Revision 22-2; Effective September 1, 2022

STAR Kids Medicaid Managed Care Program is required by Texas Government Code, §533.00253. Texas Administrative Code, Title 1, Part 15, Chapter 353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of Medically Dependent Children Program services (MDCP), as well as the STAR Kids program. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract and in this handbook.

The STAR Kids Handbook includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies, and the contractors and providers in the delivery of STAR Kids Program services to eligible members.

1110 Mission Statement

Revision 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC) mission is to provide individualized and appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:

• coordinate care across service arrays;
• improve quality, continuity and customization of care;
• improve access to care and provide person-centered health homes;
• improve ease of program participation for members, managed care organizations and providers;
• improve provider collaboration and integration of different services;
• improve member outcomes to the greatest extent achievable;
• prepare young adults for the transition to adulthood;
• foster program innovation; and
• achieve cost efficiency and cost containment.

Revision 22-3; Effective Dec. 1, 2022

STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service Medicaid. This is described in the Texas Medicaid State Plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).

1210 Acute Care Services

Revision 22-3; Effective Dec. 1, 2022

STAR Kids members must receive any medically necessary services through their managed care organization (MCO) per the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) of Individuals Under Age 21, (42 CFR Part 441). This includes, but is not limited to:

• ambulance services;
• audiology services, including hearing aids;
• behavioral health services, including:
  • in-patient mental health services;
  • out-patient mental health services;
  • out-patient chemical dependency services for children;
  • detoxification services; and
  • psychiatry services;
• birthing services provided by a certified nurse midwife in a birthing center;
• chiropractic services;
• dialysis;
• durable medical equipment and supplies;
• emergency services;
• family planning services;
• home health care services;
• hospital services, inpatient;
• hospital services, out-patient;
• laboratory;
• medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps (THSteps) Program;
• oral evaluation and fluoride varnish in conjunction with THSteps medical checkup for children six months through 35 months of age;
• optometry, glasses and contact lenses, if medically necessary;
• podiatry;
• prenatal care;
• primary care services;
• radiology;
• specialty physician services;
• therapies, including physical, occupational and speech;
• transplantation of organs and tissues; and
• vision services.

STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members receive dental care through their primary insurer, through their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service model.

1220 Long Term Services and Supports

Revision 23-4; Effective Dec. 1, 2023

STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):

• Attendant care is hands-on medical and non-medical care specific to meet the needs of a person. It includes skilled medical care, to the extent permitted by state law, and housekeeping activities which are incidental to the performance of the client-based care. Attendant care services include: 
  • Day activity and health services (DAHS) which includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services. DAHS is for members 18 through 20 years and is provided at an adult day center.
  • Personal care services (PCS) are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. 
    • PCS includes help with activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. Members who meet an institutional level of care receive personal care services through Community First Choice Personal Assistance Services (CFC-PAS). See below for more information.
  • Prescribed pediatric extended care center (PPECC) is a facility that provides nonresidential basic services. These services include medical, nursing, psychosocial, therapeutic and developmental services to medically dependent or technologically-dependent members under 21 for up to 12 hours per day. Members who qualify for private duty nursing also qualify for PPECC services.
  • Private duty nursing (PDN) services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services. 

Community First Choice (CFC)

CFC services are available to all STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI, and who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease.

Members enrolled in a Section 1915(c) Medicaid waiver program for individuals with an intellectual disability or related condition (ID/RC) receive CFC through their waiver provider. CFC services include:

• Personal Assistance Services, also called CFC-PAS assists with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. Members who meet a CFC LOC must have PAS billed through CFC. Members may not be authorized for PCS and CFC-PAS at the same time. 
• Habilitation, also called CFC habilitation or CFC-HAB, provides acquisition, maintenance and enhancement of skills necessary for the member to accomplish ADLs, IADLs and health-related tasks. 
• Emergency response services (ERS), which are back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports.
• Support management, which is training provided to members or legally authorized representatives (LARs) on how to manage and dismiss their attendants.

Medically Dependent Children Program (MDCP) – Additional Services

STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in a nursing facility (NF). Receipt of MDCP services does not impact a member's eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP include:

• Adaptive aids needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the ADLs or control the environment where they live. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources.
• Employment assistance is provided to a member to help the member locate paid, competitive employment in the community.
• Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS helps members manage funds related to the services delivered through the CDS option. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.
• Flexible family support services, which are direct care services needed because of a member's disability that help a member participate in child care, post-secondary education, employment, independent living, or support a member's move to an independent living situation.
• Minor home modifications are physical changes to a member's residence that are needed to prevent institutionalization or to support the most integrated setting for a member to stay in the community.
• Respite services are short-term direct care services needed because of a member's disability. They provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
• Supported employment helps to sustain paid, 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 where members without disabilities are employed.
• Transition assistance services are a one-time service provided to a Medicaid-eligible resident of an NF located in Texas to help the resident move from the NF into the community to receive MDCP services.

1230 Service Delivery Options for Certain Long-Term Services and Supports

Revision 22-3; Effective Dec. 1, 2022

STAR Kids provides members with an array of services identified on the individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.

STAR Kids members may choose from the following three service delivery options for the delivery of certain long-term services and supports (LTSS):

• Agency option
• Service Responsibility Option (SRO)
• Consumer Directed Services (CDS)

Members who choose the agency option select an MCO-contracted agency to deliver the services on their ISP.

Members who choose CDS are given the authority to self-direct certain services. If the member chooses to self-direct one or more approved CDS services, the MCO coordinates delivery of non-member directed services. In the CDS option, the member or their LAR, with assistance from a financial management service agency (FMSA), ensures the necessary supplies are obtained to provide all authorized services. FMSA personnel may be employed directly by, or through personal service agreements or contracts with, the providers.

In the delivery of state plan LTSS, the SRO may only be used for attendant care. A provider agency chosen by the member or their LAR is the employer of record for the attendant and handles business details (for example, paying taxes and conducting payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member or their LAR 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.

State plan LTSS available through the CDS and SRO service delivery options are:

• Community First Choice habilitation (CFC-HAB);
• Community First Choice personal assistance services (CFC-PAS), referred to as CFC-PCS for children; and
• Personal care services (PCS) (non-CFC).

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose the CDS option for the following services:

• employment assistance;
• flexible family support services;
• respite;
• supported employment;
• minor home modifications; and
• adaptive aids.

STAR Kids members receiving MDCP services may choose the SRO option for the following services:

• Employment assistance
• Flexible family support services
• Respite
• Supported employment

Find more information about these service delivery options in 5000, Service Delivery Options.

Revision 22-3; Effective Dec. 1, 2022

All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators. They may also enter into an arrangement with a health home that offers service coordinators to give some service coordination functions through the member's health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members or legally authorized representatives (LARs) request information about a referral to a nursing or other long-term care facility, the service coordinator must inform the member or their LAR about options available through home and community-based services (HCBS) programs and to facility-based options.

MCO service coordinators are responsible for assessing a member's needs, goals, and preferences with respect to delivery of services using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP at least once per year. During the assessment visit, the service coordinator, through a person-centered planning process, must:

• complete the SK-SAI, including the MDCP module and Nursing Care Assessment Module (NCAM) as applicable;
• review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
• acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
• acknowledge and document goals and objectives that may need to be adjusted;
• develop new goals and objectives with input from the member, member’s family and member’s providers;
• update the member’s ISP;
• help with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
• inform members receiving long term services and supports (LTSS) about the consumer directed services (CDS) and service responsibility options (SROs);
• educate the member or their LAR about their rights and responsibilities regarding acts that constitute Abuse or Neglect (Child Protective Services) and Abuse, Neglect or Exploitation (Adult Protective Services); and
• review member rights and responsibilities and MCO processes for service authorization, appeals and complaints.

1310 Service Coordination Requirements

Revision 22-3; Effective Dec. 1, 2022

Managed care organizations (MCOs) provide a different level of service coordination, depending on a member's needs. Members with more complex needs receive more service coordination than members whose needs are less complex. 

Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits, at least once per quarter. Visits must be spaced no less than two months or more than three months apart, from a named service coordinator annually, in addition to monthly telephonic contacts in months where no face-to-face visit occurred or in the same month as the face-to-face visit when an unmet need was identified. Variance in this schedule must be requested by a member or their legally authorized representative (LAR) and documented in Section IX: Service Coordinator Follow-up Schedule of Form 2603, STAR Kids individual service plan (ISP) - Narrative. MCOs must verify and document a member’s preference for service coordination contacts annually if they have requested fewer than the required contacts for their assigned service level. Level 1 service coordinators must be a registered nurse (RN), nurse practitioner (NP), a physician's assistant (PA), a social worker (LMSW, LCSW or LBSW) or licensed professional counselor (LPC) dependent on the member’s needs as identified in the initial telephonic screening. Level 1 members include those who: 

• are enrolled in the Medically Dependent Children Program (MDCP) or Youth Empowerment Services (YES) program; 
• have complex needs or a history of developmental or behavioral health issues (multiple outpatient visits, hospitalization or institutionalization within the past year); 
• are diagnosed with severe emotional disturbance (SED) or serious and persistent mental illness (SPMI); or 
• are at risk for institutionalization. 

Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named service coordinator, unless otherwise requested by the member or LAR, and documented on the ISP. Visits must be as evenly spaced as possible during the year. As a best practice, visits should be spaced not fewer than four months or greater than six months apart. Level 2 service coordinators must be either an RN, NP or PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who: 

• do not meet the requirements for Level 1 but receive long term services and supports (LTSS); 
• the MCO believes would benefit from a higher level of service coordination based on results from the STAR Kids Screening and Assessment Instrument (SK-SAI) and additional MCO findings; 
• have a history of substance abuse (multiple outpatient visits, hospitalization or institutionalization within the past year); or 
• are without SED or SPMI, but who have another behavioral health condition that significantly impairs function. 

Level 3 members have less needs than Level 2 members. MCOs must provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make a minimum of three telephonic contacts. The required visit and contacts must be as evenly spaced as possible during the year. As a best practice the MCO should make contact once every quarter. Level 3 service coordinators must have at least a high school diploma or a general education diploma (GED), and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years. 

Members receiving Level 1 or Level 2 service coordination must have a single, named person as their assigned service coordinator. Level 3 members, LARs or ARs may request a single named service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who live in a nursing facility or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following fee-for-service 1915(c) waivers:  

• Community Living Assistance and Support Services (CLASS) 
• Deaf Blind with Multiple Disabilities (DBMD) 
• Home and Community-based Services (HCS) or Texas Home Living (TxHmL)  

If the service coordinator changes, the MCO must notify members within five business days of the name and phone number of the new service coordinator and must document the information on the ISP. 
MCOs must notify all members in writing of the: 

• name of the service coordinator; 
• phone number of the service coordinator;
• minimum number of contacts they will receive every year; and 
• types of contacts they will receive.

1311 Member Refusal to Participate in Service Coordination

Revision 23-3; Effective July 21, 2023

The managed care organization (MCO) must educate the member on the importance of the STAR Kids Screening and Assessment Instrument (SK-SAI) process, the member’s identified service coordination level, the required contacts for the member’s identified service coordination level, and the importance of service coordination. 

A member may refuse to participate or take part in the SK-SAI, and may request to reduce service coordination contact or refuse any service coordination contacts. 

Definition

Member refusal means a member’s or member’s legally authorized representative’s  (LAR’s) unwillingness to participate in an assessment, service planning process or other program-related processes.

Refusal of SK-SAI

A member may refuse to participate in the SK-SAI process. If the member or LAR  declines the SK-SAI process, the MCO must document this in the member’s case file. The MCO must also document the applicant or member was offered an in-person visit and was not experiencing any extraordinary circumstances. This documentation must be provided to HHSC by the MCO upon request. 

When an applicant or member refuses to participate in the SK-SAI process, the MCO must send the member or LAR written information on the possible impacts to their Medicaid eligibility and services in the STAR Kids Program including the inability to make a medical necessity (MN) determination for Medically Dependent Children Program (MDCP) waiver services that would prevent eligibility for the waiver. 

For a MDCP applicant or member who refuses to participate in the SK-SAI, the MCO must notify Program Support Unit (PSU) of the refusal, and attempts made to schedule the assessment, using MCOHub and Form H2067-MC, Managed Care Programs Communication.

Reduction of Service Coordination Contact

Service coordination levels and required contacts are outlined in 1300 above. and in the STAR Kids Contract Section 8.1.38.6. The MCO must provide the member or LAR with the information on the member’s designated service coordination level and the required contacts for that service coordination level, and the importance of service coordination in meeting the member’s health care needs. 

A member or LAR may request to have fewer service coordination contacts than required by the member’s service coordination level. The MCO must educate the member on the importance of these service coordination contacts and must document any contact reduction request on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative Tool. 

A member’s or LAR’s request to reduce service coordination contact does not change the member’s assigned service coordination level as outlined in Section 1300 above. The MCO service coordinator is responsible for ensuring the member’s identified health care needs are being met. The MCO must document any actions taken including contact, referrals, service changes or other follow-up on Form 2603 in the member’s case file. 

Refusal of Service Coordination

A member or LAR may refuse all service coordination contacts required by the member’s service coordination level. The MCO must educate the member on the importance of these service coordination contacts and must document any refusal of contact on Form 2603. 

A member’s or LAR’s refusal of service coordination contact does not change the member’s assigned service coordination level as outlined in Section 1300 above. The MCO is responsible for ensuring the member’s identified health care needs are being met. The MCO must document any action taken including contact, referrals, service changes or other follow-up on Form 2603 in the member’s case file. 

Minimum Required Contact for STAR Kids Members

No later than four weeks following the ISP start date, the MCO service coordinator must follow up with the member or LAR, either face-to-face or by phone, to ensure that necessary services are in place. The MCO must document the follow up on Form 2603 in the member’s case file. This contact is in addition to the required service coordination contacts and must be completed by the MCO.

Minimum Required Contact for Community First Choice (CFC) and MDCP

The minimum utilization of an MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they receive CFC. As stated in 42 Code of Federal Regulations Section 441.510(d), all members that qualify for MAO Medicaid and receive CFC services must meet MDCP waiver requirements and must receive at least one MDCP waiver service per month. 

1320 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities

Revision 22-3; Effective Dec. 1, 2022

Members will receive only their acute care services and some state plan LTSS such as private duty nursing (PDN) through STAR Kids if they:

• have intellectual and developmental disabilities (IDD); 
• and receive most of their long-term services and supports (LTSS) through one of the programs listed below:
  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)
  • Community ICF/IID

A member with IDD that meets the above criteria has a named managed care organization (MCO) service coordinator. The number of required service coordination visits or phone calls and level of service coordination varies by acuity and the member’s or legally authorized representative’s (LAR’s) personal preference.

The MCO service coordinator is responsible for the coordination of the member’s acute care services and capitated LTSS. A member with IDD also has a person outside of the MCO who, with the member, develops and implements a separate fee-for-service service plan and monitors the delivery of home and community-based services. This person is referred to as the LTSS service coordinator or case manager. The LTSS service coordinator or case manager also cooperates with the MCO service coordinator for the provision of acute care services. The MCO service coordinator must respond to requests from the member's LTSS service coordinator or case manager. With the member’s approval, the member’s LTSS service coordinator or case manager should invite the member’s MCO service coordinator to the member’s fee-for-service service planning team meetings and other interdisciplinary team meetings. MCO service coordinator attendance at these meetings is not mandatory but is strongly recommended and participation may be in person or telephonically. 

1330 Service Coordination and the Youth Empowerment Services Program

Revision 22-3; Effective Dec. 1, 2022

Members who receive services through the Youth Empowerment Services (YES) program receive their acute care services and some long-term services and supports (LTSS) such as day activity and health services (DAHS), private duty nursing (PDN), and Community First Choice (CFC), only through STAR Kids. They continue to receive their waiver services through the YES program. Members served by the YES program have a named managed care organization (MCO) service coordinator and are considered Level 1 members.

These members also have a case manager outside of the MCO who develops and implements a YES service plan and monitors waiver service delivery. This case management is provided through the capitated Mental Health Targeted Case Management (MH TCM) benefit, which the MCO must authorize for any member receiving YES. The MCO service coordinator must respond to requests from the member's case manager. The member’s case manager should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, unless the member objects. These meetings are not mandatory but are strongly recommended and participation may be either in person or by phone. The MCO service coordinator is responsible for the coordination of these member's acute care services and capitated LTSS. 

1340 Service Coordinators and Home and Community Based Services - Adult Mental Health

Revision 22-3; Effective Dec. 1, 2022

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

• a history of extended institutional stays in psychiatric facilities;
  • Note: Extended means three cumulative or consecutive years in the past five years  
• severe mental illness (SMI) and frequent visits to the emergency department; or 
• SMI 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 for members 18 and up. 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 the Texas Health and Human Services Commission. Find more information about HCBS-AMH here.  

Program Point of Contact

Each managed care organization (MCO) must have a designated program point of contact (PPOC) for the AMH program. The PPOC is responsible for the following:

• ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
• responding within three business days to concerns from HHSC or recovery managers (RMs) to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the AMH program.

MCO Service Coordination Responsibility

MCO service coordinators must participate in telephonic recovery plan meetings, as scheduled by HHSC or RMs, and provide any requested member-specific information prior to the meeting. Service coordinators must:

• Send requested information to the RM or HHSC three business days before the scheduled recovery plan meeting. This information includes, but is not limited to the following:
  • updating the member's condition;
  • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
  • upcoming MCO service coordinator face-to-face appointments or scheduled dates for phone contacts with the member; and
  • relevant member treatment documents as requested by the RM or HHSC.
• Respond to ad-hoc requests from the RM or HHSC with "urgent" in the subject line within one business day.
• Respond to non-urgent ad-hoc requests in a timely manner.
• Coordinate with HHSC and the RM when a member transitions into or out of HCBS-AMH.

HCBS-AMH may provide transitional planning for members who live in an institution and are also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, by phone or in-person, during the member's stay. Planning meetings focus on coordination of services when discharged from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) is a home and community-based services (HCBS) waiver program authorized under Section 1915(c) of the Social Security Act. The state delivers MDCP Section1915(c) services through the STAR Kids managed care program authorized under the Section 1115 Texas Healthcare Transformation and Quality Improvement Program Demonstration. The exception is the children in state conservatorship who receive their MDCP Section 1915(c) services through the STAR Health managed care program. MDCP provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, employment assistance, supported employment and financial management services through a STAR Kids managed care organization (MCO). This section provides an overview of MDCP, including its eligibility requirements.

1410 MDCP Program Goal

Revision 22-3; Effective Dec. 1, 2022

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults 20 and younger who are medically dependent, and to encourage de-institutionalization of children and young adults who reside in nursing facilities (NFs).

MDCP accomplishes this goal by:

• enabling children and young adults who are medically dependent to remain safely in their homes;
• offering cost-effective alternatives to placement in NFs and hospitals; and
• supporting families in the role as the primary caregiver for their children and young adults who are medically dependent.

Revision 22-3; Effective Dec. 1, 2022

Individuals become eligible to be assessed for Medically Dependent Children Program (MDCP) services when their names come to the top of the MDCP interest list. Individuals may be placed on the interest list on a first come, first served basis by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if they are already enrolled in STAR Kids. See 1 Texas Administrative Code, Section 353.1155 for more information. Once an individual's name comes to the top of the list, determination of eligibility begins as the individual applies for services.  

• The term “individual” refers to a person who has been released from the interest list and has not yet applied for Medicaid benefits. 
• The term “applicant” refers to a person who has applied for Medicaid benefits. 
• The term “member” refers to a person who is currently in a Medicaid eligibility category included in the STAR Kids managed care program, and is enrolled with a MCO.

MDCP is provided by authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that help members live in the community in lieu of a nursing facility (NF). To be eligible for services under the MDCP waiver, the applicant or member must meet the criteria described in 1 Texas Administrative Code, Section 353.1155.

1510 Medical Necessity Determination

Revision 22-3; Effective Dec. 1, 2022

A Medically Dependent Children Program (MDCP) waiver individual, applicant or member must have a valid medical necessity (MN) determination before admission into the MDCP waiver. The determination of MN is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant's or member's individual service plan (ISP) cost limit is calculated based on information gathered through the SK-SAI MDCP module.

The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) for MDCP applicants and members. TMHP processes the SK-SAI to determine MN and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used in waiver programs to establish the service plan cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG value is generated and appears in the TMHP Long Term Care (LTC) Online Portal as well as the MCO's response file. An SK-SAI with incomplete RUG information results in a "BC1" code instead of a RUG value. An SK-SAI resulting in a BC1 code does not have all  the information necessary for TMHP to accurately calculate a RUG for the member. Code BC1 is not a valid RUG to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a BC1 code or that returns any other errors that require correcting. The MCO nurse must also submit any corrections to SK-SAI items used to determine MN within 14 days. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. See Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for detailed instructions pertaining to communicating corrections and inactivation to the SK-SAI to TMHP.

1511 Medical Necessity Determination for Individuals Residing in Nursing Facilities

Revision 22-2; Effective September 1, 2022

During initial contact with the applicant or member, the service coordinator must explore the individual’s status in the nursing facility (NF) and desire to transition to the community. The service coordinator completes the STAR Kids Screening and Assessment Instrument (SK-SAI) and submits the assessment to Texas Medicaid & Healthcare Partnership (TMHP) indicating a request for a determination of medical necessity. This process is described in more detail in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The managed care organization (MCO) must electronically submit the SK-SAI to TMHP indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO’s records.

1512 Medical Necessity Determination for Individuals Not Residing in Nursing Facilities

Revision 22-2; Effective September 1, 2022

For individuals not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the STAR Kids Screening and Assessment Instrument (SK-SAI) completed by the managed care organization (MCO) selected by the individual.

The MCO must electronically submit the SK-SAI to TMHP indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO's records.

1520 Individual Cost Limit

Revision 22-2; Effective September 1, 2022

The cost of Medically Dependent Children Program (MDCP) services cannot exceed 50 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the MDCP applicant must have an individual service plan (ISP) of MDCP services developed that is at or below 50 percent of the cost to provide services to that applicant, based on the Resource Utilization Group (RUG) in a nursing facility.

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

1530 Unmet Need for at Least One Waiver Service

Revision 22-3; Effective Dec. 1, 2022

In addition to requiring an individual meet a nursing facility level-of-care, the 1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year and must receive monthly monitoring when MDCP services are furnished on a less than monthly basis. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to termination from the waiver. For members without Supplemental Security Income (SSI) (i.e., members certified for medical assistance only (MAO) Medicaid), termination from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for MAO Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a 1915(c) waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) Section 441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.

1540 Age

Revision 18-1; Effective March 1, 2018

To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

1550 Citizenship

Revision 22-2; Effective September 1, 2022

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) specialists. MEPD specialists also verify an applicant is a Texas resident. HHSC will have the responsibility of verifying citizenship.

1560 Living Arrangement

Revision 22-2; Effective September 1, 2022

Managed care organization (MCO) service coordinators must confirm that the individual, if under age 18, lives with a family member such as a parent, guardian, grandparent or sibling, as defined in the Glossary. The MCO service coordinator must review guardianship documentation or obtain a statement from the individual, legally authorized representative (LAR), or family member regarding relation. The service coordinator must maintain this documentation in the member's case file.

1570 Financial Eligibility

Revision 22-2; Effective September 1, 2022

Applicants or members who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. Program Support Unit (PSU) staff must determine if an applicant or member is currently receiving the appropriate type of Medicaid. For individuals who do not receive SSI, Medicaid financial eligibility is determined by the Texas Health and Human Services Commission. Managed care organizations must abide by the eligibility determination.

Revision 22-2; Effective September 1, 2022

1610 Confidential Nature of a Case Record

Revision 22-2; Effective September 1, 2022

Information collected in determining initial or continuing eligibility is confidential. The Texas 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 or their legally authorized representative (LAR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

1611 Establishing Identity for Contact Outside the Interview Process

Revision 22-2; Effective September 1, 2022

All information that the Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) have about a member or any individual on the member's case must be kept confidential. Confidential information includes, but is not limited to, a member's name, date of birth (DOB), address, Social Security number (SSN), Medicaid ID number or any other personally identifiable health information.

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

1611.1 Telephone Contact

Revision 22-2; Effective September 1, 2022

Establish the identity of an individual who identifies themselves as a member by using the individual’s knowledge of any of the following:

• member’s Social Security number (SSN) and date of birth (DOB);
• member’s SSN and answer to a security question;
• member’s DOB and answer to a security question; or
• answers to two security questions.

Establish the identity of a legally authorized representation (LAR) by using the individual's knowledge of any of the above or the any of the following:

• LAR’s or AR’s SSN and DOB;
• LAR’s or AR’s SSN and answer to a security question;
• LAR’s or AR’s DOB and answer to a security question; or
• answers to two security questions.

Establish the identity of an attorney or LAR by asking for the individual to provide Form H1826, Case Information Release, completed and signed by the member. The managed care organization (MCO) must maintain this documentation in the member's case file.

Texas Health and Human Services Commission (HHSC) staff must use established regional procedures to confirm the identity of legislators or their staff. The MCO must use established HHSC procedures to confirm the identity of legislators or its staff. Legislators and members of their staff must also provide HHSC with Form H1826.

1611.2 In-Person Contact

Revision 22-2; Effective September 1, 2022

Establish the identity of the individual who presents themselves as a member or legally authorized representative (LAR) at a Texas Health and Human Services Commission (HHSC) or managed care organization (MCO) office by examining:

• at least one form of government-issued photo identification:
  • Valid U.S. passport;
  • driver license or Department of Public Safety Identification card; or
  •  state agency employee badge; and
• at least two forms of other identification:
  • Social Security number (SSN) card;
  • hospital record;
  • work or school identification card;
  • voter registration card; or
  • wage stub.

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers or contractors by examining at least one source such as:

• employee badge; or
• government-issued identification card with a photograph.

