Section 6000, Specific STAR+PLUS HCBS Program Services

Revision 20-2; Effective October 1, 2020

 

 

6100 Home and Community Based Services

Revision 18-2; Effective September 3, 2018

 

 

 

6110 Program Overview

Revision 18-2; Effective September 3, 2018

 

 

 

6111 Service Introduction

Revision 19-1; Effective June 3, 2019

 

The service array under the STAR+PLUS Home and Community Based Services (HCBS) 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 (ALFs) 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 STAR+PLUS HCBS Program

Revision 19-1; Effective June 3, 2019

 

All services through the STAR+PLUS Home and Community Based Services (HCBS) program, except minor home modifications (MHMs), 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 a STAR+PLUS HCBS program member residing in an assisted living facility (ALF) contracted to provide STAR+PLUS HCBS program services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, Section 441.530(a)(2), the following locations are excluded from STAR+PLUS HCBS program service locations, with the exception of out-of-home respite care:

 

6113 General Requirements for MCOs

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) must coordinate and ensure delivery and initiation of the array of services in accordance with Form H1700-1, Individual Service Plan (Pg. 1). Services include:

The MCO must identify, coordinate and when applicable, authorize available value added services, Medicare and other third-party resources (TPRs) before authorizing those services on the member's individual service plan (ISP). Refer to specific service descriptions for exceptions or limitations.

 

6114 Service Plan

Revision 19-1; Effective June 3, 2019

 

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 functional assessment documentation to the provider when requested. The MCO will upload 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 through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal or TMHP Electronic Data Interchange.

The MCO registered nurse (RN) service coordinator or MCO contracted RN service coordinator and the member or authorized representative (AR) 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 authorizations are permitted for ISP changes, as long as the name of the person who gave the verbal authorization and the date the verbal authorization 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 18-2; Effective September 3, 2018

 

Managed care organizations (MCOs) may choose to provide services through other pay arrangements with individuals awaiting determination of STAR+PLUS Home and Community Based Services (HCBS) program eligibility. MCOs will not be reimbursed for services delivered prior to the determination of STAR+PLUS HCBS program 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 (ISP) when gratuitous care or care by other resources is being provided.

 

6116 Refusal to Serve Members

Revision 18-2; Effective September 3, 2018

 

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 (MCO). 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. The provider must work with the MCO to coordinate alternative provider agency arrangements. The MCO must coordinate the transfer of services on behalf of the member.

 

6117 Service Planning

Revision 19-1; Effective June 3, 2019

 

Services and care provided, as identified and authorized on Form H1700-1, Individual Service Plan (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 her or his 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. The service planning process must be person-centered and the individual service plan (ISP) must reflect the member’s goals, needs, strengths and preferences with regard to the manner of delivery of STAR+PLUS Home and Community Based Services (HCBS) program services. Members must be encouraged and allowed to play an active role in determining their ongoing plan of care (POC).

MCOs must recognize and support the member's right to a dignified existence, privacy and self-determination.

 

6118 Personal Assistance Services

Revision 18-2; Effective September 3, 2018

 

Personal assistance services (PAS) provide assistance to members in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the member’s needs. Most members will receive PAS through Community First Choice (CFC), with the exception of members who are medical assistance only (MAO), or members who also require protective supervision. Protective supervision is not a benefit of CFC.

PAS includes assistance with the performance of ADLs and IADLs necessary to maintain the home as a clean, sanitary and safe environment. PAS is provided to the member, as authorized on Form H1700-1, Individual Service Plan (Pg. 1), or as delivered through CFC. 

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service. Federal and state rules prohibit a spouse from being a paid PAS provider.

 

6118.1 Description of Personal Assistance Services

Revision 19-1; Effective June 3, 2019

 

Shopping

Shopping is intended for the purchase of groceries, medications, or other items that support the health, safety, and well-being of a member. This may be done by the attendant on behalf of the individual or the attendant may accompany the individual to assist with this task. 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 or 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 authorized representative (AR)) 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, Form H6516 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 member'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 receipt or exchange of health information by the attendant. Escort services may be provided for safety needs, to enter or exit a building, or to remain safe during wait time while attending medical appointments. Transportation for Medicaid members to Medicaid appointments is available in every county through the Medical Transportation Program (MTP). Transportation is not included as an activity in the escort task.

