contracted provider agency (if applicable) initially and annually thereafter.

The MCO RN service coordinator will complete the Medical Necessity and Level of Care (MN/LOC) assessment, both initially and annually. AFC home providers with HCBS SPW members may not care for more than one totally dependent AFC resident. The MCO RN service coordinator must respond to a request for a change in services within the individual service plan (ISP) year.

Health maintenance activities (HMAs) are tasks which may be exempt from registered nurse delegation based on the MCO RN assessment. HMAs may enable the member to remain in an independent living environment and go beyond activities of daily living (ADLs) because of the higher skill level required to perform them (as found in the Texas Board of Nursing rules in 22 Texas Administrative Code §225.4(8)).

For members residing in Level I, Level II and Level III AFC homes not operated by an RN, the skilled nursing needs must be:

For members residing in Level I, Level II and Level III AFC homes operated by an RN, the skilled nursing needs must be:

AFC members receiving nursing services and residing with an RN who is the AFC home provider are not eligible to receive DAHS.

 

7134 Adult Protective Services and Adult Foster Care

Revision 15-1; Effective September 1, 2015

 

This section provides details regarding when Adult Protective Services (APS) staff request Adult Foster Care (AFC) as a resource for individuals who may benefit from AFC.

 

7134.1 Placement of Adult Protective Services Clients in Adult Foster Care

Revision 15-1; Effective September 1, 2015

 

Adult Protective Services (APS) may want to move an Adult Foster Care (AFC) individual into an AFC home where a Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) member resides. The managed care organization (MCO) must approve and ensure the APS individual is appropriate and document this in the case record. This includes determining the:

If the MCO determines the APS individual's placement is not appropriate, the APS individual may not move into the AFC home and the APS worker must make other living arrangements.

 

7134.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 15-1; Effective September 1, 2015

 

Any time managed care organization (MCO) staff of an MCO-contracted Adult Foster Care (AFC) provider agency suspect abuse, neglect or exploitation (ANE) of an AFC member in an unlicensed AFC home, the staff must report it immediately to Adult Protective Services (APS). Reports of ANE in a licensed AFC home must be made to the Department of Aging and Disability Services (DADS) Regulatory Services Division. The MCO-contracted AFC provider agency must also notify the MCO.

If reports of ANE taking place in an unlicensed AFC home are made to APS by other parties, the MCO or MCO-contracted AFC provider agency staff may not be notified of member allegations against an AFC provider until after the allegations have been validated. However, APS staff may ask the MCO or MCO-contracted provider agency to assist with the delivery of alternative services during the course of the investigation if the alleged mistreatment poses an immediate threat to the safety of the member or other AFC residents.

The MCO handles disenrollment and corrective actions against the AFC home provider, as appropriate. DADS takes necessary licensure actions for licensed AFC homes. If DADS terminates the licensure of an AFC home and the MCO is unable to find a suitable alternative residence for the member, the member is referred to APS for assistance in moving from the AFC home.

A member in an unlicensed AFC home who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated. In this instance, the member's AFC services will be denied, payments to the home will terminate and an MCO-contracted provider agency will withdraw from supporting ongoing management of the home. However, the member may continue to reside in the unlicensed AFC home by making private pay arrangements at that home.

If a member residing in an unlicensed AFC home who does not appear to have the capacity to consent refuses to move from an unlicensed AFC home in which an individual identified as the perpetrator in a case of validated abuse, neglect or exploitation lives and is in a state of abuse, neglect or exploitation, the MCO must make a referral to APS. The MCO-contracted AFC provider agency staff must send a referral to the MCO and APS if the agency staff identify this situation.

If the substantiated allegation of abuse, neglect, or exploitation is in a licensed AFC home, the perpetrator must be removed from the AFC home and the license holder must submit to DADS a plan for the protection of the health and safety of all residents. The resident will not be required to move.

 

7135 Private Pay Individuals in Adult Foster Care

Revision 15-1; Effective September 1, 2015

 

Some Adult Foster Care (AFC) home providers may wish to take private pay individuals. The AFC home provider must contact the managed care organization (MCO) when considering the admission of a private pay individual before he or she is accepted in the AFC home. The purpose of the approval is to determine the:

If the MCO determines placement in an AFC home is inappropriate, the AFC home provider cannot accept the private pay individual. Any issues regarding placements must be resolved by the MCO.

 

7140 Adult Foster Care Managed Care Organization Procedures

Revision 15-1; Effective September 1, 2015

 

This section provides details for a managed care organization when determining an applicant's eligibility for Adult Foster Care and for developing the applicant’s individual service plan.

 

7141 Eligibility Determination

Revision 15-1; Effective September 1, 2015

 

To determine eligibility for Adult Foster Care (AFC), the managed care organization (MCO) must determine the applicant/member meets all criteria for the Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) and complete an assessment to determine the applicant’s/member’s classification level. If the AFC placement is with an individual AFC home provider contracted with the MCO, the MCO must also ensure the applicant/member has an agreement with an enrolled AFC home provider and the applicant/member and AFC home or home provider are appropriately matched per the classification and needs of the applicant/member before the MCO pays for AFC services. If an MCO contracts with an AFC provider agency to perform AFC management services, the MCO-contracted provider agency may perform activities related to the qualification of the home and the home provider before the MCO pays for AFC services. Refer to Section 7133, Classification Levels.

 

7142 Service Planning

Revision 15-1; Effective September 1, 2015

 

The member’s plan of care must address functional, medical, social and emotional needs and how the needs will be met by the Adult Foster Care (AFC) home provider. The managed care organization (MCO) must assess whether other resources in the community should be used to meet specialized needs of the member. Use of those resources must be documented in the member’s plan of care.

The MCO must complete Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, to document the specific personal assistance tasks with which the AFC home provider must assist the member. The AFC home provider may provide more services for the member than are identified on Form H2060 as the changing needs of the member may warrant, but may not reduce or discontinue services without consultation with the MCO or MCO-contracted AFC provider agency.

Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the AFC home. The MCO must document any special needs or interventions in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.

The MCO or MCO-contracted AFC provider agency contacts the member and the AFC home provider to arrange for the initial visit and a negotiated move-in date for the member or AFC home provider. If there are health concerns regarding the member, the MCO nurse may be consulted and a recommendation may be made for the member to have a physical/medical exam before moving into the AFC home.The MCO coordinates with the interdisciplinary team and the MCO-contracted AFC home provider, if applicable, regarding the AFC member’s care.

 

7150 Finalizing the Member’s Plan of Care

Revision 15-1; Effective September 1, 2015

 

On or before the date the member begins to receive Adult Foster Care (AFC) services, a face-to-face meeting with the member and the AFC home provider is required to discuss the member's plan of care and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team, including the staff of the managed care organization (MCO)-contracted AFC provider, as applicable, and the member's family/responsible person/guardian may be included in the meeting. The meeting should preferably take place in the AFC home.

The MCO must discuss the member's plan of care with the member and family/responsible party/guardian and reach understanding with them about how the AFC home provider will meet the member’s needs. This discussion should ensure the member and family/responsible party/guardian that the AFC home provider is adequately prepared to provide services to the member and that adjustments occur smoothly. The MCO must document the plan of care and any special needs of the member or special agreements between the member and AFC home provider on Form 2327.

If the applicant or member is already residing in the AFC home, Form 2327 must be completed by the MCO service coordinator face-to-face with the applicant or member and AFC home provider or provider agency, if applicable, before the MCO pays for AFC services initially and upon annual reassessment.

 

7151 Member and AFC Home Provider Agreement

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The MCO or the MCO-contracted Adult Foster Care (AFC) provider agency reviews all of the information on the agreement with the member, family/responsible party/guardian and the AFC home provider. All conditions of the agreement and the following topics must be covered in the discussion:

The MCO or MCO-contracted provider agency must fully discuss with the AFC home provider the potential for transition issues arising after the member moves into the AFC home or when the AFC home provider moves into the member’s home. The discussion should include notification procedures and suitable actions to be taken to address issues and resolve problems, and the impact of a new living situation on family and other residents in the home.

The member and the AFC home provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Form 2327 must be completed and signed before authorizing and reauthorizing AFC. Any significant changes to the terms of the agreement must be reported by the AFC home provider within five business days. Any incidents, as referenced in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, must be reported by the AFC home provider to the MCO service coordinator assigned to the member, and the MCO-contracted AFC provider agency, as applicable, within 24 hours of the occurrence.

 

7152 Copayment and Room and Board Requirements

Revision 15-1; Effective September 1, 2015

 

Copayment and room and board are applicable to Adult Foster Care (AFC) members as described in Section 3236, Copayment and Room and Board. If the AFC service is provided in the member’s own home, the member is not required to pay room and board. It is the managed care organization’s (MCO’s) responsibility to ensure the member and the MCO-contracted AFC provider agency, as applicable, are notified in writing on Form 2327, Individual/Member and Provider Agreement, when room and board is waived. It is the MCO-contracted AFC provider agency’s responsibility to notify to AFC home provider when room and board is waived. Copayment, if applicable to the member, may be waived.

If copayment is applicable, the AFC member's copayment amount is listed on Form H2065-D, Notification of Managed Care Program Services, which is sent to the member by the Program Support Unit and posted to TXMedCentral. Form H2065-D is used to report to the member the amount of his or her copayment for the first month of authorized service and subsequent months. The MCO furnishes a copy of Form H2065-D to the AFC home provider.

The room and board amount, as applicable, is entered on Form H2065-D and Form 2327. The member does not pay room and board if the AFC home provider moves in with the member into the member’s home. The MCO or MCO-contracted AFC provider agency must ensure the member and AFC home provider understand that the room and board arrangement with the AFC home provider is separate from the MCO payment for AFC services. The member pays the AFC home provider the room and board amount listed on Form 2327 and Form H2065-D. If the member is moving into the AFC home mid-month, the amount of room and board for the month is prorated and the member and AFC home provider will be advised of the prorated amount.

When the copayment and/or room and board amounts change, the MCO must notify the AFC home provider and the member of the new amount before the change, as described in Section 3239, Copayment Changes. The member must pay his/her copayment and room and board charge by the eighth day of the month. If the member does not pay the required fees, he/she may not be eligible for Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) AFC services.

The HCBS SPW AFC home provider must collect the copayment from the member. The AFC home provider must keep receipts for all copayments collected. The AFC home provider must deduct the copayment amount authorized on Form H2065-D from reimbursement claims submitted to the MCO or advise the MCO-contracted AFC provider agency of the amount collected. If an HCBS SPW AFC member does not pay his/her copayment and/or room and board, the MCO or MCO-contracted AFC provider agency must investigate the member's failure to pay, including contacting the member to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the member's income check has not been received by the eighth day of the month, the member is still under obligation to pay the fees. Grievances between the member and the AFC home provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of HHSC Health Plan Management and the MCO.

If the member refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO shall write a letter to the member or the member's responsible party explaining the consequences of continued refusal to pay. If the member does not pay his/her required fees within 30 calendar days of the due date, the MCO can terminate AFC services to the member. If HCBS SPW AFC is being delivered in the AFC home provider’s residence, the member can then be evicted from the home, according to local eviction ordinances and procedures.

 

7153 Trust Funds

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) must offer money management assistance by the Adult Foster Care (AFC) home provider to the member and document when the member either accepted or refused the assistance. If the member expresses an interest in money management, the MCO documents the expressed interest on Form H2067-MC, Managed Care Programs Communication, and sends the form to the AFC home provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The AFC home provider must maintain trust fund records. The AFC home provider must:

The following information must be included on the receipt for all money that is received or deposited in the member’s trust fund:

All records pertaining to the member's trust fund must be kept in the manner designated above, and available for monitoring without notice.

 

7154 Hospital Leave

Revision 15-1; Effective September 1, 2015

 

If a member is receiving Adult Foster Care (AFC) services in an AFC home which is not the member’s home, the member may be required to reserve his/her space during hospital stays by paying his/her daily bedhold charge, which is the negotiated daily rate the managed care organization (MCO) pays the AFC home provider or MCO-contracted provider agency. The AFC home provider does not bill the MCO for the days the Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) AFC member is hospitalized. The AFC member's bedhold charge constitutes the entire payment to the AFC home provider or MCO-contracted AFC provider agency when an AFC member is hospitalized.

During the initial home visit, the MCO or MCO-contracted AFC provider agency reviews the information regarding the AFC member's responsibility to pay a bedhold charge when away from the home and documents this on Form 2327, Individual/Member and Provider Agreement. Hospital leave does not apply when the AFC home provider moves into the member’s home.

 

7155 Authorization of Adult Foster Care

Revision 15-1; Effective September 1, 2015

 

After Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) eligibility is established and all additional Adult Foster Care (AFC) procedures are completed, the managed care organization (MCO) authorizes AFC on Form H1700-1, Individual Service Plan — SPW (Pg. 1). The Program Support Unit (PSU) sends the member Form H2065-D, Notification of Managed Care Program Services, and registers the Individual Service Plan (ISP) in the Service Authorization System.

The MCO sends the following completed documents to the AFC home provider and MCO-contracted AFC provider agency, if applicable:

 

7160 Monitoring Quality of Care

Revision 15-1; Effective September 1, 2015

 

The managed care organization (MCO) registered nurse (RN) service coordinator (SC) will monitor the quality of care and services provided to meet the needs of the Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) members receiving Adult Foster Care (AFC) services. The SC will appropriately address any issues identified to protect the health and safety of the member.

During regular monitoring visits, the MCO RN SC must contact the MCO management and MCO-contracted AFC provider agency, if applicable, if the AFC home provider is not meeting the member's needs or the home provider requires additional support or training to meet the member’s needs. The AFC member's physical and medical condition must be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness.

Form 2327, Individual/Member and Provider Agreement (see No. 1 under Miscellaneous Arrangements), is used to document special monitoring schedules and other resources used in the plan of care.When the AFC home provider moves in with the AFC member, it is the MCO's responsibility to ensure the AFC member's needs are being met, and there are no health and safety concerns. If concerns are reported or identified, the AFC member's rights must be protected and adjustments to the care plan made accordingly.

 

7170 Significant Changes

Revision 15-1; Effective September 1, 2015

 

It is the joint responsibility of the managed care organization (MCO) and the contracted Adult Foster Care (AFC) home provider, or MCO-contracted AFC provider agency, to ensure the AFC member is in an appropriate setting to meet his/her needs. When the AFC member has a change in functional need, medical status or behavior, it is the responsibility of the AFC home provider to notify the MCO or MCO-contracted AFC provider agency within 24 hours. The MCO must follow up with the member and AFC home provider to determine if changes to the care arrangement are needed.

The MCO must give particular attention to members who have significant changes in functional need, medical status or behaviors that may mean AFC services are no longer appropriate. Family members and/or the responsible party/guardian must be alerted to these changes, and the MCO service coordinator should discuss with them and the member the potential for the member to remain in the AFC home. If the member has had a decline in his/her medical condition or functional ability, the MCO RN service coordinator should determine if a visit should be made to assess the member’s medical status.

Long-range care plans must be discussed frankly with the member, responsible party/guardian, family members and the AFC home provider to ensure that all are aware of the capabilities and limitations of AFC services for members with deteriorating medical or functional conditions. Members who become inappropriate for AFC must be advised of other available options. Assistance must be provided to members and their family/responsible party/guardian in this decision process and with transfer activities when necessary. If the AFC home provider decides the member is no longer appropriate for AFC, the AFC home provider must contact the MCO. The MCO is responsible for preparing the member for transition when the member becomes inappropriate for a particular AFC home or AFC services.