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

• official correspondence or a telephone call from a state or regional office; or
• contact with an HHSC attorney.

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

Refer to Section 1611.3, Verification and Documentation, if the individual is requesting personally identifiable information (PII) or protected health information (PHI).

1611.3 Verification and Documentation

Revision 22-2; Effective September 1, 2022

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, legally authorized representative (LAR) or a third-party to whom the applicant, member or LAR have provided written consent for the release of PII or PHI information. If disclosing PII or PHI, document transactions and maintain documentation in the member's case file pertaining to how the identity of the person was verified when contact is outside the interview and the method of how the information was released to the individual.

Verify the identity of the person who requests disclosure of PII or PHI by examining:

• at least one form of government-issued photo identification:
  • Valid U.S. passport;
  • driver license or Department of Public Safety Identification card; or
  •  state agency employee badge; and
• at least two forms of other identification:
  • Social Security number (SSN) card;
  • hospital record;
  • work or school identification card;
  • voter registration card; or
  • wage stub.

1612 Custody of Records

Revision 17-1; Effective September 1, 2017

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 the Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) regulations.

Reasonable diligence for employees responsible for records includes keeping records:

• in a locked office when the building is closed;
• properly filed during office hours; and
• in the office at all times, except when authorized to remove or transfer them.

1613 Disposal of Records

Revision 22-2; Effective September 1, 2022

To dispose of documents with member-specific information, managed care organizations (MCOs) must follow procedures contained in the STAR Kids Managed Care Contract.

1614 When and What Information May Be Disclosed

Revision 22-2; Effective September 1, 2022

Reasonable effort 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 the Texas 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 applicant, member or legally authorized representative (LAR) to obtain the information. The applicant, member or LAR authorizes the release of information by completing and signing:

• Form H1826, Case Information Release; or
• a document containing all of the following information:
  • the applicant's or member's:
    • full name (including middle initial) and Medicaid identification number; or
    • full name (including middle initial) and either date of birth (DOB) or Social Security number (SSN);
  • a description of the information to be released. Note: If a general release is authorized, provide the information that can be disclosed to the member or LAR. Withhold protected health information (PHI) from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
  • a statement specifically authorizing HHSC or the MCO to release the information;
  • the name of the person or agency to whom the information will be released;
  • the purpose of the release;
  • an expiration event that is related to the member, the purpose of the release or an expiration date of the release;
  • a statement about whether refusal to sign the release affects eligibility for delivery of services;
  • a statement describing the applicant's or member's right to revoke the authorization to release information;
  • the date the document is signed; and
  • the signature of the applicant, member or LAR.

Note: If the case information to be released includes individually identifiable health information, the document must also tell the applicant, member, or LAR 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 Chief Counsel at HHSC handles questions about the release of information. All questions and problems encountered by individuals concerning release of information should be referred to this office. MCO staff should email HPM_Complaints@hhsc.state.tx.us or use the online question and complaint form.

1615 Confidential Nature of Medical Information ─ Health Insurance Portability and Accountability Act

Revision 18-1; Effective March 1, 2018

The 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 applicant or member and that relates to the:

• past, present or future physical or behavioral health or condition of the applicant or member;
• provision of health care to the applicant or member; or
• past, present or future payment for the provision of health care to the applicant or member.

Protected health information (PHI) includes, but is not limited to, an individual's name, date of birth (DOB), address, Social Security number (SSN), Medicaid ID number or any other personally identifiable information (PII).

1616 Privacy Notice

Revision 22-2; Effective September 1, 2022

Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) staff must send each member the Texas Health and Human Services Agencies' Notice of Privacy Practices at https://hhs.texas.gov/health-and-human-services-agencies-notice-privacy-practices, upon certification. This notice tells the member or legally authorized representative (LAR) about:

• member privacy rights;
• the duties of HHSC and the MCO to protect health information (PHI); and
• how HHSC and the MCO may use or disclose health information without member authorization. Examples of use or disclosure include health care operations (e.g., Medicaid), public health purposes, reporting victims of abuse, law enforcement purposes, sharing with HHSC or MCO contractors and coordinating government programs that provide benefits.

1617 Member Authorization

Revision 22-2; Effective September 1, 2022

The member or legally authorized representative (LAR) may authorize the release of health information from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records by using a valid authorization form. Form H1826, Case Information Release, includes all the authorization elements required by Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.

1618 Minimum Necessary Information Release

Revision 17-1; Effective June 1, 2017

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 Texas 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.

1619 Legally Authorized Representatives

Revision 22-2; Effective September 1, 2022

Only the member's legally authorized representative (LAR) 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: Texas 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 1614, When and What Information May Be Disclosed, if it is believed that health information should not be released to the LAR.

Note: An LAR is not automatically designated as a responsible party.

1619.1 Adults and Emancipated Minors

Revision 22-2; Effective September 1, 2022

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

• person the member has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
• court-appointed guardian for the member; or
• person designated by law to make health care decisions when the member is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication.

Consult appropriate legal counsel, as described in Section 1614, When and What Information May Be Disclosed, for approval.

1619.2 Unemancipated Minors

Revision 22-3; Effective Dec. 1, 2022

A parent is the LAR for a minor child except when:

• the minor child can consent to medical treatment by themselves. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment by themselves when the:
  • minor is on active duty with the U.S. military;
  • minor is 16 years or older, lives separately from the parents and manages their own financial affairs;
  • consent involves diagnosis and treatment of disease that must be reported to the local health officer or the Texas Department of State Health Services (DSHS);
  • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
  • minor is 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by HHSC;
  • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by the state of Texas;
  • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
  • consent involves suicide prevention or sexual, physical or emotional abuse.
• a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about health care decisions not made by the parent.

1619.3 Deceased Members

Revision 22-2; Effective September 1, 2022

The LAR 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:

• an executor, including an independent executor;
• an administrator, including a temporary administrator;
• a surviving spouse;
• a child;
• a parent; and
• an heir.

Consult appropriate legal counsel, as described in Section 1614, When and What Information May Be Disclosed, about whether a particular person is the personal representative of an applicant or member.

1620 Correcting Information

Revision 22-2; Effective September 1, 2022

A member or legally authorized representative (LAR) has a right to correct any information that the Texas 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:

• identify the individual asking for the correction;
• identify the disputed information about the individual;
• state why the information is wrong;
• include any proof that shows the information is wrong;
• state what correction is requested; and
• include a return address, telephone number or email address at which HHSC or the MCO can contact the member.

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 or LAR 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 or the 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, HHSC or the MCO must 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 contact the HHSC privacy officer for a record of disclosures. MCOs must follow HHSC procedures as stated in the STAR Kids Managed Care Contract.

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

• fair hearing;
• civil rights hearing; or
• other appeal process.

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

1630 Communication with the Managed Care Organization

Revision 23-3; Effective July 21, 2023

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 their selected managed care organization (MCO). This makes it crucial that when documents containing member information are uploaded in the incorrect MCO folder in MCOHub, they be corrected immediately upon realization an error was made.

Send notification of all uploading errors to Program Support Unit (PSU) Operations staff. Include the document identifying information, the name of the folder in which it was erroneously uploaded and the name of the folder into which it should have been uploaded. Include the time the correction was made.

Example: Uploaded XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been uploaded to MOLSKW. Corrected at 9:22 a.m. December 20.

All emails containing member information must be sent using encryption software. No personally identifiable information (PII) may appear in the subject line. See also Section 1615, Confidential Nature of Medical Information, and Section 5100, Agency Option (AO).

1640 Alternate Means of Communication

Revision 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant’s, member's or legally authorized representative’s (LAR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member or LAR 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.

Revision 22-2; Effective September 1, 2022

Member rights and responsibilities are included in the Member Handbook. The required critical elements can be found in Chapter 3.4 Medicaid Managed Care Member Handbook of the Uniform Managed Care Manual at: https://hhs.texas.gov/services/health/medicaid-chip/managed-care-contract-management/texas-medicaid-chip-uniform-managed-care-manual. 

The Member Handbook must be provided to the member or legally authorized representative (LAR) at application. This document is shared in the language preference expressed by the applicant or member.

In addition, a member or LAR may refer to the Texas Administrative Code, Title 1 Administration, Part 15 Texas Health and Human Services Commission, Chapter 353, Medicaid Managed Care, Subchapter C, Member Bill of Rights and Responsibilities to view the full list of member rights and responsibilities. The Texas Administrative Code is available at: https://www.sos.state.tx.us/tac/index.shtml.

Revision 22-1; Effective September 1, 2022

1810 Program Support Unit Notification Requirements

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member or legally authorized representative (LAR) advising of actions taken regarding program eligibility 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 or LAR of the actions taken regarding the Medically Dependent Children Program (MDCP). The form must be completed in plain language that can be understood by the applicant, member or LAR. The language preference of the member must be considered.

The applicant, member or LAR 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 member’s room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant or LAR when services are denied or program eligibility is terminated. PSU staff must notify the applicant or LAR on Form H2065-D of the denial of application within two business days of the decision. See also Section 6000, Denials and Terminations.

Depending on when the notification is generated, it will either be uploaded to the MCO's STAR Kids folder in MCOHub or generated in the Long-Term Care (LTC) Online Portal on the case action date.

1820 MCO Notification Requirements

Revision 22-2; Effective September 1, 2022

The managed care organization (MCO) is responsible for notifying the member or legally authorized representative (LAR) when a service is either denied or reduced. This is considered an adverse action and the member or LAR has a right to appeal. Appeal rights of STAR Kids members are in the STAR Kids Managed Care Contract.

Revision 22-3; Effective Dec. 1, 2022

2110 Traditional Money Follows the Person

Revision 22-2; Effective September 1, 2022

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aged or who have disabilities live in the most integrated setting possible. The PI Initiative is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

• state's treatment professionals determine the placement is appropriate;
• affected persons do not oppose such treatment; and
• placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Texas Government Code §531.151.)

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with an external vendor. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another 1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other 1915(c) waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF (excluding Truman Smith) or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Reference the STAR Kids Contract, Section 8.1.15, for further information.

The MCO must have a protocol for quickly assessing the needs of members who have or will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

• determine the member’s assigned permanency planner;
• contact the member’s assigned permanency planner within seven days of the member’s facility admission;
• collaborate with the member, the legally authorized representative (LAR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
• contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC's contracted permanency planner to work with the member and the member's LAR to review community-based options; and
• work with the member, the LAR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid, and not enrolled in STAR Kids, requesting MDCP services through the MFP option must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff will authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because they meet the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference 2120, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

2111 Non-STAR Kids Individual Residing in an NF

Revision 23-3; Effective July 21, 2023

For requests to transition into the community under traditional Money Follows the Person (MFP) for a non-STAR Kids member, the individual's Texas Health and Human Services Commission (HHSC)-contracted permanency planner is the designated party responsible for the process. The permanency planner will:

• identify the holistic strengths, challenges, and needs of the individual and the individual's family or legally authorized representative (LAR) as part of the permanency planning process;
• lead the development of the individual's permanency plan;
• educate the individual and LAR on 1915(c) Medicaid waiver options, including the Medically Dependent Children Program (MDCP);
• document the individual's choice of the 1915(c) Medicaid waiver program; and
• educate the individual about STAR Kids, including providing information about managed care and the importance of choosing a managed care organization (MCO).

Once the individual selects a 1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the individual's 1915(c) Medicaid waiver selection under MFP and update the address on file to that of the LAR, if needed.

If the individual or LAR chooses a 1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the waiver program selected and immediately release the individual from the interest list in the Community Services Interest List (CSIL) database, using the bypass code “Residing in a Nursing facility.” ILM Unit staff will forward the request to the selected 1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, and selected 1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community. 

Prior to the individual's discharge from the NF, the individual's selected MCO service coordinator must perform the initial SK-SAI and establish the initial ISP to reflect both MDCP services and any other identified supports, such as nursing or personal care services (PCS). The MCO initiates contact with the individual or LAR to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

Within 15 business days from contact with the individual or LAR, the MCO service coordinator performs the SK-SAI, including the MDCP module (record SK-SAI items Q.6.a and Q.6.b as 1 (yes) to ensure processing for MN and RUG). The MCO service coordinator must submit the SK-SAI to TMHP), following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of the assessment’s completion.

Within one business day of completing Form 2604, STAR Kids Individual Service Plan (ISP) - Service Tracking Tool, the MCO service coordinator must:

• submit Form 2604 electronically following the requirements in Appendix I;
• complete Section B, Waiver Assessment Report, of Form H3676; and
• upload Form H3676 and, as needed, Form H2067-MC, Managed Care Programs Communication, to MCOHub.

Within one business day of verifying the applicant meets all eligibility criteria, PSU staff will upload the initial Form H2065-D, Notification of Managed Care Program Services, to MCOHub in the MCO’s STAR Kids folder, following the instructions in , STAR Kids MCOHub Naming Conventions.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload on MCOHub within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. 

If the individual chooses to leave the NF before being determined eligible for MDCP, the MDCP case must be denied.

2112 STAR Kids Member Residing in an NF

Revision 23-3; Effective July 21, 2023

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

• contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner within seven days of the member's admission;
• coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
• perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
• update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

• identify the holistic strengths, challenges, and needs of the member and family or legally authorized representative (LAR) as part of the permanency planning process;
• lead the development of the member's permanency plan;
• coordinate with the MCO service coordinator in updating the member's ISP, if applicable;
• educate the member and LAR on 1915(c) Medicaid waiver options, including MDCP; and
• document the member's choice of the 1915(c) Medicaid waiver program;

Within two business days of the referral from ILM Unit staff, PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub in the MCO's STAR Kids folder.

The MCO initiates contact with the member or LAR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member or LAR, the MCO service coordinator performs the SK-SAI. The MCO service coordinator must submit the SK-SAI to TMHP following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member and LAR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to TMHP following the requirements in Appendix I within one business day of completion.

As needed, PSU staff collaborate with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays.

2113 MDCP MFP Applications Pending Due to Delay in NF Discharge

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) and managed care organization (MCO) staff must work with an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

An individual who has not made living arrangements to return to the community, cannot decide when to return to the community, or has no viable plan or support system in the community should be denied the Medically Dependent Children Program (MDCP). PSU staff deny the request for services and will:

• send Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period; and
• upload Form H2065-D to MCOHub in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

2120 MFP Limited NF Stay Option for a Medically Fragile Individual

Revision 22-2; Effective September 1, 2022

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option but is too medically fragile to reside in an NF for an extended period. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

• ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap);
• tracheostomy;
• renal dialysis;
• 24-hour/day supplemental oxygen dependence;
• total nutrition through enteral tube feeding;
• total parenteral nutrition (TPN);
• seizures requiring medical intervention (e.g., emergency medication administration, oxygen) during the seizure, every day for the past six months;
• documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
• congestive heart failure requiring hospitalization and routine medication within the past six months; or
• hospice.

An individual determined to be medically fragile and who is approved for a limited NF stay must stay at least part of two consecutive days in the NF. Managed care organizations (MCOs) must comply with MFP limited NF stay policy for continuity of services by ensuring services are authorized within 24 hours of NF discharge; therefore, an applicant may not discharge from the NF on a Friday, Saturday, Sunday or any day preceding a state holiday. The MCO must explain that the individual must not proceed with the limited NF stay until authorized to do so by the MCO. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

2121 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 22-2; Effective September 1, 2022

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or their managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or their MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual's name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in by-passing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to by-pass the MDCP interest list:

• STAR Kids program, if not enrolled;
• an overview of MDCP services;
• the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
• the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
• Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
• required medical documentation must be within 12 months of the date the documentation is submitted to ILM Unit staff, from the individual’s clinical record at the physician’s office, hospital, or clinic (not from a patient portal); and
• admission and discharge documentation from the NF will be required.

ILM Unit staff will send Form 2406 to the individual, parent, guardian or legally authorized representative (LAR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian or LAR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian or LAR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

2130 Physician Determination of Medical Fragility

Revision 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC)  nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the documentation is sufficient and the individual meets the medically fragile criteria. If the documentation is not sufficient, the HHSC nurse will request Interest List Management (ILM) staff to contact the individual, parent, guardian or LAR to obtain needed documentation. If the HHSC nurse is unable to approve, the information is sent to the HHSC physician for review. The HHSC physician will respond by email within seven days to the HHSC nurse with their decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

2131 Individual Who is Approved for a Limited NF Stay

Revision 23-3; Effective July 21, 2023

A STAR Kids managed care organization (MCO) must be selected prior to the limited nursing facility (NF) stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option.

Within two business days of the MCO selection, orally or in writing, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to MCOHub in the MCO's STAR Kids folder.

2132 MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 23-4; Effective Dec. 1, 2023

When an individual is approved for a limited nursing facility (NF) stay, Program Support Unit (PSU) staff upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub advising the managed care organization (MCO) of the individual’s decision to complete a limited NF stay. The MCO must contact the individual, parent, guardian or legally authorized representative (LAR) within 14 days from the date the MCO receives Form H3676 to start the assessment process.

At the contact, the MCO must inform the individual, parent, guardian or LAR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO must explain to the individual, parent, guardian or LAR that the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must advise the individual that they must not proceed with the limited NF stay until authorized to do so by the MCO. 

The MCO has 60 days to complete and submit all required assessments and forms, detailed in 2030, Managed Care Organization Coordination. If the applicant is medical assistance only (MAO) and does not have a Medicaid identification (ID) number, the MCO must use “+” in the Medicaid ID field when uploading Form 2604 to the Long Term Care (LTC) Online Portal. Once the individual has discharged from the NF and MDCP services have been authorized for 30 days, a Medicaid ID number will be assigned to the individual in the Texas Integrated Eligibility Redesign System (TIERS). TIERS will automatically update the Texas Medicaid & Healthcare Partnership (TMHP) LTC Online Portal and replace the “+” with the individual’s Medicaid ID number.

PSU staff will upload Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO's STAR Kids folder to notify the MCO of the approval pending completion of the limited NF stay. The MCO must notify PSU staff within five business days of the planned NF discharge date by uploading Form H2067-MC to MCOHub, following the instructions in Appendix IX.

For applicants not receiving Medicaid, Medicaid will not be established until 30 days after the applicant completes the limited NF stay if MDCP is authorized.

The MCO must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR and PSU staff. The MCO must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with Money Follows the Person (MFP) limited NF stay policy for continuity of services. The MCO service coordinator must advise the applicant that: 

• The NF stay will not be accepted as meeting MFP limited NF stay policy if MDCP services cannot be authorized within 24 hours after the NF discharge date.
• A delay in completing the NF stay will delay the applicant’s MDCP services. 

The MCO must notify PSU at least one business day before the applicant’s NF stay, and must immediately move forward with the NF stay process. 

Within 24 hours of the limited NF stay, the MCO must notify PSU staff that the limited NF stay occurred by:

• documenting the admission and discharge dates on Form H2067-MC; and
• uploading Form H2067-MC in MCOHub, following the instructions in Appendix IX, requesting PSU staff approve MDCP services.

The MDCP effective date will be the first of the month in which the MFP applicant discharged from the NF.

MCOs must monitor the TMHP LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D.

2133 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 23-3; Effective July 21, 2023

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request that the MEPD specialist delay certification. 

If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. 

MCOs must monitor the TMHP LTC Online Portal for the status of the member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian or legally authorized representative (LAR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting Interest List Management (ILM) Unit staff, as described in 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian or LAR requesting to reopen the Medicaid application. The MCO must upload the letter on MCOHub in the MCO’s STAR Kids folder.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by uploading Form H2067-MC in MCOHub, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian or LAR that a new Form H1200 must be completed.

Revision 22-2; Effective September 1, 2022

Program Support Unit (PSU) staff determine the Medically Dependent Children Program (MDCP) waiver start of care (SOC) date for individuals coming off the MDCP interest list, and for STAR Kids members completing the Money Follows the Person (MFP) limited nursing facility stay process. PSU staff will notify managed care organizations (MCOs) of the MDCP SOC date and individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services

2210 Medical Necessity Expiration

Revision 23-3; Effective July 21, 2023

A medical necessity (MN) approval is valid for 120 days from the date of the Texas Medicaid & Healthcare Partnership (TMHP) determination for an individual seeking the Medically Dependent Children Program (MDCP) prior to approval. After 120 days from the date of TMHP determination, Program Support Unit (PSU) staff will notify the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO’s STAR Kids folder. The MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI) for the member and submit to TMHP for a new MN determination.

MFP Limited Nursing Facility Stay Example

An individual seeking MDCP through the MFP limited stay option receives an approved MN in TMHP on August 2, 2021. The individual wishes to complete the MFP limited stay by entering the nursing facility (NF) on August 11, 2021, and discharging on August 12, 2021. On August 10, 2021, the individual notifies the MCO they are unable to enter the NF on August 11, 2021, and would like to reschedule admission to January 16, 2022. The current MN approved August 2, 2021, expires November 30, 2021. The MCO must complete a new SK-SAI and obtain an MN approval from TMHP before the PSU can approve the NF limited stay of January 16, 2022. 

Interest List Release Example

An individual released from the interest list receives an approved MN from TMHP on August 2, 2021. The current MN expires November 30, 2021. The individual met all other MDCP eligibility criteria on December 15, 2021. The MCO must complete a new SK-SAI to obtain an MN approval from TMHP before the PSU can approve the applicant.

2220 MDCP Start of Care Date for Interest List Releases

Revision 23-3; Effective July 21, 2023

The Medically Dependent Children Program (MDCP) waiver start of care (SOC) date for individuals being released from the interest list is based on the following criteria: 

• Medicaid eligibility effective date, if applicable; 
  • the date the medical necessity (MN) was approved from a STAR Kids Screening and Assessment Instrument (SK-SAI) submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long-Term Care (LTC) Online Portal; and
• The date Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, is uploaded to MCOHub or the TMHP LTC Online Portal.  

Program Support Unit (PSU) staff determine the MDCP SOC date. If the date falls on the first day of the month, the eligibility and ISP 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 eligibility and ISP effective date is the first date of the following month. 

2230 MDCP Start of Care Date for STAR Kids Members Completing the MFP Limited NF Stay

Revision 23-3; Effective July 21, 2023

The Medically Dependent Children Program (MDCP) waiver start of care (SOC) date for STAR Kids members being assessed through the Money Follows the Person (MFP) limited nursing facility (NF) stay process is based on the following criteria: 

• The date the medical necessity (MN) was approved from a STAR Kids Screening and Assessment Instrument (SK-SAI) submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long-Term Care (LTC) Online Portal; 
• The date the individual was discharged from a nursing facility; and 
• The date Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, is uploaded to MCOHub or the TMHP LTC Online Portal.  

Program Support Unit (PSU) staff determine the MDCP SOC date. The MDCP effective date will be the first of the month in which the member met all MFP limited stay eligibility criteria and was discharged from the NF. Example: A member who has met all eligibility criteria for the MFP limited stay leaves the NF December 12, 2021, and begins MDCP services December 12, 2021. The eligibility date on Form H2065-D will be December 1, 2021.

Revision 22-2; Effective September 1, 2022

All children and young adults enrolled in a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and covered services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member or legally authorized representative (LAR) should notify the MCO of the intended provider of services and the MCO shall reach out to the provider.

3110 Assessment of Medical Necessity for Community First Choice

Revision 22-2; Effective September 1, 2022

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. A physician certification is required for all initial assessments for MN for CFC services. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is on file in the member's case file.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using Sections I-M of the SK-SAI, as well as questions in Section Q that assess for support management and emergency response services. For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the member's file, and no change in condition has been identified, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including Sections I-M, but leaves Field Q6a as marked "no" (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or their legally authorized representative (LAR). If a member meets MN and has a need for CFC services, the MCO prepares a service plan for the member and provides an authorization to the network provider of the member's or LAR’s choice.

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 22-2; Effective September 1, 2022

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC.

Applicants or members coming off the MDCP interest list must be assessed for MN for eligibility for MDCP and the SK-SAI must be completed no later than 60 days following notification from Program Support Unit (PSU) staff, detailed in Section 2030, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered complete when the physician certification is on file.

MCOs assessing individuals for MDCP services complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate yes on Field Q6a when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Q6a is marked yes on initial assessments for MDCP.

If a member comes off the interest list who is receiving Community First Choice (CFC) services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Q6a as a “no” (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or their legally authorized representative. A physician's certification is not required for a reassessment of MN where no change in condition has been identified.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.

Revision 23-4; Effective Dec. 1, 2023

All STAR Kids members are reassessed at least annually using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days before the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. If there is a delay in activities, the MCO must upload Form H2067-MC, Managed Care Programs Communication, to MCOHub, in their designated STAR Kids folder, documenting the reason for delay.

Before the end date of the annual SK-SAI, including applicable modules, the MCO must initiate an annual reassessment to determine and validate continued need for services for each member. The MCO must not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the member's previous assessment using the SK-SAI. 

For members in MDCP, reassessment must occur no later than 30 days before the end date of the current ISP on file. This includes posting Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool to the Long-Term Care (LTC) Online Portal. As part of the assessment and reassessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options as described in 5200, Consumer Directed Services. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

The reassessment SK-SAI will have required pre-populated information gathered during the previous assessment. The MCO must confirm the accuracy of pre-populated information with the member or member’s legally authorized representative (LAR) and make any necessary adjustments. The MCO must not administer the pre-populated SK-SAI without previously completing the full SK-SAI.

For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR.

3210 Reassessment of Medical Necessity or Level of Care

Revision 23-3; Effective July 21, 2023

For members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI). This includes appropriate modules, no earlier than 90 days before or no later than 30 days before the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Q6a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment and there has been no change to the member's health status. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for an institution of mental disease (IMD) or intermediate care facility serving individuals with an intellectual disability or related condition (ICF/IID), the MCO must reach out to the Local Mental Health Authority (LMHA) or Local Intellectual or Developmental Disability Authority (LIDDA). This ensures a reassessment is scheduled before the expiration of the member’s LOC assessment. The MCO must work with the LMHA assessing for IMD LOC, or the LIDDA, assessing for an ICF/IID LOC.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services continues using the existing ISP until a decision is received from the hearing officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and MN is denied, within five business days of the initial MN denial date on the TMHP Long-Term Care (LTC) Online Portal, the MCO must notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub, asking PSU staff to generate Form H2065-D, Notification of Managed Care Program Services. This form is generated in the LTC Online Portal at reassessment. See 3328, Reassessment Notification Requirements, for more information.

Revision 22-2; Effective September 1, 2022

Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. Except as provided below for members receiving Medically Dependent Children Program (MDCP) services, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The ISP must be completed within 60 days of completion of the SK-SAI for all subsequent reassessments. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility.

The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The ISP must be used to communicate and help align expectations between the member, their legally authorized representative (LAR), the MCO and key service providers.

The STAR Kids Individual Service Plan (SK- ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member and their LAR, on the member's behalf, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The STAR Kids ISP is for:

• documenting findings from the SK-SAI;
• developing a plan for services received through the STAR Kids MCO;
• documenting services received through third party sources, such as 1915(c) waivers operated by the state;
• identifying the member or applicant’s strengths, preferences, support needs and desired outcomes;
• identifying what is important to the member;
• identifying available natural supports available to the member and needed service system supports;
• documenting the individual’s preferences for when and how to receive services;
• identifying any special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
• documenting the member's unmet needs.

For STAR Kids members receiving MDCP services, the ISP must establish an MDCP service plan that falls within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a copy of the ISP to each member or their LAR following any significant update and no less than annually within five business days of meeting with the member or LAR. The MCO must provide a copy of the ISP to the member's providers and other individuals specified by the member or LAR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports (LTSS) no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member's current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member's service coordinator, or a representative of the MCO, must review and update each member's ISP with the member and their LAR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

3310 Service Planning

Revision 22-2; Effective September 1, 2022

All STAR Kids narrative individual service plans (ISPs) must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

• A summary document describing the recommended service needs identified through the SK-SAI;
• Covered services currently received;
• Covered services not currently received, but that the member might benefit from;
• A description of non-covered services that could benefit the member;
• Member and family goals and service preferences;
• Natural strengths and supports of the member including helpful family members, community supports or special capabilities;
• A description of roles and responsibilities for the member, their legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the managed care organization (MCO), and the member's school with respect to maintaining and maximizing the health and well-being of the member;
• A plan for coordinating and integrating care between providers and covered and non-covered services;
• Short and long-term goals for the member's health and well-being;
• If applicable, services provided to the member through waiver programs not operated by the MCO or third-party resources, and the sources or providers of those services;
• Plans specifically related to transitioning to adulthood for members age 15 and older; and
• Any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, their family and caretakers, providers and any other individual with knowledge and understanding of the member's strengths and service needs who is identified by the member, the member's LAR or the MCO. To the extent possible and applicable, the ISP must also account for school-based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member, to provide a copy of the member's Individualized Education Plan (IEP) or the Early Childhood Intervention (ECI) Individualized Family Service Plan (IFSP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Consumer Directed Services or Service Responsibility Option, if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by third-party resources, like Medicare or available community services. This form is updated, per the section below, and is maintained in the member's case file.

3311 Updates to the Individual Service Plan

Revision 19-1; Effective September 3, 2019

Each member's individual service plan must be updated at least annually, or sooner for situations outlined in the STAR Kids Contract, Section 8.1.39.1.

3320 Service Planning for Medically Dependent Children Services

Revision 22-3; Effective Dec. 1, 2022

The managed care organization (MCO) service coordinator or nurse assessor must complete Form 2605, Member SK-SAI MDCP Review Signature, for all initial assessments and reassessments of Medically Dependent Children Program applicants and members. The MCO service coordinator must maintain Form 2605 in the member’s case file. 

The service coordinator must work with the member or their legally authorized representative (LAR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member's Resource Utilization Group (RUG) value, determined by the STAR Kids Screening and Assessment Instrument (SK-SAI) MDCP module. Cost limits associated with each RUG value are found in Appendix VIII, RUG IPC Cost Limits.

The service coordinator documents these MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Agency Option, Consumer Directed Services, or Service Responsibility Option, if applicable. The form must also include a brief rationale such as why the service is needed or requested.

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the managed care organization (MCO) completes and submits the electronic SK-ISP within 60 days of the initial notification from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic SK-ISP within 60 days following receipt of a response to the SK-SAI submission. The response file from Texas Medicaid & Healthcare Partnership (TMHP) contains the determination of medical necessity and the member's RUG value. The start date for the SK-ISP must be the first day of the next month. If a Medicaid eligibility determination is required, the start date of the SK-ISP is the first day of the month following a determination of Medicaid eligibility. An ISP is valid for one year.

When the member's SK-ISP is complete and within the member's established cost limit, the MCO submits the SK-ISP as Form 2604 to the TMHP Long Term Care (LTC) Online Portal or through a 278 transaction. The MCO must submit the electronic SK-ISP before the start date of the member's ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. 

If the member is turning 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member's cost limit. To calculate the prorated cost, the MCO must:

• Step 1: divide the cost limit by the total number of days (365) in a year.
• Step 2: determine the total number of days beginning with the start date of the individual service plan (ISP) and ending the last day of the month of the member's 21st birthday. 
• Step 3: multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.

Example: The member's 21st birthday is July 9, the ISP start date is April 1, and the end date will be July 31. The member's cost limit is $25,000.

• Step 1: $25,000 ÷ 365 days = $68.49 per day
• Step 2: The number of days per month: April = 30, May = 31, June = 30, July = 31, for a total of 122 days 
• Step 3: $68.49 × 122 = $8,355.78

$8,355.78 is the prorated cost limit for the individual for the ISP.

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 22-3; Effective Dec. 1, 2022

A managed care organization (MCO) must generate an amended ISP when a significant change occurs in a member’s condition. The MCO must retain amended ISPs in the MCO’s member case file. If a member or their legally authorized representative (LAR) requests a change to the member's Medically Dependent Children Program (MDCP) service plan, but the member has not experienced a change in condition that affects their Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request in 14 days.

To revise a member's MDCP individual service plan (ISP) when there is no change in the member's RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604  – STAR Kids ISP – Tracking Tool with the updated services and a revised begin date as applicable. The MCO maintains the updated SK ISP Forms in the member's file.

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 22-2; Effective September 1, 2022

If a member and/or their legally authorized representative (LAR), the member's provider or the managed care organization (MCO) service coordinator notify the MCO about a change in the member's condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days and follow the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, to document the RUG change.

Following receipt of a STAR Kids Screening and Assessment Instrument (SK-SAI) response file indicating the member's new RUG, the MCO completes a new STAR Kids individual service plan (SK-ISP) that reflects the member’s/LAR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member's new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the member's case file.

If a member will turn age 21 between the start and end date of the member's ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or transition assistance are provided prior to the member's birthday. If the MCO authorizes adaptive aids, minor home modifications or transition assistance, the MCO remains responsible for payment for those services, including applicable warranties.

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 22-2; Effective September 1, 2022

Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member or their legally authorized representative (LAR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member/LAR chooses to set aside funds, the MCO must document the member’s/LAR's preferences and maintain documentation in the member's case file. A member or LAR may not carry forward funds between ISP periods.

3324 Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services

Revision 22-2; Effective September 1, 2022

As a part of the individual service planning process, the managed care organization (MCO) must establish a Medically Dependent Children Program (MDCP) individual service plan (ISP) that does not exceed the individual’s cost limit linked to the Resource Utilization Group (RUG) value assigned. In rare cases, the member’s condition may require a high utilization of waiver services; the MCO must make best efforts to provide State Plan services where appropriate. If the ISP cost exceeds the RUG cost limit, the MCO submits via email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

• STAR Kids Screening and Assessment Instrument (SK-SAI);
• STAR Kids Individual Service Plan (SK-ISP) and any Addendums; and
• Medical records (nursing care plan, recent care notes, doctor's orders and nursing notes).

HHSC UR may request a clinical review of the case to consider the use of state General Revenue funds to cover costs exceeding 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU).

Note: MCOs must not discuss with applicants, legally authorized representatives (LARs) or members, or request use of state General Revenue funds for services above the cost ceiling.

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 22-2; Effective September 1, 2022

In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each of those members.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member's care is based on their individual service plan (ISP) and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.

3326 Suspension of Medically Dependent Children Program Services

Revision 18-2; Effective September 3, 2018

A member enrolled in the Medically Dependent Children Program (MDCP), who is also receiving Community First Choice (CFC) and has a medical assistance only (MAO) eligibility for Medicaid, must receive one MDCP service monthly. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. For members who do not receive CFC and also have MAO Medicaid, the member must receive an MDCP service within the member’s individual service plan (ISP) year. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in the current ISP year, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file.

The MCO must include in the documentation the:

• dates during which services are suspended; and
• reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

3327 Reassessment Individual Service Plan

Revision 22-2; Effective September 1, 2022

Managed care organizations (MCOs) must ensure the member's individual service plan (ISP) is submitted annually. If the reassessment ISP is not submitted due to the member's timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

3328 Process for Reviewing the Individual Service Plan Expiring Report

Revision 22-2; Effective September 1, 2022

Program Support Unit (PSU) staff and managed care organizations (MCOs) will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) monthly to ensure annual reassessments are conducted timely. The ISP Expiring Report lists the MDCP members with ISPs that will expire within the next 90 days.

PSU staff will schedule a monthly conference call with each MCO.

The MCOs must generate the ISP Expiring Report in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal five business days prior to the monthly conference call with PSU staff. The MCO must provide a status update for all MDCP members who have ISPs expiring within the next 45 days. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.

3329 Reassessment Notification Requirements

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days as notification of reassessment determination. 

If the member files a state fair hearing or external medical review within the 10-business day adverse action period (refer to 6100, Ten-Day Adverse Action Notification), within two business days of notification PSU staff must:

• upload Form H2067-MC in MCOHub to the MCO's STAR Kids folder, using the appropriate naming convention, informing the MCO to continue services due to the timely appeal and request for continuation of benefits (if services have already ended, the MCO reinitiates services immediately); and
• extend the end date of the current ISP in the LTC Online Portal four more calendar months.

PSU staff carry out the decision within 10 days of receiving the fair hearings officer's decision.

Revision 22-3; Effective Dec. 1, 2022

3410 Transfer from One Managed Care Organization to Another

Revision 23-3; Effective July 21, 2023

A member or their legally authorized representative (LAR) may request a plan change to another managed care organization (MCO) through the state-contracted enrollment broker at any time for any reason. Texas Health and Human Services Commission (HHSC) will make only one plan change per month.

When a member or their LAR wants to change from one MCO to another MCO, the member or LAR submits a request in one of the following ways:

• by logging into YourTexasBenefits.com; or
• by contacting the state-contracted enrollment broker:
  • by phone at 800-964-2777;
  • by fax at 855-671-6038; or
  • by mail at: 
    HHSC 
    P.O. Box 149023 
    Austin TX 78714-9023

Note: Adoption Assistance or Permanency Care Assistance (AAPCA) members should contact the state’s enrollment broker to request transfer.  

If the member requests to change MCOs on or before the monthly state cut-off date, the plan change will be effective on the first day of the month following the change request. If the member requests to change MCOs after the monthly state cut-off date, the change will be effective the first day of the second month following the change request. Note: The state cut-off date is not always on the same day every month, but typically occurs mid-month.

Examples:

Cutoff Date – April 12

• If the member requests a transfer on April 9, it take effect May 1.
• If the member requests a transfer on April 20, it take effect June 1.

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

MCO Transfer Activities (Required Communication Between the Gaining and the Losing MCO)

HHSC Enrollment Operations Management (EOM) staff prepare and send a Monthly Plan Changes report to Program Support Unit (PSU) staff. The report gives a list of STAR Kids program members who have transferred MCOs from the past month. PSU staff sends the report to the regional PSU offices to confirm system changes and makes any necessary updates or transfers. The MCO can find the member-specific plan changes in their Monthly Enrollment (P34) file in MCOHub.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information about the results of the MCO’s identification and assessment upon the gaining MCO's request.

Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the member's case file from the losing MCO, such as the member's Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, existing prior authorizations, and minor home modifications (MHMs) and adaptive aids (AA) limits reached.

Within five business days of receiving the request, the losing MCO provides the requested documents to the gaining MCO. The gaining MCO must coordinate with the losing MCO to ensure a seamless transition. The gaining MCO must contact the losing MCO for any other required information maintained in the member's case file. If the gaining MCO experiences issues getting this information, the MCO must notify the Managed Care Compliance and Operations (MCCO) Health Plan manager.

Gaining MCO Responsibilities for Continuity of Care

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 10 business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. For continuity of care, this includes authorizations, assistance with finding in-network providers, additional assessments, and pending delivery of AAs, MHMs or transition assistance. The STAR Kids Screening and Assessment Instrument (SK-SAI) must be conducted if the member is due for a new assessment, has experienced a significant change in condition, or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member needs a new assessment or until the gaining MCO is able to complete its own SK-SAI, update the ISP, and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with their existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s need until a network provider can be located and accessed.

3420 Member Transfer from Waiver Program to Medically Dependent Children Program

Revision 23-3; Effective July 21, 2023

If a STAR Kids member in another Medicaid waiver program comes up on the interest list for MDCP, 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 an MDCP assessment. All attempted contacts with the member or encountered delays must be documented.

PSU staff:

• contact the member and explain MDCP services; and
• send an enrollment packet to the 1915(c) waiver member.

Within two business days of notification of the MCO selection by the waiver member, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it in the MCO's STAR Kids folder on MCOHub, using the appropriate naming convention.

The MCO completes:

• the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module;
• Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and submits it electronically in the Long Term-Care (LTC) Online Portal or through a 278 transaction; and
• Form H3676, Section B and send to PSU staff, once the SK-SAI is complete.

If the information from the MCO is not received within 60 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.

The MCO must monitor the LTC Online Portal to check the status of the member's ISP and to retrieve Form H2065-D and file in the MCO’s case file.

3430 Member Transfer from MDCP to Another Waiver

Revision 22-2; Effective September 1, 2022

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may be on an interest list for another Medicaid program such as Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD) or Texas Home Living (TxHmL). The Texas Health and Human Services Commission (HHSC) informs the managed care organization (MCO) that a member receiving MDCP services has come to the top of the interest list for another program and is assessed as eligible for that program.

The service coordinator or case manager must contact Program Support Unit (PSU) staff via Form H2067-MC, Managed Care Programs Communication, to coordinate the end of MDCP services the day prior to the member's enrollment in the new program. PSU staff must coordinate with the member's MCO about the end of MDCP services and the member's transition to another waiver. The member remains enrolled in the same STAR Kids MCO for their state plan services.

3440 Member Transfer from Community Services to STAR Kid

Revision 22-2; Effective September 1, 2022

Program Support Unit (PSU) staff must coordinate the termination of Community Care for the Aged and Disabled (CCAD) services with the Community Care Services Eligibility (CCSE) case worker so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), CCAD services are terminated by the CCSE case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.

Revision 22-2; Effective September 1, 2022

Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition activities at age 15 and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.

3510 Twelve Months Prior to the Member's 21st Birthday

Revision 22-2; Effective September 1, 2022

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

Each quarter, Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the MDCP PDN Transition Report, which lists individuals enrolled in STAR Kids and receiving MDCP and/or PDN/PPECC services, who may transition to STAR+PLUS or the STAR +PLUS Home and Community Based Services (HCBS) program in the next 12 months, to the:

• Program Support Unit (PSU) supervisors and managers; and
• UR unit for the Intellectual and Developmental Disability (IDD) 1915(c) waivers.

The managed care organization (MCO) identifies all members turning age 21 within the next 12 months and schedules a face-to-face visit with the member and the member's available supports, including the legally authorized representative (LAR), if applicable, to initiate the transition process.

During the home visit, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member's 21st birthday. The transition activity points to be discussed at the visit by the MCO can be found in Appendix VI, STAR Kids Transition Activities, Transition Activities at Age 20.

The STAR Kids MCO follows up with the member or the LAR every 90 days during the year before the member turns age 21 to ensure transition activities specified in Appendix VI, STAR Kids Transition Activities, have been completed.

3511 STAR+PLUS Transition Activities

Revision 23-4; Effective Dec. 1, 2023

Program Support Unit (PSU) staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines outlined in the STAR+PLUS Handbook, Section 3420, Individuals Transitioning to an Adult Program.

3512 Intrapulmonary Percussive Ventilator Benefit

Revision 22-2; Effective September 1, 2022

Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity (MN) criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

• Children and young adults who have been approved for and are currently utilizing IPV in traditional Medicaid will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of the child/young adult when he transitions to a STAR Kids managed care organization (MCO).
• When a member turns age 21 and transitions into STAR+PLUS, young adults who have been approved for and are currently utilizing IPV will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of a young adult.  The member will not be subjected to an abrupt removal of equipment. The member will continue to receive ongoing treatment until the final decision is made, on a case-by-case basis, with thorough review and documentation by the MCO and explicit approval by HHSC administration.
• STAR Kids MCOs will address a new request for IPV on a case-by-case basis based on MN criteria for the member.

Revision 22-3; Effective Dc. 1, 2022

Community First Choice (CFC) is a group of services delivered under the authority of Section 1915(k) of the Social Security Act. CFC is authorized by federal regulations governing home and community-based services. The settings that CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) Section 441.301(c)(4) and Section 441.710. Permissible home and community-based settings include member homes, apartment buildings and non-residential settings. Community-based settings exclude:

• nursing facilities;
• hospitals providing long-term care services;
• inpatient psychiatric facilities;
• intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID); and
• settings on the grounds of, adjacent to, or with the characteristics of, an institution.

Members served in provider owned and controlled residential settings are excluded from CFC because their provider rate includes payment for the provision of CFC-like services. To provide CFC is duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person centered, as required by 42 CFR Section 441.535 and Section 441.540. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.

4110 Community First Choice Eligibility

Revision 22-3; Effective Dc. 1, 2022

Eligibility for Community First Choice (CFC) requires a STAR Kids member to:

• be Medicaid eligible;
• meet the level of care provided in a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or an institution for mental disease (IMD); and
• have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose Medicaid eligibility is established for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per Section 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month or monthly monitoring if waiver services are furnished on a less than monthly basis, as these members meet an IMD and an NF LOC, respectively. Members whose eligibility is established as Medical Assistance Only (MAO) Medicaid must receive at least one waiver service per month to maintain eligibility. 

A member may not be authorized to receive both personal care services (PCS) and CFC services at the same time. Members eligible for CFC will receive CFC-PCS and habilitation (CFC-HAB) in lieu of PCS.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their fee-for-service waiver provider and do not receive CFC through managed care:

• Community Living Assistance and Support Services (CLASS)
• Deaf Blind with Multiple Disabilities (DBMD)
• Home and Community-based Services (HCS)
• Texas Home Living (TxHmL)
   

4111 Determining Institutional Level of Care

Revision 22-3; Effective Dc. 1, 2022

Nursing Facility (NF) Level of Care

For STAR Kids members, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP) to determine, on behalf of the Texas Health and Human Services Commission (HHSC), if a member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or NF. Questions within the SK-SAI which identify a need for Community First Choice (CFC) personal assistance services (PAS)/habilitation (HAB) services are within the Core  and Nursing Care Assessment (NCAM) modules of the SK-SAI. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of MN for CFC, the MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires NF services or alternative community based services under the supervision of a physician.

Find information about the medical necessity determination process for CFC in 3110, Assessment of Medical Necessity for Community First Choice.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) Level of Care

For STAR Kids applicants and members, the MCO must contact the Local Intellectual and Developmental Disability Authority (LIDDA) to conduct an assessment to determine whether a STAR Kids applicant or member meets the LOC provided by an ICF/IID. As part of the Intellectual Disability or Related Condition (ID/RC) assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a STAR Kids applicant or member does not have one on file. The LIDDA must submit the ID/RC information to HHSC for a determination of ICF-IID LOC. HHSC notifies the STAR Kids applicant or member's MCO of an ICF/IID LOC denial. The LIDDA notifies the STAR Kids applicant or member’s MCO of an ICF/IDD LOC approval. If a STAR Kids applicant or member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment if the applicant or member requests CFC services.

Institution for Mental Disease Level of Care

For STAR Kids applicants and members, the MCO may contact a comprehensive provider of mental health rehabilitative services or a local mental health authority (LMHA) to conduct the Children and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the STAR Kids applicant or member meets an institution of mental disease (IMD) LOC. If the STAR Kids applicant or member needs the LOC provided in an IMD, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.

4120 Community First Choice Services

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) services include personal care services (PCS), habilitation (HAB), emergency response services (ERS) and support management.

4121 Personal Care Services Provided Through Community First Choice

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) includes personal care services (PCS) which provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision or cueing. Assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. Services include:

• Non-skilled assistance with the performance of ADLs and IADLs
• Household chores necessary to maintain the home in a clean, sanitary and safe environment
• Escort services, which consist of accompanying, but not transporting, and helping a member access services or activities in the community 
• Assistance with health-related tasks per state law, health-related tasks include: 
  • tasks delegated by a registered nurse (RN);
  • health maintenance activities; and 
  • extension of therapy which is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow up to therapy sessions. If appropriate, the member's attendant can help the member accomplish such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) service delivery option, the member or legally authorized representative determines health-related tasks without a nurse assessment, per Section 531.051(e) of the Texas Government Code and Section 225.4 of the Texas Administrative Code.

CFC services include personal care services (PCS) to help with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.  Members who qualify for a CFC LOC must have PCS billed as CFC-PCS. Members may not be authorized for PCS and CFC-PCS at the same time. Information used to build a plan of care  may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Sections I-L. The member may receive CFC-PCS and CFC-HAB only if the member meets one of the CFC LOC criteria.

4122 Community First Choice Habilitation

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) habilitation helps members with acquisition, maintenance and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is given to allow a member to live successfully in a community setting by assisting the member to get, keep and improve self-help, socialization, and daily living skills or helping with and training the member on ADLs and IADLs. Personal care services may be a component of CFC habilitation for some members. CFC habilitation services include training, which is interacting face-to-face with a member to train the member in activities such as:

• self-care;
• personal hygiene;
• household tasks;
• mobility;
• money management;
• community integration, including how to get around in the community;
• use of adaptive equipment;
• personal decision-making;
• reduction of challenging behaviors to allow members to accomplish ADLs, IADLs and health-related tasks; and
• self-administration of medication.

Find information used to build a plan of care for CFC habilitation in the STAR Kids Screening and Assessment Instrument (SK-SAI) Section M. This section of the SK-SAI should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for habilitation.

4123 Community First Choice Emergency Response Service

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) emergency response services (ERS) are designed to assist individuals who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, of a member's emergency. This service is not routinely authorized for members who are minors.

ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.

The need for ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Q.

4124 Community First Choice Support Management

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.

Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Q.

4130 Community First Choice Assessment and Authorization

Revision 22-3; Effective Dec. 1, 2022

4131 Assessment for a Nursing Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Establish nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member's eligibility for NF services according to the Texas Administrative Code Section 554.101(80) definition of “medical necessity.”

The MCO must indicate yes in Field Q6a to notify TMHP that an MN determination is required. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. Note: This does not preclude the member or MCO from seeking determination of a different institutional LOC through the LIDDA or LMHA.

If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.

4132 Reassessment for a Nursing Facility Level of Care

Revision 22-2; Effective September 1, 2022

To ensure continued eligibility for Community First Choice (CFC) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 Days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Q6a to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for annual MN reassessments if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

4133 Assessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The MCO must authorize personal care services (PCS), as appropriate, while level of care (LOC) determination is pending. 

The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator’s contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability (DID) and ID/RC assessment, the LIDDA submits the assessment for a determination of LOC to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.

If a member meets an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4134 Reassessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Ninety days before the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an ICF/IID Level of Care, for all reassessments.

If a member continues to meet an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for CFC Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4135 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 22-2; Effective September 1, 2022

Described in 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to a comprehensive provider agency that can deliver mental health targeted case management and mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A member may be deviated into a higher or lower LOC, based on clinical judgement and member preference. A licensed practitioner of the healing arts (LPHA) must review the member’s diagnosis at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months. The MCO must authorize personal care services (PCS), as appropriate, while LOC determination is pending.

Members enrolled in the Youth Empowerment Services (YES) waiver meet an institution for mental disease level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their MCO for functional eligibility for CFC services at any time while enrolled in YES. 

4136 Reassessment for an Institution for Mental Disease Level of Care

Revision 22-2; Effective September 1, 2022

Assessment of an institution for mental disease (IMD) level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the local mental health authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet an IMD level of care, the MCO must conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or their representative of the denial for CFC services. The member may be eligible for personal care services (PCS), if functionally necessary.

4140 Functional Assessment for Community First Choice Services

Revision 22-3; Effective Dec. 1, 2022

Functional need for Community First Choice (CFC) services is established by Sections I, J, K, L and M of the STAR Kids Screening and Assessment Instrument (SK-SAI). These sections contain assessment questions for the personal care services (CFC-PCS) and habilitation services (CFC-HAB) available through CFC. Section M should only be completed if the member is specifically seeking CFC services. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

If a member approved for the nursing facility (NF) level of care (LOC) does not agree to the CFC service plan, they may file an appeal with the MCO.

If the STAR Kids applicant or member does not agree to the CFC service plan or refuses CFC services for the intermediate care facility for individuals with intellectual disability or related condition (ICF/IID) LOC or the institutions of mental disease (IMD) LOC, the MCO must notify the local intellectual or developmental disability authority (LIDDA) or local mental health authority (LMHA) within 10 business days of the member ending CFC services.

4141 Reassessment of Functional Need for Community First Choice

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested by the member or as needed due to a change in the member's health condition or living situation.

Revision 22-3; Effective Dec. 1, 2022

Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through 20. PCS is considered medically necessary when a member requires help with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a practitioner statement of need (PSON). STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to help the individual perform a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that affects the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

• Assistance with ADLs and IADLs
• Nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and 22 Texas Administrative Code Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions)
• Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task

The amount and duration of PCS is determined by the MCO and must take the following into account:

• Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that affects their ability to accomplish ADLs or IADLs
• The member's caregiver's need to sleep, work, attend school and meet their own medical needs
• The member's caregiver's legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household
• The member's caregiver's physical ability to perform PCS
• Whether requiring the member's caregiver to perform PCS will put the member's health or safety in jeopardy
• The time periods when PCS tasks are required by the member, as they occur over the course of a 24-hour day and a seven-day week
• Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability below what is expected of a typically developing child of the same chronological age
• Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows

PCS may be authorized to support a member's primary caregiver(s) but may not be authorized to supplant a member's natural support, nor to provide a member's total care. PCS may be authorized in an individual or group setting including, but is not limited to the:

• member's home;
• home of the primary or other caregiver;
• member's school;
• member's day care facility; or
• community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, must meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation must be submitted to the MCO with documentation of medical necessity.

PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities (ICF/IID).

PCS may not be used as respite, child care, or to restrain a member. PCS may be authorized in a group setting.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver program and are not eligible to receive PCS through the MCO:

• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS); and
• Texas Home Living (TxHmL) Program.

4210 Assessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

Sections I, J, K and L of the STAR Kids Screening and Assessment Instrument (SK-SAI) contain assessment questions for personal care services (PCS). Managed care organizations (MCOs) must have a mechanism in place to assist service coordinators in recommending a number of attendant hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

4211 Reassessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new practitioner statement of need (PSON) to substantiate the member's continued need for PCS upon each annual reassessment.

4220 Personal Care Services Providers

Revision 22-2; Effective September 1, 2022

Personal care services (PCS) must be provided by an individual who:

• is 18 years of age or older;
• is an attendant who:
  • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services; or
  • is employed by the member or their legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.

• has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
• is not the responsible adult of the member if the member is under the age of 18; and
• is not the spouse of the member.

Revision 22-3; Effective Dec. 1, 2022

Medicaid managed care organizations (MCOs) must follow all federal and state laws, rules and the provisions of the Texas Medicaid Provider Procedures Manual (TMPPM) and their contracts regarding Private Duty Nursing (PDN) services.

PDN services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services.

PDN is a THSteps-CCP benefit per the Code of Federal Regulations, Title 42, Section 440.80, relating to PDN services, and Section 440.40(b), relating to Early Periodic Screening, Diagnostic and Treatment (EPSDT) services. THSteps-CCP is an expansion of the EPSDT service mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction or amelioration of physical or mental illnesses and conditions to THSteps eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the Medicaid state plan.

MCOs must follow all EPSDT requirements, including the provision of PDN services, for STAR Kids members.

State rules governing PDN are found at Texas Administrative Code (TAC) Title 1, Part 15, Chapter 363, Subchapter C. These rules and related policies, including rules and policy related to past authorization, apply to HHSC or its designees, which include MCOs (see 1 TAC Section 363.301(c), Section 363.303(6), and Section 363.311(b)). MCOs are must follow all policies governing PDN services in the TAC, as well as the latest edition of the TMPPM. Find Texas Medicaid’s THSteps-CCP PDN policy in Section 4 of the TMPPM’s Home Health and Private Duty Nursing Services Handbook. Find more Information about the THSteps-CCP Program in Section 2 of the TMPPM’s Children’s Services Handbook.

These rules and TMPPM policy provisions are the result of the final settlement agreement in the Alberto N., Et. Al. v. Albert Hawkins, Et. Al. lawsuit.

Because PDN is a Texas Medicaid THSteps-CCP service, the rules and related policies cited above apply directly to the STAR Kids program. See 8.1.2 Covered Services of Attachment B-1 of the STAR Kids Contract. MCOs must ensure that if their internal policy and procedure manuals contain language and guidance for processing PDN service requests, these documents are updated to align with all federal and state laws and rules, as well as the Texas Medicaid medical policy guidance available in the latest version of the TMPPM. See 7.02 MCO responsibility for compliance with laws and regulations of Attachment A of the STAR Kids Contract.

4310 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.

Revision 22-3; Effective Dec. 1, 2022

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP). It is for STAR Kids members who meet the following medical necessity criteria for admission:

• eligible for THSteps-CCP;
• 20 years or younger
• have an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
• considered to be a medically dependent or technologically dependent member;
• stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
• requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
  • deterioration of a chronic condition;
  • loss of function;
  • imminent risk to health status due to medical fragility; or
  • risk of death;
• has a prescription for PPECC services signed and dated by an ordering physician who personally examined the member within 30 calendar days before admission and reviewed all appropriate medical records;
• has consent for the member's admission to the PPECC signed and dated by the member or the member's responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of private duty nursing (PDN) by the member or member's responsible adult in both managed care and non-managed care service delivery systems; and
• lives with the responsible adult and not in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility (SNF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or special care facility.

PPECC services require prior authorization and are intended as an alternative to PDN. Members who receive PDN or qualify for PDN also qualify for PPECC services. However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), home health skilled nursing (HHSN), home health aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and early childhood Intervention services rendered in the member's residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

• The development, implementation and monitoring of a comprehensive plan of care that:
  • is provided to a medically dependent or technologically dependent member;
  • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
  • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the member and the training needs of the member’s caregiver(s);
  • specifies if transportation to and from the PPECC is needed; and
  • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
• Direct skilled nursing care and caregiver training and education intended to:
  • optimize the member’s health status and outcomes; and
  • promote and support family-centered, community-based care as a component of an array of service options by:
    • preventing prolonged or frequent hospitalizations or institutionalization;
    • providing cost-effective, quality care in the most appropriate environment; and
    • providing training and education of caregivers;
• nutritional counseling and dietary services as specified in a member’s plan of care;
• help with activities of daily living while the member is in the PPECC;
• psychosocial and functional development services; and
• transportation services to and from a PPECC.
  • Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC.
  • When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle.
  • The member must be able to utilize transportation services offered by the PPECC with the help of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.
  • Transportation is billed separately by the PPECC when used by a member.
  • A non-emergency ambulance may not be used for transport to and from a PPECC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

• baby food or formula;
• services to members that are related to the PPECC owner by blood, marriage or adoption; and
• services covered separately by Texas Medicaid, such as;
  • therapies;
  • durable medical equipment; or
  • individualized comprehensive case management beyond that is required for service coordination.

Find more information about PPECC services in the STAR Kids Managed Care Contract Section 8.1.24.15, the Uniform Managed Care Manual Chapter 16.1, and the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Chapter 2.14, Prescribed Pediatric Extended Care Centers.
 
Medicaid managed care organizations also must comply with Title 1 Texas Administrative Code, Part 15, Chapter 363, Subchapter B, Prescribed Pediatric Extended Care Centers.

4410 Assessment for Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

The Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

• A current authorization for private duty nursing (PDN);
• A skilled nursing visit or PDN is provided in a school or day program;
• Member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
• Member requires enteral or parenteral feeding;
• Member received any of the following treatments in the last 30 days:
  • Chemotherapy;
  • Dialysis;
  • Intravenous (IV) medication;
  • Oxygen therapy;
  • Radiation;
  • Suctioning;
  • Tracheotomy care;
  • Transfusion;
  • Ventilator;
  • Wound care;
  • Nebulizer;
  • Urinary catheter care –insertion or maintenance;
  • Comatose or persistent vegetative state – manage care'
  • Continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
  • Chest percussive therapy;
  • Active medication adjustment;
  • Intermittent positive pressure breathing (IPPB); and/or
  • Seizure management; and
• The member is being assessed for Community First Choice (CFC) services or the Medically Dependent Children Program (MDCP).

If triggered, the service coordinator completes the NCAM to determine the member's nursing needs. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or their legally authorized representative to locate an appropriate provider and sends an authorization to the selected provider.

Members who have received an NCAM assessment and been approved for PDN services do not require a new assessment if they choose a PPECC unless there is a change in condition and additional nursing hours are needed. MCOs who have PPECC providers available in the service area are expected to provide information to members who qualify for ongoing nursing services about their options of PDN, PPECC or a combination of both.

A member has a choice of PDN, PPECC or both, as long as the services are not provided at the same time. Example: Member has PDN from 7 a.m. to 8 a.m., PPECC from 9 a.m. to 2 p.m. and PDN in the evening.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

4411 Authorization Requirements

Revision 20-2; Effective September 1, 2020

Initial, reauthorization and revision requests for Prescribed Pediatric Extended Care Center (PPECC) services must include the following documentation:

• physician order for services (a physician signature on the PPECC plan of care (POC) serves as a physician order for authorization purposes);
• a POC developed by the PPECC;
• all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual or MCO forms if they contain comparable content; and
• signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include:
  • an acknowledgement by the participant or the participant's responsible adult that they have been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services; and
  • consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care.

Forms available online for PPECC include:

• Comprehensive Care Plan (CCP) Prior Authorization Request (requires ordering physician signature).
• PPECC POC (requires ordering physician, PPECC registered nurse (RN) and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
• Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms and are subject to approval by HHSC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

4412 Reassessment and Reauthorization

Revision 20-2; Effective September 1, 2020

The need for, and the amount and duration of services from, a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed by the PPECC provider:

• 90 days following initial authorization; and
• every 180 days thereafter; or
• when requested due to a change in the member's health; or
• when the authorized services are not commensurate with the Member’s medical needs.

A physician order must be renewed with any reassessment.

4420 Providers of Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 56 Texas Administrative Code. Chapter 550 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services must not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual and PPECC medical policy. These components include:

• Member's name, date of birth and Medicaid number;
• PPECC's name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, telephone and fax numbers;
• Ordering physician's name, telephone number, TPI and NPI;
• Date the PPECC nursing assessment was completed and name, title and credentials of the registered nurse (RN) who completed the POC with their dated signature;
• Name, title and credentials of the team member who completed the POC with their dated signature;
• Date the member was last seen by the ordering physician;
• Requested start of care date for PPECC services;
• All pertinent diagnoses and known allergies;
• Nursing services to be provided, including amount, duration and frequency;
• Member's prognosis;
• Member's mental status;
• Rehabilitation potential;
• Equipment and/or supplies required;
• Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
• Other prescribed services, including amount, duration and frequency;
• Nutritional requirements, including type, method of administration and frequency;
• Medications, including the dose, route, frequency and any medication-related allergies if known;
• Treatments, including amount and frequency;
• Wound care orders and measurements;
• Safety measures to protect against injury;
• Functional developmental services and psychosocial services, including amount, duration and frequency;
• Name, telephone number and signature of the responsible adult;
• Member’s emergency contact name and telephone number;
• Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
• List of services the member receives in the home and school settings. [e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), personal care services (PCS), private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)].
  • Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
• Member-specific measurable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
• Responsible adult training needs;
• Prior and current functional or medical limitations;
• Permitted activities;
• Member's scheduled days and hours of attendance;
• Confirmation of a discharge plan, including instructions for timely discharge or referral;
• Method of transportation;
• PDN provider name, TPI, NPI, telephone, address and fax number, if known;
• Ordering physician signature and date of signature;
• Transportation services needed by a member to access PPECC service (a non-emergency ambulance must not be used for transport to and from a PPECC); and
• Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 363 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), §363.209 (Benefits and Limitations).

The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

• Speech, physical, and occupational therapies (including therapies rendered by a home health agency);
• Certified respiratory care services;
• Early intervention services provided through the ECI program, which are subject to ECI policies.

In accordance with 2.14.1 of the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, therapy services (occupational, speech, physical and respiratory) rendered in a PPECC must be provided by:

• therapists employed by or contracted with the PPECC; or
• therapists contracted with the MCO but not employed by, or contracted with, the PPECC.

Therapy providers must be Medicaid enrolled and separately contracted and credentialed with the MCO, even if they are employed by, or contracted with, the PPECC. Therapy services must be authorized and billed separately from PPECC services, and the MCO's claims systems must accommodate PPECCs as a place of service for therapy services.

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

See 4310, Private Duty Nursing and Prescribed Pediatric Extended Care Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC or a combination of both services.

Revision 17-1; Effective June 1, 2017

Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations may not require DAHS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for DAHS.

4510 Assessment for Day Activity and Health Services

Revision 22-2; Effective September 1, 2022

The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse (RN) or licensed vocational nurse (LVN), based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member's home. Health assessments must be conducted, at minimum, when:

• members need initial assessment for prior authorization by a STAR Kids managed care organization;
• members transfer to a new facility (conducted by the new facility);
• at reauthorization; and
• the DAHS nurse determines a member needs to be reassessed.

The member or their legally authorized representative must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member's functioning.

4511 Reassessment for Day Activity and Health Services

Revision 22-2; Effective September 1, 2022

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment must be no older than 90 days from the date at which an authorization is requested.

A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation, and nutritional services when:

• a member first enters the facility;
• transferring from another Day Activity and Health Services facility; and
• a member's condition changes. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.

4520 Day Activity and Health Services Providers

Revision 22-3; Effective Dec. 1, 2022

To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

• Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services (PCS).
• Physical rehabilitative services, which include restorative nursing and group and individual exercises with range of motion exercises.
• Nutrition services, which include:
  • one hot noon meal a day;
  • a mid-morning and mid-afternoon snack;
  • preparation of foods required for special diets; and
  • dietary counseling and nutrition education for the individual and their family.
• Transportation, including to and from the facility, on an activity outing, and to provide therapies if the member requires specialized services on days of attendance at the DAHS facility. The provider must:
  • coordinate the use of other transportation resources within the community;
  • make every effort to have families transport individuals;
  • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and
  • have sufficient staff to ensure the safety of members being transported to and from their homes.

• Activities and other supportive services:
  • Activities offered at the facility must be meaningful, fun, therapeutic and educational.
  • A provider must offer at least three different scheduled activities in at least one or more of the following activities:
    • exercise;
    • games;
    • educational or reality orientation; and
    • crafts.
  • A provider must offer at least one of the following activities, at cost to the provider, monthly:
    • trips or special events; or
    • cultural enrichment.

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, supported employment, and employment assistance. This is to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years old and support deinstitutionalization of nursing facility residents under 21 years old.

Only members who are assessed as meeting medical necessity (MN) and who have a slot in the MDCP waiver are eligible for MDCP services. Federal guidelines require that members must need and use one or more waiver services to qualify and maintain eligibility for MDCP. The minimum utilization of MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they utilize Community First Choice (CFC), as described in Section 1530, Unmet Need for at Least One Waiver Service.

The managed care organization (MCO) service coordinator must inform all members receiving MDCP services of the requirements outlined in Section 1530 and the following:

• If the member’s eligibility is Medical Assistance Only (MAO) and:
  • CFC has been authorized, at a minimum, one MDCP service must be used at least once a month to qualify and maintain enrollment in MDCP.
  • CFC has not been authorized, at a minimum, one MDCP service must be used at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
• If the member’s eligibility is not MAO and CFC has been authorized, at a minimum, at least one MDCP service must be used during the member’s ISP year. The member must receive monthly monitoring by the MCO if services are furnished on a less than monthly basis to qualify and maintain enrollment in MDCP.

If the member is not meeting the minimum required service utilization, the MCO must notify the Program Support Unit (PSU) following requirements in Section 6270, Denial/Termination Due to Failure to Meet Other Program Requirements. If a member is offered enrollment in MDCP or at an MDCP member's reassessment, during the STAR Kids assessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the service coordinator must discuss the member's needs relating to the available MDCP services. The service coordinator must develop a recommended individual service plan (ISP) if the member's Resource Utilization Group (RUG) is not known, as the RUG determines the member's budget.

Example: The service coordinator could ask;

• the member or their caregiver if they would like respite or have a desire for employment services. 
• if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services
• which services the member or caregiver would like more of, should the member's budget be unknown during the assessment.

Based on the discussion, the service coordinator could develop a recommended ISP for that member and work with the member or caregiver in person or by phone to develop a final service plan once the member's budget is known.

Revision 22-3; Effective Dec. 1, 2022

4710 Medically Dependent Children Program Respite Services

Revision 22-3; Effective Dec. 1, 2022

Respite is a service that provides temporary relief from caregiving to the member’s primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the member’s parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by an attendant, LVN, or RN through a home and community support services agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-home respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or private duty nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite provides relief to the primary caregiver if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of such services as suctioning or monitoring vitals and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks they would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that case, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer. Note: Respite must not be authorized in place of PDN where PDN is most appropriate. Respite is intended to provide relief to the primary caregiver and must only be authorized for that purpose.

STAR Kids MCOs must determine the number of units of respite to authorize for an MDCP member, based on the member or legally authorized representative's preferences, level of care, and the member's approved cost limit. Specialized nursing rates will be paid when a member requires, as determined by a physician, daily skilled nursing to cleanse, dress, and suction a tracheostomy or daily skilled nursing assistance with ventilator or respirator care. The member must be unable to do self-care and require the help of a nurse for the ventilator, respirator or tracheostomy care. MCOs must develop internal processes for respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP. 

4711 In-Home Respite

Revision 22-2; Effective September 1, 2022

In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option.

A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by their available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan (ISP).

4712 Attendant with Delegated Tasks

Revision 22-2; Effective September 1, 2022

A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a physician or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled nursing task need for the delivery of respite, they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the nurse service coordinator or the Home and Community Support Services Agency (HCSSA) nurse determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required. Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, they must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

4713 Out-of-Home Respite

Revision 22-2; Effective September 1, 2022

Respite may be provided out of the home if indicated in a physician's order or if the member and/or their legally authorized representative prefer. Out-of-home respite providers are:

• special care facilities licensed by the Texas Health and Human Services Commission (HHSC);
• day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
• hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
• nursing facilities licensed by the Texas Health and Human Services Commission (HHSC);
• camps licensed by DSHS and accredited by the American Camping Association; and
• foster families approved by a DFPS child placing agency.

Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.

4720 Respite Limits

Revision 22-2; Effective September 1, 2022

Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

• primary caregiver;
• member's spouse; or
• member's parent, representative, guardian or managing conservator, if the individual is under age 18.

4730 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

4740 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

4750 Flexible Family Support Services

Revision 19-1; Effective June 3, 2019

Flexible family support services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

• child care;
• independent living; and
• post-secondary education.

FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.

4751 Flexible Family Support Services in Child Care

Revision 22-2; Effective September 1, 2022

The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the number of hours needed to support the member's needs within the Medically Dependent Children Program (MDCP) cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.

FFSS does not replace personal care services (PCS) provided through Texas Health Steps (THS) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.

4752 Flexible Family Support Services for Independent Living

Revision 22-2; Effective September 1, 2022

A member may indicate a desire for increased independence as they mature. If the member needs assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with their goals for independent living.
Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.

To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.

4753 Flexible Family Support Services in Post-Secondary Education

Revision 22-2; Effective September 1, 2022

A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS, so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.

4754 Flexible Family Support Services Requiring Delegated Tasks

Revision 22-2; Effective September 1, 2022

A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or their legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

4760 Flexible Family Support Services Limits

Revision 22-2; Effective September 1, 2022

Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services (PCS) or Community First Choice (CFC).

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID).
The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.

Revision 22-2; Effective September 1, 2022

4810 Adaptive Aids

Revision 19-1; Effective June 3, 2019

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

• perform activities of daily living (ADLs); or
• control the environment in which they live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

4811 Service Limits on Adaptive Aids

Revision 22-3; Effective Dec. 1, 2022 

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. 

Adaptive aids are available through the Medically Dependent Children Program (MDCP) only after benefits available through Medicare; Medicaid, including the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, known in Texas as Texas Health Steps – Comprehensive Care Program (THSteps-CCP); or other third party resources have been exhausted. Items reimbursed with waiver funds are only accessible for items not covered under the state plan.

Health and safety of the individual are ensured through the use of non-waiver services, the Medicaid State Plan, and THSteps-CCP. 

The services under the waiver are limited to additional services not otherwise covered under the state plan, but consistent with waiver objectives of avoiding institutionalization.

After any applicable benefits (e.g., durable medical equipment) are exhausted, adaptive aids, including repair and maintenance not covered by warranty (i.e., batteries), covered through MDCP include, but are not limited to, the following:

• van lifts;
• vehicle modifications;
• jump seats;
• tumble form chairs;
• feeder seats;
• medically appropriate strollers;
• barrier-free lifts;
• stair lifts;
• environmental control units;
• alarm systems;
• support rails;
• electrical work related to use of authorized adaptive aids;
• installation of authorized adaptive aids; and
• repairs to adaptive aids.

This is not an exhaustive list. For adaptive aids not specifically listed above, the service planning team must determine the member has an established assessed need and a compromised health status without the requested equipment or supplies. Items must be prescribed by a physician and be determined to meet the criteria specified in 4810, Adaptive Aids.

The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. MCOs may also choose to pay the excess costs on a case-by-case basis with MCO funds. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

4812 Time Frames for Adaptive Aids

Revision 22-2; Effective September 1, 2022

When an adaptive aid (AA) is included in an individual service plan (ISP), the managed care organization (MCO) must purchase and ensure delivery of the AA within 14 business days of being authorized (except for vehicle modifications), counting from one of the following dates, whichever is later:

• the start date of the ISP; or
• the date of the ISP revision, if the AA service is added after the ISP start date.  

The MCO must document and notify the member of any delay in delivering the AA, the reason for the delay and the new proposed delivery date. The notification must be provided on or before the 14th business day following authorization. If the provider does not deliver the AA by the new proposed date, the MCO must document and notify the member about any additional delays until the AA is delivered. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely delivery of the AA. 

4820 Minor Home Modifications

Revision 22-2; Effective September 1, 2022

A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in their home. If a home modification is requested and the member or their legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations (MCOs) may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.

4821 Service Limits on Minor Home Modifications

Revision 22-2; Effective September 1, 2022

The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.

The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.

Minor home modifications are limited to:

• purchase and installation of permanent and portable ramps not covered by other sources;
• widening of doorways;
• modification of bathroom facilities; and
• modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

• adhere to Americans with Disabilities Act (ADA) requirements;
• meet Texas Accessibility Standards;
• meet all applicable state and/or local building codes; and
• have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or their legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

4822 Time Frames for Minor Home Modifications

Revision 21-1; Effective April 1, 2021

When a minor home modification (MHM) is included in an individual service plan (ISP), the managed care organization (MCO) must ensure completion of the MHM within 90 business days after:

• the start date of the ISP; or
• the date of the ISP revision, if the MHM service is added after the ISP start date.  

The MCO must document and notify the member of any delay in completing the MHM, the reason for the delay and the new proposed completion date. If the provider does not complete the MHM by the new proposed completion date, the MCO must document and notify the member about the additional delay. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely completion of the MHM.

4830 Transition Assistance Services

Revision 22-3; Effective Dec. 1, 2022

The service coordinator must advise individuals who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the individual needs assistance in setting up a household when relocating into the community from the NF. STAR Kids managed care organizations (MCOs) may not require TAS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for TAS. The individual may access TAS if they:

• plan to rent an apartment;
• plan to rent a house;
• have a home, but the utilities have been off while in the NF;
• have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
• need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for individuals transitioning from NFs into MDCP and to individuals suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the individual’s transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

• security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
• essential furnishings for the apartment or house;
• moving expenses required to move into the house or apartment; and
• site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The individual selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the individual or their legally authorized representative (LAR) to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the individual or their LAR that the service will not be authorized until the individual is determined eligible for MDCP waiver services, and notified in writing that they are eligible. The service coordinator must contact the individual or their LAR before certification to verify they have made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

4831 Deposits

Revision 22-2; Effective September 1, 2022

The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the individual’s name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the individual’s service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the individual’s name or to pay for arrears on previous utilities if the account is in the individual’s name and they will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.

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 requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the individual’s transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the individual’s place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the individual identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the individual not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.
 

4832 Moving Expenses

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the individual’s belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the individual from the nursing facility to their residence in the community.

4833 Site Preparation

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for preparing the individual’s place of residence for occupancy if the current condition of the residence prevents the individual’s transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and needs some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the individual is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the individual’s residence has been unattended or the individual is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.

4834 Limits on Transition Assistance Services

Revision 22-2; Effective September 1, 2022

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per individual. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. The service coordinator must be as specific as possible when describing the items purchased. A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to nursing facility placement may receive a one-time TAS authorization if the service coordinator determines that no other resources are available to pay for the basic services or items needed by the individual. TAS may not be used for:

• monthly rent or mortgage expenses;
• current or future use of utilities;
• service upgrades;
• food items; or
• any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to individuals who are discharged from a nursing facility and require TAS to set up a household.

4835 Transition Assistance Services Agency Responsibilities

Revision 22-2; Effective September 1, 2022

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 authorization carefully and contact the MCO if there are any questions regarding the authorization. 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 or their legally authorized representative (LAR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization 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 authorization made by the MCO. The TAS agency contacts the member or their LAR, 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.

4836 Three-Day Monitor Requirement

Revision 17-1; Effective June 1, 2017

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. 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.

4837 Failure to Leave the Facility

Revision 22-2; Effective September 1, 2022

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes their mind or has a change in health making it impossible for them 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 purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.

• If the TAS agency is unsuccessful in returning the item(s) for monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
• If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
• If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.

If the member is only in the community for a few days and returns to the nursing facility, the member keeps the item(s) purchased through TAS.

Revision 22-3; Effective Dec. 1, 2022

Texas Human Resources Code, Section 32.075 requires that all Medicaid waivers offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program are EA and SE. STAR Kids managed care organizations may not require SE or EA providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for SE or EA services.

4910 Employment Assistance

Revision 22-3; Effective Dec. 1, 2022

Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) services to help the individual locate paid employment in the community and includes:

• identifying a member's employment preferences, job skills, and requirements for a work setting and work conditions;
• locating prospective employers offering employment compatible with a member's identified preferences, skills and requirements; and
• contacting a prospective employer on behalf of a member and negotiating the member's employment.

For any MDCP member, the service coordinator must ensure and document that employment services are not available to the member from the member's school district or other available community resource before authorizing EA services.

The service coordinator refers the member to the Texas Workforce Solutions-Vocational Rehabilitation Services (TWS-VRS) within 30 days of meeting with a member and identifying an interest in obtaining employment. The service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at webp.twc.state.tx.us/services/VRLookup/.

A member who made contact with TWS-VRS is eligible to receive EA through MDCP until TRS-VRS has developed the Individualized Plan of Employment (IPE) and the member has signed it. If a member refuses to contact TWC, they may not receive waiver-funded EA. 

If the member has exhausted TRS-VRS services or been determined ineligible for TRS-VRS services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). EA can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member's MDCP budget.

If, after making application with TWS-VRS, the member is determined ineligible for TWS-VRS services, EA through MDCP can continue until the member obtains competitive integrated employment.

4911 Coordination with Texas Workforce Solutions-Vocational Rehabilitation Services for Employment Assistance

Revision 22-3; Effective Dec. 1, 2022

Upon request and with proper authorization for disclosure, the service coordinator helps the member provide the Texas Workforce Solutions-Vocational Rehabilitation Services (TWS-VRS) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

• photo identification;
• an original Social Security card;
• member's home address and mailing address;
• names and addresses of any doctors the member has seen recently;
• names and addresses of any schools the member has attended;
• information about the member's medical insurance;
• a list of places the member has worked, including type of job, dates, the reason for leaving and salary;
• proof of income for the member and their spouse, or parents (if the parents claim the member as a dependent on their income tax);
• proof of expenses related to monthly mortgage or rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
• names, addresses and phone numbers of two people who will know how to contact the member;
• any reports of recent medical exams, school records or other information that may help the VRC understand the member's disability;
• member's most recent service plan;
• any current vocational assessments or person-directed plans that focus on employment opportunities;
• any other available records pertaining to the member's disabilities, including but not limited to medical, psychological and psychiatric reports;
• a copy of the member's court-ordered guardianship documents, if any guardian has been appointed; and
• contact information for the member's service coordinator.

TWS-VRS will:

• notify a member in writing if the member is determined to be eligible or ineligible for TWS-VRS services;
• notify a member in writing when the member’s TWS-VRS case is closed;
• develop with the eligible member an Individualized Plan for Employment (IPE) within 90 days of determination of eligibility for services;
• After the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
• Upon request and with proper authorization for disclosure, provide copies of any of the member's records to the service coordinator, including the following documents:
  • a completed copy of the member's application statement;
  • a member's completed IPE;
  • written documentation specifying a member's eligibility status; and
  • the notification letter indicating TWS-VRS is completed.

If TWS-VRS has not notified the member of an eligibility decision within 60 days of the initial TWS-VRS appointment, the member's service coordinator attempts to contact the assigned TWS-VRS VRC to determine the status of the application and document the contact in the narrative notes.

The member's service coordinator will ensure that communication is maintained with the assigned TWS-VRS VRC about waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWS-VRS active services, as defined in the individual's TWS-VRS VR IPE.

At the request of a member determined eligible for TWC, the service coordinator, will assist the member if possible, and:

• participate in TWS-VRS planning meetings related to the member's employment, or ensure other individuals important to the member attend, as appropriate;
• take an active role in providing input to the TWC IPE, or ensure other individuals important to the member provide input, as appropriate; and
• if long-term services and supports are needed to maintain or advance in employment, supported employment will be incorporated in a revision to the member's service plan when the member reaches “Job Stability” status with TWS-VRS.

The member's provider must begin providing or subcontracting for those services and supports approved in the member's service plan without a gap between the provision of TWS-VRS and waiver services.

4912 Employment Assistance Providers

Revision 22-2; Effective September 1, 2022

Employment assistance providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option. At a minimum, the employment assistance provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and satisfy one of these options:

Option 1:

• A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
• Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

• An associate's degree in rehabilitation, business, marketing, or a related human services field; and
• One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

• A high school diploma or Certificate of High School Equivalency (GED credentials); and
• Two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

4920 Supported Employment

Revision 22-3; Effective Dec. 1, 2022

Supported employment (SE) services help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

SE services include:

• assistance provided to a member to sustain competitive employment and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting where individuals without disabilities are employed;
• employment adaptations, supervision and training related to a member's assessed need; and
• ensuring members earn at least minimum wage, if not self-employed.

Competitive employment is work:

• in the competitive labor market where anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
• where a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community where members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting where:

• groups of people with disabilities work in an area not part of the general workplace where people without disabilities work; or
• a mobile crew of people with disabilities work in the community.

An MDCP member may seek SE to aid the member in maintaining self-employment. Self-employment is work that the member:

• solely owns, manages and operates a business;
• is not an employee of another person, entity or business; and
• actively markets a service or product to potential customers.

SE may only be authorized through the MDCP waiver if 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. Section 1401 et seq.).  In the state of Texas, this service is not available to individuals under a program funded under section 110 of the Rehabilitation Act of 1973.

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 19-1; Effective June 3, 2019

The service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third party resources before using Medically Dependent Children Program (MDCP) employment services, including school districts.

Activities include:

• devoting time during a member's initial service planning meeting to discuss employment with the member and family and the process to obtain employment services and supports;
• making a referral to TWC, assisting with completing the application form, and documenting the referral and outcome of the referral in the member's case record;
• continuing to explore the possibility of employment at subsequent service planning meetings for a member who is not employed in the community;
• affirming or explaining how a member can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
• explaining rights to appeal if services are denied, reduced or terminated; and
• monitoring whether the member and family are satisfied with the employment supports.

4922 Supported Employment Providers

Revision 22-2; Effective September 1, 2022

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting individual, and satisfy one of these options:

Option 1:

• A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
• Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

• An associate's degree in rehabilitation, business, marketing, or a related human services field; and
• One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

• A high school diploma or Certificate of High School Equivalency (GED credentials), and
• Two years of paid or unpaid experience providing services to people with disabilities.

Under CDS, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

Revision 20-1; Effective March 16, 2020

5110 Description

Revision 20-1; Effective March 16, 2020

In the agency option, the managed care organization-contracted provider is responsible for managing the day-to-day activities of the direct service provider and all business details. Some individuals select the agency option because of the simplicity and convenience of receiving services. For example, in the agency option, it is the provider agency, not the member, that is responsible for:

• locating qualified attendant(s) to provide services;
• any negligent acts or omissions by the attendant(s), and liability for those acts;
• handling all conflicts with the attendant(s);
• any business details related to service delivery; and
• training the attendant(s).

Revision 22-3; Effective Dec. 1, 2022

5210 Overview

Revision 22-3; Effective Dec. 1, 2022

Consumer Directed Services (CDS) allows a member or legally authorized representative (LAR) to hire and manage the people who provide services within the member’s current home and community-based program. The philosophy behind CDS is that people are the best judges of the type and level of aid they may need and how that assistance should be delivered.

The 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. Find applicable rules for the CDS option in Texas Administrative Code, Title 40, Chapter 41.

CDS is a service delivery option where a member or LAR becomes the CDS employer of record for certain services. The CDS employer recruits, hires, trains, and supervises service providers and directs the delivery of services available through the CDS option, described in Section 5212, STAR Kids Services Available Under the Consumer Directed Services Option. CDS employers are required to use a financial management services agency (FMSA), contracted with the managed care organization to provide financial management services (FMS). FMSAs conduct payroll and pay employer federal and state taxes on behalf of CDS employers, and provide orientation and ongoing support for members who choose the CDS option. FMSA roles and responsibilities are explained in more detail in Section 5233, FMSA Responsibilities.

A member or LAR may choose the CDS option if:

• the member's program offers the CDS option;
• one or more program services in the member's authorized service plan are available for delivery through the CDS option;
• the member or LAR agrees to perform, or to appoint a designated representative (DR) to perform, the employer responsibilities required for participation in the CDS option;
• the member or LAR selects an FMSA to provide FMS; and
• the member or LAR has developed and received approval from the service planning team for each required service back-up plan.

If a member or LAR elects to participate in the CDS option, the member or LAR:

• selects one FMSA to provide FMS;
• budgets funds allocated in the member's authorized service plan for delivery through the CDS option with the assistance of the FMSA; and
• recruits, screens, hires, trains, manages and terminates service providers.

As the CDS employer, a member or LAR may appoint, in writing, a willing adult as the DR to assist in performing employer responsibilities.

5211 Consumer Directed Services Definitions

Revision 22-3; Effective Dec. 1, 2022

The following words and terms, when used in reference to the Consumer Directed Services (CDS) option, have the following meanings.

Actively involved — Involvement with a member that the member's interdisciplinary team deems to be of a quality nature based on the following:

• observed interactions of the person with the member;
• a history of advocating for the best interests of the member;
• knowledge and sensitivity to the member's preferences, values and beliefs;
• ability to communicate with the member; and
• availability to the member for assistance or support when needed.

Budget — A written projection of expenditures for each service delivered through the CDS option.

CDS employer — The member or LAR who chooses to participate in the CDS option and is responsible for hiring, training, managing and retaining service providers to deliver program services.

Designated representative (DR) — A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the employer. The DR is not the CDS employer. The DR must be a volunteer and cannot be a paid service provider. The CDS employer is responsible for actions taken by the DR.

Employee — A person employed by the member or LAR through a service agreement to deliver program services and is paid an hourly wage for those services.

Employer support services — Services and items the CDS employer needs to perform employer and employment responsibilities, such as office equipment and supplies, support consultation, expenses related to recruiting employees, and other items approved in Texas Administrative Code, Title 40, Part 1, Chapter 41,  Section 41.507, and the Consumer Directed Services Handbook, Appendix XI, Allowable and Non-Allowable Expenditure.

Financial Management Services (FMS) — Services delivered by the financial management service agency (FMSA) to the member or LAR, as described in Section 5233, FMSA Responsibilities. These services include orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member or LAR.

Financial management services agency (FMSA) — An agency that contracts with a managed care organization (MCO) to provide FMS.

Legally authorized representative (LAR) — A person authorized or required by law to act on behalf of a member regarding Consumer Directed Services, including a parent of a minor, guardian of a minor, 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.

Service Planning Team — A group of people who meet to discuss the member’s needs, which consists of the member or LAR, the service coordinator and any other person invited by the member or LAR.

5212 Services Available in the CDS Option

Revision 22-3; Effective Dec. 1, 2022

STAR Kids services available in the Consumer Directed Services (CDS) option are:

• Community First Choice Personal Care Services (CFC-PCS);
• Community First Choice Habilitation (CFC-HAB; and 
• Personal Care Services.  

The Medically Dependent Children Program (MDCP) waiver services and supports available through the CDS option are:

• respite services;
• flexible family support services;
• adaptive aids;
• minor home modifications;
• supported employment; and
• employment assistance.

See Appendix III, LTSS Billing Matrix and Crosswalk for CDS billing modifiers. 

A member or their legally authorized representative (LAR) may choose to self-direct any or all of the services available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members.

Choosing the CDS option does not impact a member's eligibility for services. A member or LAR can choose to have the above services delivered through the service delivery option of their choice.

Financial management services (FMS) are required in the CDS option. FMS assist members to manage funds associated with services elected for self-direction and is provided by a financial management service agency (FMSA) contracted with the member’s managed care organization (MCO). This includes initial orientation and ongoing training related to CDS employer responsibilities, as well as assisting with and approving the CDS employer’s budget. The FMSA also conducts payroll and pays employer taxes on behalf of the CDS employer. A monthly administrative fee is authorized on the individual service plan and paid by the MCO to the FMSA for FMS.

If requested, an FMSA can provide support consultation, including additional training and support for the CDS employer related to their employer responsibilities, beyond the ongoing support provided by the FMSA.

5220 Advantages and Risks of the Consumer Directed Services Option

Revision 20-1; Effective March 16, 2020

The member or legally authorized representative (LAR) should be informed of and consider the advantages and risks associated with the Consumer Directed Services (CDS) option before choosing to enroll. To assist the member in making an informed choice, the managed care organization (MCO) service coordinator presents information about service delivery options to the member or LAR. Refer to 5221, Advantages of Consumer Directed Services (CDS) Service Delivery Option, below.

5221 Advantages of Consumer Directed Services (CDS) Service Delivery Option

Revision 20-1; Effective March 16, 2020

Below are some of the advantages of using the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR):

• has more control over who provides services and the days and times the services are delivered;
• can offer benefits, such as bonuses, overtime pay, pay raises, vacation pay, sick pay and insurance to direct service providers, using funds from the CDS budget and in consultation with the financial management services agency (FMSA);
• can control the final rate of pay for service providers within allowable limits;
• may hire eligible service providers, such as family members, friends and other persons they know, in compliance with program and CDS rules;
• will train service providers and supervise the delivery of services;
• can appoint an eligible person as a designated representative to assist with or perform CDS employer responsibilities; and
• may use budgeted funds to hire a support advisor, if they need assistance beyond what the FMSA provides.

5222 Potential Risks Associated with the Consumer Directed Services Option

Revision 20-1; Effective March 16, 2020

Below are some of the member responsibilities and potential risks associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR) is:

• responsible for locating attendants, back-up attendants and other direct service providers since there is no home and community support services agency (HCSSA) provider to fall back on to provide services. The member or LAR may contract with an HCSSA that agrees to provide back-up services, but the HCSSA is not required to contract with the member or LAR;
• the employer in the CDS option and, therefore, assumes all liability related to employment. The member or LAR retains control over recruiting, hiring, training, managing and terminating employees. The persons providing services are not the employees of the financial management service agency (FMSA), the managed care organization (MCO), any state or federal agency or other contracted provider agency. As the CDS employer, the member or LAR is solely responsible and liable for any negligent acts or omissions made by the employee, service providers and the designated representative;
• responsible for handling all conflicts with service providers. The CDS employer can request support consultation services be added to their service plan and budget to provide training and assistance with this CDS employer responsibility, as necessary;
• not able to decrease or increase the MCO authorized service hours by adjusting the employee’s hourly wage;
• required to keep certain paperwork to be specified by the FMSA for a required period. The CDS employer must safely store the documentation for five years or longer;
• ultimately responsible for payroll taxes owed to the Internal Revenue Service (IRS) and Texas Workforce Commission (TWC), and is liable if the FMSA fails to pay; and
• responsible for meeting all state and federal requirements as an employer and can be held liable for failure to meet those requirements.

5230 Member and Financial Management Service Agency Responsibilities

Revision 20-1; Effective March 16, 2020

5231 Member Responsibilities

Revision 22-3; Effective Dec. 1, 2022

The member or legally authorized representative (LAR) assumes responsibility as the CDS employer of record. The member or LAR is responsible for:

• recruiting, hiring, training, managing and terminating direct service providers;
• setting wages and benefits for direct service providers within funds allocated for services elected for delivery through the Consumer Directed Services (CDS) option;
• following state and federal laws including the payment of overtime;
• evaluating each service provider's job performance;
• approving, signing and submitting time sheets, invoices and receipts to the financial management service agency (FMSA) for payment to direct service providers;
• providing the FMSA with necessary information to register as the member’s agent with the Internal Revenue Service (IRS) and the Texas Workforce Commission (TWC);
• having the FMSA verify eligibility of each applicant before hiring or retaining for employment or service delivery;
• resolving employee and service provider concerns and complaints;
• maintaining a personnel file on each service provider;
• developing and implementing back-up service plans for services determined by the individual's planning team to be critical to the individual's health and welfare; and
• ensuring protection of the individual receiving services and preserving evidence in the event of a Texas Department of Family and Protective Services Adult Protective Services investigation of an allegation of abuse, neglect, or exploitation against a CDS employee, designated representative, FMSA representative or managed care organization service coordinator.

5232 Designated Representative

Revision 20-1; Effective March. 16, 2020

The member or legally authorized representative (LAR) has the option to appoint a designated representative (DR) to assist with the responsibilities of being a CDS employer in the Consumer Directed Services (CDS) option. A CDS 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. If the CDS employer chooses to appoint or change a DR, the CDS employer must complete Form 1720, Appointment of Designated Representative.

The person appointed as the DR by the member or LAR must:

• be willing to serve as the member's or LAR's DR for participation in the CDS option;
• be or become actively involved with the member; and
• complete the self-assessment in Form 1582, Consumer Directed Services Responsibilities, and any assessment required by the member's program.

A DR must not:

• sign or represent themselves as the CDS employer;
• be paid to perform CDS employer responsibilities;
• be an employee of the CDS employer;
• have a spouse employed by the CDS employer; or
• provide a program service to the member.

The CDS employer must notify the financial management services agency (FMSA) by fax or phone within two business days after the appointment or change of a DR.

• If the CDS employer notifies the FMSA by phone, the CDS employer must fax or mail a copy of Form 1720 to the FMSA within five business days after the appointment or change of a DR.

If a CDS employer decides to revoke the appointment of a DR, the CDS employer must:

• complete Form 1721, Revocation of Appointment of Designated Representative; and
• provide a copy of the completed form to the FMSA within two days after the effective date of the revocation.

Based on documentation provided by the FMSA of a CDS employer's inability to meet CDS employer responsibilities, the person-centered service planning team may recommend that the employer designate a DR to assist with or to perform CDS employer responsibilities.

5233 FMSA Responsibilities

Revision 20-1; Effective March. 16, 2020

A financial management services agency (FMSA) must provide financial management services (FMS) to a Consumer Directed Services (CDS) employer or designated representative (DR), including:

• orienting and training the CDS employer or DR about CDS employer responsibilities for the CDS option, including legal requirements of various governmental agencies;
• assisting with and approving budgets for each service to be delivered through CDS;
• with the CDS employer, completing forms required to obtain an employer identification number (EIN) from federal and state agencies;
• conducting criminal history checks and registry checks of applicants;
• verifying each applicant's eligibility with program requirements, including Medicaid fraud exclusions, before an applicant is employed or retained by the CDS employer;
• registering as the employer-agent with the Internal Revenue Service (IRS) and assuming full liability for filing reports;
• paying employer taxes, on the CDS employer's behalf, to the IRS and Texas Workforce Commission;
• receiving and processing employee time sheets, computing and paying all federal and state employment-related taxes and withholdings, and distributing payroll at least twice a month;
• receiving and processing invoices and receipts for payment;
• maintaining records of all expenses and the reimbursement and monitor budget;
• submitting claims to the member's managed care organization (MCO);
• providing written summaries and budgeting balances of payroll and other expenses at least quarterly;
• preparing and filing employer-related tax and withholding forms and reports (this does not include filing personal income tax returns for employees); and
• providing ongoing training and assistance, as needed or requested.

CDS employers must perform all responsibilities as required by the IRS, Texas Workforce Commission other appropriate government agencies. The FMSA enters into service agreements with each of the member's direct service providers before issuing payment.

An FMSA may not provide financial management services (FMS) and case management services to the same member.

The FMSA must participate in all mandatory training provided or authorized by the Texas Health and Human Services Commission.

The MCO must monitor the FMSA’s performance and must ensure the FMSA performs all FMSA responsibilities, including participation in mandatory training.

5240 Member Choice in the Consumer Directed Services Option

Revision 20-1; Effective March 16, 2020

Information about the Consumer Directed Services (CDS) option is presented to the STAR Kids member by the managed care organization (MCO) service coordinator at all initial and annual planning meetings or at any time requested by the member. The MCO service coordinator should provide written and verbal information about the benefits and requirements of the CDS option. The member chooses which services will be delivered through the CDS option and which will be delivered through the agency or service responsibility option.

5241 Presentation of the CDS Option

Revision 20-1; Effective March 16, 2020

At the time of a member’s enrollment in STAR Kids or the Medically Dependent Children Program (MDCP), and at least annually thereafter, the managed care organization (MCO) service coordinator or another person designated by the member's program must:

• provide written materials on the CDS option to the member or legally authorized representative (LAR);
• meet with and provide the member or LAR with a verbal explanation of the CDS option specific to the member's program;
• present or make available to the member, the Texas Health and Human Services Commission (HHSC) video, The Consumer Directed Services Option, which can be accessed by visiting https://hhs.texas.gov/cds; and
• complete Form 1581, Consumer Directed Services (CDS) Option Overview.

A member or LAR may request that an MCO service coordinator provide additional verbal and written information to the member or LAR regarding the CDS option or assist with enrollment in the CDS option at any time. The MCO service coordinator must comply within five business days after receipt of the request.

A member or LAR declining participation in the CDS option may at any time elect to participate in the CDS option while receiving services through STAR Kids or MDCP.

The MCO service coordinator is responsible for presenting the CDS option annually to all new applicants and ongoing members who are not enrolled in the CDS option and whenever information is requested. The MCO service coordinator:

• shares an overview of the benefits and responsibilities of the CDS option by reviewing Form 1581;
• provides a copy of Form 1581 to the applicant or member or legally authorized representative (LAR); and
• informs the applicant or member of the right to choose service delivery through the CDS option, the agency option or the service responsibility option (SRO).

For initial applications, the MCO service coordinator obtains the applicant's signature on Form 1581 at the initial contact. The MCO 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 MCO service coordinator provides the member or LAR with a copy of Form 1581 and clearly documents in the case record that Form 1581 was shared with the member.

When members or LARs request information about the CDS option at other times, the MCO service coordinator must provide CDS information to the member within five business days after receipt of the request. The MCO service coordinator may provide the information by making a home visit or contacting the member or LAR by telephone. If a home visit is not made, the MCO service coordinator obtains the member's or LAR’s signature by mailing Form 1581 to the member with a postage-paid return envelope. The MCO 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 MCO service coordinator must discuss the CDS option, as well as differences in service delivery and payment options, and allow the member or LAR the opportunity to choose between delivery of services through the agency option or the CDS option.

If the member or LAR is interested in participating in the CDS option once the information on Form 1581 is shared, the MCO service coordinator reviews Form 1582, Consumer Directed Services Responsibilities. The MCO service coordinator:

• reviews with the member or LAR the responsibilities, risks and advantages of the CDS option;
• assists the member or LAR, as needed, in completing the member self-assessment on Page 4 of Form 1582;
• records the member's or LAR's choice to participate in the CDS option, and appoints a designated representative (DR), if needed, or records the choice not to participate in the CDS option;
• assists the member or LAR in selecting and appointing the DR, or their choice not to participate;
• obtains the DR's dated signature if the member or LAR chooses to appoint a DR; and
• signs and dates Form 1582.

If a member or LAR (the CDS employer) is not able to complete the Consumer Self-Assessment, a person appointed by the CDS employer to be the employer's DR must be able to complete the Consumer Self-Assessment for the member receiving services to participate in the CDS option.

If a CDS employer would like to use a DR, the financial management services agency (FMSA) assists the CDS employer in appointing a DR after the FMSA has been selected.

Refer to 5232, Designated Representative, for procedures related to a member appointing a DR.

5250 Declining the CDS Option

Revision 20-1; Effective March 16, 2020

If the member or legally authorized representative (LAR) declines or is not ready to select the Consumer Directed Services (CDS) option at any point after reviewing Form 1581, Consumer Directed Services (CDS) Option Overview, the managed care organization (MCO) service coordinator:

• obtains the applicant's, member's or LAR's signature on Form 1584, Consumer Participation Choice, indicating his or her selection of service delivery option; and
• signs and dates Form 1584.

The MCO service coordinator must ensure the member 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.

Revision 20-1; Effective March 16, 2020

A member or legally authorized representative (LAR) who decides to participate in the Consumer Directed Services (CDS) option must, with assistance from the managed care organization (MCO) service coordinator, complete the following forms:

• Form 1582, Consumer Directed Services Responsibilities;
• Form 1583, Employee Qualification Requirements;
• Form 1584, Consumer Participation Choice;
• 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 Licensure for Certain Services Delivered through Consumer Directed Services, if required by the policies of the member's program; and
• Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the member's program.

A member or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582 and, if applicable, complete any assessment required by the member's program.

A member or LAR who is not able to complete the self-assessment must appoint a designated representative (DR) to participate in the CDS option.

The MCO service coordinator presents the information on Form 1582 and allows the member or LAR to choose the CDS option. The MCO service coordinator develops the member’s service plan according to policy and CDS option rules.

5310 Choosing the CDS Option and an FMSA

Revision 20-1; Effective March 16, 2020

If the member or legally authorized representative (LAR) chooses and is able to participate in the Consumer Directed Services (CDS) option, the MCO service coordinator proceeds to Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice. The MCO service coordinator:

• provides Form 1583 information on the additional responsibilities of being a CDS employer in the CDS option and who may or may not be hired in the CDS option;
• shares Form 1584, indicating the applicant's, member's or LAR's selection of the CDS option;
• obtains the applicant's, member's or LAR's dated signature on Form 1583 and Form 1584, if applicable;
• signs and dates the forms; and
• assists the member or LAR in choosing a financial management services agency (FMSA).

The MCO service coordinator presents a list of MCO-contracted FMSAs and home and community support services agencies (HCSSAs) providers. The member or LAR must select:

• an FMSA to provide CDS financial management services (FMS); and
• an HCSSA provider to deliver all other STAR Kids and Medically Dependent Children Program (MDCP) services that are not delivered under the CDS option.

The MCO service coordinator develops the individual service plan (ISP) according to STAR Kids and MDCP program policy and CDS option rules.

5311 Developing the Individual Service Plan in the CDS Option

Revision 23-4; Effective Dec. 1, 2023

Service planning for a member who chooses to participate in the Consumer Directed Services (CDS) option is completed per the rules and requirements of the member's program in the same manner as if services are delivered through a program provider. Service planning includes:

• determining the member's needs;
• determining service levels;
• justifying changes to the service plan;
• maintaining costs and cost limits;
• reviewing services; and
• obtaining approval for planned services.

The managed care organization (MCO) must adhere to rules and requirements of the member's program if the member's services, or a request for services, is recommended for:

• denial;
• reduction;
• suspension; or
• termination.

The MCO must provide a verbal explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided verbally and per the member's program requirements.

All STAR Kids and Medically Dependent Children Program (MDCP) program financial and non-financial eligibility requirements apply. All existing Medicaid eligibility requirements apply in the CDS option. CDS is not a service, it is a service delivery option. The MCO completes all forms currently required for STAR Kids and MDCP program services, including Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool.

The member using the CDS option must have a back-up plan to assure the provision of certain or critical authorized CDS services without a service break, even if there are unexpected changes in personnel. The CDS employer or designated representative (DR) must develop and receive approval from the MCO for each required service back-up plan in order to participate in the CDS option. Refer to 5323, Service Back-Up Plans.

The MCO follows program policy when completing denials or terminations, reductions in services and suspensions. The MCO must ensure the CDS employer fully understands the reasons for actions taken relating to the individual service plan (ISP) and STAR Kids program and MDCP services, as well as actions that could affect the member's participation in the CDS option.

With respect to the CDS option, nursing services are limited to MDCP respite nursing. 

If the CDS employer or DR hires a nurse to provide services, nurses must operate within their license requirements outlined in the Texas Board of Nursing regulations (Texas Administrative Code, Title 22, Part 11), including registered nurse (RN) or physician oversight, plan of care development for nurses depending on the level of nurse hired, and RN or physician supervision, as indicated.

In the CDS option, an RN must develop the nursing plan of care specific to respite services and indicate if the nursing hours can be provided by a licensed vocational nurse (LVN). The RN and LVN must acknowledge nursing rules, including that an LVN must practice under the supervision of an RN, by completing Form 1747, Acknowledgement of Nursing Requirements. 

The MCO RN who develops the respite services plan of care in the CDS option are expected to collaborate on the plan of care.

5312 Initiation of and Transition to the CDS Option

Revision 20-1; Effective March 16, 2020

Within five business days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible member or legally authorized representative (LAR), or upon receipt of Form 1584 and within five business days after eligibility determination for an applicant applying for program services, a managed care organization (MCO) service coordinator must provide the following documentation to the financial management services agency (FMSA):

• Form 1584;
• the individual service plan (ISP);
• date the CDS employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;
• date the CDS employer may begin delivery of program services through the employer's service providers;
• the number of units, the approved rate or the amount authorized in the ISP for each service to be delivered through the CDS option;
• total funds authorized for each program service to be delivered through the CDS option; and
• 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.

Within five business days after eligibility determination for the STAR Kids program or Medically Dependent Children Program (MDCP), new applicants who choose the CDS option are referred to the FMSA they select to begin the initiation process.

Within five business days of receipt of the completed Form 1584, ongoing STAR Kids program or MDCP members who choose the CDS option are referred to the FMSA they selected to begin the CDS initiation process.

The MCO service coordinator provides the FMSA the following documentation:

• Form 1584;
• Form 1582, Consumer Directed Services Responsibilities; and
• the ISP.

The MCO service coordinator must provide the FMSA 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 MCO service coordinator must emphasize that the applicant assumes all responsibility for arranging their self-directed services.

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.

MCO service coordinators must carefully coordinate transition activities when transitioning applicants or members to and from the CDS option.

5313 Initiation and Orientation of the Member as CDS Employer

Revision 22-3; Effective Dec. 1, 2022

Upon choosing to participate in the Consumer Directed Services (CDS) option, a CDS employer, legally authorized representative (LAR), and the designated representative (DR), if applicable, must:  

• complete the initial CDS employer orientation provided by the financial management services agency (FMSA) either in-person or using a synchronous audio-visual platform based on the preference of the CDS employer; 
• complete and maintain a copy of Form 1736, Documentation of Employer Orientation by Financial Management Services Agency, upon completion of the orientation;
• complete Form 1735, Employer and Financial Management Services Agency Service Agreement, with the program addendums, if applicable;
• complete Form 1726, Relationship Definitions for Consumer Directed Services;
• complete Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (for members enrolled in Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Medically Dependent Children Program (MDCP), Home & Community-based Services (HCS), or Texas Home Living (TxHmL) programs)) or Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (for members enrolled in all other programs);
• complete Form 1728, Liability Acknowledgment;
• submit completed original forms specified in this section to the FMSA within five business days after the date of the initial orientation; and
• retain copies of completed documentation required by this section.

Upon receipt of the CDS referral from the managed care organization (MCO) service coordinator, the FMSA completes the initial CDS employer orientation with the member, LAR or DR, if applicable, in the member's residence. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the CDS employer and the FMSA.

During the initial orientation, the FMSA must also:

• explain the roles, rules and responsibilities that apply to a CDS employer, provider, FMSA, MCO and state agencies, including:
  • the employer budget based on the authorized service plan;
  • the hiring process, including documents and forms to be completed for new employees; and
  • managing paper and electronic timesheets, due dates, payday schedules and disbursing employee payroll checks;
• review and leave with the CDS employer, LAR and DR, if applicable, a printed document that clearly states the FMSA's:
  • normal hours of operation;
  • key people to contact with issues or questions and how to contact these people; and
  • the complaint process, including how to file a complaint with the FMSA or about the FMSA;
• review Form 1735 and required addendums, emphasizing rule and policy requirements of the member's program, including:
  • service definitions;
  • provider qualifications;
  • required documentation to be kept in the home;
  • training requirements for service providers;
  • program staff who will be reviewing the employer's records; and
  • if applicable, nursing requirements as described on Form 1747, Acknowledgement of Nursing Requirements; and
• review and leave with the CDS employer, LAR and DR, if applicable, printed information on how to report allegations of abuse, neglect and exploitation.

The FMSA must provide to the CDS employer, LAR or DR a printed or electronic copy of the HHSC CDS Option Employer Manual.

Upon conclusion of the orientation, the FMSA and CDS employer must complete Form 1736, Documentation of Employer Orientation by Financial Management Services Agency.

The FMSA must receive a completed Form 1735 with required attachments signed and dated by the CDS employer before initiation of the CDS option.

The CDS employer or DR, if applicable, signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five business days after the date of initial orientation.

The CDS employer and FMSA notify the MCO service coordinator when all initiation activities are complete. The MCO ensures the FMSA performs all FMSA responsibilities, including providing orientation to CDS employers.

5314 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

Revision 20-1; Effective March 16, 2020

If the Consumer Directed Services (CDS) employer will assume responsibility for training and supervising an unlicensed service provider to perform certain health related tasks, the financial management service agency (FMSA) assists the employer or designated representative (DR) in completing the CDS employer and employee acknowledgment of exemption from nursing licensure requirements for certain services delivered through CDS. Tasks prohibited from delegation are described in Texas Administrative Code §225.13, Tasks Prohibited from Delegation. The employee acknowledges that, as the person who delivers the service, they have not been:

• denied a license under Chapter 301 or 302, Occupations Code; or
• issued a license under Chapter 301, Occupation Code, that is revoked or suspended.

The FMSA verifies potential service providers selected by the CDS employer or DR meet provider qualifications and other requirements of the STAR Kids program or Medically Dependent Children Program (MDCP) before the CDS employer or DR hires the service provider.

5315 Authorizing CDS

Revision 20-1; Effective March 16, 2020

For members new to Consumer Directed Services (CDS), following orientation the member or legally authorized representative (LAR) and financial management services agency (FMSA) notify the managed care organization (MCO) service coordinator that CDS services are ready to begin. The service coordinator negotiates a start date for services and revises Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and changes the appropriate CDS services authorizations to the FMSA. 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 CDS employer and the FMSA to ensure that the expenditures for the year remain within the authorized amount. The MCO is responsible for timely payment of FMSA claims, submitted on behalf of the CDS employer, as well as for payment of the monthly service fee, which pays the FMSA for its services.

5320 Ongoing CDS Requirements and Process

Revision 20-1; Effective March 16, 2020

The financial management services agency (FMSA) must send a quarterly expenditure report to the CDS employer and service coordinator and document and notify the managed care organization (MCO) of issues or concerns, including:

• allegations of abuse, neglect, exploitation or fraud;
• concerns about the member's health, safety or welfare;
• non-delivery or extended breaks in services;
• noncompliance with CDS employer responsibilities;
• noncompliance with service back-up plans; or
• over- or under-utilization of services or funds allocated in the member's service plan for delivery of services to the member through the Consumer Directed Services (CDS) option and in accordance with the requirements of the STAR Kids program or Medically Dependent Children Program (MDCP).

The CDS employer 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 FMSA 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 FMSA. The MCO and service planning team 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 5323, Service Back-Up Plans.

5321 Budgets

Revision 20-1; Effective March 16, 2020

The CDS employer or designated representative (DR), with assistance obtained from the financial management services agency (FMSA) or others, must:

• develop an initial and annual budget for each STAR Kids and Medically Dependent Children Program (MDCP) waiver program service to be delivered through the CDS option;
• pay employees in accordance with minimum wage laws and any other applicable base wage requirements;
• project expenditures of funds allocated in the individual service plan (ISP) for the effective period of the ISP;
• use a workbook approved by the managed care organization (MCO) or applicable budget workbooks available through Texas Health and Human Services Commission (HHSC) at https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/cds-forms-handbooks;
• request assistance from the FMSA, as needed;
• submit each budget to the FMSA for review of the member's budgeted payroll spending decisions and verification that the applicable budget workbooks are within the approved budget. The FMSA must work with the CDS employer or DR to resolve issues that prevent the approval of budget plans; and
• obtain written approval for each budget from the FMSA before implementation of the budget and initiation of service delivery through the CDS option.

The FMSA must provide assistance, as requested or needed, by the member, LAR or DR to develop a budget. The FMSA 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.

Budget Revisions and Approval

A CDS employer or DR must make budget revisions if:

• a change to the individual service plan (ISP) affects funding for a program service delivered through the CDS option;
• a budget has been, or will be, exceeded before the end date of the ISP;
• authorized units, unit rate or amount of funds allocated have changed;
• an amount paid for one or more services, goods or items affects the approved budget;
• revisions are made to a service back-up plan;
• funds budgeted for a service back-up plan are not used or needed; or
• the FMSA, the MCO service coordinator, the person-centered service planning team or an HHSC representative requires a revision.

The CDS employer or DR must submit budget revisions to the FMSA for approval. Revised budgets cannot be implemented until written approval is received from the FMSA.

The FMSA must provide assistance to the CDS employer or DR with budget revisions, as requested or needed by the member, validate the budget, and provide written approval to the CDS employer or DR. The FMSA must assist the CDS employer or DR to resolve issues that prevent the approval of budget plans.

The MCO service coordinator evaluates ISP changes requested by the CDS employer and participates in the interdisciplinary team meetings to resolve issues when the CDS employer or DR does not follow the budget or comply with CDS option budget requirements.

5322 Employer Support Services in the CDS Option

Revision 20-1; Effective March 16, 2020

A Consumer Directed Services (CDS) employer or designated representative (DR) may budget employer support services and start-up expenses through the services that are delivered by one or more employees in the CDS option. Employer support services include employment-related expenses, employer-related expenses and support consultation services. Employer support services exclude non-allowable expenditures listed in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook.

Start-up expenses must be:

• budgeted for purchases projected before the delivery of services through the CDS option; and
• accrued from the budgeted unit rate for services scheduled for delivery through the CDS option within the first three months of initiation of the CDS option.

A CDS employer or DR may budget allowable, necessary and reasonable employment-related services, goods or items, including:

• recruiting expenses;
• obtaining a criminal history report from the Texas Department of Public Safety;
• purchasing employee job-specific training;
• cardiopulmonary resuscitation training;
• first aid training;
• supplies required for an employee or provider of the service to perform a task, if not available through the member's program or other source and the purchase is allowable through the member's program;
• non-taxable employee benefits; and
• services, goods, and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

A CDS employer or DR may budget employer-related services, goods or items required to meet employer responsibilities, including:

• basic office equipment, which may include a basic fax machine for the purpose of submitting documents to the financial management services agency (FMSA);
• mailing costs;
• expenses related to making copies;
• file folders and envelopes; and
• services, goods and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

A CDS employer or DR may budget up to 10 percent of the amount available, after the FMSA portion is calculated, in those services delivered by one or more employees. A CDS employer or DR must not budget more than $600 annually or more than $50 per month if less than 12 months remain in the service plan for employer support services.

Support consultation, if available through the member's program, is an optional service available to a member participating in the CDS option. Support consultation is delivered to a CDS employer, DR or a member receiving services through the CDS option if that member will be the CDS employer within six months of the initiation of support consultation services to the member.

Support consultation is provided by a person who meets the qualifications of a support advisor. A support advisor may be a contractor of the CDS employer or an employee or contractor of an FMSA.

Support consultation must provide a level of training, assistance and support that does not duplicate or replace the services delivered by the FMSA, managed care organization (MCO) service coordinator, or other available program or non-program services or resources.

Support consultation provides practical skills training and assistance to successfully manage service providers for authorized program services delivered through the CDS option. This includes skills training and assistance for:

• recruiting, screening and hiring workers;
• developing and documenting job descriptions;
• verifying employment eligibility and qualifications;
• completing documents required to:
  • employ an individual;
  • retain a contractor or vendor; and
  • manage service providers;
• communicating effectively, solving problems and documenting CDS employer responsibilities in the CDS option;
• developing, revising and implementing service back-up plans;
• performing CDS employer responsibilities;
• complying with the member's program and this section; and
• developing ongoing decision-making skills for employer-related and employment-related situations.

A CDS employer or DR may budget and initiate support consultation services while the member is participating in the CDS option. Before initiation of the service, the CDS employer or DR must:

• identify the person or persons (the CDS employer, the DR or the member within six months after becoming the CDS employer) to receive the service and establish goals specific to the service;
• obtain approval of the goals established for the service from the member's service planning team;
• develop a budget for support consultation; and
• obtain approval of the budget from the FMSA.

If the member's service planning team authorizes support consultation, the team must:

• approve the funds, the duration and the frequency of the service;
• assist with development of goals and ensure that the activities required to meet the goals through support consultation comply with this section;
• approve the goals for support consultation and the person or persons who will receive the service (the member, CDS employer or DR); and
• terminate the service when goals are met.

5323 Service Back-Up Plans

Revision 22-3; Effective Dec. 1, 2022

The managed care organization (MCO) service coordinator must discuss with the Consumer Directed Services (CDS) employer or designated representative (DR) the services delivered through CDS that are critical to the member's health and welfare. The MCO service coordinator must require the CDS employer or DR 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 CDS employer or DR must develop a back-up plan, and document the plan on Form 1740, Service Backup Plan, to assure the provision of all authorized personal assistance services without a service break.

The CDS employer or DR, with the assistance of the MCO service coordinator (if needed), completes Form 1740. The service back-up plan must list the steps the CDS employer or DR will implement in the absence of the regular 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 CDS employer 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 service coordinator. The MCO service coordinator and service planning team, as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or service planning team must approve each service back-up plan and any revision before implementation by the member, LAR or DR. The MCO service coordinator approves the service back-up plan by signing, dating and returning a copy of the plan to the CDS employer or DR.

The CDS employer or DR is required to:

• budget sufficient funds in the CDS option budget to implement a service back-up plan;
• review and revise each service back-up plan annually;
• revise a service back-up plan if:
  • the member experiences a problem in the implementation, or
  • there are changes in availability of resources;
• redistribute funds that are not used in carrying out a service back-up plan; and
• provide a copy of the initial and revised service back-up plans and budgets to the financial management services agency (FMSA) within five business days after a plan's approval by the service planning team.

The FMSA must:

• assist a CDS employer or DR as requested to revise budget to meet service back-up plan strategies approved by the member's service planning team;
• review, validate, and approve revised budgets per Section 41.511, Texas Administrative Code relating to Budget Revisions and Approval;
• reimburse documented, budgeted, allowable expenses incurred related to implementing service back-up plan strategies; and
• retain a copy of service back-up plans received from the CDS employer or DR.

 Form 1741, Corrective Action Plan, is used to document the CAP.  

5324 Corrective Action Plans

Revision 20-1; Effective March 16, 2020

The Consumer Directed Services (CDS) employer, meaning the member or legally authorized representative (LAR) or designated representative (DR), must provide a written corrective action plan (CAP) to the person requiring the plan within 10 days after receiving a CAP request. CAPs may be requested in writing by the financial management services agency (FMSA) or managed care organization (MCO) service coordinator.

A written CAP may be required from an employer or designated representative (DR) if the employer or DR:

• hires an ineligible service provider;
• submits incomplete, inaccurate or late documentation of service delivery;
• does not comply with program requirements related to the CDS option; or
• does not meet other employer responsibilities.
•  

The written CAP must include the:

• reason the CAP is required;
• action to be taken;
• person responsible for each action; and
• date the action must be completed.

The CDS employer or DR may request assistance in the development or implementation of a CAP from the:

• FMSA or others, if the plan is related to employer responsibilities; and
• MCO, if the CAP is related to the Medically Dependent Children Program waiver STAR Kids rules or requirements.

Form 1741, Corrective Action Plan, is used to document the CAP.

5330 Terminating the CDS Option

Revision 20-1; Effective March 16, 2020

A Consumer Directed Services (CDS) employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. A member may also be involuntarily terminated from participation in the CDS option in accordance with the requirements of the member's program and Texas Administrative Code §41.407, Termination of Participation in the CDS Option. Termination from the CDS option must last at least 90 days.

A member’s managed care organization (MCO) service coordinator convenes the member's service planning team concerning issues that may warrant immediate termination of the member's participation in the CDS option. On review of the information, the service planning team may recommend immediate termination of participation in the CDS option when:

• the member's health or welfare is immediately jeopardized by the member's participation in the CDS option;
• the designated representative (DR) has been convicted of an offense under Chapter 32 of the Penal Code or an offense barring employment, as listed in the Texas Health and Safety Code, §250.006(a) and (b); or
• HHSC or another government agency with applicable regulatory authority recommends that participation in the CDS option be immediately terminated.

If a CDS employer or designated representative (DR) does not implement and successfully complete the following steps and interventions, a member's service planning team may recommend termination of participation in the CDS option in accordance with the member's program requirements:

• eliminate jeopardy to the member's health or welfare;
• successfully direct the delivery of program services through CDS;
• meet employer responsibilities;
• successfully implement corrective action plans; or
• appoint a DR or access other available supports to assist the employer in meeting employer responsibilities.

Before a financial management services agency (FMSA) recommends involuntary termination of participation in the CDS option to a member's MCO service coordinator, the FMSA must:

• provide documentation to the member's MCO service coordinator of additional and ongoing training and supports provided by the FMSA when a CDS employer or DR demonstrates noncompliance with employer responsibilities;
• provide assistance requested by the CDS employer or DR to develop and implement a corrective action plan;
• provide documentation of any corrective action plan required of the CDS employer or DR by the FMSA in accordance with this section; and
• notify the MCO service coordinator in writing, in accordance with the requirements of the member's program when recommending termination of a member's participation in the CDS option.

On receipt of a recommendation for involuntary termination from the FMSA or other party, the member's MCO service coordinator must:

• provide assistance with accessing supports and developing and implementing a corrective action plan related to noncompliance with program and CDS requirements;
• document interventions utilized by the CDS employer or DR to eliminate noncompliance with program requirements for delivery of program services through the CDS option; and
• convene the service planning team to:
  • consider recommendations related to the member's participation in the CDS option;
  • recommend additional interventions to be implemented to protect the member's health and welfare for continued participation in the CDS option; and
  • make revisions to the member's service plan, if needed.

If the service planning team recommends terminating participation in the CDS option, the member's MCO service coordinator must document:

• the reasons for the recommendation;
• the conditions and time frame established by the member's service planning team that the member must meet prior to re-enrollment in the CDS option;
• justification for any time period for a termination in excess of the minimum 90-day requirement; and
• if applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination.

When a member's participation in the CDS option is terminated, the MCO service coordinator must take steps and interventions in accordance with the requirements of the member's program to:

• ensure continuity of delivery of program services that were being delivered through the CDS option; and
• document arrangements made for delivery of program services that were being delivered through the CDS option to be delivered by the member's program provider or other resources.

5331 Re-enrollment in the CDS Option

Revision 20-1; Effective March 16, 2020

Following termination of participation in the Consumer Directed Services (CDS) option, a member or legally authorized representative (LAR) must request re-enrollment in the CDS option by notifying the member's managed care organization (MCO) service coordinator. If a member or LAR wishes to re-enroll in the CDS option, the MCO service coordinator must:

• review the reason that the member was suspended or terminated from the CDS option;
• verify that the member has fulfilled the minimum 90-day period and any conditions specified by the member's service planning team or a hearing officer, if applicable;
• verify how each issue that contributed to the suspension or termination has been resolved; and
• refer the request for re-enrollment in the CDS option to the member's service planning team and follow requirements of the member's program, including:
  • revising the member's service plan and re-enrolling the member in the CDS option upon approval; and
  • issuing a denial and providing information related to requesting a fair hearing if the request is not approved.

If approved for re-enrollment, the FMSA must:

• provide an initial orientation in accordance with this section, following the member's re-enrollment in the CDS option if the current CDS employer or DR has not received initial orientation; and
• notify the CDS employer, DR and the member's MCO service coordinator in writing within two business days after any repeat of prior noncompliance or additional noncompliance with requirements of the member's program or this section during the member's participation in the CDS option.

Revision 20-1; Effective March 16, 2020

The Service Responsibility Option (SRO) empowers the member to manage most day-to-day activities. This includes supervision of the individual providing direct services.

The member decides how services are provided. The SRO leaves the business details to the member's managed care organization (MCO) and contracted provider. The rules for the SRO are found in Texas Administrative Code, Title 40, Chapter 43.

See STAR+PLUS Handbook, Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

5410 Service Responsibility Option Roles and Responsibilities

Revision 20-1; Effective March 16, 2020

Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, specifies the roles and responsibilities assigned to the member or legally authorized representative (LAR), provider and managed care organization (MCO). The member or LAR, provider and MCO receive and sign Form 1582-SRO indicating their agreement to accept the service responsibility option responsibilities.

5411 Managed Care Organization Responsibilities

Revision 20-1; Effective March 16, 2020

The intake, referral and assessment procedures for the member or legally authorized representative (LAR) requesting service delivery through the Service Responsibility Option (SRO) are handled in the usual way. The managed care organizations (MCOs) are responsible for:

• ensuring the member or LAR has an opportunity to make an informed choice by providing an objective and balanced review of the options; and
• monitoring the quality of services and service delivery.

Once the assessment is complete, the MCO is required to:

• inform the member about all options for managing services; and
• review Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, with the member to determine if the SRO is an appropriate choice.

In addition, the MCO's responsibilities include:

• presenting all service delivery options;
• documenting the member's or LAR's choice on Form 1584, Consumer Participation Choice;
• explaining SRO rights, responsibilities and resources to the member or LAR;
• presenting the MCO provider list and the support consultation provider to the member or LAR;
• making a referral to the provider(s) selected by the member or LAR;
• processing the member's request to change service delivery options;
• redeveloping the service plan when a member's needs change;
• serving as a resource if the member has health or safety concerns, issues involving the attendant or other service-related concerns;
• convening a service planning team meeting in instances where the member has:
  • health and safety concerns;
  • difficulty selecting or keeping an attendant; or
  • other issues relating to services that cannot otherwise be resolved; and
• monitoring services in accordance with 5422, Monitoring.

5412 Agency Responsibilities

Revision 20-1; Effective March 16, 2020

The agency contracted with the managed care organization (MCO) 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 staff:

• discuss and negotiate potential back-up plans for those times when the attendant is absent from work;
• send a maximum of three attendants, including any individuals recommended by the member, for the member to review;
• explain to the selected attendants that the agency is the employer of record and the member is the day-to-day manager;
• provide agency time sheets to the member and orient the member to the time sheet submission process, including how frequently time sheets must be completed;
• receive and process attendant time sheets;
• send new attendants within the required time frame to interview at the member's or LAR's request; and
• orient the member or LAR to the agency's attendant evaluation process, including forms and the schedule for evaluating attendants.

5413 Member Responsibilities

Revision 20-1; Effective March 16, 2020

The member or legally authorized representative (LAR) 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 or LAR must be capable of performing all management tasks as described below or may identify a representative to assist or perform those management tasks on the member's or LAR’s behalf.

The member or LAR is responsible for:

• choosing the SRO;
• choosing the SRO service and support provider(s);
• meeting with the SRO support provider within 14 days of selecting the SRO;
• coordinating with the agency supervisor as part of the service planning process by:
  • negotiating the type, frequency and schedule of quality assurance contacts;
  • discussing any concerns about care management;
  • requesting on-site assistance while orienting a new attendant, if desired; and
  • negotiating to develop a back-up plan for when the attendant cannot come to work;
• selecting personal attendant(s) from candidates sent by the agency, including someone the person recommends to the agency supervisor or someone who has completed the agency pre-employment screening;
• informing the agency supervisor within 24 hours:
  • of the personal attendant selected;
  • if the attendant gives notice of his intention to quit;
  • if the attendant quits; or
  • if the member wants to dismiss the attendant;
• training the personal attendant on how to safely perform the approved tasks in the manner desired;
• supervising the personal attendant;
• ensuring the attendant only does the tasks authorized in the service plan and works only the number of hours authorized in the service plan;
• complying with agency payroll and attendance policies;
• evaluating the attendant's job performance at the time designated by the agency;
• reviewing, approving and signing agency employee time sheets after the attendant completes them;
• ensuring employee time sheets are submitted to the agency within the time frames designated by the agency;
• notifying the agency as soon as possible if the personal attendant will be absent and a substitute is needed;
• taking responsibility for liability risk if the member or attendant is injured while doing tasks under the member's training and supervision;
• using the following complaint procedures:
  • If the agency is not fulfilling the expected responsibilities, addressing those issues directly with the agency. If the agency and the member or LAR are not able to resolve the concerns/issues, the member or LAR should contact the managed care organization (MCO).
  • If concerns and issues are still not resolved, the member or LAR may select another agency. The member must contact the MCO to transfer from one agency to another. The MCO will make all necessary arrangements for the transfer.
• notifying the MCO and/or agency supervisor of any health or safety concerns or issues with the attendant (the member or LAR may, at any time, request a service planning team meeting); and
• notifying the MCO and agency supervisor if a change to either the agency option or Consumer Directed Services (CDS) is desired. A service planning team meeting will be held to plan for the change.

5420 Managed Care Organization Procedures

Revision 20-1; Effective March 16, 2020

The Service Responsibility Option (SRO) is not a 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, managed care organization procedures are not impacted by the member's choice of SRO. Complete all forms currently required and continue to identify any caregivers who are currently providing for the member's needs.

5421 Initial Authorization of Services

Revision 20-1; Effective March 16, 2020

The member's or legally authorized representative's decision to receive services using the Service Responsibility Option does not change the manner in which initial services are authorized. See 3300, Member Service Planning and Authorization, for specific information.

5422 Monitoring

Revision 20-1; Effective March 16, 2020

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 will:

• discuss the issues with the agency staff;
• talk to the member or legally authorized representative (LAR) to determine if the issues can be resolved; and
• convene a service planning team meeting if the issue cannot be resolved.

Because the member or LAR now shares responsibility for service delivery, the MCO, in addition to other monitoring requirements, must monitor the member's:

• satisfaction with the SRO; and
• ability to comply with SRO requirements.

If it is evident that the member is having difficulty in the management of SRO responsibilities, the MCO staff must:

• consult the agency staff; and
• advise the member of the option to transfer back to the agency option.

5423 Presentation of SRO

Revision 20-1; Effective March 16, 2020

The managed care organization (MCO) service coordinator must offer the Service Responsibility Option (SRO) upon enrollment and annually thereafter. Additionally, the SRO must be presented to the member or legally authorized representative (LAR) 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 or LAR understands the responsibility he 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 H2067-MC, when the transition planning is complete. Negotiate a start date with the member and the agency.

Revision 22-3; Effective Dec. 1, 2022

Managed care organizations must comply with the requirements for member notices of Adverse Benefit Determination described in federal and state law, in the Medicaid managed care contracts, including Uniform Managed Care Manual, Chapter 3.21.

Revision 23-3; Effective July 21, 2023

Program level denials are started when the member does not meet one or more Medically Dependent Children Program (MDCP) eligibility criteria. 

The managed care organization (MCO) must:

• monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN denial notice; and
• notify the Program Support Unit (PSU) of the reason for denial request by submitting Form H2067-MC, Managed Care Programs Communication, to MCOHub per the conventions identified in Chapter 16.2 of the Uniform Managed Care Manual. 

MDCP may be denied or terminated by HHSC for the following reasons, which will be included on Form H2065-D, Notification of Managed Care Program Services:

• residence in a nursing facility for more than 90 days;
• member voluntary withdrawal; 
• Medicaid financial eligibility;
• exceeding the cost limit;
• medical necessity (MN); or
• inability to locate the member. 

PSU will:

• mail the member Form H2065-D; 
• upload Form H2065-D to MCOHub in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions. 

6210 Denial/Termination Due to Death

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) staff posts Form H2067-MC, Managed Care Programs Communication, to MCOHub in the managed care organization’s (MCO’s) STAR Kids folder within two business days of verification of the death of a member.  They follow the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

If a member's Medicaid eligibility is denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries are made by PSU staff to end enrollment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. 

Services must be terminated by PSU staff once the member’s death is confirmed. 

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

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 23-3; Effective July 21, 2023

The process for members living in a nursing facility (NF) excluding Truman Smith*, is as follows:

• For members enrolled in STAR Kids, the enrollment remains open while a member resides in an NF.
  • For members with Supplemental Security Income (SSI) or SSI-related Medicaid, the member remains enrolled in STAR Kids but Medically Dependent Children Program (MDCP) services must be suspended per Section 3326, Suspension of Medically Dependent Children Program Services.
  • For members without SSI or SSI-related Medicaid (i.e., medical assistance only (MAO) members), the member remains enrolled in STAR Kids but MDCP services must be suspended per Section 3326.
• If a member enrolled in MDCP has resided in an NF for 90 days or more, the managed care organization (MCO) must notify Program Support Unit (PSU) staff within 14 days following the 90th day of residence.
  • The MCO sends this notice to PSU staff by posting Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Once a denial is complete, if a member decides to discharge from the NF, he or she would be directed to pursue Money Follows the Person (MFP) found in 2100, Money Follows the Person.

*Members enrolled in STAR Kids who enter the Truman Smith NF or a state veteran's home are excluded from STAR Kids. STAR Kids and MDCP eligibility will be denied by HHSC.

6230 Denial/Termination of Medicaid Financial Eligibility

Revision 22-3; Effective Dec. 1, 2022

A member's continued receipt of STAR Kids 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 Medicaid for the Elderly and People with Disabilities (MEPD) specialists for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate.

Notification can come from:

• monthly reports;
• Enrollment Resolution Services (ERS);
• an MCO; or
• other reliable sources.

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 Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month. The individual has the right to appeal. The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS). 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 per the date of the request.

Disenrollment from the STAR Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month. The individual has the right to request a State Fair Hearing. The individual can contact the local HHSC office to request other LTSS. 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 per the date of the request.

6240 Denial/Termination as a Result of Exceeding the Cost Limit

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) waiver serves individuals who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems to determine if the MDCP individual service plan (ISP) ensures the needs of the applicant or member. 

As part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid Healthcare Partnership (TMHP). HHSC expects a denial because exceeding the cost limit will be a rare occurrence as MDCP members primarily receive state plan services.

When MDCP applicants or members exceed their assigned cost limit, the MCO must notify Program Support Unit (PSU) staff of the MDCP program denial request of MDCP and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial request is based on the inadequacy of the ISP, including both MDCP and non-MDCP services, to meet the needs of the individual within the RUG cost limit. The MCO does not make the denial decision. That decision is made by HHSC.

6250 Denial/Termination of Medical Necessity

Revision 22-3; Effective Dec. 1, 2022

Medically Dependent Children Program (MDCP) participation is denied by HHSC when an applicant or member fails to meet medical necessity (MN) criteria.

The MCO must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for notification of a preliminary denial of medical necessity “MN Pending Denial.”

When the MN status is in the “MN Pending Denial” status, the MCO must: 
 

• Verify with the TMHP nurse assessor what information is missing for MN to: 
  • discuss the missing information during a peer-to-peer with the physician (see process below); 
  • obtain any available missing information from the physician during the peer-to-peer; and 
  • provide that information to TMHP. If the missing information is not available, the MCO must provide to TMHP the reasons the information is not available.
• Review Form 2605, Member SK-SAI MDCP Review Signature, Question 8. 
  • If the answer on Form 2605 is marked “Yes”:
    • contact the member or legally authorized representative (LAR) to confirm the peer-to-peer review request;
    • contact the listed physician of choice on Form 2605 to schedule and complete a peer-to-peer review; 
    • submit any information obtained during the review to TMHP to support MN; and
    • continue monitoring the MN process as outlined below.
  • If the answer on Form 2605 is marked “No”:
    • Contact the member or LAR and offer an opportunity to hold a peer-to-peer review with the treating physician of the member or LAR’s choice and the MCO medical director. 
    • If the member or LAR requests the peer-to-peer review:
      • verify the physician of the member or LAR’s choice,
      • contact the physician of the member or LAR’s choice to schedule and complete a peer-to-peer review; 
      • submit any information obtained during the review to TMHP to support MN; and
      • continue monitoring the MN process outlined below.
    • If the member or LAR refuse the peer-to-peer review:
      • document the refusal in the member’s file; and
      • continue monitoring the MN process as outlined below. 

The peer-to-peer review should cover items on the STAR Kids Screening and Assessment Instrument (SK-SAI) related to MN. The MCO must ensure that the member’s or LAR’s physician of choice has access to the completed SK-SAI before the peer-to-peer review. 

Any information obtained in the peer-to-peer review must be submitted to TMHP. 

The MCO must ensure that the peer-to-peer review does not affect member rights to appeal an initial assessment or reassessment through the MCO internal appeal process or the state fair hearing process. 
In addition, the MCO must monitor the TMHP portal through the final MN determination.

The MN status of "MN Denied" in the TMHP LTC Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 business days to submit additional information. Once an SK-SAI MN status is in "MN Denied" status, several actions may follow:

• MN Approved: The status changes to "MN Approved" if the TMHP doctor overturns the denial because additional information is received;
• Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14 business day period for the TMHP doctor to overturn the denied MN has expired. No additional information was submitted for the doctor review. The denied MN remains in this status unless a fair hearing is requested; or
• Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

While the MN is in the “MN Denied” status, the MCOs must monitor the TMHP LTC Online Portal for the MN status by completing a current activity or Form Status query in the TMHP LTC Online Portal every seven days, at a minimum. If a member’s MN status enters the period when the MDCP waiver applicant or member’s physician has 14 business days to submit more information, listed in the TMHP LTC Online Portal as “MN Denied,” the MCO must help the member to get any additional medical information pertinent to the member’s MN determination from their physician. The MCO must help through calling the member and physicians to get necessary documents for provision to TMHP within the 14 business day time frame for consideration. Program Support Unit (PSU) staff will electronically generate Form H2065-D, Notification of Managed Care Program Services, within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP. 

If Form H2065-D is not received by the MCO within the TMHP LTCOP within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP, the MCO must notify Program Support Unit (PSU) staff of the need for Form H2065-D.

6260 Unable to Locate

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) must be denied when Program Support Unit (PSU) staff are notified that a member cannot be found.

Before notifying PSU that the member cannot be found, the managed care organization (MCO) must make at least three efforts to contact members by phone. The phone contact attempts must be made on separate days, over a period of no more than five business days and must be made at a different time of day upon each attempt. 

If an MCO is unable to reach a member or a member’s legally authorized representative (LAR) by phone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible. 

If the MCO has not made any contact with the member or LAR 15 business days after sending the written correspondence, the MCO must attempt to contact the member or LAR in person by visiting the member’s address on file. 

Notification that the member cannot be located can come from:

• monthly reports;
• Managed Care Compliance Operations (MCCO);
• an MCO; or
• other reliable sources.

If the MCO is still unable to locate the member and wishes to request a denial or termination, the MCO must include all documented attempts when sending notification to PSU staff.

6270 Denial/Termination Due to Failure to Meet Other Program Requirements

Revision 23-3; Effective July 21, 2023

Use this denial citation if the applicant or member does not meet a Medically Dependent Children Program (MDCP) requirement mentioned in Sections 6210 through Section 6260 above. For example, this citation would be used if the applicant or member does not require at least one service. Within two business days of the denial, Program Support Unit (PSU) staff must:

• send the applicant or member Form H2065-D, Notification of Managed Care Program Services; and
• post Form H2065-D to MCOHub in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

6280 Denial/Termination for Other Reasons

Revision 23-3; Effective July 21, 2023

Use this citation if initiating denial or termination for a reason not covered in Sections 6210 through Section 6270. Within two business days of the denial, Program Support Unit (PSU) staff must:

• send the member Form H2065-D, Notification of Managed Care Program Services; and
• post Form H2065-D to MCOHub in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Notification can come from:

• monthly reports;
• Enrollment Resolution Services (ERS);
• an MCO; or
• other reliable sources.

Revision 20-3; Effective December 1, 2020

Texas Health and Human Services Commission (HHSC) conducts member disenrollment activities. Although a STAR Kids member may request disenrollment from managed care, membership in managed care is mandatory with limited exceptions.

See Chapter 533 of the Government Code and Title 1 of the Texas Administrative Code Sections 353.1201 and 353.1203 (related to STAR Kids Medicaid managed care) and Section 353.403 (related to enrollment and disenrollment standards for Medicaid managed care).

Members who receive HHSC approval to disenroll from managed care and who maintain Medicaid eligibility may continue to receive services available through fee-for-service (FFS) Medicaid. All members who transition to FFS Medicaid lose any value-added services provided by the managed care organization (MCO). Those members who were receiving services under the STAR Kids Medically Dependent Children Program (MDCP) waiver may also lose some, if not all, of their MDCP waiver services in the transition to FFS Medicaid.

6310 Disenrollment Request by the Managed Care Organization

Revision 20-3; Effective December 1, 2020

A managed care organization (MCO) has a limited right to request a member be disenrolled from the MCO’s plan without the member’s consent pursuant to 42 C.F.R. Section 438.56. Refer to the HHSC Uniform Managed Care Manual, Chapter 11.5 (PDF), Medicaid Managed Care (MMC) Member Disenrollment Policy, for procedures to request the involuntary disenrollment of members.

Revision 22-3; Effective Dec. 1, 2022

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 42 Code of Federal Regulations (CFR) Section 431.200, 42 CFR Part 438 Subpart F, Grievance System, and the provisions of 1 Texas Administrative Code Chapter 357, relating to Medicaid MCOs.

The MCO's complaint and appeal system must include:

• a complaint process;
• an internal appeal process; and
• access to the Texas Health and Human Services Commission fair hearing process.

7110 Managed Care Organization Complaint Procedures

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission's (HHSC) STAR Kids Contract, 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 42 C.F.R. Section 438.400, possible subjects for complaints include the quality of care of services provided, 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 members want to file a complaint, they must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide designated member advocates to:

• assist members in using the complaint system:
• assist members in writing or filing a complaint; and
• monitor the complaint throughout the process until the issue is resolved.

In addition to filing complaints with the MCO, a STAR Kids member may file complaints with the state of Texas. If a STAR Kids member contacts the MCO or any HHSC employee with a complaint about an agency licensed by HHSC, or any other state agency, the member is referred to 800-458-9858 to file a regulatory complaint. If the complaint is initially received by HHSC, HHSC informs the MCO of the complaint.

Members may also contact the HHSC Ombudsman's Managed Care Assistance Team for assistance filing a complaint not related to licensure issues.

• submit through the Online Question or Complaint Form; or
• contact by phone 866-566-8989

7120 Managed Care Organization Internal Appeal Procedures

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission (HHSC) STAR Kids Contract, Attachment A, defines an appeal as the formal process that a member or his or her authorized representative requests a review of the managed care organization’s (MCO’s) action. An action is:

• the denial or limited authorization of a requested Medicaid service, including the type or level of service;
• the reduction, suspension or termination of a previously authorized service not caused by loss of eligibility;
• denial in whole or in part of payment for service;
• failure to provide services in a timely manner;
• failure of an MCO to act within the time frames set forth in the contract and 42 Code of Federal Regulations (CFR) Section 438.408(b); or
• for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside of the network.

The member may file an internal appeal by contacting the MCO after 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 related to the actions listed above as an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members or authorized representatives by monitoring the appeal throughout the process until the issue is resolved.

During the internal appeal process, the MCO must provide the member or an authorized representative 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 or the authorized representative of the time available for providing this information.

The MCO must provide the member and his or her authorized 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 Section 438.420, the MCO must continue the individual's benefits pending the outcome of the internal appeal if all the following criteria are met:

• The member or his or her authorized representative files the internal appeal timely, as defined in the STAR Kids contract.
• The appeal involves the termination, suspension or reduction of a previously authorized course of treatment.
• The services were ordered by an authorized provider.
• The original period covered by the original authorization has not expired.
• The member requests an extension of the benefits.

7121 Expedited Managed Care Organization Internal Appeals

Revision 22-3; Effective Dec. 1, 2022

Per 42 Code of Federal Regulations Section 438.410 and STAR Kids Contract, Attachment B-1, Section 8.1.29.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related internal 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 internal appeal requirements for standard member internal appeals as set forth in the STAR Kids contract, Attachment B-1, Section 8.1.29.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited internal appeals.

After the MCO receives a request for an expedited internal appeal, the MCO must notify the member or his or her authorized representative of the outcome of the expedited internal appeal request within 72 hours. However, the MCO must complete investigation and resolution of an internal appeal relating to an ongoing emergency or denial of continued hospitalization:

• per the medical or dental immediacy of the case; and
• not later than one business day after receiving the member's request for an expedited internal appeal.

Members must exhaust the MCO’s expedited internal appeal process before making a request for an expedited State Fair Hearing.

Except for an internal appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited internal appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Texas Health and Human Services Commission (HHSC), upon HHSC’s request) there is a need for more 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 determination is adverse to the member, the MCO must follow the procedures relating to the notice in the STAR Kids Contract, Attachment B-1, Section 8.1.29.5. The MCO is responsible for notifying the member of his or her right to access a State Fair Hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the determination was made, before the HHSC’s fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his or her representative for requesting an expedited internal appeal. The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s request.

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

• transfer the appeal to the time frame for standard internal resolution; and
• make a reasonable effort to give the member prompt oral notice of the denial, and follow up within two calendar days with a written notice.

Revision 23-4; Effective Dec. 1, 2023

A member can ask for an External Medical Review (EMR) when they disagree with the health plan’s internal appeal decision. An EMR is an optional, extra step the member can take to get an adverse benefit determination reviewed. The EMR is conducted by a third-party Independent Review Organization (IRO) and occurs before the State Fair Hearing.

A standard EMR takes place within 15 calendar days of the request. An expedited EMR takes place within two business days of the request.

When a member requests an EMR with a  State Fair Hearing, the MCO must upload all required State Fair Hearing documentation into the Texas Health and Human Services Commission (HHSC) State Benefits Portal within the following time frames:

• expedited EMR request – within one calendar day of receiving the EMR request from the member, the member’s authorized representative, or the member’s legally authorized representative (LAR), unless received after 3:00 p.m. CST on a Friday, or any calendar day HHSC is closed for business. If the EMR Request is received after 3:00 p.m. CST on Friday, or on a day HHSC is closed for business, the documentation must be uploaded no later than noon the following business day; or
• standard EMR request – no later than three calendar days after receiving the EMR request from the member, the member’s authorized representative, or the member’s LAR.

Only information used to make the MCO internal appeal decision can be uploaded into the HHSC State Benefits Portal for the IRO to review. The IRO will not consider any new information submitted by the MCO or member.

The IRO will conduct the EMR and notify the MCO of the decision to uphold, partially overturn, or overturn the MCO’s internal appeal decision. The IRO can only grant or reinstate the member’s benefits up to the level identified as medically necessary by the member’s physician or as previously authorized before the adverse benefit determination. An EMR request does not change the member’s right to a State Fair Hearing. Regardless of the EMR decision, the member continues to have the right to proceed with the State Fair Hearing. The State Fair Hearing will proceed after the EMR decision unless the member withdraws their request for a State Fair Hearing.

The member may qualify for an expedited EMR with a State Fair Hearing as outlined in STAR Kids Contract, Attachment B-1, Sections 8.1.29.3 and 8.1.29.4. More information can be found in the Uniformed Managed Care Manual (UMCM) 3.21 (PDF) and 3.21.1 (Word).

Revision 22-3; Effective Dec. 1, 2022

If an applicant, member, or legally authorized representative (LAR) wishes to request a State Fair Hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver eligibility denial, they 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 MDCP waiver member may also request a State Fair Hearing by contacting PSU.

If an applicant, member, or legally authorized representative (LAR) wishes to request a fair hearing with the managed care organization (MCO) not related to program eligibility they may contact the MCO as instructed on the denial notification.

7310 Program Support Unit Coordination

Revision 22-3; Effective Dec. 1, 2022

When a request for a State Fair Hearing about Medically Dependent Children Program (MDCP) eligibility is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the Texas Health and Human Services Commission Appeals Division within five calendar days from the date of the request. Upon receipt of the fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. 

Form H4800 records the names, titles, addresses and phone 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. 

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

• MCO (whenever possible, this should be the individual who completed the assessment) and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity denials);
• MCO (for denials of individual service plans (ISPs) over the cost ceiling); and
• Medicaid for the Elderly and People with Disabilities (MEPD) (for financial denials).

The MCO must ensure that the appropriate staff members who have firsthand knowledge of the member’s appeal are able to speak and provide relevant information on the case and attend all State Fair Hearings as scheduled.  

7311 Fair Hearings and Appeals Procedures

Revision 22-3; Effective Dec. 1, 2022

If a member requests a State Fair Hearing, the managed care organization (MCO) completes and submits the request via the Texas Integrated Eligibility Redesign System (TIERS) to the appropriate State Fair Hearings office, within five days of the member's request for a State Fair Hearing.

TIERS generates a hearing packet, which includes:

• Form H4803, Notice of Hearing
• Form H4800, Fair Hearing Request Summary

Managed care organizations (MCOs) receive a copy of Forms H4800 and H4803, identifying the hearings officer assigned to the appeal and the date, time, and location of the hearing. 

7312 Evidence Packet

Revision 22-3; Effective Dec. 1, 2022

All related documentation necessary to support the determination on an appeal must be uploaded into the Texas Health and Human Services Commission (HHSC) State Benefits Portal and mailed to the appellant at least 10 business days before the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet and uploading it to the HHSC State Benefits Portal. Within five business days of notification that the State Fair Hearing is set, the MCO will prepare an evidence packet for submission to the HHSC State Fair Hearings staff and send a copy of the packet to the member. All documentation must be neatly and logically organized, and all pages numbered.

The following are examples of documentation that may be submitted as evidence and the entity responsible for uploading that information to the HHSC State Benefits Portal:

• Managed care organization (MCO):
  • MCO policy handbook, STAR Kids Handbook or STAR Kids contract and STAR Kids Managed Care Manual; 
  • summary of events;
  • other documentation supportive of the determination, such as documentation of phone calls and visit summaries; and
  • copies of the signed Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and all relevant attachments;
• Medicaid for the Elderly and People with Disabilities Centralized Representation Unit:
  • documentation supportive of the financial determination, including official documentation forms and phone calls; and
  • a copy of the original signed denial form;
• Texas Medicaid & Healthcare Partnership (TMHP):
  • a copy of the STAR Kids Screening and Assessment Instrument (SK-SAI); and
  • other documentation supporting the determination; and
• Program Support Unit: Refer to procedures outlined in the Program support Unit Operational Handbook, Section 7000, Applicant or Member Complaints and State Fair Hearings.

7320 Additional State Fair Hearing Requirements and Information

Revision 22-3; Effective Dec. 1, 2022

7321 Presentation of the Evidence Packet

Revision 22-3; Effective Dec. 1, 2022

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The managed care organization (MCO) receives a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time, and location of the hearing. 

Documentation contained in the evidence packet is not considered in the hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the agency or MCO representative must present the packet, ask that it be admitted 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 2603, STAR Kids, Individual Service Plan (ISP) Narrative. Pages 11-15 contain policy from the STAR Kids 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, 2016."

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

7322 Hearing Decision

Revision 22-3; Effective Dec. 1, 2022 

After the hearing, the hearings officer sends a hearing decision to the appellant and copies to individuals listed on Form H4800, Fair Hearing Request Summary. 

If the determination on appeal is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. 

Revision 22-3; Effective Dec. 1, 2022

7410 Action Taken on the Hearing Decision

Revision 22-3; Effective Dec. 1, 2022

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken. Managed care organizations (MCOs) can retrieve the information on the Texas Health and Human Services Commission (HHSC) State Benefits Portal.

7411 State Fair Hearing Reversal of Denial

Revision 22-3; Effective Dec. 1, 2022

If the State Fair Hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the managed care organization (MCO) appeal was pending, the MCO must authorize or provide the disputed services as expeditiously as the member’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. If the State Fair Hearing officer reverses a decision to deny authorization of services and the member received the disputed services while the appeal was pending, the MCO is responsible for the payment of services.

If the State Fair Hearing officer reverses an MCO's denial of a prior authorization for a durable medical equipment (DME) or DME service after the member has enrolled with a second MCO, the original MCO must pay for the DME service or equipment from the date it denied the authorization until the date the member enrolled with the second MCO. In the case of custom DME, the original MCO must pay for the custom DME if the denial is reversed.

Revision 22-3; Effective Dec. 1, 2022

If the State Fair Hearing is pending, and the member has timely requested continuation of benefits, the benefits must be continued until:

• the member withdraws the request for State Fair Hearing; or
• a State Fair Hearing officer issues a hearing decision adverse to the member. 

See Section 7400, Post Hearing Actions, for information on how to proceed following receipt of the State Fair Hearing decision.

7510 Continuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 23-3; Effective July 21, 2023

Medically Dependent Children Program (MDCP) waiver services must continue until the hearings officer issues a decision about the State Fair Hearing of an active MDCP waiver member, if the request is for a continuation of benefits was timely filed. Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the request for a continuation of benefits within three business days by posting Form H2067-MC, Managed Care Programs Communication, to the MCO via MCOHub.

If the member has timely requested continued benefits, MDCP waiver services must continue to be provided until the hearings officer renders a decision. The PSU includes this information on Form H2067-MC posted on MCOHub.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, the current ISP will be extended for four calendar months or until the outcome of the state appeal is determined. PSU staff do not mail Form H2065-D, Notification of Managed Care Program Services, to the member notifying them of continued eligibility related to the reassessment action taken to continue services until the hearings officer renders a State Fair Hearing decision. 

If a State Fair Hearing is initially dismissed and then re-opened, the PSU staff continues or restarts services pending the decision outcome, if the member has timely requested continued services. When the hearings officer sets a date for a new State Fair Hearing this voids the prior State Fair Hearing decision.

7520 Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 23-3; Effective July 21, 2023

If the member does not timely request continuation of benefits, Medically Dependent Children Program (MDCP) waiver 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). Program Support Unit (PSU) staff must process according to the following:

• For Medical Assistance Only (MAO)-eligible members, Form H2065-D is posted to MCOHub to inform the managed care organization (MCO) that MDCP waiver services will be terminated effective the day after the date noted on Form H2065-D. For Supplemental Security Income (SSI)-eligible members, Form H2067-MC is posted by PSU staff to MCOHub to inform the MCO MDCP waiver services will be terminated effective the day after the date noted on Form H2065-D.

Even if a member loses eligibility for MDCP, SSI-eligible members are still enrolled in a STAR Kids MCO and are still eligible for state plan services, which include acute care and long-term services and supports, such as personal care services, day activity and health services, and Community First Choice Services.
 