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 her or his cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn herself or himself, 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. Protective supervision is not a benefit of CFC and can be on a member’s individual service plan (ISP), even if the member receives CFC.

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 PAS attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance or 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 19-1; Effective June 3, 2019

 

Personal assistance services (PAS) are performed by personal care attendants who:

 

6200 Nursing Services

Revision 18-2; Effective September 3, 2018

 

Nursing services are services that are within the scope of the Texas Nursing Practice Act and are provided by a registered nurse (RN) (or licensed vocational nurse (LVN) under the supervision of an RN) 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 STAR+PLUS Home and Community Based Services (HCBS) program cover nursing tasks associated with 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 services provided which exceed benefits allowed under the state plan.

Nursing services purchased through the STAR+PLUS HCBS program 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 STAR+PLUS HCBS program, the managed care organization (MCO) is responsible for coordinating services following a significant change in the member's condition. The MCO may become aware of a significant change in condition through interaction with members, family or an authorized representative (AR), and by performing interim assessments on current STAR+PLUS HCBS program members. The MCO is responsible for initiating appropriate services and supports to meet the care and well-being of the member interventions on a timely basis.

 

6210 Settings

Revision 18-2; Effective September 3, 2018

 

Nursing services can be delivered in a member's own home or family home, in a personal care facility, assisted living facility (ALF) or an adult foster care (AFC) setting. Nursing services purchased through the STAR+PLUS Home and Community Based Services (HCBS) program may not be provided in the following settings as defined in 42 Code of Federal Regulations (CFR), §441.530(a)(2):

 

6220 Nursing Services to Meet Member Needs

Revision 18-2; Effective September 3, 2018

 

All STAR+PLUS Home and Community Based Services (HCBS) program members meet medical necessity (MN) and have a need for one or more nursing tasks, as described in the Texas Administrative Code (TAC), Title 40, §19.2401. It is the responsibility of the managed care organization (MCO) service coordinator to identify and document in the individual service plan (ISP) or Form H1700-B, Non-STAR+PLUS HCBS Program Services, 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), informal support, or a combination, as described below:

For information about delegation and HMAs, refer to the TAC for Texas Board of Nursing, Title 22, Part 11, Chapters 224 and 225.

 

6230 Nursing Services in Assisted Living Facilities

Revision 20-1; Effective March 16, 2020

 

Assisted living facilities (ALFs) must have sufficient staff to assist with member medication regimens (Texas Administrative Code (TAC), Title 26, §553.41). Nursing for this task may be included on the individual service plan (ISP), depending on the member’s needs and the facility type. Licensed nurses who own an ALF or are employed by the facility may directly administer medication to members residing in ALFs, but are not required to do so. In ALFs, 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.

If, because of licensure, an ALF does not provide nursing services, other facility employees may not deliver services other than personal assistance services (PAS) and administration of medications. If a resident needs additional services that are not available in the ALF, the managed care organization (MCO) must ensure the member’s needs are met. The MCO may do so through contract with a Home and Community Support Services Agency (HCSSA) or an independent health care provider.

PAS provided by the ALF include 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 ALF; or assistance to a member to manage her or his personal life, regardless of whether a guardian has been appointed for the person.

 

6240 Nursing Services in Adult Foster Care Homes

Revision 18-2; Effective September 3, 2018

 

Based upon the assessment performed by the managed care organization (MCO) registered nurse (RN) service coordinator, 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 STAR+PLUS Home and Community Based Services (HCBS) program, depending on the member's assessed need and the AFC home classification. See Section 7133 Classification Levels, for additional information.

 

6250 Specialized Nursing

Revision 18-2; Effective September 3, 2018

 

Specialized nursing services delivered by a registered nurse (RN) or licensed vocational nurse (LVN) are available through the STAR+PLUS Home and Community Based Services (HCBS) program. Specialized nursing services may be used when a member requires, as determined by a physician, daily skilled nursing to:

 

6300 Therapy Services

Revision 19-1; Effective June 3, 2019

 

Therapy services provided through the STAR+PLUS Home and Community Based Services (HCBS) program 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 her or his 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 her or his own transportation or accessing the Medicaid Medical Transportation Program (MTP).

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 (AFC) or an assisted living (AL) setting and therapy is provided in an outpatient center or clinic (see Section 6112, Service Locations for STAR+PLUS HCBS Program), the AL provider or AFC provider is responsible for arranging for transport or directly transporting the member.