 

7171 Termination of Adult Foster Care Services

Revision 15-1; Effective September 1, 2015

 

During the course of a member's stay in an Adult Foster Care (AFC) home, the member may experience changes in his/her condition or the care required. If the member begins to need services that cannot be provided by the AFC home provider, the managed care organization (MCO) must consult with the AFC home provider regarding increased needs of the member to assure the necessary care is obtained. Another provider, such as a home and community support services agency (HCSSA), may deliver skilled care in the AFC home.

If the skilled services provided in the home by the provider, such as an HCSSA, are not sufficient and other services are not available to support the member, the MCO, in conjunction with other members of the interdisciplinary team (IDT), should explore alternatives.

The AFC home provider is expected to take actions necessary if the member's condition deteriorates or the member is a threat to his/her own health and safety or the health and safety of others. The AFC home provider is required to notify the MCO and MCO-contracted AFC provider agency, as applicable, of actions taken on the same day of awareness. If necessary, the MCO must follow the procedures identified in Section 7172, Discharge and Termination Due to Health and Safety.

AFC home providers cannot reduce or terminate AFC services to members without the prior approval of the MCO and must follow procedures for providing a 30-day written notice, with an exception for a member whose behavior or condition threatens the health or safety of himself/herself or others. During the 30 days after written notice is provided to the member, the MCO is responsible for working with the member to assure alternative services are available.

Once a member is identified as inappropriate for AFC, the MCO must negotiate a time frame with the member, family/responsible party/guardian and the AFC home provider for the member to have an alternate service plan. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the member has been a threat to the health and safety of other(s) or has exhibited inappropriate behaviors where the member must move immediately, the MCO must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the member, the MCO must refer the member to Adult Protective Services (APS) to assist in locating appropriate placement.

If there is resistance to the move from the member, family/responsible party/guardian or the AFC home provider, additional support from the IDT may be required to resolve the problem. The MCO advises Program Support Unit (PSU) to send the member Form H2065-D, Notification of Managed Care Program Services, by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral to deny AFC services. The MCO follows up on this PSU action by advising the member and AFC home provider of the AFC services termination date specified on Form H2065-D. If the member transfers to another AFC home or Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW) living arrangement, the MCO must notify the member and AFC home provider of the change in services. If the member does not transfer to another AFC or HCBS SPW living arrangement and all HCBS SPW services are terminated, the MCO informs the PSU by posting Form H2067-MC to TxMedCentral. The PSU sends the member Form H2065-D and posts a copy of the form to TxMedCentral within three business days of posting Form H2067-MC. If services are not provided in the member’s home, the AFC home provider has the right to begin eviction proceedings as specified in the AFC home provider's resident rights and responsibilities. The MCO must ensure that the member and responsible party understand the consequences of eviction. If the AFC home provider must use eviction procedures and the member has refused to make other living arrangements, the MCO must refer the member to APS.

If the member and AFC home provider decide that the member will remain in the home as a private pay member, the MCO must give approval. The MCO must also ensure the member and AFC home provider understand that there are no case management services or payment arrangements from the MCO for a private pay member.

Refer to Section 7172 below for more details on how to handle situations in which the AFC member threatens the health and/or safety of himself/herself or others in the AFC home.

 

7172 Discharge and Termination Due to Health and Safety

Revision 15-1; Effective September 1, 2015

 

Any member residing in the AFC home provider’s residence, whose medical condition or behavior threatens the health and/or safety of himself/herself or others, is subject to discharge without notice from the Adult Foster Care (AFC) home.

The AFC home provider must take appropriate action if the member's medical condition deteriorates and he/she requires more skilled intervention to ensure his/her health and safety. Depending on the member's condition, appropriate action could include calling emergency medical services, the member's physician or the managed care organization (MCO) service coordinator working with the member or MCO-contracted AFC provider agency, as applicable. The AFC home provider must take action and must inform the MCO on the same day the AFC home provider becomes aware of the need to respond to a change in the member's medical condition.

The MCO must work with the AFC home provider or with providers of other services to arrange alternate services to meet the member's needs.

When the member's behavior causes the member to threaten the health and safety of himself/herself or others, the AFC home provider must take appropriate action which could include calling the police or sheriff's department, the member's physician, the MCO service coordinator or MCO-contracted AFC provider agency, as applicable. The member must be removed from the AFC home as soon as possible if he/she becomes a threat to the health or safety of himself/herself or others. In some instances, the MCO may call Adult Protective Services (APS) if hospitalization for psychiatric observation seems warranted.

The MCO must issue an Adverse Determination letter to the member within three days of receiving information regarding an incident which warranted the involuntary removal of the member from the AFC home. The effective date on the Adverse Determination letter is the date the form is dated and mailed/given to the member, even if the decision is appealed. Though the member may not be denied all services through Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW), the member has a right to appeal the decision of removal from the AFC home.

The member may not remain in the HCBS SPW AFC home during the appeal process. The MCO must work with APS or providers of other HCBS SPW services to arrange alternate placement for the member.

In circumstances in which the AFC home provider has moved in with the AFC member into the member’s home, the AFC member has the right to request termination of the arrangement at any time by contacting the MCO or MCO-contracted AFC provider, and request assistance with eviction of the AFC home provider. The MCO must ensure other HCBS service options are offered should the AFC arrangement terminate.

 

7180 Annual Reassessment of the AFC Member

Revision 15-1; Effective September 1, 2015

 

In addition to the regular reassessment for Home and Community-based Services (HCBS) STAR+PLUS Waiver (SPW), which includes the managed care organization (MCO) registered nurse service coordinator completing the Medical Necessity and Level of Care, Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums, and the individual service planning documents, the MCO or MCO-contracted AFC provider agency must also continue to meet all eligibility requirements and complete Form 2327, Individual/Member and Provider Agreement.

 

7200 Assisted Living Services

Revision 12-3; Effective October 1, 2012

 

 

7210 Introduction

Revision 12-3; Effective October 1, 2012

 

This section applies to the HCBS STAR+PLUS Waiver (SPW) program. Assisted Living (AL) services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Department of Aging and Disability Services (DADS). SPW participants are responsible for their room and board costs and, if applicable, copayment for AL.

The purpose of AL services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision making ability of the participant. The personal care facility must provide each participant a separate living unit to guarantee their privacy, dignity and independence.

 

 

7211 Housing Options in Licensed Personal Care Facilities

Revision 12-3; Effective October 1, 2012

The Assisted Living (AL) apartment may be an efficiency or one or two bedroom apartment, and each apartment must have a private bath and cooking facilities. An AL non-apartment setting is defined as a Licensed Personal Care facility which has living units that do not meet the definition of an AL apartment, may be double occupancy, and must be:

HCBS STAR+PLUS Waiver (SPW) AL contracts specify whether the facility has contracted to provide services under the housing options of AL or AL Non-Apartment. The provider may not deliver SPW services in a housing option for which he/she does not have a contract to deliver services. If a provider wishes to maintain both AL (single occupancy) and AL apartments (double occupancy) in one facility, his/her contract must specify that information.

If the AL provider wishes to limit the types of apartments in the facility available to SPW participants, the provider must specify these limitations in their contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications as specified in this section. If there are no such specifications in the contract, all types of apartments in the facility must be available to SPW participants.

If the provider limits the type of apartment available for SPW members and there is no apartment of that size available, they can refuse to accept any SPW member, based on not having space available. This would apply both for a member wanting to move into the facility from the outside, or to a private pay member currently in the facility who is becoming an SPW member. The member would then have the option of reviewing other available AL facilities in the area or Adult Foster Care homes.

"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At minimum, a covered walkway between buildings is required for physical connection.

At the member's request, portable kitchen units may be removed from the living area.

 

7211.1 Single Occupancy Apartments

Revision 11-3; Effective September 1, 2011

An Assisted Living apartment setting is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom and adequate storage space, as specified in the following:

 

7211.2 Double Occupancy Apartments

Revision 11-3; Effective September 1, 2011

 

An Assisted Living apartment must be a double occupancy apartment with a connected bedroom, kitchen and bathroom area that provides a minimum of 350 square feet of space per participant, and meet the following specifications:

 

7220 Description of Services

Revision 11-3; Effective September 1, 2011

 

The Assisted Living (AL) facility must provide 24-hour care in a personal care facility licensed by the Department of Aging and Disability Services. Services include, but are not limited to:

Personal care tasks must be provided, as identified in Section III, Form 3050, Day Activity and Health Services Health Assessment/Individual Service Plan. A registered nurse must perform the medication administration assessment part of Form 3050.

The AL provider is responsible through its licensure requirements for providing the administration of medications, which is the direct administration of all medications, or the assistance with or supervision of medication. This includes injections, if needed. Only a licensed nurse can give injections. The personal care facility may provide more services for the member than are identified on Form 3050, but not fewer services.

 

7221 Requirements Related to Assisted Living

Revision 11-3; Effective September 1, 2011

STAR+PLUS Waiver (SPW) members who wish to reside in a personal care facility must reside in a licensed Assisted Living (AL) facility which is contracted with the managed care organization (MCO) to provide SPW services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services to four or more persons who are unrelated to the owner. The member is required to pay room and board, and possibly a copayment based on income in the AL setting. See Section 3230, Financial Eligibility, for detailed information.

 

7222 Initial Responsibilities for Members Residing in AL Facilities

Revision 14-1; Effective March 3, 2014

 

The managed care organization (MCO) is responsible for helping the applicant or member select an Assisted Living (AL) facility that can meet his/her needs. The MCO sends an authorization to the AL facility that the member selects.

The AL facility must explain the copayment requirement and room and board charges, described in Section 3236, Copayment and Room and Board, and Appendix VI, STAR+PLUS Inquiries Chart, to the applicant/member. Room and board must be paid by every STAR+PLUS Waiver (SPW) AL member. A copayment is not required of Supplemental Security Income recipients. A copayment is required from those AL members whose financial eligibility was determined under the special institutional criteria. The MCO must:

As described Section 3236, the PSU may have to estimate the initial and ongoing copayment amounts for the initial ISP development. If the Medicaid for the Elderly and People with Disabilities (MEPD) specialist is unable to provide an estimate on the amount available for copayment prior to the Medicaid eligibility determination, the PSU estimates the copayments based on the applicant's self-reported income from Form H1200, Application for Assistance – Your Texas Benefits. The estimated copayments are necessary in order to compute an ISP for AL residents. When the accurate amount available for copayment is received from the MEPD specialist, PSU recalculates the copayment amounts. The MCO must explain to the member that failure to pay his/her room and board charges or copayment will result in termination of his/her SPW services.

 

7223 Admission to Facility

Revision 15-1; Effective September 1, 2015

 

Before admission, the managed care organization faxes or mails to the Assisted Living (AL) facility:

The STAR+PLUS Waiver (SPW) AL provider is expected to provide to the new member a tour of the facility, including staff and resident introductions. Members are encouraged to bring basic furnishings for bedroom areas with them.

In the event the member does not provide his own furnishings, the facility must provide for each member:

Furnishings provided by the facility must be maintained in good repair.

 

7224 Personal Care 3

Revision 13-1; Effective March 1, 2013

 

STAR+PLUS Waiver (SPW) applicants/members with heavy personal care needs who choose to reside in Assisted Living (AL) non-apartment settings may be approved for Personal Care 3 level services. Classification of an SPW applicant/member at the Personal Care 3 level is based on the applicant's/member's assessed needs, as evidenced by a value of two or greater in one or more of the activities of daily living of transferring, eating or toileting, as assessed on the Medical Necessity and Level of Care (MN/LOC) Assessment, Section G, Physical Functioning and Structural Problems, Column A, Self Performance.

During the initial pre-enrollment assessment and annual reassessment, the managed care organization (MCO) nurse completes the MN/LOC Assessment and uses the information recorded for transferring, eating or toileting to make a recommendation regarding the applicant's/member's need for the Personal Care 3 level. The recommendation is recorded on Form H1700-1, Individual Service Plan — SPW (Pg. 1).

At the initial certification and each annual reassessment, the MCO must check Form H1700-1 to determine if the applicant/member who chooses to reside in an AL non-apartment setting is identified as meeting the Personal Care 3 level. If the provider nurse does not provide a recommendation for Personal Care 3 level, the MCO must contact the nurse to obtain a Personal Care 3 level. The MCO documents the nurse's recommendation in the case record. The MCO must inform the applicant/member that he/she meets the Personal Care 3 level, and ensure the applicant/member is aware of all facilities contracted to provide care at the Personal Care 3 level by presenting a choice list of AL facilities that specifically identifies the Personal Care 3 facilities. The MCO authorizes the Personal Care 3 reimbursement rate if the applicant/member meets the Personal Care 3 level and chooses to reside in a contracted Personal Care 3 facility.

Changes may occur in an SPW member's health during the individual service plan year that may cause the member to require a greater level of care in an AL facility, or move to an AL setting from a community setting. The MCO must review the most current MN/LOC Assessment to determine the provider nurse's recommendation regarding the member's Personal Care 3 level and ensure the member is presented with a choice of AL facilities that are contracted at the Personal Care 3 level to provide a higher level of care.

Designation of an AL facility as a Personal Care 3 facility is determined in the contracting process. To qualify as a Personal Care 3 facility, the AL facility must meet the following requirements:

 

7230 Other Services Available to Members

Revision 12-3; Effective October 1, 2012

 

Each of the following services are provided according to the needs of the member, as authorized on the individual service plan (ISP), as a STAR+PLUS Waiver (SPW) service and not included in the Assisted Living (AL) daily rate. The managed care organization (MCO) makes referrals for the services and coordinates delivery.

Adaptive Aids and Medical Supplies — The SPW AL member is eligible to receive needed adaptive aids and medical supplies under SPW. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live. See Section 6410, List of Adaptive Aids and Medical Supplies, for a list of adaptive aids and supplies that can be purchased through SPW.

Minor Home Modifications — Services that assess the need, arrange for and provide modifications, and/or improvements to an individual's residence to enable the individual to reside in the community and ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the ISP and apply to Type A facilities only. (See Texas Administrative Code §92.3, Types of Assisted Living Facilities.)

Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. Occupational therapy services consist of the full range of activities provided by a licensed occupational therapist or a licensed occupational therapy assistant, if under the direction of a licensed occupational therapist, within the scope of state licensure.

Physical Therapy — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Physical therapy services consist of the full range of activities provided by a licensed physical therapist or a licensed physical therapy assistant, under the direction of a licensed physical therapist and within the scope of state licensure.

Hearing and Language Therapy — The evaluation and treatment of impairments, disorders or deficiencies related to a member's speech and language. Services include the full range of activities provided by licensed speech and language pathologists under the scope of the pathologist's state licensure.

Nursing Services — Services provided by a licensed registered nurse or licensed vocational nurse within the scope of state licensure. Nursing services can be brought into the personal care facility for the member. If the projected cost of the member's services exceeds the annual cost limit, the MCO meets with the member to discuss the options for care, such as other living arrangements in Adult Foster Care or Title XIX Day Activity and Health Services. The member's choice for service delivery is given first priority as long as the cost for the service does not exceed the annual cost limit. STAR+PLUS services are also explored by the MCO for the delivery of all waiver services.

The use of self-administered oxygen is allowed in an SPW AL facility. Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.

 

7240 Room and Board and Copayment Requirements

Revision 11-3; Effective September 1, 2011

 

The member must pay the required fees to be eligible for Assisted Living (AL) services. Refusal to pay the required fees can result in termination of services.

The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied. The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first business day thereafter.

 

7241 Room and Board Requirements

Revision 11-3; Effective September 1, 2011

 

All members must pay the room and board charges to be eligible for Assisted Living (AL). Room and board cannot be waived, but an AL facility may choose to accept an individual for a lower amount. STAR+PLUS Waiver (SPW) policy does not direct the facility to accept or reject the individual. The room and board charge is based on the Supplemental Security Income federal benefit rate (FBR), minus a personal needs allowance of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on January 1. The room and board charge is adjusted accordingly based on that change. For the initial month of entry, the monthly rate is divided by the number of days in that month, then multiplied by the number of days the member is in the facility. See Appendix VI, Calculation of Copayment and Room and Board for SPW Members, for calculations. The member must be notified of the initial amount of room and board to pay and the ongoing amount of room and board to pay.

 

7241.1 Copayment Requirements

Revision 14-1; Effective March 3, 2014

 

The amount of copayment the member is required to pay is determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff through use of the MEPD copayment worksheet. The MEPD specialist makes the determination of the amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.

The Program Support Unit specialist sends Form H2065-D, Notification of Managed Care Program Services, to the member. Once received, the MCO sends a copy to the assisted living facility, detailing the first month's copayment amount and the subsequent months' amounts.

 

7242 Personal Leave

Revision 11-3; Effective September 1, 2011

 

The member is entitled to 14 days of personal leave from the facility each calendar year. The member is responsible for the room and board charge and copayment for personal leave days.

A day of personal leave is defined as 24 continuous hours. STAR+PLUS Waiver assisted living members must sign out when leaving the facility and sign in upon returning. The sign-in log must have at minimum the following information:

 

7243 Nursing Services for AL Members

Revision 11-3; Effective September 1, 2011

If a member is residing in an Assisted Living (AL) setting, all of the administration of his/her medications, including injections, are provided by the nurse. It is possible that a member residing in an AL setting does not need any nursing tasks that are to be delivered by STAR+PLUS Waiver. Examples of when this may occur include when the member's only nursing need is for medication administration that is provided by the nurse or when the member is receiving nursing services through Medicare.

 

7244 Response to AL Member Condition Change

Revision 11-3; Effective September 1, 2011

 

If the member experiences a change in health or conditions related to the amount and type of care he/she requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member/legal representative may explore other means to serve the member adequately in his/her current setting. The use of Day Activity and Health Services for daily nursing tasks or the direct provision of nursing by provider nurses may be explored as alternatives that would avoid disrupting the member's living arrangement. Nursing tasks cannot be delegated in Assisted Living (AL) settings.

If a member exhibits behavior that threatens the health or safety of himself or others, or his needs exceed the licensed capacity of the facility, the AL provider must take appropriate action and notify the MCO verbally by the next business day. The provider must confirm his verbal report in writing within seven calendar days. The MCO must take appropriate actions based on the verbal notification to assess the member's continued eligibility for STAR+PLUS Waiver (SPW). See Section 7251, Facility Reporting and Notification Requirements.

If an SPW member living in an AL apartment becomes a safety hazard to himself or others due to his operation of the stove or cooking unit in the apartment, the AL provider can disconnect the unit and must notify the MCO by the next business day. The MCO must investigate the situation and document any recent or previous incident which indicates a threat to the health or safety of the member or others. The MCO, in cooperation with the IDT, the AL provider, and the member's family or responsible party, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The decision is documented on Form H2067-MC, Managed Care Programs Communication, which is sent to the AL provider within three business days of the IDT meeting.

 

7245 Hospital and Nursing Facility Stays

Revision 11-3; Effective September 1, 2011

 

Hospital Stays

To reserve his space during hospital stays, the member must pay his daily room and board charge.

The facility's bedhold charge or the negotiated bedhold charge for reserving a member's space during hospital stays may not exceed the maximum amount established by the managed care organization (MCO).

The facility does not bill the MCO for days the member is hospitalized. The member's room and board charge, used as a bedhold charge, constitutes the entire payment to the facility when a member is hospitalized.

The facility must notify the MCO via Form H2067-MC, Managed Care Programs Communication, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every calendar month up to four calendar months to determine if the stay will become permanent. If the member stays in the hospital longer than four calendar months, the member is systemically disenrolled.

A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.

Nursing Facility Stays

For issues related to nursing facility payment see the Medicaid for the Elderly and People with Disabilities Handbook, Section H-1700, Deduction for Home Maintenance.

The MCO must follow the Uniform Managed Care Contract, Attachment B.1, Section 8.3.2.6, Nursing Facilities, related to nursing facility stays.

 

7246 Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 14-1; Effective March 3, 2014

 

If the member or the member's representative fails to pay the entire copayment and room and board by the facility's due date, the facility must notify the member or the member's representative and the managed care organization (MCO) in writing that payment was not received. The facility must make an oral notification no later than the first business day after the due date. The facility follows up in writing within five calendar days of when the member or the member's representative fails to pay the required payments.

Upon receipt of the written notice, the MCO:

After the IDT meeting, the MCO:

If the situation cannot be resolved and the member refuses to pay for any reason, within three business days of the MCO's notification, the PSU:

If the member does not appeal:

If the member does appeal by the effective date of the action on Form H2065-D, PSU notifies the MCO, MEPD and Health Plan Operations. The member may receive other services, but remains ineligible for AL until all outstanding payments are made.

 

7250 Standards for Operation

Revision 14-1; Effective March 3, 2014

 

Assisted Living (AL) facilities must:

The only reason a STAR+PLUS Waiver (SPW) AL provider could refuse to accept a referral is if the member's condition makes the member inappropriate for the facility according to the facility's personal care licensure.

Having a communicable disease does not necessarily make a member inappropriate for placement in an AL setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have Infection Control Policy and Procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases, and contagious conditions. If transmission of the condition or disease cannot be controlled, the member cannot be placed in an SPW AL setting.

To receive AL services under SPW, the applicant must first be determined eligible for SPW. The Program Support Unit (PSU) coordinates with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, where applicable, to complete the Medicaid eligibility determination.

The MCO discusses residential options with the member, allowing him/her to choose his/her preference. If AL is chosen, a verbal referral is made to the provider as an alert that space is needed. The starting date for services is a negotiated date between the MCO, the member and the AL provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan — SPW (Pg. 1), and applicable attachments are sent as follow-up, along with a copy of Form H2065-D, Notification of Managed Care Program Services, which authorizes the provider to deliver SPW services, and Form H2067-MC, Managed Care Programs Communication, confirming the negotiated service initiation date.

In addition, AL facilities must:

Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of others or himself/herself. If a stove or cooking unit needs to be disconnected, the service coordinator, in cooperation with the IDT, makes this decision. The IDT must also include the MCO, the AL provider and the member's family or responsible party, if any.

The AL provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of others or himself. He must inform the service coordinator of the disconnection by the next business day after it occurs. The MCO investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the member or others. If the decision is made to approve a disconnection, the service coordinator documents it on Form H2067-MC that is sent to the AL provider within three calendar days.

Note: The facility must make oral notification no later than the first business day after the due date. Within five business days of the MCO receiving notification from the provider that the member has failed to pay the copayment or room and board, the MCO posts Form H2067-MC to TxMedCentral in the XXXSPW folder using the appropriate naming convention. Form H2067-MC serves as notification to PSU of the member's failure to pay the copayment or room and board. Within three business days, PSU must send the member Form H2065-D stating services will be terminated if the member fails to pay his copayment/room and board within 30 calendar days of the date on Form H2065-D.

If an SPW member does not pay his copayment and/or room and board within 30 calendar days of the date on Form H2065-D, the MCO contacts the member to learn the reason the fees were not paid. Even if there is a legitimate reason (such as the member's income check has not been received by the 10th day of the month) for the non-payment of the required fees, the member is still under obligation to pay the fees.

If the member simply refuses to pay the fees, or there is no legitimate reason for his/her failing to pay, the MCO writes a letter to the member, with copies to the facility manager and to the member's responsible party, if applicable, explaining the possible consequences of continued refusal to pay.

The MCO is responsible for working with the member during this time period to assure alternative services will be available. If the member refuses to leave the facility when his/her services are terminated, the facility must follow its written eviction procedures.

Examples of charges not paid by the MCO could be the destruction of facility property or any additional charges, such as pet deposits. Items not required to be provided by the AL provider through the AL facility licensing standards (for example, returned check fees, service deposits) may be charged to the member if listed in the admission agreement. The MCO may contact Regional Regulatory Services regarding any questionable items charged to the member.

 

7251 Facility Reporting and Notification Requirements

Revision 11-3; Effective September 1, 2011

 

The facility must verbally report to the managed care organization (MCO) the following occurrences pertinent to member services by the next business day after they occur. These occurrences must be followed up in writing within five business days after they occur and may lead to MCO intervention and/or termination of services, including but not limited to:

If a member exhibits behavior that threatens the health or safety of others or himself, or his needs exceed the licensed capability of the facility, the provider's written notice must explain the situation and the reasons the member is no longer appropriate for the services. With the concurrence of the MCO, discharge can be as soon as practical when:

 

7252 Member Documentation

Revision 11-3; Effective September 1, 2011

 

The facility must maintain records for each member that include at least the following information:

 

7260 Staffing and Training Requirements

Revision 11-3; Effective September 1, 2011

 

The facility must provide all staff with training in the fire, disaster and evacuation procedures within three business days of employment. The training must be documented in the facility records.

 

7270 Copayment and Trust Fund Records

Revision 11-3; Effective September 1, 2011

 

 

7271 Copayment

Revision 11-3; Effective September 1, 2011

 

The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form H2065-D, Notification of Managed Care Program Services.

The facility must maintain a current member copayment ledger system that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances; it must be maintained in accordance with generally accepted accounting principles. If a member copayment is paid from a trust fund, the facility still must prepare a receipt.

The ledger must also reflect room and board charges and payments, and the member must be given a receipt for the room and board payments.

 

7272 Trust Fund Records/Written Receipts

Revision 11-3; Effective September 1, 2011

 

The facility must maintain trust fund records based on recognized fiscal and accounting principles, and have written permission from the member to handle his/her personal financial affairs.

Members must be informed that:

If the member is unable to sign or initial the transaction, or if he/she signs his/her name with a mark (x), the transaction must be signed by a witness. The facility must:

The facility may choose one of the following options:

Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his/her trust fund, the transaction or receipt must be signed by a witness or signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his/her name, a witness must sign the transaction or receipt.

If the facility earns interest on any pooled interest account, the interest earned must be prorated to each member's account. Deposit entries should be documented as "interest" in the member's ledger. All transactions must be posted by the middle of the following month. The facility may:

If the facility maintains a trust fund, the facility staff must:

Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account. If the member writes a check to be deposited into his/her trust fund account and there are insufficient funds to cover the check, the facility can charge the member only the actual insufficient funds fee charged by the bank.

There is no requirement that the deposit into the trust fund be made on the same date the money is received. However, the facility must ensure that the deposit slip/bank statement reflects the same amount recorded on the receipt.

 

7273 Records and Receipts

Revision 11-3; Effective September 1, 2011

 

The facility must ensure that records include written receipts for all purchases made by or for members. A receipt is a written or computer-generated, signed record of payment prepared at the time of payment. If the payment is in person, the written or computer-generated receipt must be signed and contemporaneous with the payment. If the payment is by mail, a statement at the end of the month satisfies the requirement for a written receipt and a bill for the next month. If a single receipt is written for different items, the receipt must clearly describe what the receipt covers.

The record or receipt must include the:

The facility is required to have both a trust fund ledger and a copayment ledger. A current member copayment ledger system must be maintained that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances, and be maintained in accordance with generally accepted accounting principles.

The facility must maintain both receipts for monies received from members and bank deposit slips showing the money deposited. These amounts must correspond to amounts recorded in the individual member's trust fund ledger. This system must be maintained in accordance with generally accepted accounting principles.

Vendor withdrawal records must be maintained, regardless of how facility staff account for trust fund transactions (withdrawals on a ledger, cash envelope or individual checkbook register). They must retain receipts for any payment out of a trust fund account that is more than $1.00. The receipt, cash register tape or sales statement is documentation of who actually received the money that was withdrawn from the trust fund account, and that the money was spent as authorized. Any unused money returned to the trust fund custodian must be redeposited to the member's trust fund account and appropriately documented. The prerequisites that allow withdrawal from the member's trust fund are:

 

7274 Vendor Receipts

Revision 11-3; Effective September 1, 2011

 

The following information must be included on all trust fund vendor receipts (other than long-term payments):

 

7275 Group Purchases

Revision 11-3; Effective September 1, 2011

 

Often, a single purchase is made for goods to be distributed among specific members (for example, cigarettes). In such a case, the invoice or receipt should show the:

Group purchases are only allowable if they can be traced to the individual member.

 

7276 Payment of Copayment and Room and Board from Trust Fund

Revision 11-3; Effective September 1, 2011

 

It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the copayment and room and board from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the copayment and room and board is paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.

Long-term Payments

For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on his/her behalf. Examples of long-term payments include insurance premiums, church tithe and cable TV. If the facility:

Daily Withdrawals for Minor Purchases or Petty Cash Withdrawals

Members usually require small amounts of money to meet their daily needs for items such as soft drinks, snacks, etc. It is often difficult to keep supporting documents for all such minor purchases.

The member's signature or authorization for a cash withdrawal must be on the individual member ledger, the cash envelope or on a receipt.

Bulk Purchases

Bulk purchase of the same items may be made by the facility. In this case, the member's signature and the amount of the purchase must be on the individual member ledger or a receipt.

 

7277 Member Authorization

Revision 11-3; Effective September 1, 2011

 

If the member is unable to sign or initial the transaction, or if he/she signs his/her name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than the:

 

7278 Refunds to Discharged or Deceased Members

Revision 11-3; Effective September 1, 2011

 

The facility must refund the full balance of the member's monies deposited in his/her trust fund account within five days after the member is discharged. If the member dies, there should be no payment from his/her trust fund account other than the refund to the responsible party. No funds may be dispensed to reimburse the facility for damages caused by the member to an Assisted Living apartment. If there is a responsible party, the facility may request voluntary reimbursement prior to the refund, but the responsible party is not obligated to agree.

Maintenance to the facility is included in the cost report as an allowance expense.

The two types of refunds are listed below:

Check — If the refund was made by check, the cancelled check or a copy of the receipt must be signed by the member or responsible party.

Cash — If the refund was made by cash, the receipt must be signed by the member or responsible party.

 

7300 Respite Care

Revision 12-3; Effective October 1, 2012

 

Respite Services in the HCBS STAR+PLUS Waiver (SPW) are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for an SPW member unable to care for himself/herself.

 

7310 Service Coordination Duties Related to Respite Care

Revision 13-1; Effective March 1, 2013

 

To be eligible for Respite Services, the member must live in his/her own home or with relatives or other individuals. The member may not live in an Adult Foster Care (AFC) or Assisted Living (AL) setting.

The respite provider must not be a primary caregiver, whether or not he/she is related to the member, and must not live with the HCBS STAR+PLUS Waiver (SPW) member for whom respite is needed. If the member's caregiver is the paid attendant who also provides uncompensated care, in-home respite may be provided only during those hours the caregiver would be providing uncompensated care to the member. If the caregiver is the paid attendant and will be absent during hours for which he/she is normally paid, it is the provider's obligation to provide a substitute attendant during this period.

Respite Services is intended to relieve the caregiver during emergency or planned short-term periods. Respite must be authorized on the individual service plan (ISP) before it can be delivered. The respite rate for out-of-home settings includes payment for room and board. There are no member copayment or room and board charges for respite in out-of-home settings.

The service coordinator is responsible for documenting the Respite Care Services needed by the member. For example, a member needs respite every Friday afternoon so the caregiver can attend class, or a member's caregiver has three four-day trips planned during the ISP year, or a caregiver has a history of emergency hospitalizations. Documentation must also support that the member meets the eligibility criteria for respite. The service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested/authorized. Respite cannot be authorized retroactively. For SPW members who have an emergency need for respite and respite is not authorized on the ISP, the provider must contact the managed care organization (MCO) for authorization prior to delivery of Respite Services.

The member must be given the opportunity to choose from the contracted providers that are appropriate considering his/her needs and the licensed capabilities of the provider. In-home respite is provided by licensed providers contracting with the MCO and/or a Home and Community Support Services Agency (HCSSA) that is contracted with the MCO to provide services. Out-of-home respite is provided by licensed nursing facilities, licensed personal care facilities and licensed AFC homes.

The provider who delivers in-home respite is responsible for providing the personal assistance services authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite and the attendant providing the personal care is not the same attendant to whom the nursing tasks were delegated, the nurse may directly provide the nursing care. It is necessary for the MCO to modify the ISP to include the increased direct nursing based on information provided by the provider. Other services (for example, physical therapy or minor home modifications) may continue to be delivered at the same time as the in-home respite.

Respite Services can be authorized as often as needed for caregiver relief or emergency absences of the caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. Respite must be authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1), in daily units. For example, if two hours of respite are to be used per week, the ISP authorization is for five units. The calculation is two hours per week times 52 weeks = 104 hours divided by 24 hours = 4.33 units, rounded to next higher unit, or 5. The annual limit on Respite Services is 30 days, equivalent to 720 hours (30 days times 24 hours per day), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of SPW services, must keep track of the units a member has used. The provider may use Form H2067-MC, Managed Care Programs Communication, to notify the MCO of the dates and duration of Respite Services delivered so the MCO can track the number of respite days used.

 

7311 Requesting MCO Approval to Exceed the Respite Service Cap

Revision 11-2; Effective June 1, 2011

 

To request approval to exceed the annual individual service plan (ISP) 30-day limit on Respite Services, the provider must send a written request to the managed care organization (MCO) documenting the:

The provider includes his/her telephone number and address in the written request. The MCO provides written approval or disapproval of the request.

In reviewing requests to exceed the respite limit, the MCO must consider the intent of Respite Services to relieve the caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:

 

7320 In-Home Respite Care

Revision 13-1; Effective March 1, 2013

 

In-home respite care offers services provided by managed care organization (MCO) contracted providers, on a short-term basis, to members unable to care for themselves because of the absence or need of relief for their unpaid caregiver.

In-home respite care is provided in the member's own home, as authorized on the member's Form H1700-1, Individual Service Plan — SPW (Pg. 1), when the unpaid caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, during the time he/she is receiving in-home respite care.

The provider must document in the member's clinical record:

In-home Respite Care helps prevent member and/or family support breakdown and the consequent institutionalization, which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.

The in-home Respite Services provider must deliver the personal assistance services. The MCO may allow the in-home Respite Services provider's registered nurse the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home Respite Services provider.

In-home respite is not intended to be used when the caregiver needs to be out of the house for short periods of time (for example, to go to the pharmacy or grocery store to pick up medications or grocery items). The caregiver should be encouraged to be out of the house for brief respite when the attendant is providing the personal assistance services.

 

7330 Out-of-Home Respite Services

Revision 11-2; Effective June 1, 2011

 

Out-of-home Respite Services provide a 24-hour living arrangement in an Adult Foster Care (AFC) home, a licensed personal care facility or a licensed nursing facility for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living, supervision, and the provision or arrangement of transportation.

Nursing tasks may be directly provided by licensed nurses in out-of-home Respite Services or may be delegated as determined by the professional judgment of the provider's registered nurse, unless facility licensure prohibits delegation.

 

7331 Member Eligibility

Revision 12-3; Effective October 1, 2012

 

The Respite Services applicant or member must:

The applicant for HCBS STAR+PLUS Waiver (SPW) Respite Services must complete the same eligibility determination process as other SPW applicants.

 

7332 Provider Qualifications

Revision 12-3; Effective October 1, 2012

 

Out-of-home Respite Services providers must be a:

In order to deliver HCBS STAR+PLUS Waiver (SPW) out-of-home Respite Services, the provider must complete and sign a contract with the managed care organization (MCO). The contract must be signed by both the provider and MCO prior to the provider serving members.

 

7333 Description of Services

Revision 12-3; Effective October 1, 2012

 

The HCBS STAR+PLUS Waiver (SPW) member may receive out-of-home Respite Services in a nursing facility, a personal care facility or a Department of Aging and Disability Services licensed Adult Foster Care home, with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The SPW member may take any adaptive aids he/she is using to the out-of-home respite setting.

The managed care organization provides the out-of-home respite provider with the ISP attachments pertinent to the services the member will receive while in the facility/home. The provider must deliver services as identified on the member's ISP attachments.

 

7334 Respite Services in a Personal Care Facility or AFC Home

Revision 12-3; Effective October 1, 2012

 

The HCBS STAR+PLUS Waiver (SPW) member receiving Respite Services in a personal care facility or Adult Foster Care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite setting. The member's need for any service must be authorized on his/her individual service plan before he/she receives the service.

The SPW member receiving Respite Services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.

Nursing services provided in a Level I or Level II AFC home may be delegated, according to the professional judgment of the provider's registered nurse. Personal care facility licensure prohibits delegation of nursing tasks. In Assisted Living out-of-home respite settings, nursing services must be provided directly by licensed nurses.

 

7335 Respite Services in a Nursing Facility

Revision 12-3; Effective October 1, 2012

 

The HCBS STAR+PLUS Waiver (SPW) member receiving Respite Services in a nursing facility may receive therapy services from outside providers. The member's need for any service must be authorized on his/her individual service plan before receiving the service. The nursing facility is responsible for providing the needed nursing services to the member.

 

7340 Room and Board

Revision 12-3; Effective October 1, 2012

 

Room and board charges are not allowable charges to the HCBS STAR+PLUS Waiver (SPW) member receiving out-of-home Respite Services. Room and board charges are included in the rates for the services.

 

7400 Emergency Response Services

Revision 12-3; Effective October 1, 2012

 

 

7410 Introduction to ERS

Revision 11-4; Effective December 1, 2011

 

Emergency Response Services (ERS) are provided through an electronic monitoring system and are used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure the appropriate person or service provider responds to an alarm call from a member.

 

7420 ERS Program Purpose

Revision 12-3; Effective October 1, 2012

 

The purpose of Emergency Response Services under the HCBS STAR+PLUS Waiver (SPW) is to:

 

7430 Member Eligibility

Revision 12-3; Effective October 1, 2012

 

In order to be eligible for Emergency Response Services (ERS) through the HCBS STAR+PLUS Waiver (SPW), a member must:

STAR+PLUS services members are not eligible to receive ERS through the STAR+PLUS program.

 

7440 Referral and Selection of Providers

Revision 11-4; Effective December 1, 2011

 

If the member is considered eligible for Emergency Response Services (ERS), the managed care organization (MCO) shares its contracted list of all ERS providers with the member, who selects a provider from the list. The member can request a provider change; however, the member must contact his service coordinator to request the change.

The MCO follows the procedures in Section 3600, Ongoing Service Coordination, and gives members an explanation of the service and requirements.

 

7450 Duties Related to ERS

Revision 12-3; Effective October 1, 2012

 

If the member wants and appears to be in need of Emergency Response Services (ERS), the service coordinator determines if the member meets the general criteria for participating in ERS, as described in Section 7430, Member Eligibility. The managed care organization (MCO) may involve other members of the interdisciplinary team in the decision regarding the member's physical and mental ability to participate in the ERS program. ERS may be authorized through the HCBS STAR+PLUS Waiver (SPW) when it appears the member may need the capability to notify a respondent of an emergency. ERS services are limited to those individuals who:

During the course of the services, the MCO and the provider have the joint responsibility of keeping each other informed of changes or problems.

 

7460 Provider Duties

Revision 11-4; Effective December 1, 2011

 

Managed care organization contracted providers' duties specific to Emergency Response Services are described in Texas Administrative Code, Part 1, Chapter 52, Subchapter D.

 

7500 Home-Delivered Meals

Revision 10-0; Effective September 1, 2010

 

 

7510 Description

Revision 10-0; Effective September 1, 2010

 

Home-Delivered Meals provides hot, nutritious meals that are served in the member's home. Meals provided by contracted agencies are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics or food service management.

 

7520 Provider Responsibilities

Revision 14-3; Effective September 2, 2014

 

Home-delivered meals are delivered to the member’s home as authorized by the managed care organization (MCO). The individual delivering the meal reports any member illnesses, potential threats to his/her safety or observable changes in the member’s condition to the provider. The provider must notify the service coordinator about the report within 24 hours.

The provider also informs the service coordinator whenever:

This report must also reach the MCO within 24 hours of the event.

The MCO must notify the provider on the day that meals services are suspended. The MCO must suspend services in any of the following situations:

Unless the interruption is the result of one of the above situations, the provider must obtain the service coordinator's approval for service interruptions of more than two consecutive days. When the member requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the service coordinator.

 

7520.1 Frozen or Shelf-Stable Meals

Revision 10-0; Effective September 1, 2010

 

A provider that contracts with the managed care organization (MCO) to provide home-delivered meals must agree to provide services:

Providers of home-delivered meals must submit a waiver request to the MCO if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the provider’s contracted service area. Any waiver granted is effective for a period not to exceed one fiscal year. The provider must not implement the waiver for delivery of a hot meal five days a week before MCO approval of the waiver request.

 

7600 Transition Assistance Services

Revision 10-0; Effective September 1, 2010

 

 

7610 Introduction

Revision 10-0; Effective September 1, 2010

 

Transition Assistance Services (TAS) assists Medicaid recipients who are nursing facility residents discharged from the facility to a waiver program with setting up a household. A nursing facility resident discharged from the facility into a waiver program is eligible to receive up to $2,500 in TAS. TAS is available on a one-time only basis and is not available to residents moving from a nursing facility who are approved for any of the following waiver services:

Waiver individuals who are temporarily residing in a nursing facility may also be eligible for TAS. TAS may be used if the waiver member's living conditions are inadequate. Inadequate living conditions may include situations in which the individual has lost his residence because of moving into the nursing facility or conditions in the previous residence are so inadequate that the individual cannot return.

 

7611 Service Description

Revision 10-0; Effective September 1, 2010

 

Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for individuals transitioning from nursing facilities to a home in the community. Allowable expenses are those necessary to enable the individual to establish a basic household and may include:

TAS does not include relocation services and is not available to assist the applicant in locating a residence.

 

7620 Procedures at the Initial Interview

Revision 12-3; Effective October 1, 2012

 

All HCBS STAR+PLUS Waiver (SPW) applicants who are in a nursing facility (NF) must be advised of the availability of Transition Assistance Services (TAS) and screened for the potential need for services.

At the initial interview with the applicant, the managed care organization service coordinator discusses the applicant's available living arrangements in the community and asks the applicant where he/she intends to live upon discharge from the nursing facility.

TAS may be considered when the applicant:

If these or any other situations exist in which the applicant could benefit from TAS services, continue with the screening for TAS.

 

7630 Assistance from Relocation Specialists

Revision 12-3; Effective October 1, 2012

 

All applicants for HCBS STAR+PLUS Waiver (SPW) using the Money Follows the Person option must be referred to a relocation specialist. Relocation assistance consists of, but is not limited to:

In addition to providing relocation assistance, some relocation specialists may also contract to provide Transition Assistance Services (TAS).

Form 1579, Referral for Relocation Services, is also used to refer an ongoing SPW member who has entered a nursing facility (NF). Form 1579 must be sent to the relocation specialist within two business days of release from the nursing facility.

Although relocation services may be available when the member is discharged back to the community after a temporary NF stay, TAS may not be available if the member previously used TAS services to move from the NF to the community and used the entire $2,500 allocation.

 

7640 Identification of Needed Items and Services

Revision 10-0; Effective September 1, 2010

 

The managed care organization (MCO) conducts the interview with the applicant and/or authorized representative to identify the applicant's needs and determine if other resources are available to meet the needs. The MCO completes Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, by marking each identified need and writing a description of the exact need.

Example: If the applicant needs a deposit made for electricity, the MCO enters the name and address of the utility company and the amount required.

 

7641 Items and Services Included Under TAS

Revision 10-0; Effective September 1, 2010

 

Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.

 

7641.1 Deposits

Revision 10-0; Effective September 1, 2010

 

Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's name.

Security deposits may be paid as long as the payment is specifically called a security deposit and not rent, the payment is for a one-time expense, and the amount of the payment is no more than the equivalent of two months rent. Transition Assistance Services (TAS) cannot pay for rent.

TAS can be used to pay for arrears on previous utilities if the account is in the member's name and the member will not be able to get the utilities unless the previous balance is paid. TAS cannot pay the first month's payment on utilities.

TAS can be used to pay for a telephone since it is a basic need, but minutes or services on the telephone are not allowable expenses.

TAS cannot pay for any charges for upgraded services beyond the basic service.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company has a policy that requires a minimal supply of fuel to be delivered during the initial or reconnection service call. TAS funds cannot be used to top off a tank with fuel when the individual's home is connected and has a supply of butane or propane.

TAS can pay for pet deposits only if the pet is a service animal essential to the member.

 

7641.2 Household Needs

Revision 10-0; Effective September 1, 2010

 

Household needs include basic furniture/appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, etc.

An applicant may request a specific brand or type of appliance, furniture or other Transition Assistance Services (TAS) item as long as the applicant's needs are met within the cost limit.

TAS items may be placed in a home other than the applicant’s only when furnishings are not available and are necessary for the applicant to transition to the community. TAS cannot pay for items that would only be used by the other person.

If existing items are not usable and the lack of a usable basic/essential item creates a barrier keeping the individual from returning to the community, the item is considered a need.

 

7641.3 Housewares

Revision 10-0; Effective September 1, 2010

 

Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.

 

7641.4 Small Appliances

Revision 10-0; Effective September 1, 2010

 

Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.

 

7641.5 Cleaning Supplies

Revision 10-0; Effective September 1, 2010

 

Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.

 

7641.6 Other Items Not Listed

Revision 10-0; Effective September 1, 2010

 

Any special requests from the applicant not covered in the general list that meet the criteria as basic essential items to move to the community may be considered.

 

7642 Services and Items Not Included in Transition Assistance Services

Revision 12-3; Effective October 1, 2012

 

Transition Assistance Services (TAS) does not include any items or services that are included under HCBS STAR+PLUS Waiver (SPW) services such as adaptive aids, minor home modifications, medical supplies or medications.

TAS does not include any recreational items/appliances, including televisions, VCR or DVD players, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not cover the cost of repairs on the individual's dwelling. TAS is not used for remodeling or renovation, upgrading of existing items or purchase of non-essential items.

TAS funds cannot be used for food. The managed care organization may refer the individual to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources. Some funds are still available through the Transition to Living in the Community (TLC) Program. While funds are primarily designated for non-waiver individuals, if a waiver individual has no other resources, TLC could be used to pay for food.

Room and board are not allowable TAS expenses.

TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.

 

7643 Site Preparation

Revision 10-0; Effective September 1, 2010

 

Site preparation can include the following services:

Transition Assistance Services cannot pay for septic systems.

 

7650 Estimated Cost of Items and Services

Revision 10-0; Effective September 1, 2010

 

The managed care organization service coordinator provides a description and estimated cost of each item identified as needed under each service category on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The actual cost of an item may be used, if known. The amounts, either actual or estimated, must be less than or equal to $2,500.

The service coordinator must be as specific as possible when describing what items are needed and the estimated cost. The description must include size, color, specific types or any other identifying information, as specified by the individual, which will assist the TAS agency in meeting the individual's needs.

 

7651 Totaling the Estimated Cost and Authorization of Transition Assistance Services

Revision 12-3; Effective October 1, 2012

 

The service coordinator totals each section of Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and enters the amounts in the totals section to arrive at the final amount to be authorized under the TAS program. The $2,500 total amount is not entered as a flat rate.

The applicant must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he/she agrees that the TAS agency selected is authorized to make the purchases for him/her.

The applicant selects a TAS agency from the list of contracted agencies.

The service coordinator must explain to the applicant that the service will not be authorized until the applicant is determined eligible for HCBS STAR+PLUS Waiver (SPW) services, and notified in writing that he/she is eligible. The service coordinator must contact the applicant or applicant's representative before certification to verify the applicant has made arrangements for relocating to the community and has finalized a projected discharge date.

The service coordinator sends the applicant the notification of eligibility and sends the TAS agency Form 8604 and the authorization. The completion date on the authorization is two days before the projected nursing facility discharge date. Allow at least five business days between the authorization date and the completion date. The TAS agency is expected to have all services and items completed by that date. For situations in which a shorter completion date is needed, the service coordinator must contact the TAS agency and negotiate an earlier date.

Additional applicant information to the TAS agency may be included on Form 8604 or Form H2067-MC, Managed Care Programs Communication. Form 8604 is mailed after the applicant is determined eligible for waiver services.

The TAS agency may only obtain items/services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items/services that the individual may need, the TAS agency must obtain prior approval from the managed care organization. Refer to Section 7652 below.

 

7652 Changes to the Authorization

Revision 10-0; Effective September 1, 2010

 

If the Transition Assistance Services (TAS) agency or the member identifies additional items required by the member after the TAS authorization has been sent, the TAS agency must obtain approval from the managed care organization (MCO) on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, prior to obtaining the item/service.

The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items/services needed is more than the total amount authorized, the TAS agency must obtain prior approval and an updated Form 8604 from the MCO.

The MCO must send an amended Form 8604 updating the authorization to the TAS agency within two business days with the additional items and amounts authorized.

MCO approval is required to authorize delivery of TAS services.

 

7660 Transition Assistance Services Agency Responsibilities

Revision 10-0; Effective September 1, 2010

 

The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the forms carefully and contact the MCO if there are any questions regarding what has been authorized. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization form within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the dollar amount authorized by the MCO. The TAS agency contacts the member or member's authorized representative, if necessary, to coordinate service delivery.

The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.

 

7670 Three-Day Monitor Required

Revision 10-0; Effective September 1, 2010

 

The managed care organization (MCO) monitors the member within three business days after the discharge date to assure that all services and items authorized through the Transition Assistance Services (TAS) agency have been received. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.

 

7680 Failure to Leave the Facility

Revision 10-0; Effective September 1, 2010

 

While the managed care organization (MCO) makes every effort to confirm that the member has definite plans to leave the facility, there may be situations in which the member changes his/her mind or has a change in his/her health making it impossible for him/her to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual.

If the individual is only in the community for a few days and returns to the nursing facility, the individual keeps the item(s) purchased through TAS.

 

7690 Member Notifications and Appeals

Revision 14-1; Effective March 3, 2014

 

The purpose and limitations of Transition Assistance Services (TAS) must be explained to the applicant when determining the applicant's needs. The applicant may appeal a decision regarding a needed item or service, but services should not be delayed due to the appeal.

Form H2065-D, Notification of Managed Care Program Services, must be sent advising the member of the date of eligibility for the HCBS STAR+PLUS Waiver (SPW) service before the authorization of any services. If the member has finalized his/her discharge plans, Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, may be sent to the TAS provider on the same day Form H2065-D is sent to the member. If discharge plans are not finalized at the time of eligibility, Form 8604 may be sent at a later date. TAS information may be addressed in the Form H2065-D comments section.

The managed care organization notifies the applicant in writing of any changes in TAS services or items. The TAS provider is given provider authorization to deliver TAS services on Form 8604.

SPH, Section 8000, Service Delivery Options

Revision 15-1; Effective September 1, 2015

 

 

 

8100 Agency Option (AO)

Revision 10-0; Effective September 1, 2010

 

 

8110 Description

Revision 10-0; Effective September 1, 2010

 

Under the Agency Option (AO), the managed care organization-contracted provider is responsible for managing the day-to-day activities of the attendant and all business details. Most individuals select the AO model because of the simplicity and convenience of receiving services. For example, under AO the member is not responsible for:

 

8120 Selection of a Service Delivery Option

Revision 10-0; Effective September 1, 2010

 

All service delivery options are presented to the applicant/member at the initial assessment and each subsequent annual recertification. Use Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, or a document created by the managed care organization (MCO) and with Health and Human Services Commission approval , to assist the member or applicant in making the service delivery decision.

MCOs must obtain a signature on Form 1584, Consumer Participation Choice, indicating the member's choice of options. If, at any time during the year, a current member calls requesting information on service delivery options, the MCO must present the information to the member.

 

8121 Member Decision

Revision 10-0; Effective September 1, 2010

 

The managed care organization (MCO) must keep Form 1584, Consumer Participation Choice, in the member's case record. Ensure the member understands he/she may request a service delivery option change at any time by contacting the MCO.

 

8200 Consumer Directed Services

Revision 12-3; Effective October 1, 2012

 

 

8210 Overview

Revision 12-3; Effective October 1, 2012

 

The Consumer Directed Services (CDS) option was codified in Section 531.051 of the Government Code and expanded by the 79th Texas Legislature to provide more options for members to direct their long-term services and supports. The rules for the CDS option are found in Texas Administrative Code, Title 40, Chapter 41.

§41.107 — Overview of the CDS Option.

(a) An individual or LAR may elect the CDS option if:

(1) the individual's program offers the CDS option;

(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;

(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;

(4) the individual or LAR selects a CDSA to provide FMS; and

(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:

(1) selects a CDSA to provide FMS;

(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and

(3) recruits, screens, hires, trains, manages, and terminates service providers.

(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities.

CDS is a service delivery option in which a member or legally authorized representative (LAR) employs and retains service providers and directs the delivery of HCBS STAR+PLUS Waiver (SPW) personal assistance services and respite services. A member participating in the CDS option is required to use a CDS agency (CDSA) chosen by the member or LAR to provide financial management services (FMS). FMS is assistance to members to manage funds associated with services elected for self-direction. This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.

An individual or LAR may elect the CDS option if:

If an individual or LAR elects to participate in the CDS option, the individual or LAR selects a CDSA to provide FMS. The CDSA assists the individual or LAR with the budgeting of funds allocated in the individual’s service plan for delivery through the CDS option. If requested, the CDSA may also assist with recruiting, screening, hiring, training, managing and terminating service providers.

 

8211 Definitions

Revision 12-3; Effective October 1, 2012

 

§41.107 — Overview of the CDS Option.

(a) An individual or LAR may elect the CDS option if:

(1) the individual's program offers the CDS option;

(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;

(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;

(4) the individual or LAR selects a CDSA to provide FMS; and

(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:

(1) selects a CDSA to provide FMS;

(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and

(3) recruits, screens, hires, trains, manages, and terminates service providers.

(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities.

The following words and terms, when used in reference to the Consumer Directed Services (CDS) option, have the following meanings.

Actively involved — Involvement with an individual that the individual's interdisciplinary team deems to be of a quality nature based on the following:

Budget — A written projection of expenditures for each program service delivered through the CDS option.

Designated representative (DR) — A willing adult appointed by the employer of record to assist with or perform the employer's required responsibilities to the extent approved by the employer. The DR is not the employer of record.

Employee — A person employed by the member or legally authorized representative (LAR) through a service agreement to deliver program services and is paid an hourly wage for those services.

Employer of Record — The member or LAR who chooses to participate in the CDS option and is responsible for hiring and retaining service providers to deliver program services.

Employer support services — Services and items the member or LAR needs to perform employer and employment responsibilities, such as office equipment and supplies, recruitment and payment of Hepatitis B vaccinations for employees.

Financial Management Services (FMS) — Financial management services delivered by the Consumer Directed Services agency (CDSA) to the member or LAR such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member or LAR.

Legally authorized representative (LAR) — A person authorized by law to act on behalf of an HCBS STAR+PLUS Waiver (SPW) member, including a parent, guardian, managing conservator of a minor or the guardian of an adult.

Service Back-Up Plan — A documented plan to ensure that critical program services delivered through the CDS option are provided to a member when normal service delivery is interrupted or there is an emergency.

 

8212 SPW Services Available Under the CDS Option

Revision 13-2; Effective June 3, 2013

 

The HCBS STAR+PLUS Waiver (SPW) program services available in the Consumer Directed Services (CDS) option are:

SPW members may choose to self-direct any or all services available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members. The CDS option is not available to members living in Adult Foster Care homes or Assisted Living facilities.

All applicants and ongoing members will be assessed for financial and functional eligibility under the SPW program guidelines currently in use. There is no change in eligibility determination for the CDS applicant/member. Members have the option of having PAS and Respite services delivered through a contracted Home and Community Support Services Agency (HCSSA) provider or by using the CDS option, in which they hire and manage their own employees to provide the services.

Financial Management Services (FMS), assistance to members to manage funds associated with services elected for self-direction, is provided by the CDS agency. This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers. A monthly administrative fee is authorized on the individual service plan and paid to the CDS agency for FMS.

 

8213 Risks and Advantages of the CDS Option

Revision 10-0; Effective September 1, 2010

 

The member should consider the risks and advantages associated with the Consumer Directed Services (CDS) option before choosing to enroll. To assist the member in making a decision, information is presented by the service coordinator. Refer to Section 8221, Presentation of the CDS Option.

 

8213.1 Risks Associated with the CDS Option

Revision 10-0; Effective September 1, 2010

 

Below are some of the risks associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR) is:

 

8213.2 Advantages of CDS Service Delivery Option

Revision 10-0; Effective September 1, 2010

 

Below are some of the advantages associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative:

 

8214 Member and CDSA Responsibilities

Revision 10-0; Effective September 1, 2010

 

 

8214.1 Member Responsibilities

Revision 10-0; Effective September 1, 2010

 

The member or legally authorized representative (LAR) assumes responsibility as the employer of record.

§41.201 — Employer Responsibilities.

(b) An employer or DR hires and is responsible and liable for a person, contractor or vendor hired to deliver program services.

(c) An employer is responsible for:

(1) service planning with the individual's service planning team;

(2) budgeting allocated program funds in the individual's service plan for services delivered through the CDS option;

(3) determining compensation for service providers within the service rate and spending limits established by the Health and Human Services Commission;

(4) ensuring that employees and contractors are paid for services delivered based on an hourly rate;

(5) recruiting, screening, hiring and training qualified employees;

(6) recruiting, screening and retaining qualified contractors;

(7) managing and terminating service providers; and

(8) planning and arranging for back-up services.

(d) An employer or DR must hire or retain service providers in accordance with qualifications and other requirements of the individual's program.

The member or LAR must agree to accept financial management services from the selected Consumer Directed Services agency (CDSA). The individual or LAR must obtain an employer identification number from applicable government agencies and may request assistance from the CDSA to meet the requirements. The member or LAR must provide the information needed for the CDSA to register as the member's agent with the Internal Revenue Service and other appropriate government agencies.

 

8214.2 CDSA Responsibilities

Revision 10-0; Effective September 1, 2010

 

§41.309 — Financial Management Services and Employer-Agent Responsibilities.

(a) A CDSA must provide FMS to an employer or DR, including:

(1) providing initial orientation as described in §41.307 of this chapter (relating to Initial Orientation of an Employer);

(2) providing ongoing training, assistance, and support for employer-related responsibilities;

(3) verifying qualifications of applicants before services are delivered;

(4) monitoring continued eligibility of service providers;

(5) approving and monitoring budgets for services delivered through the CDS option;

(6) managing payroll, including calculations of employee withholdings and employer contributions and depositing these funds with appropriate agencies;

(7) complying with applicable government regulations concerning employee withholdings, garnishments, mandated withholdings and benefits;

(8) preparing and filing required tax forms and reports;

(9) paying allowable expenses incurred by the employer;

(10) providing status reports concerning the individual's budget, expenditures, and compliance with CDS option requirements; and

(11) responding to the employer or DR as soon as possible, but at least within two working days after receipt of information requiring a response from the CDSA, unless indicated otherwise in this chapter.

The Consumer Directed Services agency (CDSA) must obtain employer-agent status and perform all responsibilities as required by the Internal Revenue Service and other appropriate government agencies. The CDSA enters into service agreements with each of the individual's service providers before issuing payment.

A CDSA may not provide financial management services (FMS) and case management services to the same individual.

The CDSA must accept the designated program service fee established by the Health and Human Services Commission as payment in full for providing FMS.

 

8220 Member Choice in the CDS Option

Revision 12-3; Effective October 1, 2012

 

Information about the Consumer Directed Services (CDS) option is presented to the HCBS STAR+PLUS Waiver (SPW) member by the service coordinator. Written and verbal information is shared about the benefits and requirements of the CDS option. The member chooses to have personal assistance services and Respite services delivered though the CDS option or the agency option.

 

8221 Presentation of the CDS Option

Revision 10-0; Effective September 1, 2010

 

§41.109 — Enrollment in the CDS Option.

(a) At the time of an individual's enrollment in a DADS program that offers the CDS option, and at least annually thereafter, a case manager, service coordinator, or other person designated by the individual's program must:

(1) provide written materials on the CDS option to the individual or LAR;

(2) meet with and provide the individual or LAR with an oral explanation of the CDS option specific to the individual's program; and

(3) complete Form 1581, Consumer Directed Services Option Overview.

(b) An individual or LAR may request that a case manager, service coordinator, or other person designated by the individual's program provide additional oral and written information to the individual or LAR regarding the CDS option or assist with enrollment in the CDS option at any time. The case manager, service coordinator, or designee must comply within five working days after receipt of the request.

(c) An individual or LAR declining participation in the CDS option may at any time elect to participate in the CDS option while receiving services through a DADS program that offers the CDS option.

(d) An individual or LAR who decides to participate in the CDS option must, with assistance from a case manager or service coordinator, complete the following forms:

(1) Form 1582, Consumer Directed Services Responsibilities …

The service coordinator is responsible for presenting the Consumer Directed Services (CDS) option annually to all new applicants and ongoing members who are not enrolled in the CDS option and whenever information is requested. The service coordinator:

For initial applications, the service coordinator obtains the applicant's signature on Form 1581 at the initial contact. The service coordinator signs and dates the form verifying the information was presented to the applicant. A copy of Form 1581 is placed in the case record to document that CDS information was shared.

For annual redeterminations, the service coordinator provides the member with a copy of Form 1581 and clearly documents in the case record that Form 1581 was shared with the member.

When members request information about the CDS option at other times, the service coordinator must provide CDS information to the member within five business days after receipt of the request. The service coordinator may provide the information by making a home visit or contacting the individual by telephone. If a home visit is not made, the service coordinator obtains the member's signature by mailing Form 1581 to the member with a postage-paid, return envelope. The service coordinator signs and dates Form 1581 indicating the information was presented. A copy of Form 1581 is placed in the member's case record to document Form 1581 was shared.

The service coordinator must discuss the CDS option, as well as differences in service delivery and payment options, and allow the individual the opportunity to choose between delivery of services through the agency option or the CDS option.

If the member is interested in participating in the CDS option once the information on Form 1581 is shared, the service coordinator reviews Form 1582, Consumer Directed Services Responsibilities. The service coordinator:

Refer to Section 8223, Designated Representative, for procedures related to an individual appointing a DR.

 

8222 Member Choice in the CDS Option

Revision 10-0; Effective September 1, 2010

 

§41.409 — Enrollment in the CDS Option.

(d) An individual or LAR who decides to participate in the CDS option must, with assistance from a case manager or service coordinator, complete the following forms:

(1) Form 1582, Consumer Directed Services Responsibilities

(2) Form 1583, Employee Qualification Requirements;

(3) Form 1584, Consumer Participation Choice;

(4) Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services through Consumer Directed Services, or Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing License for Certain Services Delivered through Consumer Directed Services, if required by the policies of the individual's program; and

(5) Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the individual's program.

(e) An individual or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582, Consumer Directed Services Responsibilities, and if applicable, complete any assessment required by the individual's program.

(f) An individual or LAR who is not able to complete the self-assessment must appoint a DR in order to participate in the CDS option.

(g) The person appointed as the DR by the individual or LAR must:

(1) be willing to serve as the individual's or LAR's DR for participation in the CDS option;

(2) be or become actively involved with the individual; and

(3) complete the self-assessment in Form 1582, and any assessment required by the individual's program.

The service coordinator presents the information on Form 1582, Consumer Directed Services Responsibilities, and allows the member or legally authorized representative to choose between the Consumer Directed Services option or the Agency Option.

 

8222.1 Choosing the CDS Option

Revision 12-3; Effective October 1, 2012

 

The service coordinator presents a list of contracted Consumer Directed Services (CDS) agencies (CDSA) and Home and Community Support Services (HCSS) providers. The individual must select:

If the member or legally authorized representative (LAR) chooses and is able to participate in the Consumer Directed Services (CDS) option, the CDSA proceeds to Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice. The CDSA:

The service coordinator develops the member's service plan according to SPW program policy and CDS option rules.

 

8222.2 Declining the CDS Option

Revision 10-0; Effective September 1, 2010

 

If the member or legally authorized representative (LAR) declines or is not ready to select the Consumer Directed Services (CDS) option after Form 1582, Consumer Directed Services Responsibilities, is shared, the service coordinator:

The service coordinator must ensure the individual understands the CDS option is always available and that the individual may call the service coordinator to request a change to the CDS option at any time.

Form 1584 is signed by the member when a different service delivery option is chosen.

 

8223 Designated Representative

Revision 10-0; Effective September 1, 2010

 

§41.205 — Employer Appointment of a Designated Representative.

(a) An employer may appoint a willing adult as a DR to assist or to perform employer responsibilities. The employer maintains responsibility and accountability for decisions and actions taken by the DR.

(b) If the employer chooses to appoint or change a DR, the employer must complete DADS Form 1720, Appointment of Designated Representative.

(1) The employer must notify a CDSA by fax or telephone within two working days after the appointment or change of a DR.

(2) If the employer notifies the CDSA by telephone, the employer must fax or mail a copy of Form 1720 to the CDSA within five working days after the appointment or change of a DR.

(c) If an employer decides to revoke the appointment of a DR, the employer must:

(1) complete DADS Form 1721, Revocation of Appointment of Designated Representative; and

(2) provide a copy of the completed form to the CDSA within two calendar days after the effective date of the revocation.

(d) Based on documentation provided by the CDSA of an employer's inability to meet employer responsibilities, the service planning team may recommend that the employer designate a DR to assist with or to perform employer responsibilities.

(e) A DR must not:

(1) sign or represent himself as the employer;

(2) be paid to perform employer responsibilities;

(3) be an employee of the employer;

(4) have a spouse employed by the employer; or

(5) provide a program service to the individual.

The member or legally authorized representative (LAR) has the option of designating a representative to assist with the responsibilities of being an employer in the Consumer Directed Services (CDS) option. The CDS agency assists the member or LAR in selecting a designated representative (DR) and documents the decision on Form 1582, Consumer Directed Services Responsibilities.

The DR signs Form 1582 in agreement to perform employer functions on behalf of the CDS individual. The DR may not be hired as the Personal Assistance Services attendant.

The CDS agency assists the member or LAR in completing the designation of a representative. Form 1720, Appointment of a Designated Representative, is used to appoint a DR. Form 1721, Revocation of Appointment of Designated Representative, is used if the member or LAR elects to participate in the CDS option without the use of a DR.

 

8230 Determining the Individual Service Plan

Revision 15-1; Effective September 1, 2015

 

§41.111 — Service Planning in the CDS Option.

(a) Service planning for an individual who chooses to participate in the CDS option is completed in accordance with the rules and requirements of the individual's program in the same manner as if services are delivered through a program provider. Service planning includes:

(1) determining the individual's needs

(2) determining service levels;

(3) justifying changes to the service plan;

(4) maintaining costs and cost ceilings;

(5) reviewing services; and

(6) obtaining approval for planned services.

(b) A case manager or service coordinator must adhere to rules and requirements of the individual's program and in Subchapter D of this chapter (relating to Enrollment, Transfer, Suspension, and Termination) if the individual's services or a request for services is recommended for:

(1) denial;

(2) reduction;

(3) suspension; or

(4) termination.

(c) A case manager or service coordinator must provide an oral explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided orally and in accordance with the individual's program requirements.

All HCBS STAR+PLUS Waiver (SPW) financial and non-financial eligibility requirements apply. Consumer Directed Services (CDS) is not a different service; it is a service delivery option. The service coordinator completes all forms currently required for SPW services, including Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum, as applicable.

The member using the CDS option must have a back-up system to assure the provision of all authorized personal assistance services without a service break, even if there are unexpected changes in personnel. The member or legally authorized representative must develop and receive approval from the service coordinator for each required service back-up plan in order to participate in the CDS option. Refer to Section 8245, Service Back-Up Plans.

The service coordinator follows program policy when completing denials or terminations, reductions in services and suspensions.

The service coordinator must ensure the member fully understands the reasons for actions taken relating to the individual service plan and SPW services, as well as actions that could affect the member's participation in the CDS option.

 

8231 Respite Services

Revision 12-3; Effective October 1, 2012

 

Respite services that provide temporary relief to persons caring for HCBS STAR+PLUS Waiver (SPW) members residing in the community are available through the Consumer Directed Services option. The member may choose to receive respite in his/her own home or in an out-of-home setting.

 

8231.1 In-Home Respite in the CDS Option

Revision 10-0; Effective September 1, 2010

 

In determining the member's needs for services in the individual service plan (ISP), the service coordinator discusses the member's need for Respite services. If the member has a caregiver and Respite is requested, the service coordinator includes the authorization for Respite in the ISP.

In selecting the Consumer Directed Services (CDS) option, the member assumes responsibility for managing in-home Respite as well as Personal Assistance Services (PAS). It is the member's or legally authorized representative's responsibility to advise the CDS agency (CDSA) when Respite hours are used so that the CDSA can bill correctly. The member may use the same attendant for PAS hours and in-home Respite or may hire a different attendant for the in-home Respite.

 

8231.2 Out-of-Home Respite in the CDS Option

Revision 10-0; Effective September 1, 2010

 

Out-of-Home Respite services chosen in the Consumer Directed Services (CDS) option must be authorized on the individual service plan (ISP) based on the particular setting for services. The member may select from the array of settings, including Adult Foster Care, Assisted Living (apartment or non-apartment) or nursing facility. If the member requests that out-of-home Respite be included in the ISP, the service coordinator furnishes the member with information on the contracted facilities available in the area.

In the CDS option, it is the member's or legally authorized representative's responsibility to make the arrangements with the contracted facility for an out-of-home respite stay. The CDS agency is responsible for the appropriate billing.

 

8240 Initiation of and Transition to the CDS Option

Revision 12-3; Effective October 1, 2012

 

§41.401 — Enrollment Process. The enrollment process is conducted in accordance with §41.109 of this chapter (relating to Enrollment in the CDS Option). Within five working days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible individual or LAR, or upon receipt of Form 1584 and within five working days after eligibility determination for an applicant applying for program services, a service coordinator or service coordinator must provide the following documentation to the CDSA:

(1) Form 1584;

(2) the individual's authorized service plan;

(3) the individual's plan of care; and

(4) if not provided in paragraph (1)-(3) of this section:

(A) the date the employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;

(B) the date the employer may begin delivery of program services through the employer's service providers;

(C) the number of units, the approved rate, or the amount authorized in the individual's service plan for each service to be delivered through the CDS option;

(D) the total funds authorized for each program service to be delivered through the CDS option; and

(E) the authorized schedule of service delivery per day, week, month, or other time frame specific to the service.

Within five business days after eligibility determination for the HCBS STAR+PLUS Waiver (SPW) program, new applicants who choose the Consumer Directed Services (CDS) option are referred to the CDS agency (CDSA) to begin the initiation process.

Within five business days of receipt of the completed Form 1584, Consumer Participation Choice, ongoing SPW individuals who choose the CDS option are referred to the CDSA to begin the CDS initiation process.

The service coordinator provides the CDSA the following documentation:

The service coordinator must provide the CDSA with the authorized schedule of service delivery per day, week, month or other time frame specific to the service if not listed on the above forms.

Some applicants may have been anticipating the availability of the CDS option and may elect to go directly to the CDS option. The service coordinator must emphasize that the applicant assumes all responsibility for arranging Personal Assistance Services and Respite.

Members who participate in the CDS option and choose to transfer back to the Agency Option will not have the choice of returning to the CDS option for at least 90 days.

Service coordinators must carefully coordinate transition activities when transitioning applicants/members to and from the CDS option.

 

8241 Initiation and Orientation of the Member as Employer

Revision 10-0; Effective September 1, 2010

 

§41.207 — Initial Orientation of an Employer. Upon choosing to participate in the CDS option, an employer, and the DR, if applicable, must:

(1) complete the initial orientation provided by the CDSA in the residence of the individual;

(2) complete and maintain a copy of Form 1736, Documentation of Employer Orientation, upon completion of the orientation;

(3) complete Form 1735, Employer and Consumer Directed Services Agency Service Agreement, with the following required attachments:

(A) Form 1726, Relationship Definitions in Consumer Directed Services;

(B) as required by the individual's program, Form 1733, Employer and Employee Exemption from Nursing License for Certain Services, or Form 1585, Statement of Responsibilities for Consumer Directed Services; and

(C) Form 1738, Rules Acknowledgment;

(4) submit completed original forms specified in paragraph (3) of this subsection to the CDSA within five calendar days after the date of the initial orientation; and

(5) retain copies of completed documentation required by this section.

Upon receipt of the Consumer Directed Services (CDS) referral from the service coordinator, the CDS agency (CDSA) completes the initial employer orientation with the member, legally authorized representative (LAR) or designated representative (DR) in the member's residence. The CDSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the employer and the CDSA.

The member, LAR or DR signs and submits all required forms for participation in the CDS option and returns the forms to the CDSA within five calendar days after the date of initial orientation.

The member and CDSA notify the service coordinator when all initiation activities are complete.

 

8242 Employer and Employee Acknowledgment

Revision 12-3; Effective October 1, 2012

 

The Consumer Directed Services agency (CDSA) assists the member, legally authorized representative (LAR) or designated representative (DR) in completing the employer and employee acknowledgment. The employee acknowledges that, as the person who delivers the service, he/she has not been:

The CDSA assists the member, LAR or DR in hiring or retaining service providers in accordance with qualifications and other requirements of the HCBS STAR+PLUS Waiver (SPW) program.

 

8243 Authorizing CDS

Revision 13-1; Effective March 1, 2013

 

When the member or legally authorized representative (LAR) and Consumer Directed Services (CDS) agency (CDSA) notify the service coordinator that CDS services are ready to begin, the service coordinator negotiates a start date for services. The service coordinator revises Form H1700-1, Individual Service Plan — SPW (Pg. 1), and changes the Personal Assistance Services and Respite authorizations to the CDSA. For ongoing members, the individual service plan year remains the same. The same procedures are followed for any other transfer of agencies.

It is the responsibility of the member, LAR and the CDSA to ensure that the expenditures for the year remain within the authorized amount.

 

8244 CDS Service Planning

Revision 12-3; Effective October 1, 2012

 

§41.215 — Employer Role in the Service Planning Process.

(a) An individual's service planning team consists of persons required or allowed by the individual's program.

(b) An employer must attend and participate in the individual's service planning meeting. An employer's DR may also attend the meeting with approval of the individual or LAR.

(c) An employer or DR must provide documentation related to services, service delivery, and participation in the CDS option when requested by a HMO or service coordinator.

(d) An employer or DR must, when requesting a change in a service or the addition of a service for delivery through the CDS option, provide the service planning team with documentation of circumstances that require a revision to the individual's service plan.

The managed care organization (MCO) and HCBS STAR+PLUS Waiver (SPW) interdisciplinary team (IDT) members make up the service planning team for the member who selects the Consumer Directed Services (CDS) option. The MCO convenes the IDT as required by SPW program policy and obtains approvals as appropriate from IDT members. The MCO and IDT also assist in resolving issues and concerns related to the member's participation in the CDS option.

The CDS agency (CDSA) must document and notify the MCO of issues or concerns, including:

The member is required to participate in the service planning meetings and provide requested documentation related to services and service delivery. The member or legally authorized representative (LAR) must provide documentation to support any requests for a revision to the individual service plan.

The CDSA may also participate in the member's service planning if requested by the member, LAR or designated representative (DR) and if agreed to by the CDSA. Within three days after receiving a request from the member, LAR, DR, MCO or other involved parties, the CDSA must provide information related to the member's participation in the CDS option.

The MCO and IDT members, as appropriate, participate in approving back-up plans, developing corrective action plans, if necessary, and recommending suspension or termination of the CDS option. Refer to Section 8245 below and Section 8246, Corrective Action Plans.

 

8245 Service Back-Up Plans

Revision 10-0; Effective September 1, 2010

 

§41.217 — Service Back-up Plan.

(a) An employer or DR must develop and document a service back-up plan for each service to be delivered through the CDS option that the individual's service planning team has determined to be critical to the health and welfare of the individual.

(b) An individual's service planning team must describe:

(1) which services are critical; and

(2) the length of time that constitutes a service interruption or an emergency for the individual.

(c) An employer or DR must develop a service back-up plan that:

(1) ensures the provision of services when the employer's regular service provider is not available to deliver the service or in an emergency; and

(2) may include the use of:

(A) paid service providers;

(B) unpaid service providers, such as family members, friends, or non-program services; or

(C) use of respite, if included in the authorized service plan.

The managed care organization (MCO) must discuss with the member, legally authorized representative (LAR) or designated representative (DR) the services delivered through Consumer Directed Services (CDS) that are critical to the member's health and welfare. The MCO must inform the member, LAR or DR to develop a service back-up plan to ensure the health and safety of the member when regular service providers are not available to deliver services or in an emergency. The member, LAR or DR must develop a back-up system to assure the provision of all authorized personal assistance services without a service break.

The member, LAR or DR, with the assistance of the MCO (if needed), completes Form 1740, Service Backup Plan. The service back-up plan must list the steps the member, LAR or DR implements in the absence of the service provider. The service back-up plan may include the use of paid service providers, unpaid service providers such as family members, friends or non-program services, or respite (if included in the authorized service plan). The member, LAR or DR is responsible for implementation of the service back-up plan in the absence of the employee.

Service back-up plans are submitted by the member, LAR or DR to the MCO. The MCO and interdisciplinary team (IDT), as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or IDT must approve each service back-up plan and any revision before implementation by the member, LAR or DR. The MCO approves the service back-up plan by signing, dating and returning a copy of the plan to the member, LAR or DR.

The member, LAR or DR is required to:

The CDSA must assist a member, LAR or DR as requested to revise budgets to:

 

8246 Corrective Action Plans

Revision 12-3; Effective October 1, 2012

 

§41.221 — Corrective Action Plans.

(a) A written corrective action plan may be required from an employer or DR if the employer or DR:

(1) hires an ineligible service provider;

(2) submits incomplete, inaccurate, or late documentation of service delivery;

(3) does not follow the budget;

(4) does not comply with program requirements related to the CDS option;

(5) does not meet other employer responsibilities.

The individual, legally authorized representative (LAR) or designated representative (DR) must provide written corrective action plans (CAP) to the person requiring the plan within 10 calendar days after receiving a CAP request. CAPs may be requested in writing by the Consumer Directed Services agency (CDSA), managed care organization (MCO) or interdisciplinary team member.

The written CAP must include the:

The member, LAR or DR may request assistance in the development or implementation of a CAP from the:

Form 1741, Corrective Action Plan, is used to document the CAP.

 

8247 Budgets

Revision 12-3; Effective October 1, 2012

 

§41.501 — Budget Development.

(a) The employer or DR, with assistance obtained from the CDSA or others, must:

(1) develop a budget for each program service to be delivered through the CDS option;

(2) project expenditures of funds allocated in the individual's authorized service plan for the effective period of the service plan;

(3) use applicable budget workbooks available through DADS at www.dads.state.tx.us/business/communitycare/cds/CDSforms.html;

(4) request assistance from the CDSA as needed;

(5) submit each budget to the CDSA for review; and

(6) obtain written approval for each budget from the CDSA before initiating services or making purchases for payment.

The member, legally authorized representative (LAR) or designated representative (DR) develops a budget for each HCBS STAR+PLUS Waiver (SPW) service to be delivered through the Consumer Directed Services (CDS) option based on the projected expenditures allocated in the individual service plan period. The member must budget the monthly amount established by the Health and Human Services Commission for payment of Financial Management Services delivered by the CDS agency (CDSA) through the CDS option.

The member, LAR or DR develops an initial and annual budget and receives written approval from the CDSA before implementation of the budget and initiation of service delivery through the CDS option.

The CDSA must provide assistance as requested or needed by the member, LAR or DR to develop a budget. The CDSA reviews the member's budgeted payroll spending decisions, verifies the applicable budget workbooks are within the approved budget, and notifies the member in writing of budget approval or disapproval. The CDSA must work with the member, LAR or DR to resolve issues that prevent the approval of budget plans.

§41.511 — Budget Revisions and Approval.

(a) An employer or DR must make budget revisions if:

(1) a change to the individual's authorized service plan affects funding for a program service delivered through the CDS option;

(2) a budget has been or will be exceeded before the end date of the service plan;

(3) authorized units, unit rate, or amount of funds allocated have changed;

(4) an amount paid for one or more services, goods or items affects the approved budget;

(5) strategies are added or revisions are made to a service back-up plan;

(6) funds budgeted for a service back-up plan are not used or needed; or

(7) the CDSA, the case manager or service coordinator, the individual's service planning team, or a DADS representative require a revision.

The member, LAR or DR must submit budget revisions to the CDSA for approval. Revised budgets cannot be implemented until written approval is received from the CDSA.

The CDSA must provide assistance to the member, LAR or DR with budget revisions as requested or needed by the member, validate the budget, and provide written approval to the member, LAR or DR.

The managed care organization evaluates service plan changes requested by the member and participates in the interdisciplinary team meetings to resolve issues when the member does not follow the budget or comply with CDS option budget requirements.

 

8300 Service Responsibility Option (SRO) Description

Revision 11-2; Effective June 1, 2011

 

SRO is a service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal assistance services and respite services.

The member decides how services are provided. SRO leaves the business details to the member's managed care organization. See Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

 

8310 SRO Roles and Responsibilities

Revision 11-2; Effective June 1, 2011

 

Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, specifies the roles and responsibilities assigned to the member, provider and managed care organization (MCO). The member, provider and MCO receive and sign Form 1582-SRO indicating their agreement to accept the service responsibility option (SRO) responsibilities.

 

8311 MCO Responsibilities

Revision 11-2; Effective June 1, 2011

 

The intake, referral and assessment procedures for members requesting service delivery through the service responsibility option (SRO) are handled in the usual way. The managed care organizations (MCOs) are responsible for:

Once the assessment is complete, the MCO is required to:

In addition, the MCO's responsibilities include:

 

8312 Agency Responsibilities

Revision 11-2; Effective June 1, 2011

 

The agency contracted with the managed care organization is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to policies and standards before sending the attendants to members' homes.

The agency:

 

8313 Member Responsibilities

Revision 11-2; Effective June 1, 2011

 

The member or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant. To participate in the service responsibility option (SRO), the member must be capable of performing all management tasks as described below, or may identify a DR to assist or perform those management tasks on the member's behalf.

The member is responsible for:

 

8320 Managed Care Organization (MCO) Procedures

Revision 15-1; Effective September 1, 2015

 

The service responsibility option (SRO) is not a different service; it is a service delivery option. All financial and non-financial eligibility criteria, including unmet need and "do not hire" policy, continue to apply for each program area. Unless otherwise stated in this section, MCO procedures are not impacted by the member's choice of SRO.

Complete all forms currently required, including the assessment of functional needs on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum. Continue to identify any caregivers who are currently providing for the member's needs.

 

8321 Initial Authorization of Services

Revision 11-2; Effective June 1, 2011

 

The member's decision to receive services using the service responsibility option does not change the manner in which initial services are authorized. See Section 3300, Administrative Procedures, for specific information.

 

8322 Monitoring

Revision 11-2; Effective June 1, 2011

 

All monitoring for service responsibility option (SRO) members is done by the managed care organization (MCO) according to the mandated schedule for its specific services. When health and safety issues arise, the MCO staff:

Because the member now shares responsibility for service delivery, the MCO, in addition to other monitoring requirements, must monitor the member's:

If it is evident that the member is having difficulty in the management of SRO responsibilities, the MCO staff must:

 

8323 Procedures for Ongoing Cases

Revision 11-2; Effective June 1, 2011

 

Members must be offered the service responsibility option (SRO) by the managed care organization (MCO) annually, and may request a transfer to the SRO at any time. Additionally, the SRO must be presented to ongoing members at each annual reassessment or upon request. If the member is interested in transferring to the SRO, the member must sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

The MCO must ensure the member understands the responsibility he/she is assuming. Send Form H2067-MC, Managed Care Programs Communication, to the agency to advise it of the member's selection. Notify the agency the member will be contacting it for training. Request the agency to advise the MCO, using Form 2067, when the transition planning is complete. Negotiate a start date with the member and the agency.

SPH, Section 9000, Service Authorization System Help File

Revision 17-1; Effective March 1, 2017

 

 

 

9100 Initial Service Authorization

Revision 17-1; Effective March 1, 2017

 

These records must be completed to check or create an initial service authorization for the STAR+PLUS Home and Community Based Services (HCBS) program.

 

9110 Authorizing Agent

Revision 17-1; Effective March 1, 2017

 

There will normally be one authorizing agent registered for a STAR+PLUS Home and Community Based Services (HCBS) program applicant.

Initial individual service plans (ISPs) submitted through the Long Term Care (LTC) portal have a system-generated authorizing agent. The LTC portal interfaces with the Service Authorization System (SAS) and records "STAR+PLUS" in the Authorizing Agent Field and records the managed care organization (MCO) service coordinator's name in the Name field.

The LTC portal generates changes to the SAS authorizing agent records for a member with a plan code change during an ISP year for which a current or future ISP is in a "processed/complete" status. In this case, a SAS authorizing agent record is created for the 'child' ISP with a begin date equal to the new plan effective date. The SAS authorizing agent record for the ‘parent’ (transferred) ISP is automatically ended with the prior plan enrollment end date.

The Program Support Unit (PSU) does not register an authorizing agent for electronic ISPs. PSU confirms the authorizing agent registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

The PSU or Texas Health and Human Services Commission (HHSC) Enrollment Resolution Services (ERS) staff are registered as the authorizing agent when the initial authorization is authorized.

To register an authorizing agent for a  STAR+PLUS HCBS program applicant whose ISP is posted to TxMedCentral:

  1. Select the Authorizing Agent area in the Case Worker Functional area.
  2. Select Add and a blank Authorizing Agent Details record will appear.
  3. Move to the Type field and select CM – Case Manager from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the date the record is being created. Leave the End Date field blank.
  7. Move to the Authorizing Agent field and enter STAR+PLUS.
  8. Leave the Agency field at the default selection 324 - DHS.
  9. Move to the Name field and enter the PSU/ERS staff’s name.
  10. Move to the Phone field and enter the telephone number of the authorizing agent. Enter the area code, phone number and extension.
  11. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) Plan Code from the table below. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service Area MCO Plan Name MCO Plan Code

Bexar

Amerigroup

45

Molina

46

Superior 47
Amerigroup MMP 4F
Molina MMP 4G

Superior MMP

4H

Dallas

 

Molina

9F

Superior Health Plan

9H

Molina MMP 9J
Superior MMP 9K

El Paso

Amerigroup

34

Molina

33

Amerigroup MMP 3G
Molina MMP 3H

Harris

Amerigroup

7P

United Healthcare

7R

Molina

7S

Amerigroup MMP 7Z
United Healthcare MMP 7Q
Molina MMP 7V

Hidalgo

Cigna-HealthSpring

H7

Molina

H6

Superior

H5

Cigna-HealthSpring MMP H8
Molina MMP H9
Superior MMP HA
Jefferson

Amerigroup

8R

United Healthcare

8S

Molina

8T

Lubbock

Amerigroup

5A

Superior 5B
Medicaid Rural Service Area (RSA) Central Texas Superior C4
United Healthcare C5
Medicaid RSA
Northeast Texas
Cigna-HealthSpring N3
United Healthcare N4
Medicaid RSA
West Texas
Amerigroup W5
Superior W6

Nueces

United Healthcare

85

Superior Health Plan

86

Tarrant

Amerigroup

69

Cigna-HealthSpring

6C

Amerigroup MMP 6F
Cigna-Healthspring MMP 6G

Travis

Amerigroup

19

United Healthcare

18

  1. Select the Save button.

 

 

9120 Enrollment

Revision 17-1; Effective March 1, 2017

 

To register enrollment for a STAR+PLUS Home and Community Based Services (HCBS) program applicant:

  1. Select the Enrollment area in the Program and Service Functional area.
  2. Select Add and a blank Enrollment Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu.
  5. Move to the Living Arrangement field, and select the appropriate community-based living arrangement from the drop-down menu.
  6. Move to the Begin Date field and enter the date the member is to be enrolled in his MCO, which will always be the first day of a month.
  7. Leave the End Date field blank.
  8. Leave the Termination Code and Waiver Type fields at the defaults.
  9. Select the Save button.

 

 

9130 Service Plan

Revision 17-1; Effective March 1, 2017

 

The Service Plan record is used to register an individual service plan (ISP) for a Home and Community Based Services (HCBS) program plan member. The record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost of STAR+PLUS HCBS program services taken from the member’s Form H1700-1, Individual Service Plan, for individuals who do not have an electronic ISP.

To register a service plan for a STAR+PLUS HCBS program applicant whose ISP is posted to TxMedCentral:

  1. Select the Service Plan area in the Program and Service Functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost ceiling for the RUG value entered on the Level of Service record. For a STAR+PLUS HCBS program member who is ventilator use-dependent, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).
  6. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  7. Move to the End Date field and enter the last day of the ISP coverage period.
  8. Move to the Amount Authorized field and enter the total estimated cost of all STAR+PLUS HCBS program services authorized for the current ISP coverage period, from Form H1700-1.
  9. Leave the Amount Paid field at the default setting of 0.00.
  10. Leave the Units Authorized field at the default of 0.00.
  11. Leave the Units Paid field at the default of 0.00.
  12. Select the Save button.

 

 

9140 Service Authorization

Revision 17-1; Effective March 1, 2017

 

If the individual service plan (ISP) is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). Program Support Unit (PSU) does not register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

PSU staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for individuals who do not have an electronic ISP.

To register a service authorization record for initial STAR+PLUS HCBS program eligibility for a member whose ISP is posted to TxMedCentral:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  11. Move to the End Date field and enter the last day of the ISP coverage period.
  12. Move to the Contract No field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior Medicaid Rural Service Area (RSA) Central 1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

 

9150 Level of Service

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) registered on a Level of Service record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care Assessment (MN/LOC) and submits the information from this form to TMHP. After TMHP determines MN and computes the RUG value, this information is transmitted and stored in the Service Authorization System (SAS) database

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the individual service plan (ISP) expires.

Example: If MN/RUG is approved with an effective date of May 13, 2017, the system-generated end date for the Level of Service record will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the Level of Service record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend a Level of Service record for a STAR+PLUS HCBS program applicant:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select the check box for the Level of Service record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If a Level of Service record has not been created in SAS, complete the following steps to add the record:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

 

 

9160 Medical Necessity

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information to Texas Medicaid & Healthcare Partnership (TMHP). After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision and it is stored in the Service Authorization System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the MN determination expires.

Example: If MN is approved with an effective date of May 13, 2017, the system-generated end date will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the MN record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend an MN record for a STAR+PLUS Home and Community Based Services (HCBS) program applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select the check box for the MN record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SAS, complete the following steps to add the record:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Move to the MN field and select Y - YES from the drop-down menu.
  4. Move to the Permanent field and select N – NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

Situations in which the MN record must be forced:

The MN record must be forced in SAS to register an MN determination for these situations:

To force register MN for a STAR+PLUS HCBS program applicant/member:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Move to the MN field and select Y - YES from the drop-down menu.
  4. Move to the Permanent field and select N – NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Move to the Force field and set the Force Flag. Enter Comments explaining why the record is being forced.
  8. Select Force.
  9. Select the Save button.
  10. Select Submit to SAS to submit the authorization.
  11. Select Outbox and then Inbox to ensure the case processed accurately.

 

 

9170 Diagnosis

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to Texas Medicaid & Healthcare Partnership (TMHP). After TMHP determines MN and computes the RUG value, this information along with the diagnosis code(s) is transmitted to the Texas Health and Human Services Commission (HHSC) and stored in the Service Authorized System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that is extended through the last day of the month in which the determination expires.

Example: If MN is approved with an effective date of Nov. 13, 2017, the system-generated end date will be Nov. 12, 2018. If the individual service plan (ISP) period is Dec. 1, 2017 to Nov. 30, 2018, the diagnosis record will need to be extended to Nov. 30, 2018, so the member has diagnosis coverage for the entire ISP period.

To extend a diagnosis record for a STAR+PLUS Home and Community Based Services (HCBS) program applicant/member:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select the check box for the Diagnosis record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If a diagnosis record has not been created in SAS, complete the following steps to add the record:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version at the default.
  8. Select the Save button.

 

 

9200 Reassessment Service Authorization

Revision 17-1; Effective March 1, 2017

 

When authorizing STAR+PLUS Home and Community Based Services (HCBS) program services for a reassessment of the individual service plan (ISP), check or create the following records according to the instructions for each record:

 

 

9210 Authorizing Agent – Reassessment

Revision 17-1; Effective March 1, 2017

 

Check the record for accuracy. If there are no changes, leave the record open-ended. Currently, although the Service Authorization System (SAS) will accept multiple authorizing agent records, Texas Medicaid & Healthcare Partnership (TMHP) will only accept two authorizing agent records when a SAS file is transmitted to TMHP. Therefore, select NO in the Send to TMHP field for all updates.

 

9220 Enrollment – Reassessment

Revision 17-1; Effective March 1, 2017

 

Check the Enrollment record for accuracy and to be sure it is open-ended. If it is open-ended, make no changes. If it has an End Date, delete the End Date or create another record with a new Begin Date. To ensure that there is not a gap in service, the Begin Date of the enrollment for the new ISP year is the day after the End Date of the previous ISP year.

 

9230 Service Plan – Reassessment

Revision 17-1; Effective March 1, 2017

 

A new Service Plan record must be created to register the Resource Utilization Group (RUG) cost level and the amount of services authorized for the new individual service plan (ISP) year.