Revision 22-3; Effective Dec. 1, 2022

7610 Sustained State Fair Hearing Decisions

Revision 22-3; Effective Dec. 1, 2022

When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver services, the written decision is mailed to the applicant, member, or their legally authorized representative (LAR). Copies are sent to all witnesses listed on Form H4800, Fair Hearing Request Summary.

7611 Sustained Decisions – Termination Effective Dates

Revision 22-4; Effective Dec. 1, 2022

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the State Fair Hearing decision is known, the Medically Dependent Children Program (MDCP) waiver termination effective date varies depending on the following circumstances.

• In cases where the hearings officer's decision is 30 calendar days or more before the end of the individual service plan (ISP) in effect when the State Fair Hearing was filed, MDCP waiver termination is effective at the end of the ISP in effect at the time the State Fair Hearing was filed. See Example 1.
• When the hearings officer's decision date is less than 30 calendar days before the end of the ISP in effect when the State Fair Hearing was filed, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date (the date the order is signed). See Example 2.
• When the hearings officer's decision date is after the end of the ISP in effect when the State Fair Hearing was filed, and a new ISP was developed to continue services past the ISP end date until the appeal decision was made, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date. See Example 3.
• If the hearings officer assigns a specific medical necessity (MN) expiration date not equal to the last day of the month but after the end of the ISP in effect when the State Fair Hearing was filed, the termination effective date is the end of the month the hearings officer identified as the expiration month. See Example 4.
• When the hearings officer assigns a specific MN expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the State Fair Hearing was filed, the termination effective date is the end of that ISP period. See Example 5.
• If the hearings officer assigns a specific MN expiration date that is before the end of the MN in effect when the State Fair Hearing was filed, the termination effective date is the end of the month of the original MN expiration date. See Example 6.

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.	1/31/22	5/31/22	11/2/21	1/31/22
2	Hearings officer decision is less than 30 days from the original expiration date.	1/31/22	5/31/22	1/15/22	2/28/22
3	Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date.	1/31/22	5/31/22	2/15/22	3/31/22
4	Hearings officer decision assigns a specific expiration date.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 2/15/16.	2/29/22
5	Hearings officer decision assigns a specific expiration date that occurs in the future.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 2/29/16.	2/29/22
6	Hearings officer decision assigns a specific expiration date that occurred in the past.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 12/31/21.	1/31/22

7612 Reversed Appeal Decisions

Revision 23-4; Effective Dec. 1, 2023

Within two business days from the hearings officer’s decision to reverse an applicant’s or member’s Medically Dependent Children Program (MDCP) denial of the program, Program Support Unit (PSU) staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral:  

• Notifying the managed care organization (MCO) of the hearings officer’s decision to reverse the denial of MDCP;
• Advising the MCO that MDCP services are to continue as directed in the hearings officer’s decision; and
• Requesting the MCO to submit the STAR Kids individual service plan (SK-ISP).

Within two business days from the receipt of Form H2067-MC from PSU staff, the MCO will provide PSU staff with the SK-ISP by uploading to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

7613 Reversed Decisions – Effective Dates

Revision 22-3 Effective Dec. 1, 2022

When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) waiver eligibility, the MDCP waiver effective date for:

• members - reassessment is one day after the end of the individual service plan in effect when the state fair hearing was filed; and
• applicants - MDCP waiver denied at initial application is the first of the month following the hearings officer's decision.

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 the Implementation Delays screen in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation.

7620 New Assessment Required by Fair Hearing Decision

Revision 22-3; Effective Dec. 1, 2022

If the hearings officer’s final decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI), 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. If the new assessment results in a denied medical necessity (MN), 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 H4800, Fair Hearing Request Summary, that the new assessment was ordered from a previous fair hearing decision.

If the member requests a State Fair Hearing 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 Medically Dependent Children Program (MDCP) waiver member is denied 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 before the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member informing him or her of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO continues services at the same level services were continued before 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 continues services at the same level services were continued before the first fair hearing.

7630 Request to Withdraw a State Fair Hearing

Revision 22-3; Effective Dec. 1, 2022

An appellant or appellant representative must request to withdraw a State Fair Hearing by sending a notice to the hearings office. The appellant or appellant representative may request withdraw of the State Fair Hearing orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing.

If the individual requesting to withdraw contacts Program Support Unit (PSU) staff, PSU staff must advise them the request to withdraw the State Fair Hearing must be provided directly to the hearings office. If PSU staff receive a written request to withdraw, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the applicant, member or LAR, and must be made to the hearings office.

If the request to withdraw a State Fair Hearing is within five business 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 request to withdraw a State Fair Hearing is more than five business days before the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written notice to participants informing them of the fair hearing cancellation.

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission (HHSC) hearings officer:

• notifies all people listed on Form H4800, Fair Hearing Request Summary, of the date, time and location of the hearing;
• prepares a final order disposing of a case through withdrawal
• sends copies of final order to the appellant and Program Support Unit (PSU) upon written notification from the appellant to withdraw a state appeal;
• conducts the hearing;
• considers all testimony and exhibits;
• uses the Texas Medicaid & Healthcare Partnership (TMHP) nurse to determine if any new medical information introduced at the hearing meets the medical necessity (MN) criteria for nursing facility care;
• reserves the right to hold a hearing record open after a State Fair Hearing to get more information;
• submits a written request for medical review to TMHP for all new medical information presented at a hearing in situations where the TMHP nurse determines the new medical information presented does not meet the MN criteria;
• renders a decision; and
• sends a written copy of all hearing decisions to the member or applicant, TMHP and the PSU staff within five days of making the decision.

Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant (applicant, member or legally authorized representative). Program staff may disagree with the decision. However, the hearings officer's decision is final. Program staff submit disagreements on policy or legal issues to the regional attorney.

Revision 23-3; Effective July 21, 2023

When managed care organization (MCO) staff enter fair hearing requests in the Texas Integrated Eligibility Redesign System (TIERS), as outlined in the policy below, use the following entries per the Community First Choice (CFC) level of care (LOC) denial being appealed:

• For Medical Necessity (MN/LOC) fair hearing requests:
  • Program: Community Care
  • Type of Assistance (TOA): Community First Choice
  • Issue Code: 57 - Medical Necessity
• For intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) LOC or institutions for mental diseases (IMD) LOC fair hearing requests:
  • Program: Community Care
  • TOA: Community First Choice
  • Issue Code: 99 - Other (Only use this code in rare instances when there is not a more appropriate code)

STAR Kids Screening and Assessment Instrument (SK-SAI) Denials for Initial or Reassessment Eligibility

As part of the CFC eligibility determination process, the MCO is responsible for completing the SK-SAI assessment to determine MN/LOC. The MCO then submits the SK-SAI assessment to the Texas Medicaid and Healthcare Partnership (TMHP) for approval of the MN/LOC determination. Based on TMHP's decision, the following occurs:

• If TMHP approves MN on the initial or reassessment SK SAI:
  • TMHP notifies the MCO that the member meets medical necessity criteria; and
  • the MCO authorizes CFC services.
• If TMHP denies MN on an initial or reassessment SK-SAI assessment, TMHP notifies the MCO the member does not meet MN. The MCO must follow appeal procedures outlined in the UMCM and take the following action based on the member's situation:
  • For MN denials when the member is not requesting or receiving MDCP program services, the MCO sends the member a denial notice with fair hearing rights. The MCO must include the required elements in the notice. This information will be incorporated in requirements outlined in the Uniform Managed Care Manual. If the member requests a fair hearing, the MCO must enter the fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) and attend the fair hearing. TMHP staff is also required to attend the fair hearing because TMHP is the entity making the LOC decision.

For MN denials when the member is requesting or receiving CFC services and MDCP program services, the MCO must post Form H2067-MC, Managed Care Programs Communication, to MCOHub within two business days of receiving the notice from TMHP (and when the assessment is in MN denied status). This is to notify PSU of the denial and that the member requested or is receiving both MDCP and CFC services. PSU sends the member a denial notice (Form H2065-D, Notification of Managed Care Program Services) for MDCP with fair hearing rights. The notice instructs the member to contact PSU staff to request a State Fair Hearing. If a member makes this request, PSU:

• enters the fair hearing in TIERS within five days; and
• identifies TMHP as the agency representative.

The MCO also attends the fair hearing as the agency witness. The local intellectual and developmental disability authority (LIDDA) or local mental health authority (LMHA) may also be required to attend as an agency representative for State Fair Hearings. If the member requests a timely fair hearing at reassessment and requests continued benefits, the MCO continues services pending the outcome of the fair hearing.

Revision 19-1; Effective June 3, 2019

Utilization Review (UR) is a division within the Medicaid Children's Health Insurance Program (CHIP) Services Department of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83^rd Legislature Regular Session, 2013. This bill amended Section 533.00281 of the Texas Government Code to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.

STAR Kids managed care organizations (MCOs) must make information including, but not limited to, documents, assessments, notes and authorizations regarding STAR Kids members available upon request from UR. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

Effective September 2022

Appendix I, MCO Business Rules for SK-SAI & SK-ISP (PDF)

6-2017

 

The managed care organization (MCO) must require all providers rendering Long-Term Services and Support (LTSS), with the exception of atypical providers, to use the CMS 1500 Claim Form or the HIPAA 837 Professional Transaction when billing. Atypical providers are LTSS providers that render non-health or non-medical services to STAR+PLUS members.  Examples include pest control services and building and supply services.
 
Providers using the Paper CMS 1500

Providers billing on paper will provide complete information about the service event and will use the state assigned provider identification (ID) to represent the provider(s) involved in the service event. The provider ID (billing and/or rendering) will be located in Block 33 on the paper form.

• If the billing provider and the rendering provider are the same, then the state assigned provider ID will be populated in Block 33.
• If the rendering provider is different than the billing provider, then the billing provider state assigned provider ID will be populated in Block 33, and the rendering provider state assigned provider ID will be populated in Block 24K.
• Under specific scenarios, the additional usage of Block 17a (Referring Provider (Optional)) and Block 24k can be used to report additional information on providers that are involved in the service event.

Providers using the Electronic HIPAA 837

Providers billing electronically will comply with HIPAA 837 guidelines, including the accurate and complete conveyance of information pertaining to the provider(s) involved in the service event.
 
Atypical Providers

Atypical providers will submit appropriate documentation to the MCO.  The MCO must obtain sufficient documentation from the atypical provider to accurately populate an 837 professional encounter. Refer to the HIPAA-compliant 837 Professional Combined Implementation Guide and the 837 Professional Companion Guide for further information. (See “Claims Processing Requirements” in §2, Claims, in the UMCM.)

Providers and MCOs will bill and report LTSS in compliance with the STAR Kids Billing Matrix (Matrix).

Providers – LTSS providers must use the “designated position” of the modifiers, as indicated on the Matrix, when filing claims.

MCOs – MCOs must use the “designated position” of the modifiers, as indicated on the Matrix, when reporting encounters.

Nursing Facilities (NFs) – Services pertaining to a member entering a nursing facility will be filed (paper or electronic) through the state’s claims administrator under traditional Medicaid (fee for service) following the claims submission guidelines applicable to traditional Medicaid billing. Services that do not involve a member entering a nursing facility (i.e., respite care) will conform to normal LTSS billing procedures.

The LTSS Bulletin posted on the Texas Medicaid Health Partnership website (www.tmhp.com) provides additional information and updates.

Appendix VII, CDS Training Manual

Revision 23-1; Effective March 1, 2023

Overview of Home and Community-Based Services Settings Rule

The federal regulations at 42 Code of Federal Regulations (CFR) Sections 441.301(c)(4) and 441.530 (Home and Community-Based Services Settings Rule) require settings where Medicaid home and community-based services are delivered. This includes services provided to members in the STAR Kids and Medically Dependent Children Program (MDCP), to have certain qualities as described below. 

Services and Settings Subject to the Home and Community-Based Services Settings Rule 

The managed care organization (MCO) must ensure settings where the following STAR Kids and MDCP services are delivered comply with requirements of the Home and Community-Based Services Settings Rule: 

• Community First Choice (CFC) personal assistance services;
• CFC Habilitation;
• respite care;
• flexible family support services;
• employment assistance;
• supported employment; 
• adaptive aids; and
• minor home modifications.

Requirements for Home and Community Based Services Settings

All Settings

A managed care organization (MCO) ensures that the settings listed above have the following qualities described in the Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i-v) and Section 441.530(a)(1)(i-v):  

• The setting provides opportunities for members to seek employment and work in competitive, integrated settings. 
• The setting provides opportunities for members to engage in community life. 
• The setting gives opportunities for members to control personal resources.
• The setting gives opportunities for members to receive services in the community. 
• The member selects the setting from the setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the person-centered service plan and are based on the individual’s needs and preferences.
• The setting ensures the member’s rights of privacy, dignity and respect, and freedom from coercion and restraint.
• The setting optimizes, but does not regiment, the member’s individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.
• The setting facilitates member choice regarding services and supports, and who provides them. 

Settings that are Provider-Owned and Controlled

A host family home where MDCP respite is delivered is considered a provider-owned or controlled setting. An MCO must ensure that a setting where a host family provides respite care has the following qualities as described in 42 CFR Section 441.301(c)(4)(vi):

• each member has privacy in their sleeping or living unit;
• the member has the freedom and support to control their own schedules and activities and has access to food at any time;
• the member is able to have visitors of their choosing at any time; and
• the setting is physically accessible to the member.

Any modifications to these requirements must be supported by a specific assessed need and documented in the person-centered service plan. Include the following criteria in the plan:

• a description of the specific and individualized assessed need that justifies the modification;
• a description of the positive interventions and supports that were tried but did not work;
• a description of less intrusive methods of meeting the need that were tried but did not work;
• a description of the condition that is directly proportionate to the specific assessed need;
• a description of routine collection and review of data to measure the ongoing effectiveness of the modification;
• the established time limits for periodic reviews to determine if the modification is still necessary or can be stopped;
• the member’s or legally authorized representative’s  signature showing evidence of informed consent to the modification; and
• the MCO service coordinator's assurance that the modification will cause no harm to the individual.

Access to the Community 

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i) and 42 CFR Section 441.530(a)(1)(i) require the member to have full access to the greater community. This includes opportunities to engage in community life, control personal resources, and receive services in the community to the same degree as a person not receiving Medicaid services.

The MCO must ensure that providers not have policies or practices in place that restrict or obstruct the member’s access to the community. The MCO must also ensure provider service and support practices do not create an environment that is institutional in nature. The MCO must support the member’s desire to participate in the community.

The MCO must use the person-centered planning process to: 

• ensure the member has opportunities and supports needed to participate in the community when they want, both individually and in groups; 
• identify, develop, and make available information on transportation options for community access; 
• assist the member with developing meaningful relationships with other members of the community; and
• ensure the member has services, resources, and supports to help them explore or maintain meaningful activities.

Employment 

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i) and 42 CFR Section 441.530(a)(1)(i) requires that the member has opportunities to seek employment and work in competitive integrated settings, in the same way a person not receiving Medicaid home and community-based services has.

As part of the person-centered planning process, the MCO must assess the member’s preferences and goals. This may include preferences and goals related to seeking employment and working in competitive integrated settings. The MCO is responsible for assessing and providing information to the member about employment assistance and supported employment services available through MDCP (STAR Kids Contract 8.3.2). 

Setting Choice

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(ii) and 42 CFR §441.530(a)(1)(ii) requires that the member is allowed to select a setting where services are delivered from setting options. Setting options should include non-disability specific settings. 

The MCO must facilitate the service planning process, including offering setting options that a member may choose. The MCO must identify and document the setting options and selection, based on the member’s needs and preferences, in the member’s individual service plan (ISP).

Privacy, Dignity and Respect, and Freedom from Coercion and Restraint

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iii) and 42 CFR Section 441.530(a)(1)(iii) require that the setting ensures the individual’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

The MCO must ensure the member is treated respectfully by providers and is free from coercion and restraint. 

The member has the right to privacy, in the same way as children and youth not receiving Medicaid home and community-based services. The right to privacy includes having their information kept private and having personal care provided in private. The MCO must ensure providers respect and protect the member’s privacy.

The MCO must also ensure licensed and certified providers meet applicable licensing and certification requirements about privacy, dignity and respect, and freedom from coercion and restraint.

Initiative, Autonomy, and Independence

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iv) and 42 CFR Section 441.530(a)(1)(iv) require that a setting optimize but not regiment, the member’s initiative, autonomy, and independence in making life choices. This includes, but is not limited to, daily activities, physical environment, and with who they interact. The managed care organization (MCO) and providers must maximize the member’s ability to make choices while minimizing the risk of endangering the member or others. 

The MCO must ensure providers support the member’s right to make choices about how they spend their time in any given setting, to the same degree as children and youth not receiving Medicaid home and community-based services. The MCO must ensure the member has opportunities to participate in community activities appropriate for children and youth. 

The MCO should coordinate with the member, LAR, other family members involved in service planning, and the provider to ensure: 

• the member is offered actual experiences to base future choices; 
• the member’s daily activities have the appropriate balance between autonomy and safety; 
• the member’s personal preferences are prioritized over a guardian’s or provider’s preferences, unless a health and safety reason is documented; and 
• the member feels supported in working toward their goals.

The MCO ensures a provider does not: 

• force or coerce the member to participate when they do not wish to participate in an activity; 
• punish the member for not participating in an activity; or
• make activity schedules without input from the members in the setting.

Member Choice

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(v) and 42 CFR Section 441.530(a)(1)(v) requires that the member has a choice about services and supports, and who provides them. 

The MCO ensures the member is free to choose who provides the services they receive and where they receive those services. The member must not be coerced or forced to get services in a particular setting. They may instead choose to go out into the community for the same services. 

The service plan is the central place where the MCO should document and honor the member’s choices for services, supports and who provides them. The MCO ensures the person-centered planning process addresses the member’s needs. The MCO must inform the member that they can request a change to their person-centered service plan if they are not happy with their services. The MCO requires providers to help the member with contacting their MCO to discuss possible changes to their service plan if they are unhappy with their services.  

Requirements for Host Family Settings Where MDCP Respite is Delivered

MDCP respite may be delivered in host family settings for members using the Consumer Directed Services (CDS) option. 

Note: As of November 2022, there are no host homes delivering respite services in MDCP. 

Privacy

The regulation at 42 CFR Section 441.301(c)(4)(vi)(B) requires that the member has privacy in their living unit or bedroom, in the same way a child or youth not receiving Medicaid home and community-based services does.

The member’s right to privacy includes:

• an entrance door to their bedroom or living unit that is lockable by the member;
• a choice of room and roommate, to the extent possible in the setting; and 
• ability to decorate their bedroom or living unit. 

Base any modifications or restrictions to the member’s  privacy on a specific, assessed need and documented in the member’s person-centered service plan.

Control of Daily Schedule and Access to Food

The regulation at 42 CFR Section 441.301(c)(4)(vi)(C) requires that the member has the freedom and support to control their own schedules and activities and has access to food at any time.

As part of the person-centered planning process, the MCO should discuss with the member their goals and preferences, including for daily schedules and activities. The MCO must also ensure the host family setting has processes in place to discuss with the member their preferences for their daily schedule and activities. 

The MCO must ensure the host family allows the member to access food at any time, in the same way a child or youth not receiving Medicaid home and community-based services can. This includes allowing the member to have food or snacks before or after scheduled mealtimes. As appropriate, the host family may leave the kitchen accessible to the member or may allow the member to keep their own food in their bedroom or another designated space, such as a pantry or cupboard, that they can access whenever they want. 

Base any modification to the member’s ability to control their daily schedule, including access to food at any time, on a specific assessed need and documented in the member’s person-centered service plan.

Visitation

The regulation at 42 CFR Section 441.301(c)(4)(vi)(D) requires that the member can have visitors of their choosing at any time. 

The MCO must ensure a host family allows the member to receive visitors at any time, in the same way as children and youth not receiving Medicaid home and community-based services. 

Base any modification to the member’s ability to have visitors at any time on a specific assessed need and documented in the members person-centered service plan.

Physical Accessibility

The regulation at 42 CFR Section 441.301(c)(4)(vi)(E) requires that the host family setting be physically accessible to the member. 

The MCO must ensure a host family setting is physically accessible to the member. 

Modifications to Home and Community Based Services Settings Rule Requirements

The regulation at 42 CFR Section 441.301(c)(4)(vi)(F) requires any modifications to the following conditions of the settings regulations be supported by a specific need and justified in the member’s person-centered service plan:

1. the member has privacy in their living unit or bedroom;
2. the member has a choice of roommates;
3. the member has the freedom to decorate their living space;
4. the member has freedom and support to control their schedules and activities, and has access to food at any time; 
5. the member is able to have visitors of their choosing at any time; and
6. the host family setting is physically accessible to the member.

The MCO ensures any modifications or restrictions to these conditions one through five above are based on an individualized, assessed need and documented in the person-centered service plan. Document the following information in the person-centered service plan: 

• a description of the specific and individualized assessed need that justifies the modification;
• a description of the positive interventions and supports that were tried but did not work;
• a description of the less intrusive methods of meeting the need that were tried but did not work;
• a description of the condition that is directly proportionate to the specific assessed need;
• a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;
• the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;
• the member’s or legally authorized representative’s  signature evidencing informed consent to the modification; and
• the MCO service coordinator's assurance that the modification will cause no harm to the individual.

The MCO must ensure that condition number six listed above is not modified.
 

Revision Notice 23-4; Effective Dec. 1, 2023

The following change(s) were made:

Section	Title	Change
1220	Long Term Services and Supports	Amends language for clarification purposes. Updates the definition of attendant care services.
2132	MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay	Amends language for clarification purposes. Updates instructions for MCOs around limited nursing facility (NF) stay. Removes the word “service coordinator” from mentions of “MCO service coordinator”.
3200	Member Reassessment	Removes an incorrect reference to Community First Choice (CFC). Removes the word “service coordinator” from mentions of “MCO service coordinator”.
3511	STAR+PLUS Transition Activities	Updates link to STAR+PLUS Handbook.
5311	Developing the Individual Service Plan in the CDS Option	Updates instructions for completing denials, reductions in services and suspensions. Updates instructions in the Consumer Directed Services (CDS) option for a registered nurse (RN). Removes the word “service coordinator” from mentions of “MCO service coordinator”.
7200	External Medical Review	Amends language around the external medical review (EMR) process.
7612	Reversed Appeal Decisions	Updates language around PSU procedures for reversed appeal decisions.
Form 2603 Instructions	Form 2603, STAR Kids Individual Service Plan (ISP) Narrative	Revises instructions for when to prepare or update Form 2603. Provides clarification on documenting changes to services on the individual service plan (ISP) and provides clarification for when changes can be made.

Revision Notice 23-3; Effective July 21, 2023

The following change(s) were made:

Section	Title	Change
1311	Member Refusal to Participate in Service Coordination	Changes reference from TxMedCentral to MCOHub.
1630	Communication with the Managed Care Organization	Changes reference from TxMedCentral to MCOHub.
1810	Program Support Unit Notification Requirements	Changes reference from TxMedCentral to MCOHub.
2030	Managed Care Organization Coordination	Changes reference from TxMedCentral to MCOHub.
2111	Non-STAR Kids Individual Residing in an NF	Changes reference from TxMedCentral to MCOHub.
2112	STAR Kids Member Residing in an NF	Changes reference from TxMedCentral to MCOHub.
2113	MDCP MFP Applications Pending Due to Delay in NF Discharge	Changes reference from TxMedCentral to MCOHub.
2131	Individual Who is Approved for a Limited NF Stay	Changes reference from TxMedCentral to MCOHub.
2132	MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay	Changes reference from TxMedCentral to MCOHub.
2133	Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids	Changes reference from TxMedCentral to MCOHub.
2210	Medical Necessity Expiration	Changes reference from TxMedCentral to MCOHub.
2220	MDCP Start of Care Date for Interest List Releases	Changes reference from TxMedCentral to MCOHub.
2230	Member Reassessment	Changes reference from TxMedCentral to MCOHub.
3200	Reassessment of Medical Necessity or Level of Care	Changes reference from TxMedCentral to MCOHub.
3210	Reassessment of Medical Necessity or Level of Care	Changes reference from TxMedCentral to MCOHub.
3329	Reassessment Notification Requirements	Changes reference from TxMedCentral to MCOHub.
3410	Transfer from One Managed Care Organization to Another	Changes all references to TxMedCentral to MCOHub
3420	Member Transfer from Waiver Program to Medically Dependent Children Program	Changes all references to TxMedCentral to MCOHub
6200	Denial/Termination of Medically Dependent Children Program	Changes reference from TxMedCentral to MCOHub.
6210	Denial/Termination Due to Death	Changes reference from TxMedCentral to MCOHub.
6220	Denial/Termination Due to Residence in a Nursing Facility	Changes reference from TxMedCentral to MCOHub.
6270	Denial/Termination Due to Failure to Meet Other Program Requirements	Changes reference from TxMedCentral to MCOHub.
6280	Denial/Termination for Other Reasons	Changes reference from TxMedCentral to MCOHub.
7510	Continuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing	Changes reference from TxMedCentral to MCOHub.
7520	Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing	Changes reference from TxMedCentral to MCOHub.
7800	Community First Choice State Fair Hearing	Changes reference from TxMedCentral to MCOHub.
Appendix IX	Star Kids TxMedCentral Naming Conventions	Changes reference from TxMedCentral to MCOHub.
Glossary	Glossary	Changes reference from TxMedCentral to MCOHub. Relocates MCOHub to the M section of the glossary for alphabetical order.

Revision Notice 23-2; Effective July 7, 2023

The following change(s) were made:

Section	Title	Change
Appendix III	LTSS Billing Matrix and Crosswalk	Updates billing matrix. Adds clarifying language and corrects a revenue code.

Revision Notice 23-1; Effective March 1, 2023

The following change(s) were made:

Section	Title	Change
Appendix XIV	Home and Community-Based Services Settings Rule	Creates new appendix for the Home and Community-Based Services Settings Rule.