Occupational therapy (OT), physical therapy (PT), speech therapy (ST) and cognitive rehabilitative therapy services are covered by the STAR+PLUS HCBS program only after the member has exhausted her or his therapy benefit under Medicare, Medicaid or other third-party resources (TPRs). Providers contracted with the managed care organization (MCO) must provide the OT, PT, ST and cognitive rehabilitation therapy (CRT) services as identified on the member's individual service plan (ISP). 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 (CDS) Option.

PT 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 PT assistant directly supervised by a licensed physical therapist. PT 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.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist.

ST in the STAR+PLUS HCBS program 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 STAR+PLUS HCBS program 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 18-2; Effective September 3, 2018

 

Upon member request or recommendation from the nurse, primary care provider or service coordinator for a therapy assessment, the managed care organization (MCO) service coordinator must work with the member to select a provider for the assessment. The assessment must be submitted by the provider for the MCO to authorize service hours based on physician orders and medical necessity (MN) review.  Any therapy for the management of a chronic condition must be included on the individual service plan (ISP).

 

6320 Responsibilities of Licensed Therapists in STAR+PLUS HCBS Program

Revision 18-2; Effective September 3, 2018

 

Responsibilities of the licensed therapists include, but are not limited to, the following:

 

6330 Cognitive Rehabilitation Therapy

Revision 18-2; Effective September 3, 2018

 

Cognitive rehabilitation therapy (CRT) 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 (MN) through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the individual service plan (ISP) 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 19-1; Effective June 3, 2019

 

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 (ADLs), or to perceive, control or communicate with the environment in which they live. Adaptive aids and medical supplies are reimbursed with STAR+PLUS Home and Community Based Services (HCBS) program funds, when specified in the individual service plan (ISP), 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 ISP year. The managed care organization (MCO) may exceed the $10,000 cost limit; however, the MCO must not include any costs over the $10,000 on any cost reports, claims, encounters or financial statistical reports. 

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's 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 18-2; Effective September 3, 2018

 

Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted state plan benefits and any third-party resources (TPRs), including product warranties or Medicare and Medicaid home health the member is eligible to receive.

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 managed care organization (MCO) contracted provider must:

Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of but are not limited to following:

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.

The STAR+PLUS HCBS program 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 the STAR+PLUS HCBS program does not pay for restraints.

Gloves

Gloves may be purchased through the STAR+PLUS HCBS program for family or caregiver use in the care of a member with incontinence, or if the member has an active infectious disease that is transmitted via body fluids. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis. Gloves may be purchased for family or 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 or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using STAR+PLUS HCBS program 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 20-2; Effective October 1, 2020

 

In the initial pre-enrollment assessment and at reassessment, the managed care organization (MCO) service coordinator identifies the basic needs of the member for adaptive aids and STAR+PLUS Home and Community Based Services (HCBS) program medical supplies along with the estimated costs on Form H1700-1, Individual Service Plan (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 member's ordering, referring or prescribing provider. This can be a physician, physician assistant, nurse practitioner, registered nurse (RN), physical therapist, occupational therapist or speech pathologist. The service coordinator must use Form H1700-A, Rationale for STAR+PLUS HCBS Program 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 STAR+PLUS HCBS program 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). The acute care benefit for any equipment or medical supplies must be expended before STAR+PLUS HCBS program benefits may be used.

If the member's request for a particular adaptive aid or medical supply is denied, the member must receive written notice of action 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 must send a notice of action 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 must send a notice of action 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 and used to support or increase level of independence.

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 ISP to exceed the annual cost limit, the nurse may authorize the service 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 18-2; Effective September 3, 2018

 

Lift chairs may be authorized as adaptive aids as part of the STAR+PLUS Home and Community Based Services (HCBS) program 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 member to determine if the member meets all of the following criteria required for Medicare to pay for the lift mechanism:

Member Does Not Meet All Criteria

If the member does not meet all of the Medicare criteria, the MCO completes Form H1700-A, Rationale for STAR+PLUS HCBS Program 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.

Member Meets All Criteria

If the MCO determines the member 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 STAR+PLUS HCBS program 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 18-2; Effective September 3, 2018

 

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 MCO which authorized the service is responsible for payment and delivery of the adaptive aid.