Because the ISP is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). Program Support Unit (PSU) does not register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

 

9240 Service Authorization – Reassessment

Revision 17-1; Effective March 1, 2017

 

If the managed care organization (MCO) posts a timely reassessment packet, Program Support Unit (PSU) staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for the new individual service plan (ISP) year. To ensure there is no gap in service, the Begin Date of the authorization for the new ISP year is the day after the End Date of the previous ISP year.

Because the ISP is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). PSU does not need to register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

If the MCO does not post a timely reassessment packet, two service authorization records will be required for STAR+PLUS HCBS program eligibility. The first service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 13 for the month(s) for which the ISP was late. The second service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 12 for the remaining ISP period.

To enter a service authorization record for an untimely reassessment for STAR+PLUS HCBS program eligibility for a member whose ISP is not electronic:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 13 – NURSING SERVICES  from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 4 – PER AUTHORIZATION from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the new ISP coverage period.
  11. Move to the End Date field and enter the last day of the new ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup Medicaid RSA West 1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026328

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

To register a service authorization record for STAR+PLUS HCBS program eligibility for the remainder of the ISP period:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT  from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select  4 – PER AUTHORIZATION from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount field at the default.
  10. Move to the Begin Date field and enter the day after the end date of the Service Code 13 record entered above. (This should be the first of the month after the month the late reassessment packet was received.)
  11. Move to the End Date field and enter the last day of the month the packet was received.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include MMP.
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid RSA Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

9250 Level of Service – Reassessment

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) value registered on a Level of Service record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to TMHP. After TMHP determines MN and computes the RUG value, this information is transmitted and stored in the SAS database.

This record is system-generated from the information stored in the SAS database. This system-generated record will have a Begin and End Date that matches the new individual service plan (ISP) year.

Example: A member with an initial ISP coverage period of Dec. 1, 2017 through Nov. 30, 2018 is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective Dec. 1, 2017 through Nov. 30, 2018. These new Begin and End Dates will be system-generated in the Level of Service record.

 

9260 Medical Necessity – Reassessment

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment for the annual reassessment and submits the information from this form to Texas Medicaid & Healthcare Partnership (TMHP). After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where it is stored in the Service Authorization (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have a Begin Date and an End Date that matches the newly certified individual service plan (ISP) year.

Example: A member with an initial ISP coverage period of Feb. 1, 2017 through Jan. 31, 2018 is re-authorized for STAR+PLUS Home and Community Based Service (HCBS) program eligibility. The new ISP year will be effective Feb. 1, 2017 through Jan. 31, 2018. These new Begin and End Dates will be system generated in the MN record. The MN record must be forced in SAS to register an MN determination for a reassessment when the MN is approved in the portal but will not convert to SAS because of a mismatch of member information between the MN/LOC Assessment and TIERS.

 

9270 Diagnosis – Reassessment

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a diagnosis registered on a Diagnosis record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to TMHP. After TMHP determines MN and computes the Resource Utilization Group (RUG) value, this diagnosis information is transmitted to the Texas Health and Human Services Commission (HHSC) and stored in the Service Authorization System (SAS) database.

This record is system-generated from the information stored in the SAS database. This system-generated record will have a Begin and End Date that matches the new ISP year.

Example: A member with an initial ISP coverage period of Nov. 1, 2017 through Oct. 31, 2018 is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective Nov. 1, 2017 through Oct. 31, 2018. These new Begin and End Dates will be system-generated in the Diagnosis record.

 

9300 Transfers

Revision 17-1; Effective March 1, 2017

 

There are several situations that are considered transfers for STAR+PLUS Home and Community Based Service (HCBS) program members, and the procedures differ for each.

 

9310 Transfers from One STAR+PLUS Area to Another STAR+PLUS Area

Revision 17-1; Effective March 1, 2017

 

There are two different situations that can occur when a STAR+PLUS member transfers from one service area to another service area. The first is when a member transfers to a new service area that his current managed care organization (MCO) also serves, and he or she wants to stay with that MCO. Even though he or she is staying with the same MCO, the contract number will change and his records will need to be closed under the previous contract number and opened under the new contract number. The second is when the member changes MCOs in the new service area.

If the member's individual service plan (ISP) is electronic and the member made a new MCO selection timely, the Texas Integrated Eligibility Redesign System updates the Long Term Care (LTC) portal, which automatically closes the registration for the losing MCO and creates the registration for the gaining MCO in the Service Authorization System. If the member's plan change is not timely, the Program Support Unit (PSU) follows existing policy, stated below.

To process the transfer, the losing PSU staff close the existing Authorizing Agent and Service Authorization (SC 12) records. The gaining PSU staff open a new Service Authorization record (SC 12) using the MCO contract number in the new service area.

To close the authorizing agent record:

  1. Open the STAR+PLUS Home and Community Based Services (HCBS) program member’s case in the Service Authorization System (SAS).
  2. Select the Authorizing Agent area from the Case Worker Functional area.
  3. Select the check box for the Authorizing Agent record you wish to close.
  4. Select the Modify button to open and modify.
  5. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member moved to the new service area.
  6. Select the Save button.

To close the authorizing agent record:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for the appropriate Service Authorization (SC 12) record you wish to close.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and enter the effective date of the termination. This will be the last day of the month in which the member moved to the new service area.
  5. Move to the Termination Code field and select “23 - Transferred to another service” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SAS.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

Once the gaining PSU staff verify the month in which the member moves to the new service area, he is responsible for opening the Authorizing Agent and Service Authorization (SC 12) records necessary to authorize the STAR+PLUS HCBS program in the new service area.

The Service Authorization records are opened according to procedures outlined in Initial Service Authorizations for STAR+PLUS HCBS program members with the following exceptions:

Example: If a  STAR+PLUS HCBS program member with an ISP period of Nov. 1, 2017 to Oct. 31, 2018 transfers to another STAR+PLUS service area on Jan. 15, 2018, the End Date for these records remains Oct. 31, 2018.

 

9320 Transfers from One Managed Care Organization to Another Managed Care Organization in the Same Service Area

Revision 17-1; Effective March 1, 2017

 

If the member's individual service plan (ISP) is electronic and the member made a new managed care organization (MCO) selection timely, the Texas Integrated Eligibility Redesign System updates the Long Term Care (LTC) portal, which automatically closes the registration for the losing MCO and creates the registration for the gaining MCO in the Service Authorization System (SAS). If the member's plan change is not timely, the Program Support Unit (PSU) follows existing policy, stated below.

The Program Support Unit (PSU) processes the request by closing the existing Service Authorization record (SC 12) for the losing MCO and creating a new Service Authorization record (SC 12) for the gaining MCO.

To close the existing service authorization records:

  1. Move to the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for the appropriate Service Authorization record you wish to close.
  3. Select the Modify button.
  4. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member was enrolled in the losing MCO.
  5. Move to the Termination Code field and select “39 – Other” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SAS.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

To create a new service authorization record for the new MCO:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the new MCO contract number/plan code enrollment date.
  11. Move to the End Date field; the end date for the service authorization record is the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.
  3. Select Submit to SAS.
  4. Select Outbox and then Inbox to ensure the case processed accurately.

 

9400 Follows the Person Authorization for a STAR+PLUS Home and Community Based Services Program Applicant

Revision 17-1; Effective March 1, 2017

 

After the Program Support Unit (PSU) verifies that the individual left the nursing facility, PSU staff complete the following steps listed below. PSU does not close the Authorizing AgentMedical NecessityLevel of Service Resource Utilization Group (RUG) records. PSU must also ensure Provider Claims Services closes the enrollment and service authorization records for Service Codes 1 or 350, and 60.

For individuals who are not enrolled in STAR+PLUS until they begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program, create a one-day service authorization record for the first day of the month in which a Money Follows the Person (MFP) individual is discharged from a nursing facility, unless the individual discharges on the first of a month.

Example: An individual who is not enrolled in STAR+PLUS leaves the nursing facility and begins the STAR+PLUS HCBS program on Dec. 25, 2017. PSU staff register the initial individual service plan (ISP) in the Service Authorization System (SAS) with an effective date of Dec. 25, 2017 through Dec. 31, 2018. In addition to registering the initial ISP, PSU staff create all the records listed below with a Begin Date of Dec. 1, 2018, and an End Date of Dec. 1, 2018.

Add the following records for Service Group 19 to check or create the one-day service authorization:

A one day overlap of the records listed is allowed.

Note: Individuals released from a nursing facility and authorized for STAR+PLUS HCBS program services should be enrolled under MFP. In the Enrollment record, select "12 – MONEY FOLLOWS THE PERSON” from the drop-down menu in the Enrolled From field. Do not use “Enrolled from nursing facility” to designate MFP members.

To authorize STAR+PLUS HCBS program eligibility for an MFP applicant:

After creating the one-day records above, when applicable, create the records needed for the ongoing MFP STAR+PLUS HCBS program eligibility. These records must be completed to check or create an initial service authorization for the STAR+PLUS HCBS program:

 

9410 Authorizing Agent for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

There will be one authorizing agent registered for a Money Follows the Person (MFP) applicant.

The Program Support Unit (PSU) or Texas Health and Human Services Commission Enrollment Resolution Services (ERS) staff are registered as the authorizing agent when the initial authorization is authorized.

To register an authorizing agent for an MFP applicant:

  1. Select the Authorizing Agent area in the Case Worker Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Type field and select CM - CASE MANAGER from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the date the record is being created. Leave the End Date field blank.
  7. Move to the Authorizing Agent ID field and enter STAR+PLUS.
  8. Leave the Agency field at the default selection 324 - DHS.
  9. Move to the Name field and enter the PSU/ERS staff’s name.
  10. Move to the Phone field and enter the telephone number of the authorizing agent. Enter the area code, phone number and extension.
  11. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) Plan Code. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service Area MCO Plan Name MCO Plan Code

Bexar

Amerigroup

45

Molina

46

Superior

47

Amerigroup MMP 4F
Molina MMP 4G
Superior MMP 4H

Dallas

Molina

9F

Superior

9H

Molina MMP 9J
Superior MMP 9K

El Paso

Molina

33

Amerigroup

34

Molina MMP 3G
Amerigroup MMP 3H

Harris

Amerigroup

7P

United Healthcare

7R

Molina

7S

Amerigroup MMP 7Z
United Healthcare MMP 7Q
Molina MMP 7V

Hidalgo

Cigna-HealthSpring

H7

Molina

H6

Superior

H5

Cigna-HealthSpring MMP H8
Molina MMP H9
Superior MMP HA

Jefferson

Amerigroup

8R

United Healthcare

8S

Molina

8T

Lubbock

Amerigroup

5A

Superior

5B

Medicaid Rural Service Area (RSA) Central Texas Superior C4
United Healthcare C5
Medicaid RSA
Northeast Texas
Cigna-HealthSpring N3
United Healthcare N4
Medicaid RSA
West Texas
Amerigroup W5
Superior W6

Nueces

United Healthcare

85

Superior

86

Tarrant

Amerigroup

69

Cigna-HealthSpring

6C

Amerigroup MMP 6F
Cigna-HealthSpring MMP 6G

Travis

Amerigroup

19

United Healthcare

18

  1. Select the Save button.

 

 

9420 Enrollment for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

To register an authorizing agent for a Money Follows the Person (MFP) applicant:

  1. Select the Enrollment area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu. If this is an MFP authorization, be sure to select 12 - MONEY FOLLOWS THE PERSON from the drop-down menu.
  5. Move to the Living Arrangement field, and select the appropriate community-based living arrangement from the drop-down menu.
  6. Move to the Begin Date field and enter the date the member is enrolled in his MCO, which will always be the first day of a month. Leave the End Date field blank.
  7. Leave the Termination Code and Waiver Type at the defaults.
  8. Select the Save button.

 

 

9430 Service Plan for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

The Service Plan record is used to register an individual service plan (ISP) for a STAR+PLUS Home and Community Based Services (HCBS) program member. The record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost of STAR+PLUS HCBS program services taken from the member’s Form H1700-1, Individual Service Plan.

To register a service plan for a Money Follows the Person (MFP) applicant:

  1. Select the Service Plan area in the Program and Service Functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost ceiling for the RUG value entered on the Level of Service record. For a STAR+PLUS HCBS program member who uses a ventilator, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).

Move to the Begin Date field and enter the effective date of the ISP coverage period.

  1. Move to the End Date field and enter the last day of the ISP coverage period.
  2. Move to the Amount Authorized field and enter the total estimated cost of all  STAR+PLUS HCBS program services authorized for the current ISP coverage period from Form H1700-1.
  3. Leave the Amount Paid field at the default setting of 0.00.
  4. Leave the Units Authorized field at the default of 0.00.
  5. Leave the Units Paid field at the default of 0.00.
  6. Select the Save button.

 

9440 Service Authorization for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

Program Support Unit (PSU) staff create one service authorization record for  STAR+PLUS HCBS program eligibility.

To register a service authorization record for a Money Follows the Person (MFP) applicant:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop down list.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  11. Move to the End Date field and enter the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

 

9450 Level of Service

Revision 17-1; Effective March 1, 2017

 

There will be an existing Service Group 1 (NF) Level of Service record. However, the Program Support Unit (PSU) will be required to create a new Level of Service record for Service Group 19 STAR+PLUS Home and Community Based Services (HCBS) program. The Service Group 1 (NF) Level of Service record can remain open.

To add a Level of Service record, complete the following steps:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

 

 

9460 Medical Necessity for a  Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information to Texas Medicaid & Healthcare Partnership (TMHP) or uses the nursing facility (NF) minimum data set. After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Service Authorization System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the MN determination expires.

Example: If MN is approved with an effective date of May 13, 2017, the system-generated end date will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the MN record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend an MN record for an MFP applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select the check box for the existing MN record.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SAS, complete the following steps to add the record:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Leave the MN field at the default of Y - YES.
  4. Leave the Permanent field at the default of N - NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

Situations in which the MN record must be forced:

The MN record must be forced in SAS to register an MN determination for these situations:

To force register MN for an MFP applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Leave the MN field at the default of Y - YES.
  4. Leave the Permanent field at the default of N - NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Force button and enter the reason for the force under Force Comments.
  8. Select the Save button.

 

9470 Diagnosis

Revision 17-1; Effective March 1, 2017

 

There will be an existing Service Group 1 Diagnosis record. The Program Support Unit (PSU) must create a new Diagnosis record for Service Group 19 STAR+PLUS Home and Community Based Services (HCBS) program.

To add a Service Group 19 Diagnosis record in the Service Authorization System (SAS), complete the following steps:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version field at the default.
  8. Select the Save button.

 

 

9480 Money Follows the Person Demonstration for a STAR+PLUS Home and Community Based Services Program Applicant

Revision 17-1; Effective March 1, 2017

 

At this time, the option to electronically submit an individual service plan (ISP) for a nursing facility (NF) resident is not available. Managed care organizations (MCOs) must not use the Long Term Care (LTC) portal Money Follows the Person Demonstration (MFPD) check box. The Program Support Unit (PSU) continues to manually register this fund code in the Service Authorization System (SAS).

Follow the instructions for a Money Follows the Person (MFP) applicant above, with the Service Authorization record completed as follows.

  1. Select the Service Authorization area in the Program and Service Functional Area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Move to the Fund field and select 19MFP – MONEY FOLLOWS PERSON.
  6. Leave the Term. Code field at the defaults.
  7. Leave the Agency field at the default selection 324 - DHS.
  8. Move to the Unit Type field and select 2 – MONTH from the drop down list.
  9. Move to the Units field and enter 1.00.
  10. Leave the Amount field at the default.
  11. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  12. Move to the End Date field and enter the last day of the ISP coverage period.
  13. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces