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

Revision 19-1; Effective June 3, 2019

 

 

1100 Program Overview

Revision 19-1; Effective June 3, 2019

 

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 (ADLs), home modifications, respite (short-term supervision) and personal assistance services (PAS). 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 (NF) 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 19-1; Effective June 3, 2019

 

Statutory basis for the STAR+PLUS program:

 

1120 Values

Revision 19-1; Effective June 3, 2019

 

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 18-2; Effective September 3, 2018

 

 

 

1131 Service Delivery Model

Revision 19-1; Effective June 3, 2019

 

Individuals enrolled in the STAR+PLUS program may select a service 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, including adult foster care (AFC) homes or in licensed assisted living facilities (ALFs).

The STAR+PLUS HCBS program provides individuals with an array of services necessary to allow the individual to remain in or return to a community setting. Providers are contracted with managed care organizations (MCOs) to provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). 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 individuals not eligible for Supplemental Security Income (SSI). SSI eligible individuals are Medicaid eligible and can obtain STAR+PLUS HCBS program services without additional financial screening. (Refer to 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 18-2; Effective September 3, 2018

 

 

 

1141 Services Available Under STAR+PLUS

Revision 19-1; Effective June 3, 2019

 

If the service coordinator identifies a need, or the member requests additional services, the managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP). 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. Refer to 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 19-1; Effective June 3, 2019

 

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 (FFS) 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 FFS Medicaid coverage:

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members and prescription drugs.  STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual (TMPPM) 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 19-1; Effective June 3, 2019

 

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

 

1143.1.2 Long-term Services and Support Listing

Revision 19-1; Effective June 3, 2019

 

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

 

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

Revision 19-1; Effective June 3, 2019

 

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 MCO Service Coordination

Revision 19-1; Effective June 3, 2019

 

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 (LTSS), has a history of behavioral health issues or substance use disorders (SUD), 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 (NF), the MCO service coordinator must meet with the member face-to-face at a minimum of four times per year.

All applicants or recipients of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) 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 or 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 NFs, 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, STAR+PLUS HCBS Program Eligibility and Services, Section 6000, Specific STAR+PLUS HCBS 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 19-1; Effective June 3, 2019

 

Members residing in a nursing facility (NF), (except members receiving hospice care or living outside the managed care organization (MCO) service 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:

 

1220 MCO Service Coordinators and Programs Serving Members with Intellectual or Development Disabilities

Revision 19-1; Effective June 3, 2019

 

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 the STAR+PLUS program and continue to receive their long-term services and supports (LTSS) through the 1915(c) Medicaid waivers:

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

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 authorized representative's (AR's) personal preference.

These members also have a LIDDA provider that is a person(s) outside of the MCO who develops and implements an individual service plan (ISP) 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 the 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 19-1; Effective June 3, 2019

 

The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves individuals who have severe and persistent mental illness (SPMI) and:

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 (FFS) basis through the Texas Health and Human Services Commission (HHSC). Each individual 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 (PPOC)

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 (UMCC), Section 8.3.2.5.

 

1240 MCO Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 19-1; Effective June 3, 2019

 

The Section 811 Project Rental Assistance (PRA) program 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).

Provision of Services

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. Continued participation in these services is voluntary and not a prerequisite for remaining in Section 811 PRA housing.

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. 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 may delegate this responsibility to the relocation specialist. If eligible, the MCO service coordinator must assist eligible individuals in accessing funding available to assist with relocations.

Communication between MCO and Texas Health and Human Services Commission (HHSC)

The MCO service coordinator must coordinate with the HHSC Section 811 Point of Contact (HHSC POC) on an ongoing basis regarding members participating in the Section 811 PRA program. The HHSC 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.

MCO Responsibilities – Helping Potential Applicants

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:

MCO Point of Contact Requirements – for Potential Applicants

For members who have applied to the Section 811 PRA program, the MCO must update information that was collected at the time of application to the program, if anything changes. This will ensure the member can be contacted and the information on file with TDHCA is accurate. The MCO must ensure the HHSC Section 811 POC and the TDHCA POC have the means to identify and contact the member within one business day of receiving a notice that a Section 811 PRA program unit is available.

MCO Responsibilities – for Existing Tenants

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 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, owner's designee, or TDHCA POC.

MCO Point of Contact Requirements – for Existing Tenants

MCO service coordinators serving members who are participating in the Section 811 PRA program must ensure that the HHSC POC has the MCO service coordinator’s contact information. If the MCO service coordinator information changes or is no longer fulfilling the roles and responsibilities associated with the Section 811 PRA program for a member, the MCO service coordinator must notify the HHSC POC.

Additional references for Section 811 Program Requirements for MCOs

MCO service coordinators serving members exiting an NF 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, available on TDHCA's webpage.

If requested by HHSC, the MCO service coordinator or designee must attend training on the Section 811 PRA program. Trainings can include, but are not limited to, in-person training, webinars, conference calls or responding to requests via email.

 

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

Revision 19-1; Effective June 3, 2019

 

Individuals eligible for Medicaid through the Medicaid for Breast and Cervical Cancer (MBCC) program are a mandatory population in the STAR+PLUS program. The MBCC program provides Medicaid services including, but not limited to, the treatment of cancer and precancerous conditions for individuals with qualifying diagnoses between age 18 and their 65th birth month. An MBCC program member 18 to 20 years of age will be enrolled in STAR+PLUS. Eligibility for the MBCC program allows an individual under the age of 21 to participate in the STAR+PLUS program. Individuals in the MBCC program 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 breast or cervical cancer or pre-cancer. The physician attestation and eligibility paperwork must be submitted every six months.

An MBCC individual under 21 can also be on the Medically Dependent Children Program (MDCP) interest list. If the individual reaches the top of the MDCP interest list, the individual can transfer from STAR+PLUS into MDCP since MDCP provides additional services not available in STAR+PLUS or the STAR+PLUS HCBS programs. Upon release from the MDCP interest list, the individual will be processed as a STAR member transitioning to MDCP.

When the individual reaches age 21, the MDCP member will transfer to STAR+PLUS HCBS program as a medical assistance only (MAO) upgrade using the high needs transition process.

MBCC members age 21 or older requesting STAR+PLUS HCBS program services can be upgraded to the STAR+PLUS HCBS program without going on the interest list. However, PSU staff must send an enrollment packet that includes Form H1200, Application for Assistance – Your Texas Benefits, as Medicaid for the Elderly and People with Disabilities (MEPD) is required to assess the Medicaid application using ME-Waiver eligibility rules.

After the enrollment packet is received, PSU staff will send Form H1200, along with Form H1746-A, MEPD Referral Cover Sheet, to MEPD. If the individual is eligible as an MAO applicant, MEPD will change the individual’s Medicaid from MBCC to ME-Waivers in the Texas Integrated Eligibility Redesign System (TIERS).