 

6440 Temporary Lease and Equipment Rental

Revision 18-2; Effective September 3, 2018

 

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 (MCO) must document the equipment functions properly and is appropriate for the member, so STAR+PLUS Home and Community Based Services (HCBS) program funds may be expended.

 

6450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 18-2; Effective September 3, 2018

 

 

 

6451 Time Frames for Adaptive Aids

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized (except for vehicle modifications) 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. The MCO must authorize a vehicle modification on the effective date of the member’s ISP. The MCO must work with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

 

6452 Time Frames for Medical Supplies

Revision 18-2; Effective September 3, 2018

 

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Home and Community Based Service (HCBS) program 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 18-2; Effective September 3, 2018

 

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 (TPRs). 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 her or his premium deductible under a TPR for items covered under the STAR+PLUS Home and Community Based Services (HCBS) program, the deductible can be listed under adaptive aids on Form H1700-1, Individual Service Plan (Pg. 1), for payment.

 

6470 Bulk Purchase of Medical Supplies

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) 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 18-2; Effective September 3, 2018

 

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 (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.

The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), 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 18-2; Effective September 3, 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 Home and Community Based Services (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 the member's provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.

The annual cost limit of this service is $5,000 per individual service plan (ISP) 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.

 

6520 Documentation of Dental Services by a Dentist

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) or its contractor 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 (MN) for dental treatment and submit a detailed treatment plan to the MCO to document the MN and all specific dental procedures to be completed. The dentist may not bill the STAR+PLUS Home and Community Based Services (HCBS) program member for the remainder of the cost over the approved amount.

Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services, must be completed by the MCO to document the medical need for requested STAR+PLUS HCBS program items or services. MN for dental services is completed by the professional dentist, 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 20-1; Effective March 16, 2020

 

The managed care organization (MCO) must work with the member to identify a dental provider or contracted provider no later than the first day of the member’s individual service plan (ISP). The 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.

 

6600 Minor Home Modifications

Revision 18-2; Effective September 3, 2018

 

Minor home modifications (MHMs) 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 providers contracted with the managed care organization (MCO). 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 type of 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 19-1; Effective June 3, 2019

 

The following minor home modifications (MHM) 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 members 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 members 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 limit, but documentation must support the justification for additional ramps as related to medical need or health and safety of the member.

Carbon monoxide detectors cannot be purchased under STAR+PLUS Home and Community Based Services (HCBS) program 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 an MHM.

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 member.

 

6630 Minor Home Modification Service Cost Lifetime Limit

Revision 20-2; Effective October 1, 2020

 

There is a lifetime limit of $7,500 per member for this service and $300 yearly for repairs. Once the $7,500 cost limit is reached, only $300 per year per member, excluding associated fees, will be allowed for repairs, replacement or additional modifications. The managed care organization (MCO) is responsible for obtaining cost-effective modifications authorized on the member's individual service plan (ISP) that is more fully described in Section 6117, Service Planning, and Title 1 Texas Administration Code (TAC) §353.1153(c)(1). If a member’s ISP includes an identified need for minor home modifications (MHMs) that exceed the lifetime benefit limit, the MCO is permitted to exceed the cost limit without prior approval from Texas Health and Human Services Commission (HHSC). The MCO must not include any costs over the lifetime limit on any cost reports, claims, encounters or financial statistical reports.

If a member changes MCOs, the losing MCO must provide documentation to the gaining MCO related to any MHM expenditures. See Section 3413, Transferring from One MCO to Another Within Same Service Area.

 

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 18-2; Effective September 3, 2018

 

 

 

6710 Employment Assistance

Revision 20-2; Effective October 1, 2020

 

Employment assistance is assistance provided to help a member locate paid employment in the community and includes:

Documentation must be maintained in the member’s record that the service is not available to the member under a program funded under Section 110 of the Rehabilitation Act of 1973 or under a program funded by the Individuals with Disabilities Education Act (Title 20 U.S.C. §1401 et seq.).

An employment assistance service provider's credentials must satisfy one of these options:

Option 1:

Option 2:

Option 3:

 

6720 Supported Employment

Revision 18-2; Effective September 3, 2018

 

Supported employment is assistance provided, in order to sustain competitive employment, to a member 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 a member's assessed needs and earning at least minimum wage (if not self-employed). In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the member's record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).

A supported employment service provider's credentials must satisfy one of these options:

Option 1:

Option 2:

Option 3: