STAR Kids Handbook

 

Section 1000, Overview and Eligibility

Revision 18-2; Effective September 3, 2018

 

Senate Bill 7 from the 83rd Legislature, Regular Session, 2013 required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).

STAR Kids does not change or impact an individual's Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, ages birth through 20, enrolled in a STAR Kids MCO are called members of the MCO. All STAR Kids members have access to service coordination, provided by an MCO employee or through a member's primary care provider, authorized by the MCO.

Service coordination is specialized care management performed by a service coordinator and includes but is not limited to:

All STAR Kids members receive a comprehensive assessment of their physical and functional needs by a service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI), annually. Within the time frame listed in the STAR Kids Contract, Section 8.1.39, STAR Kids Initial Screening and Assessment Process, if a member has a significant change in condition, the MCO must reassess the member and update their individual service plan (ISP), as applicable, and authorize necessary services. Upon request from the member, legally authorized representative (LAR), authorized representative (AR) or health home, the MCO must update their ISP, as applicable, and authorize necessary services.

In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, flexible family support services, adaptive aids, minor home modifications, employment services and transition assistance to children and young adults who meet the level of care provided in a nursing facility (NF) so they can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list for MDCP. A child, young adult, LAR or AR may ask their MCO about how to be placed on the MDCP interest list at any time.

 

1100 Legal Basis and Values

Revision 18-1; Effective March 1, 2018

 

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 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) mission is to provide individually 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:

 

1200 STAR Kids Services and Service Delivery Options

Revision 18-1; Effective March 1, 2018

 

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, 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 18-2; Effective September 3, 2018

 

STAR Kids members may receive any medically necessary services through their managed care organization (MCO), and as required under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT), (42 CFR Part 441). This includes, but is not limited to:

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 18-2; Effective September 3, 2018

 

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):

STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following service through their STAR Kids MCO.

Community First Choice (CFC), which is available to all STAR Kids members who meet an institutional 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 waiver program for individuals with an intellectual disability or related condition (ID/RC) receive CFC through their waiver provider. CFC services include:

Note: CFC-PAS is the same service as PCS. The key difference is that CFC-PAS is part of the CFC benefit and must be reported differently. Members may choose to receive CFC-PAS only if they do not need or want CFC habilitation.

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 an 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 are:

 

1230 Service Delivery Options for Certain Long Term Services and Supports

Revision 18-1; Effective March 1, 2018

 

STAR Kids provides members with an array of services, as 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 three service delivery options for the delivery of certain long term services and supports (LTSS). The options are agency, service responsibility, and consumer directed. State plan LTSS which can be delivered through these service delivery options are:

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:

STAR Kids members, legally authorized representatives (LARs) or authorized representatives (ARs) may choose to participate in the agency option, consumer directed services (CDS) or service responsibility option (SRO) delivery models. Members who choose the agency model select an MCO-contracted agency to coordinate service delivery for 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 certain services, the MCO coordinates delivery of non-member directed services.

In the SRO model, an agency is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member, LAR or AR 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.

In the CDS model, the member, LAR or AR with assistance from a financial management service agency (FMSA), ensures all supplies necessary to provide all authorized services. These personnel may be employed directly by or through personal service agreements or subcontracts with the providers.

More information about these service delivery options is available in Section 5000, Service Delivery Options.

 

1300 Service Coordination

Revision 18-1; Effective March 1, 2018

 

All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide 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, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing or other long-term care facility, the service coordinator must inform the member, LAR or AR about options available through home and community based services (HCBS) programs, in addition to facility-based options.

MCO service coordinators are responsible for assessing a member's needs 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. During the annual face-to-face visit, the service coordinator must:

 

1310 Service Coordination Requirements

Revision 18-2; Effective September 3, 2018

 

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 from a named service coordinator annually, in addition to monthly phone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 service coordinators must be a registered nurse (RN), nurse practitioner (NP), a physician's assistant (PA), a social worker (MSW, LCSW, or LBSW) or licensed professional counselor (LPC) if the member's service needs are primarily behavioral. Level 1 members include those who:

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, LAR or AR. Level 2 service coordinators must be either an RN, NP, 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:

Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 service coordinators must have a minimum of 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 qualify for Level 3 who reside 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 non-capitated 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). The MCO must notify members within five business days of the name and phone number of the new service coordinator, if the service coordinator changes.

MCOs must notify all members in writing of the:

 

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

Revision 18-1; Effective March 1, 2018

 

Members who have intellectual and developmental disabilities (IDD) living in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or who receive services through one of the following IDD waivers, receive their acute care services and some long term services supports (LTSS) (e.g., private duty nursing (PDN)) through STAR Kids and continue to receive most of their LTSS through the following programs:

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

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

 

1330 Service Coordination and the Youth Empowerment Services Program

Revision 18-1; Effective March 1, 2018

 

Members who receive services through the Youth Empowerment Services (YES) program receive their acute care services and some long term services and supports (LTSS) (e.g., day activity and health services (DAHS), private duty nursing (PDN), and Community First Choice (CFC)) only through STAR Kids and continue to receive their waiver services through the YES program. Members served by the YES program will have a named managed care organization (MCO) service coordinator and will be 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 waiver case manager. The member’s waiver case manager should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be either in person or telephonically. The MCO service coordinator is responsible for the coordination of these member's acute care services and capitated long term services and supports.

 

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

Revision 18-1; Effective March 1, 2017

 

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

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program's population. HCBS-AMH is operated on a fee-for-service basis for members age 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 Department of State Health Services (DSHS). Additional information about HCBS-AMH can be found at https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

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:

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:

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

 

1350 Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 18-1; Effective March 1, 2018

 

This section is reserved for future use.

 

1400 Medically Dependent Children Program

 

Revision 18-1; Effective March 1, 2018

 

The Medically Dependent Children Program (MDCP) is a home and community based services (HCBS) program authorized under §1915(c) of the Social Security Act. 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 18-1; Effective March 1, 2018

 

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults age 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:

 

1500 Medically Dependent Children Program Eligibility

Revision 18-2; Effective September 3, 2018

 

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. Once an individual's name comes to the top of the list, determination of eligibility begins as the individual applies for services. Individuals not already enrolled in STAR Kids are referred to as applicants. Individuals enrolled in STAR Kids who are assessed for MDCP are referred to as members.

MDCP is provided by virtue of authority granted to the state of Texas to allow delivery of long term services and supports (LTSS) that assist members to 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 following criteria:

 

1510 Medical Necessity Determination

Revision 18-2; Effective September 3, 2018

 

A Medically Dependent Children Program (MDCP) waiver 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/members. TMHP processes the SK-SAI for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in waiver programs to categorize needs for applicants or members and establish the service plan cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG 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 of 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. 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 inactivations to the SK-SAI to TMHP.

 

1511 Medical Necessity Determination for Applicants/Members Residing in Nursing Facilities

Revision 18-1; Effective March 1, 2018

 

During initial contact with the applicant or member, the service coordinator must explore the applicant’s or member'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.

 

1512 Medical Necessity Determination for Applicants/Members Not Residing in Nursing Facilities

Revision 18-1; Effective March 1, 2018

 

For applicants or members 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 applicant or member.

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 18-1; Effective March 1, 2018

 

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 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 18-2; Effective September 3, 2018

 

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 the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. 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 disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (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) §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 18-1; Effective March 1, 2018

 

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.

 

1560 Living Arrangement

Revision 18-1; Effective March 1, 2018

 

Managed care organization (MCO) service coordinators must confirm that the applicant or member, 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 applicant, member, legally authorized representative (LAR), authorized representative (AR) or family member regarding relation. The service coordinator must maintain this documentation in the member's case file.

 

1570 Financial Eligibility

Revision 18-2; Effective September 3, 2018

 

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 on Medicaid.

 

1600 Disclosure of Information

Revision 18-2; Effective September 3, 2018

 

 

1610 Confidential Nature of a Case Record

Revision 18-1; Effective March 1, 2018

 

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, legally authorized representative (LAR) or authorized representative (AR) 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 18-2; Effective September 3, 2018

 

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

 

1611.1 Telephone Contact

Revision 18-1; Effective March 1, 2018

 

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

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

Establish the identity of an attorney, LAR or AR by asking for the individual to provide Form 1826-D, 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.

 

1611.2 In-Person Contact

Revision 18-1; Effective March 1, 2018

 

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

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

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

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 18-1; Effective March 1, 2018

 

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party to whom the applicant, member, LAR or AR 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:

 

1612 Custody of Records

Revision 17-1; Effective June 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:

 

1613 Disposal of Records

Revision 17-1; Effective June 1, 2017

 

To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data. Managed care organizations (MCOs) must follow procedures contained in Section 7.06 of the STAR Kids Managed Care Contract.

 

1614 When and What Information May Be Disclosed

Revision 18-1; Effective March 1, 2018

 

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

Note: If the case information to be released includes individually identifiable health information, the document must also tell the applicant, member, LAR or AR 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.

 

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:

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 18-2; Effective September 3, 2018

 

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, legally authorized representative (LAR) or authorized representative (AR) about:

 

1617 Member Authorization

Revision 18-1; Effective March 1, 2018

 

The member, legally authorized representative (LAR) or authorized representative (AR) 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 1826-D, 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 and Authorized Representatives

Revision 18-1; Effective March 1, 2018

 

Only the member's legally authorized representative (LAR) or authorized representative (AR) 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 or AR.

Note: A responsible party is not automatically an LAR or AR.

 

1619.1 Adults and Emancipated Minors

Revision 18-1; Effective March 1, 2018

 

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

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

 

1619.2 Unemancipated Minors

Revision 18-1; Effective March 1, 2018

 

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

 

1619.3 Deceased Members

Revision 18-1; Effective March 1, 2018

 

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

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

 

1620 Confidential Information on Notifications

Revision 18-1; Effective March 1, 2018

 

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

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

Examples:

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

 

1630 Correcting Information

Revision 18-1; Effective March 1, 2018

 

A member, legally authorized representative (LAR) or authorized representative (AR) 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:

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, LAR or AR 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 follow regional procedures to 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, LAR or AR is determined by another review process, such as a:

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

 

1640 Communication with the Managed Care Organization

Revision 18-1; Effective March 1, 2018

 

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

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

Example: Posted XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been posted 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).

 

1650 Alternate Means of Communication

Revision 18-1; Effective March 1, 2018

 

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

The applicant, member, LAR or AR 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.

 

1700 Citizenship and Identity Verification

Revision 18-1; Effective March 1, 2018

 

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.

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

 

1710 Acceptable Documentation for Both Citizenship and Identity

Revision 18-2; Effective September 3, 2018

 

 

1711 Supplemental Security Income Recipients

Revision 18-1; Effective March 1, 2018

 

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

 

1712 Medicare Recipients

Revision 18-2; Effective September 3, 2018

 

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

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

 

1713 All Other Individuals

Revision 18-2; Effective September 3, 2018

 

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

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

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

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

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

 

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

Second Level of Evidence of Citizenship
(Use only when primary evidence is not available.)
  • A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the U. S. Virgin Islands. (if born on or after Jan. 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (if born after Nov. 4, 1986). Contact the Bureau of Vital Statistics (BVS) for an individual born in Texas. If an individual's date of birth (DOB) is earlier than than 1903 or if the birth was out of state, accept a legible, non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through: BirthCertificate.com; vitalchek.com; and usbirthcertificate.net or the toll-free number, 1-888-736-2692.
  • Report of Birth Abroad of a U.S. Citizen (FS-240).
  • Certification of Birth Abroad (FS 545 or DS-1350).
  • U.S. Citizen Identification card (Form I-179 or I-197).
  • Northern Mariana Identification card (I-873).
  • American Indian card (I-872) issued by the Department of Homeland Security with classification code "KIC".
  • Final adoption decree showing the child's name and U.S. place of birth.
  • Evidence of U.S. Civil Service employment before June 1, 1976.
  • U.S. military record showing a U.S. place of birth (Example: DD-214).
Third Level of Evidence of Citizenship
(Use only when primary and second level evidence is not available.)
  • Hospital record of birth showing the U.S. place of birth.
  • Life, health or other insurance record showing the U.S. place of birth.
  • Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual's age at the time the record was made.
  • Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and the name(s) and place(s) of birth of the applicant's/recipient's parents.
Fourth Level of Evidence of Citizenship
(Use only when primary, second and third level evidence is not available.)
Any listed documents used must include biographical information, including U.S. place of birth.
  • Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual's age (generally for individuals born 1900-1950).
  • Seneca Indian Tribal census record showing a U.S. place of birth.
  • Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth.
  • Bureau of Indian Affairs Roll of Alaska Natives.
  • U.S. state vital statistics official notification of birth registration showing a U.S. place of birth.
  • Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth.
  • Institutional admission papers from a nursing facility (NF), skilled care facility or other institution showing a U.S. place of birth.
  • Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth.
  • Affidavits from two adults regardless of blood relationship to the individual. (Use only as a last resort when no other evidence is available.)
Evidence of Identity
  • Driver license issued by a state either with a photograph or other personally identifying information (PII) such as name, age, sex, race, height, weight or eye color.
  • School identification card with a photograph.
  • U.S. military card or draft record.
  • Identification card issued by the federal, state or local government with the same information that is included on a driver license.
  • Department of Public Safety identification card with a photograph or other PII such as name, age, sex, race, height, weight or eye color.
  • Birth certificate.
  • Hospital record of birth.
  • Military dependent's identification card.
  • Native American Tribal document.
  • U.S. Coast Guard Merchant Mariner card.
  • Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other PII.
  • Data matches with other state or federal government agencies (Example: Employee Retirement System (ERS) and Teacher Retirement System (TRS)).
  • Three or more supporting documents such as a marriage license, divorce decree, high school diploma or employer identification card (use only with second and third level evidence of citizenship).
  • Adoption papers or records.
  • Work identification card with photograph.
  • Signed application for Medicaid (accept signature of a legally authorized representative (LAR) or authorized representative (AR)).
  • Health care admission statement.
  • For children under age 16, school records (may include nursery or day care records).
  • For children under age 16, doctor, clinic or hospital records.
  • For children under age 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).
  • For disabled individuals in residential care facilities who cannot provide any document on this list, an affidavit signed by the facility director or administrator attesting the identity of the individual (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).

 

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

If an individual is unable to provide any other documentary evidence of citizenship, an affidavit signed under penalty of perjury is only accepted as a last resort. If the MCO is notified, the MCO staff must notify PSU staff via Form H2067-MC, Managed Care Programs Communication, along with a copy of the affidavit.

 

1800 Member Rights and Responsibilities

Revision 18-1; Effective March 1, 2018

 

Member rights and responsibilities are included in the Member Handbook. The required critical elements can be found at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the member, legally authorized representative (LAR) or authorized representative (AR) 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: http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

 

1900 Notifications

Revision 18-1; Effective March 1, 2018

 

 

1910 Program Support Unit Notification Requirements

Revision 18-1; Effective March 1, 2018

 

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member, LAR or AR of the actions taken regarding Medically Dependent Children Program (MDCP) services. The form must be completed in plain language that can be understood by the applicant, member, LAR or AR. The language preference of the member must be considered.

The applicant, member, LAR or AR 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, LAR or AR who is denied or a member, LAR or AR whose services are terminated. PSU staff must notify the applicant, LAR or AR on Form H2065-D of the denial of application within two business days of the decision. See also Section 6000, Denials and Terminations.

Once it is determined that a case action must be taken, Form H2065-D must be prepared and mailed to the member, LAR or AR the same date the form is signed. Notification forms must be posted to the managed care organization's (MCO’s) XXXSKW folder using the correct naming convention in TxMedCentral on the case action date. PSU staff's signature date on Form H2065-D is the case action date.

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

 

1920 MCO Notification Requirements

Revision 18-1; Effective March 1, 2018

 

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

Section 2000, Medically Dependent Children Program Intake and Initial Application

Revision 18-2; Effective September 3, 2018

 

 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-2; Effective September 3, 2018

 

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list according to the date and time of the request, regardless of the program's enrollment status. Each individual is released from the interest list in the order of the request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual's name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

 

2020 Individual Who Receives STAR Health

Revision 18-2; Effective September 3, 2018

 

See the Uniform Managed Care Manual (UMCM) for STAR Health members. The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

An individual enrolled with a STAR Health managed care organization (MCO) must remain enrolled with the STAR Health MCO.

Additional information on MDCP STAR Health members is located in the STAR Health MDCP Policy §16.2 of the UMCM.

 

2021 Individual Who Receives Other Types of Medicaid

Revision 18-2; Effective September 3, 2018

 

An individual who receives other types of Medicaid (i.e., non-Supplemental Security Income (SSI) and is either served in fee-for-service or enrolled with a STAR managed care organization (MCO) must select a STAR Kids MCO.

 

2030 Managed Care Organization Coordination

 

Revision 18-2; Effective September 3, 2018

 

The STAR Kids managed care organization (MCO) has 30 days following the initial notice from Program Support Unit (PSU) staff to complete all assessments for an individual enrolled in the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation, for a total of 60 days following the initial notice from PSU staff. The MCO must:

If the MCO does not submit Form 2604 within 60 days after PSU staff posted Form H3676, Section A, Referral/Assessment Authorization, authorizing the MCO to begin the eligibility process, PSU staff must email Managed Care Compliance & Operations (MCCO).

The MCO must schedule and complete the SK-SAI, including the MDCP module, within 30 days of notice from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP, following the requirements in Appendix I within 72 hours of completion. For the purposes of this requirement, an SK-SAI is considered "complete" when the MCO has obtained the physician's signature on Form 2601, Physician Certification, and has retained this form in the individual's case file.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI. The MN determination must be made by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff process the SK-SAI for an individual to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for an individual or member and establish the service plan cost limit. The MDCP module of the SK-SAI (Section R, MDCP Related Items) is used to determine the RUG.

Once TMHP staff process an SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG value. This code may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A “BC1” code indicates the SK-SAI does not have all of the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value 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. After 14 days, the MCO must inactivate the SK-SAI and submit a new SK-SAI in its place. Information about the process of transmitting, correcting and inactivating an SK-SAI is available in Appendix I.

As a part of the individual service plan (ISP) planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or RUG value assigned by TMHP. If the MCO does not properly establish this plan of care and the individual’s/member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual's/member's ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member's MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member or legally authorized representative (LAR) no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.

 

2100 Money Follows the Person

 

Revision 18-2; Effective September 3, 2018

 

 

2110 Traditional Money Follows the Person

Revision 18-2; Effective September 3, 2018

 

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:

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, as amended by Senate Bill 368, 77th Legislature, Regular Session, 2001).

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 EveryChild, Inc. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, in accordance with legislative direction, 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 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:

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 Section 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 18-2; Effective September 3, 2018

 

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

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 the Texas Health and Human Services Commission (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 Z5a and Z5b 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) Narrative, the MCO service coordinator must:

Within one business day following communication from the MEPD specialist of the individual's Medicaid eligibility, PSU staff will post Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Within one business day prior to the individual's discharge, PSU staff generate the final Form H2065-D in the LTC Online Portal containing the service effective date and:

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 post on TxMedCentral within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

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

 

2112 STAR Kids Member Residing in an NF

Revision 18-2; Effective September 3, 2018

 

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

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:

Within two business days of the referral from ILM Unit staff, PSU staff must post Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral 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. PSU staff must track all actions and communications in the HEART case record until all MDCP enrollment activities are complete.

If within 30 days after the member’s or LAR's request to return to the community the MCO has not completed the MN process and submitted the ISP, PSU staff will email Managed Care Compliance & Operations (MCCO) to advise of the delay. PSU staff will continue to monitor TxMedCentral for receipt of Form H3676 or Form H2067-MC, Managed Care Programs Communication.

Within one business day following receipt of Form H2067-MC from the MCO, PSU staff will:

Within one business day prior to the member’s discharge from the NF, PSU staff will:

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

 

2113 MDCP MFP Applications Pending Due to Delay in NF Discharge

Revision 18-2; Effective September 3, 2018

 

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and 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.

Examples:

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:

 

2120 MFP Limited NF Stay Option for a Medically Fragile Individual

Revision 18-2; Effective September 3, 2018

 

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 of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. 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:

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. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress that in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday because services must be authorized within 24 hours of discharge. 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 18-2; Effective September 3, 2018

 

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 his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her 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:

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 18-2; Effective September 3, 2018

 

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her 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 ILM Unit staff and reply all to notify ILM Unit staff of the decision.

 

2131 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Not Enrolled in Medicaid/Without Medicaid (including an individual enrolled in CHIP)

 

Revision 18-2; Effective September 3, 2018

 

When an individual who is not enrolled in STAR Kids Medicaid is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

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 post to TxMedCentral in the MCO's STAR Kids folder.

 

2132 PSU Procedures for an Individual Who is Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 18-2; Effective September 3, 2018

 

When an individual with Medicaid eligibility, but who is not enrolled in STAR Kids, is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

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

 

2133 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 18-2; Effective September 3, 2018

 

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A, Referral/Assessment Authorization, of Form H3676 stating the member resides at home and, in the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option, and post the form to TxMedCentral in the MCO's STAR Kids folder.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian or legally authorized representative (LAR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator.

 

2134 PSU and MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 18-2; Effective September 3, 2018

 

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian or legally authorized representative (LAR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral informing the individual of the decision to complete a limited NF stay. The MCO must initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian or LAR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual must present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the limited NF stay admission and discharge before MDCP services can be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay option funding requirements. MCO service coordinators 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 MFP limited NF stay policy for continuity of services. 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.

The MCO has 60 days to complete all assessments and submit required forms to Program Support Unit (PSU) staff. The MCO must complete:

The MCO must post Form H3676 to TxMedCentral in the MCO's STAR Kids folder and submit the electronic Form 2604 to TMHP, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must maintain a copy of Form 2603 in the member’s or applicant's case file.

If the MCO does not submit an ISP within 60 days after PSU staff posted Form H3676, Part A, PSU staff notify Managed Care Compliance & Operations by email.

For STAR Kids members accessing MDCP through the limited NF stay process for the limited NF stay, PSU staff post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions, to notify the MCO of the approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff post Form H2067-MC to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by posting Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator within 24 hours of the time of discharge.

MCO service coordinators 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 MFP limited NF stay policy for continuity of services. 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.

Within 24 hours of the limited NF stay, the following activities must occur:

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff will post Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, if the form was manually completed, and upload all applicable documents in the HEART case record.

The MDCP effective date will be the first of the month in which the MFP individual was 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.

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 post within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

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

 

2135 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 18-2; Effective September 3, 2018

 

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, 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. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, fax Form H1746-A, Form H1200, and Form 0003, Authorization to Furnish Information, if available, to the MEPD specialist, and upload all documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.”

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. Once PSU staff confirm the Medicaid denial, PSU staff must deny MDCP eligibility by:

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 ILM Unit staff, as described in Section 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 post the letter on TxMedCentral in the MCO’s STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request that the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

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 posting Form H2067-MC in TxMedCentral, 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.

Section 3000, STAR Kids Screening and Assessment and Service Planning

Revision 18-2; Effective September 3, 2018

 

 

3100 STAR Kids Screening and Assessment

Revision 18-1; Effective March 1, 2018

 

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 Community First Choice (CFC), personal care services and/or Medically Dependent Children Program (MDCP) 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 18-1; Effective March 1, 2018

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids 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 the personal care assessment module (PCAM), including Section P, as well as questions in Section Z 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, 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 the PCAM and Section P, but leaves Field Z5a 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 his 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 17-3; Effective September 1, 2017

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids 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 30 days following notification from Program Support Unit (PSU) staff, detailed in Section 2220, 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 applicants/members for MDCP services complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate yes on Field Z5a 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 Z5a 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 Z5a 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 his legally authorized representative. A physician's certification is not required for a reassessment of MN.

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.

 

3200 Member Reassessment

Revision 18-1; Effective March 1, 2018

 

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed. Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. 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 may not conduct the SK-SAI earlier than 90 days prior to the one year anniversary of the member's previous assessment using the SK-SAI. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member or member’s legally authorized representative (LAR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive personal care services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). 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. The MCO must also complete the NCAM at any time it determines the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

 

3210 Reassessment of Medical Necessity or Level of Care

Revision 18-1; Effective March 1, 2018

 

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), 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 Z5a 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 a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member and/or the member's legally authorized representative (LAR) to schedule a reassessment prior to the expiration of the member's LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure that the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member's ISP is completed annually. PSU staff:

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services will continue 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 the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, asking PSU staff to manually generate Form H2065-D, Notification of Managed Care Program Services. This form is not generated in the LTC Online Portal at reassessment. PSU staff send Form H2065-D to the member and post a copy to the appropriate MCO STAR Kids folder in TxMedCentral. See Section 3328, Reassessment Notification Requirements, for additional information.

 

3300 Member Service Planning and Authorization

Revision 17-3; Effective September 1, 2017

 

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 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, his 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 his 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:

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 printed or electronic copy of the ISP to each member or his 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 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 his 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 18-1; Effective March 1, 2018

 

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:

The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, his 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).

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 18-1; Effective March 1, 2018

 

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 18-1; Effective March 1, 2018

 

The service coordinator must work with the member and/or member's 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), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG 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 (if applicable), begin/end date, and whether the member has chosen the Agency Option, Consumer Directed Services, or Service Responsibility Option, if applicable. The form must also include a brief rationale (i.e., 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 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. 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 prior to the start date of the member's ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must retain a copy of Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, in the member's case file.

If the member is turning age 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:

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

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

 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 17-3; Effective September 1, 2017

 

If a member and/or his 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 his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 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 submits the SK-ISP to the Long Term Care Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the member's file.

 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 18-1; Effective March 1, 2018

 

If a member and/or his 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. The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) in the Long Term Care Online Portal, including the MDCP module, and complete the following fields according to Appendix I, MCO Business Rules for SK-SAI and SK-ISP:

Following receipt of a response file indicating the member's new RUG and associated cost limit, 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 18-1; Effective March 1, 2018

 

Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member or his 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 17-3; Effective September 1, 2017

 

If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits via email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

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.

Note: MCOs must not discuss with applicants 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 17-1; Effective June 1, 2017

 

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 his or her individual service plan 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:

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 Section 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 Provider Procedures

Revision 17-3; Effective September 1, 2017

 

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is authorized annually. PSU staff:

If the reassessment ISP is developed but 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.

 

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 18-1; Effective March 1, 2018

 

Texas Health and Human Services Commission (HHSC) will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that will expire within the next 90 days.

Program Support Unit (PSU) staff will provide this report to the managed care organizations (MCOs) prior to the monthly call with PSU staff. The MCOs must provide a status update for all 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.

The process for managing this report is as follows:

Note: There will not be a need to review each member for the status of the ISP if the MCO's response is sufficient.

 

3328 Reassessment Notification Requirements

Revision 18-1; Effective March 1, 2018

 

If the member continues to meet waiver requirements, Program Support Unit (PSU) staff do not send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. PSU staff upload appropriate documentation into the HHS Enterprise Administrative Report and Tracking System (HEART) to record the approved reassessment.

If the member does not meet waiver requirements, PSU staff must, within two business days of receiving Form H2067-MC, Managed Care Programs Communication, from the managed care organization (MCO):

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

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

 

3400 Member Transfers

Revision 18-1; Effective March 1, 2018

 

 

3410 Transfer from One Managed Care Organization to Another

Revision 18-1; Effective March 1, 2018

 

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

The member can request to change MCOs as many times as the member wants, but the change cannot be made more than once per month. If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day of the month, the change will take place the first day of the second month following the change request.

Examples:

Texas Health and Human Services Commission (HHSC) Operations prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. PSU staff receive a full list and share MCO specific information with Health Plan Management (HPM) staff, who share it with MCOs. The MCO receives a member-specific report that gives a list of STAR Kids members who have changed MCOs from the previous month.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning 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. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must ensure the member’s new service coordinator, once assigned, contacts the member’s former service coordinator at the losing MCO to ensure a seamless transition of service coordination. The gaining MCO must contact the losing MCO for additional information maintained in the member's case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify HPM.

HPM must contact the losing MCO and require the MCO to upload information contained in the member's file, including Form 2603 and any current authorizations, within two business days of notification. HPM informs PSU staff by email the date by which the MCO must upload the information to TxMedCentral. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from HPM. The STAR Kids Screening and Assessment Instrument (SK-SAI) and electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, as well as historical SK-SAIs and ISPs, will be available to the gaining MCO upon enrollment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within five business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 15 business days of enrollment of the new member, the gaining MCO must conduct a home visit to assess the member's needs. For continuity of care, this includes authorizations, additional assessments, and pending delivery of adaptive aids, minor home modifications or transition assistance. This home visit may include conducting the SK-SAI 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 the SK-SAI business rules.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires 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 his or her 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 needs. If the gaining MCO is in a different service delivery area because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member or his LAR. Out-of-network authorizations must continue until the existing service plan expires or the gaining MCO can provide comparable services to transition the member to a provider that will be able to meet the member’s complex needs.

 

3420 Member Transfer from Waiver Program to Medically Dependent Children Program

Revision 18-1; Effective March 1, 2018

 

Participants in other 1915(c) Medicaid waivers operated by the state may be on the interest list for the Medically Dependent Children Program (MDCP). 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:

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 post it in the MCO's STAR Kids folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

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.

Within two business days of receipt of all required waiver eligibility documentation, PSU staff determine waiver eligibility based upon medical necessity (MN) and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for MDCP is denied or the individual decides not to accept MDCP services, PSU staff:

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.

If eligibility is approved and the individual chooses to accept MDCP services, the individual is enrolled in MDCP the first day of the next month. Within two business days of determining the start of care date for MDCP services, PSU staff:

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) waiver services end the day before enrollment in MDCP. The MCO must monitor the LTC Online Portal for 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 18-1; Effective March 1, 2018

 

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) or Home and Community-based Services (HCS). 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 to assist in coordinating 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 in the same STAR Kids MCO he is currently enrolled in for his state plan services.

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:

 

3440 Member Transfer from Community Services to STAR Kids

Revision 18-1; Effective March 1, 2018

 

Program Support Unit (PSU) staff must coordinate the termination of Community Care for the Aged and Disabled (CCAD) services with the CCAD 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), PSU staff coordinate the termination of CCAD services with the CCAD case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through CCAD service.

CCAD services are terminated by the CCAD 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.

 

3500 Member Transition to Adult Programs

Revision 18-1; Effective March 1, 2018

 

Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are 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 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC

Revision 18-1; Effective March 1, 2018

 

Possible waiver and service combinations the member may be receiving prior to transition:

 

3511 Twelve Months Prior to the Member's 21st Birthday

Revision 18-1; Effective March 1, 2018

 

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, Utilization Review (UR) provides a copy of the  Comprehensive Care Program (CCP) 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 18 months, to the:

Procedures for managing this report, including time frames, can be found in Appendix VI, STAR Kids Transition Activities.

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 with the member/LAR/supports, 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 by the MCO include:

The STAR Kids MCO:

PSU staff for STAR+PLUS HCBS program:

The following chart outlines the responsibilities for monitoring the STAR Kids Transition Report and contacting members transitioning from STAR Kids who receive MDCP, PDN or PPECC within the next 12 months:

Twelve Month Transition Chart

 

Under Age 21 MDCP Waiver Under Age 21 Other Services Received Monitors STAR Kids Report: 12-Month Contact:
MDCP PDN/PPECC PSU Staff STAR Kids MCO
MDCP CFC PSU Staff STAR Kids MCO
MDCP

PCS

PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP PDN/PPECC and PCS PSU Staff STAR Kids MCO
MDCP None PSU Staff STAR Kids MCO
None PDN/PPECC PSU Staff STAR Kids MCO
None

PDN/PPECC and CFC

PSU Staff STAR Kids MCO
None PDN/PPECC and PCS PSU Staff STAR Kids MCO

 

3512 STAR+PLUS Transition Activities

Revision 18-1; Effective March 1, 2018

 

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

 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 18-1; Effective March 1, 2018

 

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:

 

3520 Transition Policy for Non-Waiver Members Receiving Personal Care Services or Community First Choice Only

Revision 18-1; Effective March 1, 2018

 

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

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

Section 4000, STAR Kids Community Services

Revision 18-2; Effective September 3, 2018

 

 

4010 Outline

 

This section outlines the delivery of STAR Kids community long term services and supports. Sections 4100-4520 describe Medicaid state plan long term services and supports, assessment and reassessment requirements, and provider requirements.

Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements and limitations, and provider requirements.

 

4100 Community First Choice

Revision 17-1; Effective June 1, 2017

 

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

Provider owned and controlled settings are also excluded from CFC because those providers are paid for CFC-like services as part of the provider’s rates, and to provide CFC would be duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person-centered, per 42 CFR §441.665. 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 17-1; Effective June 1, 2017

 

Eligibility for Community First Choice (CFC) requires a STAR Kids member to meet the following conditions:

All STAR Kids members are Medicaid eligible. Members whose eligibility is established due to eligibility for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per § 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month, as these members meet eligibility for an institution providing psychiatric services and an NF, respectively.

A member may not be authorized to receive both Personal Care Services (PCS) and CFC services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver provider and are not eligible to receive CFC through the managed care organization:

 

4111 Determining Institutional Level of Care

Revision 17-1; Effective June 1, 2017

 

STAR Kids Screening and Assessment Instrument (SK-SAI)

For members with physical disabilities, the SK-SAI contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP), on behalf of the Texas Health and Human Services Commission (HHSC), to determine if a member meets medical necessity for the level of care provided in a hospital or nursing facility. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of medical necessity for Community First Choice (CFC) services, the MCO must indicate so before submitting the assessment. The MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires nursing facility services or alternative community based services under the supervision of a physician.

Further information about the medical necessity determination process for CFC may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.

Intellectual Disability or Related Condition Assessment (ID/RC)

Upon notification from the MCO, Local Intellectual or Development Disability Authorities (LIDDAs) conduct assessments to determine whether a member meets the level of care (LOC) provided by an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID). In addition to the ID/RC, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a member does not have one on file. The LIDDA submits this information to the state for a determination of ID/RC. The state notifies both the LIDDA and the member's MCO about the determination. If a member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment. If the member does not agree to the CFC service plan or refuses CFC services, the MCO must notify the LIDDA within 10 business days of the member ending CFC services.

 

Child and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA)

 

A comprehensive provider of mental health rehabilitative services or a Local Mental Health Authority (LMHA) conduct the CANS or ANSA and a licensed practitioner determines whether the member meets an inpatient psychiatric facility level of care. If the member meets that LOC, 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 17-1; Effective June 1, 2017

 

Community First Choice services are personal assistance services, habilitation, emergency response services and support management.

 

4121 Community First Choice Personal Assistance

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) personal assistance service (PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Such assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC PAS include:

In the Consumer Directed Services (CDS) model, the member or legally authorized representative determines health-related tasks without a nurse assessment, in accordance with state laws, §531.051(e), Texas Government Code, and 22 Texas Administrative Code, §225.4.

CFC PAS is the same service (i.e., attendant care) as Personal Care Services (PCS). The only difference is the member's level of care (LOC) and how the service is billed. Information used to build a plan of care for CFC PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by the appropriate items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC PAS if he meets CFC level of care criteria.

Members may choose to receive CFC PAS only if they do not need or want CFC habilitation.

 

4122 Community First Choice Habilitation

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) habilitation assists 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 provided to allow a member to reside successfully in a community setting by assisting the member to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the member on ADLs and IADLs. Personal assistance 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:

Information used to build a plan of care for CFC habilitation may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. This section of the PCAM should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for CFC emergency response services (ERS).

CFC 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 and are available for members who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use ERS for ERS to be authorized.

Need for ERS is assessed using the SK-SAI, Section Z.

 

4123 Community First Choice Emergency Response Service

Revision 17-1; Effective June 1, 2017

 

Community First Choice emergency response services (ERS) is designed to assist individuals who do not require supervision during the day or are alone for large parts of the day, and are cognitively able to recognize an emergency. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, to a member's emergency. This service is not routinely authorized for members who are minors.

 

4124 Community First Choice Support Management

Revision 17-1; Effective June 1, 2017

 

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 Z.

 

4130 Community First Choice Assessment and Authorization

Revision 17-1; Effective June 1, 2017

 

 

4131 Assessment for a Nursing Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

Nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services is established 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 §19.2401 definition of “medical necessity.”

To ensure the TMHP evaluates the submitted SK-SAI for the nursing facility LOC, the MCO must submit the SK-SAI with field Z5a=1 to indicate that an MN determination is needed. 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. This does not preclude the member or MCO from seeking determination of a different institutional LOC. 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.

 

4131.1 Reassessment for a Nursing Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

For members requiring a reassessment of medical necessity (MN) for a nursing facility level of care for continued eligibility for Community First Choice 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 Z5a 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. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

 

4132 Assessment for an Intermediate Care Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

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 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 and his contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability and ID/RC, the LIDDA submits the assessment for a determination of level of care 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 (ICF), 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 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.

 

4132.1 Reassessment for an Intermediate Care Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

Ninety days prior to 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 (ICF) 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 Intermediate Care Facility Level of Care, for all reassessments.

If a member continues to meet an ICF 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 CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

 

4133 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 17-1; Effective June 1, 2017

 

Described in Section 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 the Local Mental Health Authority (LMHA) or to a comprehensive provider of 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 licensed practitioner must concur with the assessment or may deviate a member to a higher or lower LOC, based on his clinical judgement. A licensed practitioner must review the CANS or ANSA 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.

Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their health plan for functional necessity of CFC services at any time while enrolled in YES.

 

4133.1 Reassessment for an Institution for Mental Disease Level of Care

Revision 17-1; Effective June 1, 2017

 

Assessment of a psychiatric institutional 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 a psychiatric institutional level of care, the MCO may 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 his representative of the denial for CFC services. The member may be eligible for personal care services, if functionally necessary.

 

4140 Functional Assessment for Community First Choice Services

Revision 17-1; Effective June 1, 2017

 

Functional need for Community First Choice (CFC) services is primarily established by Sections J, K, L, M, N, O, and P of the STAR Kids Screening and Assessment Instrument (SK-SAI) which form the Personal Care Assessment Module (PCAM). This module contains assessment questions for the attendant care (CFC PAS) and habilitation services available through CFC. The following questions/information in the SK-SAI core module are triggers for the PCAM and may indicate the member has functional need for CFC services:

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should only be completed if the member is specifically seeking CFC services. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. 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 his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4140.1 Reassessment of Functional Need for Community First Choice

Revision 17-1; Effective June 1, 2017

 

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

 

4200 Personal Care Services

Revision 17-1; Effective June 1, 2017

 

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 age 20. PCS is considered medically necessary when a member requires assistance 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 physician statement of need. 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 assist the individual in performing 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 inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

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

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:

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, is required to 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 may 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.

PCS may not be used as respite, child care, or for the purposes of restraining 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:

 

4210 Assessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

Sections J, K, L, and M of the STAR Kids Screening and Assessment Instrument (SK-SAI) form the Personal Care Assessment Module (PCAM). This module contains assessment questions for personal care services (PCS). The following questions in the SK-SAI core module are triggers for the PCAM and may indicate the member requires PCS:

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of 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 his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4211 Reassessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

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 physician statement of need to substantiate the member's continued need for PCS upon each annual reassessment.

 

4220 Personal Care Services Providers

Revision 17-1; Effective June 1, 2017

 

Personal care services must be provided by an individual who:

 

4300 Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Private duty nursing (PDN) 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). PDN is available to STAR Kids members from birth through age 20. PDN services must be available when the services are medically necessary to correct or ameliorate a member's disability, physical or mental illness, or condition. The services correct or ameliorate when the services improve, maintain or slow the deterioration of the member's health status.

Nursing services are medically necessary under the following conditions:

PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize member health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options.

PDN is considered only when the services are consistent with the definition of "nursing" as described in the Texas Nursing Practice Act or its implementing regulations. PDN must not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the member's nursing needs.

The managed care organization (MCO) may deny or reduce PDN hours if the member's PDN needs decrease. The MCO may not:

 

4310 Assessment for Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for private duty nursing (PDN). The following questions/information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires PDN:

If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PDN. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4311 Reassessment and Reauthorization

Revision 17-1; Effective June 1, 2017

 

At a minimum, the need for and the amount and duration of private duty nursing must be reassessed 90 days following initial authorization and every six months, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.

 

4320 Providers of Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Private duty nursing (PDN) may be provided by a licensed Home and Community Support Services Agency (HCSSA), an independently enrolled registered nurse (RN) or a licensed vocational nurse (LVN) under the supervision of an RN, contracted with the STAR Kids managed care organization.

An RN must develop a plan of care that accounts for the following items, at a minimum:

PDN must not be provided by a member's legally responsible adult if the member is under age 18 or the spouse of the member.

 

4330 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 17-1; Effective June 1, 2017

 

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.

 

4400 Prescribed Pediatric Extended Care Centers

Revision 17-1; Effective June 1, 2017

 

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

PPECC services require prior authorization and are intended as an alternative to private duty nursing (PDN). 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 PPECC services 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:

Note: A member or the member's responsible adult may decline a PPECC's transportation and choose to be transported by other means, including his or her responsible adult. A member’s legally authorized representative is not required to accompany a member when the member receives services in a PPECC, including transportation services to and from the center and therapy services that are billed separately. Fee-for-service Medicaid does not require prior authorization for the transportation billing code. Rather, authorization for PPECC services implies authorization for transportation.

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:

 

4410 Assessment for Prescribed Pediatric Extended Care

Revision 17-1; Effective June 1, 2017

 

Section Q from 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:

If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. 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 his representative to locate an appropriate provider and sends an authorization to the selected provider.

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

 

4411 Reassessment and Reauthorization

Revision 17-1; Effective June 1, 2017

 

At a minimum, the need for and the amount and duration of services from a Prescribed Pediatric Extended Care Center must be reassessed 90 days following initial authorization and every 180 days following, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.

 

4420 Providers of Prescribed Pediatric Extended Care

Revision 17-1; Effective June 1, 2017

 

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 40 Texas Administrative Code Chapter 15 (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 may 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:

A face-to-face evaluation must be performed annually by the ordering physician. A physician order is required for each initial and recertification authorization, and revisions. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician's order, unless the physician is the member’s treating physician and has examined the member outside of the PPECC setting. 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:

Authorization Requirements

Per Rule §363.211, initial, recertification and revision requests for PPECC services must include the following documentation, which adheres to requirements in the Texas Medicaid Provider Procedures Manual:

(1) physician order for services (a physician signature on the PPECC plan of care serves as a physician order for authorization purposes);

(2) a plan of care developed by the PPECC;

(3) all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual, or MCO forms if they contain comparable content; and

(4) 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 he or she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care, must also be obtained.

Forms available online for PPECC include:

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.

 

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 17-1; Effective June 1, 2017

 

See Section 4330, Private Duty Nursing and Prescribed Pediatric Extended Care Center 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.

 

4500 Day Activity and Health 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 17-1; Effective June 1, 2017

 

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 or licensed vocational nurse, 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:

The member or his 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 17-1; Effective June 1, 2017

 

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may 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:

 

4520 Day Activity and Health Services Providers

Revision 17-1; Effective June 1, 2017

 

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 Care and Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

 

4600 Medically Dependent Children Program Services

Revision 18-2; Effective September 3, 2018

 

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 to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.

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 service coordinator must inform all members receiving MDCP services of the requirements outlined in Section 1530 and the following:

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 may discuss the member's needs as they relate to the available MDCP services. The service coordinator may 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 and/or his caregiver if they would like respite or have a desire for employment services. The service coordinator could ask if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services. The service coordinator could inquire which services the member/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/caregiver in person or telephonically to develop a final service plan once the member's budget is known.

 

4700 Medically Dependent Children Program Respite and Flexible Family Support Services

Revision 17-1; Effective June 1, 2017

 

 

4710 Medically Dependent Children Program Respite

Revision 17-1; Effective June 1, 2017

 

Respite is a service that provides temporary relief from caregiving to the applicant/member or his primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/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 a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the 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 is a service to provide 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 suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he 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 scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member and/or legally authorized representative's preferences and the member's approved cost limit. MCOs must develop internal processes related to 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. The MCO must document banked hours using Form 2605, Respite Tracking Tool.

 

4711 In-Home Respite

Revision 17-1; Effective June 1, 2017

 

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 his 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 his available budget. Managed care organizations 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.

 

4711.1 Attendant with Delegated Tasks

Revision 18-2; Effective September 3, 2018

 

A delegated task is defined as a task that a practitioner 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 his supervision, per BON rules. A member with a skilled task need may to 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 respite, he does 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 Home and Community Support Services Agency 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 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 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 his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

4712 Out-of-Home Respite

Revision 17-1; Effective June 1, 2017

 

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

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 17-1; Effective June 1, 2017

 

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:

 

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 17-1; Effective June 1, 2017

 

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

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 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 17-1; Effective June 1, 2017

 

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 amount of hours needed to support the member's needs within the Medically Dependent Children Program 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 provided through Texas Health Steps or Community First Choice. 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 17-1; Effective June 1, 2017

 

A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with his or her goal 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 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 17-1; Effective June 1, 2017

 

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 17-1; Effective June 1, 2017

 

A delegated task is defined as a task that a practitioner 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 his 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), he does 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 his 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 his 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 17-1; Effective June 1, 2017

 

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 or Community First Choice.

42 Code of Federal Regulations §446.301(b)(1)(ii) requires that Medically Dependent Children Program services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions.

The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.

 

4800 Adaptive Aids, Minor Home Modifications, and Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

 

4810 Adaptive Aids

Revision 17-1; Effective June 1, 2017

 

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

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 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 17-1; Effective June 1, 2017

 

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. After any applicable state plan benefits (e.g., durable medical equipment) are exhausted, adaptive aids covered in the Medically Dependent Children Program include:

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. 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.

 

4820 Minor Home Modifications

Revision 17-1; Effective June 1, 2017

 

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 his or her home. If a home modification is requested and the member or his 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 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 17-1; Effective June 1, 2017

 

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:

Minor home modifications must:

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 his 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.

 

4830 Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

The service coordinator must advise applicants or members 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 applicant or member 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 applicant or member may access TAS if they:

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

The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, or legally authorized representative 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 applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP waiver services, and notified in writing that he or she is eligible. The service coordinator must contact the applicant/member or applicant's/member's representative before certification to verify the applicant or member has 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 2416, Minor Home Modifications and Adaptive Aids Service Authorization.

 

4831 Deposits

Revision 17-1; Effective June 1, 2017

 

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 applicant's or member'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 applicant's or member's service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant's or member's name or to pay for arrears on previous utilities if the account is in the applicant's or member's name and he or she 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 applicant's or member'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 applicant's or member'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 applicant or member 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 applicant or member 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 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant's or member'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 applicant or member from the nursing facility to his or her residence in the community.

 

4833 Site Preparation

Revision 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for preparing the applicant's or member's place of residence for occupancy if the current condition of the residence prevents the applicant's or member'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 is in need of some type of extermination.

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

One-time Cleaning – TAS can be used if the applicant's or member's residence has been unattended or the applicant or member 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 17-1; Effective June 1, 2017

 

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per applicant or member. 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 applicant or member. TAS may not be used for:

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 applicants or members who are discharged from a nursing facility and require TAS to set up a household.

 

4835 Transition Assistance Services Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

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 his legally authorized representative, 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 member's authorized representative, if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.

 

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 17-1; Effective June 1, 2017

 

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 his mind or has a change in health making it impossible for him to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.

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.

 

4900 Supported Employment and Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Senate Bill 45, 83rd Legislature, Regular Session, 2013, required 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 17-1; Effective June 1, 2017

 

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

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 waiver EA services.

The service coordinator refers the member to the Texas Workforce Commission (TWC) 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 http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.

A member who has been referred for TWC or contacted TWC himself is not eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed it, or until the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive waiver-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.

If the member has exhausted TWC services or been determined ineligible for TWC services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). Employment assistance 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.

 

4911 Coordination with Texas Workforce Commission for Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Upon request and with proper authorization for disclosure, the service coordinator will assist the member to provide the Texas Workforce Commission (TWC) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

If the VRC determines that TWC is not the appropriate resource to meet the member's needs and does not take an application for services, documentation of this decision in the member's record serves as sufficient evidence that TWC is not available and the member is eligible to receive waiver-funded employment assistance.

TWC will:

If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member's service coordinator will attempt to contact the assigned TWC 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 TWC VRC regarding waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWC, as defined in the individual's TWC VR IPE.

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

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 TWC and waiver services.

 

4912 Employment Assistance Providers

Revision 17-1; Effective June 1, 2017

 

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 his legally authorized representative (LAR) 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:

Option 2:

Option 3:

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

 

4920 Supported Employment

Revision 17-1; Effective June 1, 2017

 

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

SE services include:

Competitive employment is work:

An integrated setting is a setting typically found in the community in which 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 in which:

An MDCP member may seek SE to provide assistance to the member in maintaining self-employment. Self-employment is work in which the member:

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. §1401 et seq.) or the Texas Workforce Commission.

 

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 17-1; Effective June 1, 2017

 

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 employment services, including school districts.

Activities include:

 

4922 Supported Employment Providers

Revision 17-1; Effective June 1, 2017

 

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency, also called a home health agency, or are employed by a member or his 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:

Option 2:

Option 3:

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

Section 5000, Service Delivery Options

Revision 17-1; Effective June 1, 2017

 

 

5010 Selection of a Service Delivery Option

Revision 17-1; Effective June 1, 2017

 

Service coordinators must present all service delivery options to the applicant/member and/or the legally authorized representative at the initial assessment and each annual reassessment. In addition to the documents described in Section 5221, Advantages of Consumer Directed Services (CDS) Service Delivery Options, the managed care organization (MCO) may use Form 1581, Consumer Directed Services Overview, and Form 1582, Consumer Directed Services Responsibilities, or a document created by the MCO and approved by the Texas Health and Human Services Commission, to assist the member or applicant in making the service delivery decision.

MCOs must obtain a signature on Form 1584, Consumer Participation Choice, indicating the member's choice of option. If, at any time during the year, a current member calls requesting information on service delivery options, the MCO must present the information to the member.

 

5020 Member Decision

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) must keep Form 1584, Consumer Participation Choice, in the member's case record. The MCO must ensure the member understands he may request a service delivery option change at any time by contacting the MCO.

 

5100 Agency Option

Revision 17-1; Effective June 1, 2017

 

 

5110 Description

Revision 17-1; Effective June 1, 2017

 

Under the agency option (AO), 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 AO because of the simplicity and convenience of receiving services. For example, under AO the agency, not the member, is responsible for:

 

5200 Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

 

5210 Overview

Revision 17-1; Effective June 1, 2017

 

The Consumer Directed Services (CDS) option was codified in Section 531.051 of the Government Code and expanded by the 79th Texas Legislature to provide more options for members to direct their long term services and supports. The rules for the CDS option are found in Texas Administrative Code, Title 40, Chapter 41.

CDS is a service delivery option in which a member or legally authorized representative (LAR) becomes the CDS employer of record for certain services. The CDS employer recruits, selects, 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 that they choose 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 5232, Financial Management Service Agency Responsibilities.

A member or LAR may elect the CDS option if the:

 

5211 Consumer Directed Services Definitions

Revision 17-1; Effective June 1, 2017

 

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

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

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.

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

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

Employer support services — Services and items needed and allocated in the member's budget for the member or LAR to perform employer and employment responsibilities, such as office equipment and supplies, expenses related to recruiting employees, and other items approved in Texas Administrative Code, Title 40, Part 1, Chapter 41, §41.507.

Financial Management Services (FMS) — Financial management services delivered by the financial management service agency (FMSA) to the member or LAR, as described in Section 5232, Financial Management Service Agency Responsibilities, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member or LAR.

 

Legally authorized representative (LAR) — A person authorized by law to act on behalf of a member, 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.

 

5212 STAR Kids Services Available Under the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

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

The Medically Dependent Children Program waiver services available in the CDS option are:

STAR Kids members may choose to self-direct any or all services available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members.

All applicants and ongoing members will be assessed for financial and functional eligibility using the STAR Kids Screening and Assessment Instrument (SK-SAI). Choosing the CDS option in no way impacts a member's eligibility for services. Members have the option of having services delivered through a contracted Home and Community Support Services Agency provider using the agency or service responsibility options, or through the CDS option, in which they hire and manage their own employees to provide the services.

Financial management services (FMS), a required service under the CDS option, provides assistance to members to manage funds associated with services elected for self-direction, and is provided by the financial management service agency (FMSA). This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers. If requested, an FMSA can provide support consultation, which is extra help training, working with, and if necessary, dismissing an employee provided by a support advisor. FMSAs also conduct payroll and pay employer taxes on behalf of the employer. A monthly administrative fee is authorized on the individual service plan and paid to the FMSA for FMS.

 

5220 Advantages and Risks of the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

The member should consider the advantages and risks associated with the Consumer Directed Services option before choosing to enroll. To assist the member in making an informed choice, information is presented by the service coordinator. See Section 5521 below.

 

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

Revision 17-1; Effective June 1, 2017

 

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

 

5222 Potential Risks Associated with the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

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

 

5230 Member and Financial Management Service Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

 

5231 Member Responsibilities

Revision 17-1; Effective June 1, 2017

 

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

 

5232 Financial Management Service Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

Under the Consumer Directed Services (CDS) option, a financial management service agency (FMSA) must:

The FMSA must obtain employer-agent status as defined by IRS Rev. Proc., 2013-39 and perform all responsibilities as required by the IRS and other appropriate government agencies. The FMSA must enter into service agreements with each of the member's direct service providers before issuing payment.

 

5240 Member Choice in the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Information about the Consumer Directed Services (CDS) option is presented to the STAR Kids member by the service coordinator. Written and verbal information is shared 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 through the agency or service responsibility option.

 

5241 Presentation of the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

The service coordinator is responsible for offering the Consumer Directed Services (CDS) option to all new STAR Kids members and Medically Dependent Children Program applicants annually, and to current members who are not enrolled in the CDS option and whenever information is requested. The service coordinator:

The service coordinator obtains the member’s or applicant's signature on Form 1581 at the initial contact. The service coordinator signs and dates the form verifying the information was presented to the member or applicant. A copy of Form 1581 is placed in the case record to document that CDS information was shared.

At annual reassessment, the service coordinator provides the member with a copy of Form 1581 and clearly documents in the case record that Form 1581 was shared with the member.

When members request information about the CDS option at other times, the service coordinator must provide CDS information to the member within five business days after receipt of the request. The service coordinator may provide the information by making a home visit or contacting the individual by telephone. If a home visit is not made, the service coordinator obtains the member's signature by mailing Form 1581 to the member with a postage-paid return envelope. The service coordinator signs and dates Form 1581 indicating the information was presented. A copy of Form 1581 is placed in the member's case record to document Form 1581 was shared.

If the member is still interested in participating in the CDS option once the information on Form 1581 is shared, the service coordinator reviews Form 1582. The service coordinator:

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

If an employer would like to use a DR, the financial management services agency assists the employer in appointing a DR.

 

5300 Initiating the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Once a member and/or his legally authorized representative (LAR) has chosen the Consumer Directed Services (CDS) option, the service coordinator presents a list of contracted financial management services agencies (FMSAs). The individual must select an FMSA to perform CDS financial management services.

If the member or LAR chooses the CDS option, the service coordinator proceeds to Form 1583, Employee Qualification Requirements, Form 1584, Consumer Participation Choice, and Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option. The service coordinator:

The service coordinator develops the member's service plan according to policy and CDS option rules.

 

5310 Declining the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

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 Form 1581, Consumer Directed Services Overview, is shared, the service coordinator:

The 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. The member must wait 90 days before switching to a different service delivery option.

 

5320 Determining the Individual Service Plan

Revision 17-1; Effective June 1, 2017

 

All existing Medicaid eligibility requirements apply in the Consumer Directed Services (CDS) option. CDS is not a different program; it is a service delivery option. The service coordinator completes all forms currently required for STAR Kids services.

The member using the CDS option must have a back-up system to assure the provision of certain or critical authorized CDS services without a service break, even if there are unexpected changes in personnel. The member or legally authorized representative must develop and receive approval from the service coordinator for each required service back-up plan in order to participate in the CDS option. Refer to Section 5326, Service Back-Up Plans.

If the member hires a nurse to provide services, the nurse must operate within the 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 delegation as indicated.

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

 

5321 Initiation of and Transition to the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Within five business days of receipt of the completed Form 1584, Consumer Participation Choice, existing STAR Kids members who choose the Consumer Directed Services (CDS) option are referred to the financial management services agency (FMSA) they selected to begin the CDS initiation process.

The service coordinator provides the FMSA the following documentation:

The 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.

Members who participate in the CDS option and choose to transfer back to the Agency Option (AO) will not have the choice of returning to the CDS option for at least 90 days. Service coordinators must carefully coordinate transition activities when transitioning members to and from the CDS option.

 

5322 Initiation and Orientation of the Member as Employer

Revision 17-1; Effective June 1, 2017

 

Upon receipt of the Consumer Directed Services (CDS) referral from the service coordinator, the financial management service agency (FMSA) completes the initial employer orientation with the member, legally authorized representative (LAR) and designated representative (DR), if one is appointed, in the member's residence or setting of the member’s choosing. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the employer and the FMSA.

The member, LAR and DR, if one is appointed, signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five calendar days after the date of initial orientation.

 

5323 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

If the Consumer Directed Services (CDS) employer is going to assume responsibility for training and supervising an unlicensed service provider to perform certain health related tasks, the financial management service agency (FMSA) assists the member, legally authorized representative (LAR) or designated representative (DR) in completing the employer and employee acknowledgment. Tasks prohibited from delegation are described in the Texas Administrative Code §225.13, Tasks Prohibited From Delegation. The employee acknowledges that, as the person who delivers the service, he/she has not been:

The FMSA verifies potential service providers selected by the member, LAR or DR meet provider qualifications and other requirements of the STAR Kids program before the member, LAR or DR hires the service provider.

 

5324 Authorizing Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

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 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 member, LAR and the FMSA to ensure that the expenditures for the year remain within the authorized amount. The managed care organization 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.

 

5325 Ongoing Requirements

Revision 17-1; Effective June 1, 2017

 

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

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, 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 Section 5326 below.

 

5326 Service Back-Up Plans

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) must discuss with the member, legally authorized representative (LAR) or designated representative (DR) the services delivered through Consumer Directed Services (CDS) that are critical to the member's health and welfare. The MCO must inform the member, LAR or DR to develop a service back-up plan to ensure the health and safety of the member when regular service providers are not available to deliver services, or in an emergency. The member, LAR or DR must develop a back-up 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 member, LAR or DR, with the assistance of the MCO (if needed), completes Form 1740. The service back-up plan must list the steps the member, LAR or DR implements in the absence of the service provider. The service back-up plan may include the use of paid service providers, unpaid service providers such as family members, friends or non-program services, or respite (if included in the authorized service plan). The member, LAR or DR is responsible for implementation of the service back-up plan in the absence of the employee.

Service back-up plans are submitted by the member, LAR or DR to the MCO. The MCO and 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 approves the service back-up plan by signing, dating and returning a copy of the plan to the member, LAR or DR.

The member, LAR or DR is required to:

The FMSA must assist a member, LAR or DR, as requested to revise budgets, to:

 

5327 Corrective Action Plans

Revision 17-1; Effective June 1, 2017

 

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

The written CAP must include the:

The member, LAR or DR may request assistance in the development or implementation of a CAP from the:

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

 

5328 Budgets

Revision 17-1; Effective June 1, 2017

 

The member, legally authorized representative (LAR), or designated representative (DR) with the financial management service agency (FMSA) develops a budget for each STAR Kids service to be delivered through the Consumer Directed Services (CDS) option based on the projected expenditures allocated in the individual service plan period. The member must budget the monthly amount established by the Texas Health and Human Services Commission for payment of financial management services delivered by the FMSA through the CDS option.

The member, LAR or DR develops an initial and annual budget and receives written approval 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. The FMSA must work with the member, LAR or DR to resolve issues that prevent the approval of budget plans.

The member, LAR 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 member, LAR or DR with budget revisions as requested or needed by the member, validate the budget, and provide written approval to the member, LAR or DR.

The managed care organization evaluates service plan changes requested by the member and participates in the service planning team meetings to resolve issues when the member does not follow the budget or comply with CDS option budget requirements.

 

5400 Service Responsibility Option Description

Revision 17-1; Effective June 1, 2017

 

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. The rules for the SRO are found in Texas Administrative Code, Title 40, Chapter 43.

 

5410 Service Responsibility Option Roles and Responsibilities

Revision 17-1; Effective June 1, 2017

 

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

 

5411 Managed Care Organization Responsibilities

Revision 17-1; Effective June 1, 2017

 

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

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

In addition, the MCO's responsibilities include:

 

5412 Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

The agency contracted with the managed care organization is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to policies and standards before sending the attendants to members' homes.

The agency staff:

 

5413 Member Responsibilities

Revision 17-1; Effective June 1, 2017

 

The member or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant. To participate in the Service Responsibility Option (SRO), the member must be capable of performing all management tasks as described below, or may identify a DR to assist or perform those management tasks on the member's behalf.

The member is responsible for:

 

5420 Managed Care Organization Procedures

Revision 17-1; Effective June 1, 2017

 

The Service Responsibility Option (SRO) is not a different service; it is a service delivery option. All financial and non-financial eligibility criteria, including unmet need and "do not hire" policy, continue to apply for each program area. Unless otherwise stated in this section, 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 17-1; Effective June 1, 2017

 

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

 

5422 Monitoring

Revision 17-1; Effective June 1, 2017

 

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:

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

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

 

5423 Procedures for Ongoing Members

Revision 17-1; Effective June 1, 2017

 

Members must be offered the Service Responsibility Option (SRO) by the managed care organization (MCO) annually, and may request a transfer to the SRO at any time. Additionally, the SRO must be presented to ongoing members at each annual reassessment or upon request. If the member is interested in transferring to the SRO, the member must sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

The MCO must ensure the member understands the responsibility he 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.

Section 6000, Denials and Terminations

Revision 18-2; Effective September 3, 2018

 

 

6050 Description

Revision 18-2; Effective September 3, 2018

 

This section provides information, procedures and references pertaining to denial or termination of Medically Dependent Children Program (MDCP) services for active members, along with adequate notice of a member's rights and opportunities to due process.

42 Code of Federal Regulations (CFR) Part 431, Subpart E, governs fair hearing rights for Medicaid applicants and beneficiaries. In general, the managed care organization must adhere to the federally-mandated 10-day adverse action period for denials and terminations related to MDCP services. However, 42 CFR § 431.213 specifies situations in which an adverse action period is not required. The agency may mail a notice not later than the date of action if —

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

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

(1) He no longer wishes services; or

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

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

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

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

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

(g) The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or

(h) The date of action will occur in less than 10 days, in accordance with §483.12(a)(5)(ii), which provides exceptions to the 30 days' notice requirements of §483.12(a)(5)(i).

1 Texas Administrative Code §353.1209, which is cited on Form H2065-D, Notification of Managed Care Program Services, is the basis for all STAR Kids case actions.

 

6100 Ten-Day Adverse Action Notification

Revision 18-2; Effective September 3, 2018

 

42 Code of Federal Regulations (CFR) §431.230 requires that the Texas Health and Human Services Commission (HHSC) provide a notice to the member at least 10 days before the action effective date. The member must be given the full 10-day adverse action period to give him or her time to file an appeal or request a fair hearing, as described below:

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

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

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

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

The managed care organization (MCO) must calculate time periods related to adverse actions in accordance with instruction provided in §311.014 of the Code Construction Act. It specifies that:

(a) In computing a period of days, the first day is excluded and the last day is included.

(b) If the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

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

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

To ensure the member is provided the full 10-day adverse action period, the MCOs must mail the adverse determination document no later than 10 business days prior to the date the adverse action is to occur.

 

6110 Denial of Medical Necessity/Individual Service Plan

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet medical necessity (MN) criteria or does not have a valid individual service plan (ISP), the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

 

Date Informed Eligibility Lost Date Form H2065-D Sent Current ISP End Date 10-Day Adverse Action Expiration Date Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal Data Entry
April 10 April 12 May 31 April 22 May 31 None
May 20 May 21 May 31 May 31 May 31 None
May 20 May 22 May 31 June 1 June 30 ISP must be extended to June 30.
June 5 June 7 May 31 June 17 June 30 ISP must be extended to June 30.
June 22 June 24 May 31 July 4 July 31 ISP must be extended to July 31.

 

6120 Denial of Medicaid Eligibility

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet Medicaid eligibility, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

 

Actual Date of Medicaid Eligibility Denial Date PSU Informed Eligibility Lost Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP)
Long Term Care (LTC) Online Portal Data Entry
12-31-2016 12-31-2016 5-31-2017 1-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 10-31-2016 5-31-2017 11-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 2-5-2017 5-31-2017 2-7-2017 12-31-2016 ISP must be corrected to 12-31-2016.

Notes:

 

6130 Unable to Locate

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she cannot be located, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date PSU Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP)
Long Term Care (LTC) Online Portal Data Entry
12-31-2016 5-31-2017 1-2-2017 1-31-2017 ISP must be corrected to 1-31-2017.
5-3-2017 5-31-2017 5-5-2017 5-31-2017 None
5-25-2017 5-31-2017 5-27-2017 6-30-2017* ISP must be corrected to 06-30-2017.
6-9-2017 5-31-2017 6-11-2017 6-30-2017 Managed care organization (MCO) should have submitted an ISP and medical necessity (MN) for 6-1-2017.

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

 

6200 Program Support Unit Initiated Denials/Terminations

Revision 18-2; Effective September 3, 2018

 

The following sections contain policy citations that must be included on Form H2065-D, Notification of Managed Care Program Services, when the denial or termination action is initiated by Program Support Unit (PSU) staff.

 

6210 Denial/Termination Due to Death

Revision 18-2; Effective September 3, 2018

 

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

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

Services must be terminated once death of the member has been confirmed by PSU staff. A 10-day adverse action period is not required for death denials.

 

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 18-2; Effective September 3, 2018

 

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

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

*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 must be denied.

 

6230 Denial/Termination Due to Member Request

Revision 18-2; Effective September 3, 2018

 

When Program Support Unit (PSU) staff have been notified a member no longer wants Medically Dependent Children Program (MDCP) services, within two business day of becoming aware the member no longer wants services, PSU staff must:

 

6240 Denial/Termination of Financial Eligibility

Revision 18-2; Effective September 3, 2018

 

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. Within two business days of the denial, Program Support Unit (PSU) staff must:

Notification can come from:

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

 

When the individual is denied SSI: When the individual is denied MAO:
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to SSA is available to the individual.
  • The 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 according to the date of the request.
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to MEPD is available to the individual.
  • 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 according to the date of the request.

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

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

 

6250 Denial/Termination of Medical Necessity

Revision 18-2; Effective September 3, 2018

 

Medically Dependent Children Program (MDCP) services must be denied or terminated when the member's medical necessity (MN) is denied. Within two business days of the denial, Program Support Unit (PSU) staff must:

Notification can come from:

The MN status of "MN Denied" in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 buisness days to submit additional information. Once a STAR Kids Screening and Assessment Instrument (SK-SAI) MN status is in "MN Denied" status, several actions may follow:

While the MN is in the MN Denied status, the MCOs must monitor the TMHP LTC Online Portal for the MN status through 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 days to submit additional information, listed in the TMHP LTC Online Portal as “MN Denied,” the MCO must assist the member to obtain from their physician any additional medical information pertinent to the member’s MN determination. The MCO must assist through calling the member and physicians to obtain necessary documents for provision to TMHP within the 14 business day time frame for consideration.

 

6260 Denial/Termination Due to Inability to Locate the Member

Revision 18-2; Effective September 3, 2018

 

The Medically Dependent Children Program (MDCP) must be denied/terminated when Program Support Unit (PSU) staff are notified that a member cannot be found. Within two business days, the PSU staff must:

Notification can come from:

 

6270 Denial/Termination Due to Failure to Meet Other Program Requirements

Revision 18-2; Effective September 3, 2018

 

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:

 

6280 Denial/Termination for Other Reasons

Revision 18-2; Effective September 3, 2018

 

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:

Notification can come from:

 

6300 Denial/Termination Initiated by the Managed Care Organization

Revision 18-2; Effective September 3, 2018

 

MCOs may request to disenroll a member from Medicaid managed Care. Reference the HHSC Uniform Managed Care Manual, Chapter 11.5, Medicaid Managed Care Member Disenrollment Policy. 

Sections 6310 through Section 6370 contain policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. Within two business days of the notification by the MCO, Program Support Unit (PSU) staff must:

 

6310 Denial/Termination Due to Threats to Health and Safety

Revision 18-2; Effective September 3, 2018

 

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

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

Within two business days of the notification by the MCO, Program Support Unit (PSU) staff must:

The 10-day adverse action notification period does not apply in this situation.

 

6320 Denial/Termination Due to Hazardous Conditions or Reckless Behavior

Revision 18-2; Effective September 3, 2018

 

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

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

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

Within two business days of the notification by the MCO, the Program Support Unit staff must:

The 10-day adverse action notification period does not apply in this situation.

 

6330 Denial/Termination Due to Harassment, Abuse or Discrimination

Revision 18-2; Effective September 3, 2018

 

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

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

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

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

Within two business days of the notification from the HHSC staff, PSU staff must:

The 10-day adverse action notification period does not apply in this situation.

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

 

6340 Denial as a Result of Exceeding the Cost Limit

Revision 18-2; Effective September 3, 2018

 

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

If the individual service plan (ISP) is over the cost limit, within two business days of receipt of the ISP, PSU staff must:

 

6350 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions

Revision 18-2; Effective September 3, 2018

 

If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, services may be denied or terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member's home that prevent determining eligibility, carrying out the service plan or monitoring services. Within two business days of the notification, Program Support Unit (PSU) staff must:

 

6360 Denial/Termination Due to Failure to Pay

Revision 18-2; Effective September 3, 2018

 

If the member refuses to pay a required copayment, room and board payment or Qualified Income Trust (QIT) payment, the Medically Dependent Children Program (MDCP) must be denied. After notification by the managed care organization (MCO), within two business days of notification, Program Support Unit (PSU) staff must:

The 10-day adverse action period does apply in this situation.

 

6370 Denial/Termination Due to Other Reasons

Revision 18-2; Effective September 3, 2018

 

Use this denial or termination citation if initiating denial for a reason not covered above. After notification by the managed care organization (MCO), within two business days of notification, Program Support Unit (PSU) staff must:

Section 7000, Complaint, Appeal and Fair Hearing Procedures

Revision 17-1; Effective June 1, 2017

 

 

7100 Managed Care Organization Procedures

Revision 17-1; Effective June 1, 2017

 

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) §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:

 

7110 Managed Care Organization Complaint Procedures

Revision 17-1; Effective June 1, 2017

 

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. §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:

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 regarding an agency licensed by HHSC, or any other state agency, the member is referred to 1-800-458-9858 to file a regulatory complaint. If the complaint is initially received by HHSC, HHSC will inform the MCO of the complaint.

Members may also call the HHSC Ombudsman's Managed Care Assistance Team at 1-866-566-8989 for assistance filing a complaint not related to licensure issues.

 

7120 Managed Care Organization Internal Appeal Procedures

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) STAR Kids Contract, Attachment A, defines an appeal as the formal process by which a member or his or her authorized representative requests a review of the managed care organization’s (MCO’s) action. An action is:

The member may file an internal appeal by contacting the MCO following the procedures specified in the MCO's member handbook. The MCO is contractually required to regard any oral or written expression of dissatisfaction or disagreement 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 §438.420, the MCO must continue the individual's benefits pending the outcome of the internal appeal if all the following criteria are met:

 

7121 Expedited Managed Care Organization Internal Appeals

Revision 17-1; Effective June 1, 2017

 

In accordance with 42 Code of Federal Regulations §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 three business days. However, the MCO must complete investigation and resolution of an internal appeal relating to an ongoing emergency or denial of continued hospitalization:

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 additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the 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, prior to HHSC’s fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his/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:

 

7200 State Fair Hearing Procedures for Medically Dependent Children Program

Revision 17-1; Effective June 1, 2017

 

 

7210 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

When a request for a state fair hearing related to 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. The PSU staff either:

Form H4800 records the names, titles, addresses and telephone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup. PSU staff should contact the MCO if there is doubt as to who should be listed on Form H4800.

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

When PSU staff complete Form H4800, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

PSU staff must indicate the ISP begin and end dates, as applicable, in Section 3.D., Summary of Agency Action and Citation. The begin and end dates must also be mentioned during the state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP waiver denial.

The format for Form H4800 follows the data entry screens. See the form instructions for more specific directions for completion and transmittal.

 

7211 Designated Data Entry Representative Procedures

Revision 17-1; Effective June 1, 2017

 

Within two calendar days of receipt of Form H4800, Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Hearings and Appeals section of the Texas Integrated Eligibility Redesign System (TIERS). When entry of all information is complete, the system assigns the appeal identification (ID) number. The DER notes the appeal ID number on the bottom of the form and in the designated space on the front of the form, and sends a copy back to the Program Support Unit staff.

 

7212 Fair Hearings and Appeals Procedures

Revision 17-1; Effective June 1, 2017

 

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

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

 

7213 Evidence Packet

Revision 17-1; Effective June 1, 2017

 

All related documentation necessary to support the determination on an appeal must be uploaded into the State Portal and mailed to the appellant at least 10 business days prior to the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet, uploading it to the State Portal, and forwarding it to the appellant. 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 State Portal:

 

7214 Fair Hearing Request Summary (Addendum)

Revision 17-1; Effective June 1, 2017

 

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

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

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

 

7220 Special Procedures for Cases – Medicaid for the Elderly and People with Disabilities or Texas Works Determined Financial Eligibility

Revision 17-1; Effective June 1, 2017

 

 

7221 Centralized Representation Unit

Revision 17-1; Effective June 1, 2017

 

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

PSU staff must coordinate all state appeals involving TW/MEPD-related eligibility with CRU, including Medically Dependent Children Program (MDCP) waiver cases. The procedures in Section 7222 below must be used to coordinate state appeal actions with CRU in cases for which TW or MEPD staff determine financial eligibility. All correspondence on state appeals will go to the CRU supervisor and the CRU administrative assistant.

 

7222 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a state fair hearing. For state appeals that involve the Centralized Representation Unit (CRU), the method in which the form is completed depends on the action being appealed. PSU staff must determine if the appealed action is a:

If the appealed action is related to an MEPD waiver denial based on an eligibility factor other than financial, PSU staff complete Form H4800, entering the managed care organization (MCO) contact as the agency representative.

If the appealed action is related to an MDCP waiver denial based on a TW/MEPD financial denial, PSU staff complete Form H4800 and enter the name of the PSU staff person who will appear at the fair hearing as the agency representative. This information must be entered through the Manage Office Resources (MOR) search function for the PSU staff person to receive the hearing information.

For members requesting continued benefits and who are part of the Medical Assistance Only eligibility group, when Form H4800 is sent to the designated data entry representative, PSU staff send an email notification regarding the request for a state fair hearing to CRU. PSU staff send the email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings. In the subject line of the email, include the following: Request for Continued Benefits- Appeal ID-XXXXXXX. In an attachment to the email, staff must also include a copy of the notification form sent to the applicant or member.

The email must include:

When an MDCP waiver denial fair hearing decision is rendered by the hearings officer, the PSU staff are notified via email of the decision by the hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver according to program-specific time frames. For more information, refer to Section 7500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must send an email to the HHSC OES Fair Hearings mailbox, and include Form H1746-A, MEPD Referral Cover Sheet. PSU staff report the implementation of the hearing decision through TIERS Decision Implementation.

If a member appeals a Medicaid denial issued by the TW or MEPD program, the CRU enters the fair hearing request in TIERS and notifies PSU the applicant/member appealed the Medicaid denial by sending an email to the PSU supervisor and backup designee. When notifying the PSU, CRU staff use the following subject line: "URGENT: STAR Kids member appealed financial denial of MDCP program. MCO Plan Code XX (if available)." The CRU processes the fair hearing request of the Medicaid denial following established procedures. CRU does not list the MCO or PSU staff on the fair hearing request.

Within two business days of receiving the notice the applicant or member is appealing the financial denial, the PSU contacts the applicant or member, or his or her authorized representative, to determine whether he or she wants to appeal the MDCP program denial. If so, PSU staff process the fair hearing request following established procedures.

For TW/MEPD appeals, once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff by sending an email to the PSU supervisor and backup designee of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, PSU staff determine the appropriate action for the MDCP waiver. The email sent by CRU includes the:

If Medicaid eligibility will be denied, the CRU includes the effective date of the Medicaid denial in the email. If Medicaid eligibility will be reinstated, the PSU must send the CRU an email with Form H1746-A to the HHSC OES Fair Hearings mailbox, indicating all other eligibility criteria are in place and Medicaid needs to be reestablished. The CRU will respond to the PSU by sending an email to the PSU supervisor and backup designee with the effective date of Medicaid eligibility.

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

 

7230 Evidence Packet and Hearing Decision

Revision 17-1; Effective June 1, 2017

 

 

7231 Uploading the Appeals Evidence Packet into the State Portal

Revision 17-1; Effective June 1, 2017

 

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

At least 12 business days prior to the fair hearing date, the Program Support Unit staff must:

Within two business days after receipt, the DER must:

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

 

7232 Presentation of the Evidence Packet

Revision 17-1; Effective June 1, 2017

 

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 Program Support Unit (PSU) staff and supervisors receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time and location of the hearing. PSU staff are not expected or required to attend state fair hearings.

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 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.

 

7233 Hearing Decision

Revision 17-1; Effective June 1, 2017

 

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, which includes Program Support Unit (PSU) staff. If the determination on appeal is sustained, the PSU staff take the appropriate action. If the member requested continued services during the state appeal period, the PSU follows procedures described in Section 7500, Hearing Decision Actions.

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. PSU staff actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation, within the 10-day time frame designated by the hearings officer.

 

7300 Post Hearing Actions

Revision 17-1; Effective June 1, 2017

 

 

7310 Action Taken on the Hearing Decision

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the designated data entry representative (DER). PSU staff must send Form H4807 within the time frame specified by the hearings officer to allow at least two days for the DER to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, Form H4807 is completed and sent to the supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on the form; the begin delay date and end delay date must be included.

 

7400 Continuation of Services

Revision 17-1; Effective June 1, 2017

 

 

7410 Continuation of Medically Dependent Children Program Waiver Services During a State Appeal

Revision 17-1; Effective June 1, 2017

 

Medically Dependent Children Program (MDCP) waiver services must continue until the hearings officer issues a decision regarding the appeal of an active MDCP waiver member, if the appeal is filed by the effective date of the action pending the appeal. If a state appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, to the MCO via TxMedCentral and uploading a copy of this form in the HHS Enterprise Administrative Record Tracking (HEART) system.

If the member requests 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 TxMedCentral.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four calendar months or until the outcome of the state appeal is determined. PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to the member notifying of continued eligibility related to the reassessment action taken to continue services until the appeal decision is issued.

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

 

7420 Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 17-1; Effective June 1, 2017

 

If a state fair hearing is not requested by the effective date of the action, 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). The Program Support Unit (PSU) must complete Form H2067-MC, Managed Care Programs Communication, and process according to the following:

SSI 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.

 

7500 Hearing Decision Actions

Revision 17-1; Effective June 1, 2017

 

 

7510 Sustained Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver services, Program Support Unit (PSU) staff must:

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

 

7511 Sustained Decisions – Termination Effective Dates

Revision 17-1; Effective June 1, 2017

 

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 will vary depending on the following circumstances.

Examples

Example Conditions Original MN/ISP Expiration Date New Expiration Date Hearings Officer Decision Date Final MN/ISP Expiration Date
1 Hearings officer decision is more than 30 days from the original expiration date. 1/31/16 5/31/16 11/30/15 1/31/16
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/16 5/31/16 1/15/16 2/28/16
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/16 5/31/16 2/15/16 3/31/16
4 Hearings officer decision assigns a specific expiration date. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/15/16. 2/29/16
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/29/16. 2/29/16
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 12/31/15. 1/31/16

 

7520 Reversed Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision reverses the denial of a Medically Dependent Children Program (MDCP) waiver applicant or member, Program Support Unit (PSU) staff must:

 

7521 Reversed Decisions – Effective Dates

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) waiver eligibility, the MDCP waiver effective date for:

When a fair hearing decision reverses a Program Support Unit (PSU) action but PSU staff cannot implement the fair hearing decision within the required time frame, PSU staff must complete the Implementation Delays screen in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation.

 

7522 New Assessment Required by Fair Hearing Decision

Revision 17-1; Effective June 1, 2017

 

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 prior to 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 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 prior to the first fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member requests a fair hearing due to the lower RUG level, the MCO would continue services at the same level services were continued prior to the first fair hearing.

 

7523 Request to Withdraw an Appeal

Revision 17-1; Effective June 1, 2017

 

An appellant or appellant representative must request to withdraw his appeal by sending written notice to the hearings office. The hearings office cannot accept an oral request to withdraw his or her appeal. If the appellant or appellant representative contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the appellant or the appellant's representative the request to withdraw the appeal must be a written notice to the hearings office. If the appellant or appellant's representative sends a written request to withdraw to PSU staff, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the appellant or appellant representative and must be made to the hearings office.

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

 

7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearing Officers

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) hearings officer:

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

 

7700 Fair Hearings for Managed Care Organization Determinations

Revision 17-1; Effective June 1, 2017

 

If an applicant wishes to request a fair hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver eligibility denial, he or she must contact the Program Support Unit (PSU) as instructed in the denial notification.

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

Section 8000, Utilization Management and Review by the State

Revision 17-1; Effective June 1, 2017

 

 

8100 Description

Revision 17-1; Effective June 1, 2017

 

Utilization Review (UR) is a division within the Medicaid Children's Health Insurance Program (CHIP) Division of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd 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 appropriate utilization 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 documents, assessments, notes and authorizations contained in a STAR Kids member's file 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.

Appendices

Appendix I, MCO Business Rules for SK-SAI and SK-ISP

Appendix II, Long Term Services and Support Billing Procedures

Appendix III, LTSS Billing Matrix and Crosswalk

Appendix IV, MDCP Frequently Asked Questions

Appendix V, Reserved for Future Use

Revision 17-1; Effective June 1, 2017

Appendix VI, STAR Kids Transition Activities

Appendix VII, CDS Training Manual

AppendixVII Appendix VII, CDS Training Manual

Appendix VIII, RUG IPC Cost Limits

Appendix IX, Naming Conventions

Appendix X, Monthly Income/Resource Limits

Upcoming Form Revisions

The forms below have recently been revised and will publish on the date listed. Do NOT use these forms until the date published.

Publish Date Form No. and Title
12/3/2018 Form 1579, Referral for Relocation Services, Form 1579-S (Spanish) and Instructions
12/3/2018 Form 1747, Acknowledgement of Nursing Requirements

Forms

ES = Spanish version available.

Form Title
0003 Authorization to Furnish Information
1579 Referral for Relocation Services
1580 Texas Money Follows the Person Demonstration Project Informed Consent for Participation
1581 Consumer Directed Services Overview ES
1582 Consumer Directed Services Responsibilities ES
1582-SRO Service Responsibility Option Roles and Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1585 Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
1586 Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1826-D Case Information Release
2406 Physician Recommendation for Length of Stay in a Nursing Facility ES
2416 Minor Home Modifications and Adaptive Aids Service Authorization
2442 Notification of Interest List Release Closure ES
2600-A MDCP Waiver Release Letter - Medical Assistance Only ES
2600-B MDCP Waiver Release Letter - Supplemental Security Income ES
2601 Physician Certification ES
2602 Application Acknowledgment ES
2603 STAR Kids Individual Service Plan (ISP) Narrative ES
2604 STAR Kids Individual Service Plan - Service Tracking Tool ES
3618 Resident Transaction Notice
H1097 Affidavit for Citizenship/Identity ES
H1746-A MEPD Referral Cover Sheet
H2053-B Health Plan Selection ES
H2065-D Notification of Managed Care Program Services ES
H2067-MC Managed Care Programs Communication
H1200 Application for Assistance – Your Texas Benefits
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES
H3676 Managed Care Pre-Enrollment Assessment Authorization
H4800 Fair Hearing Request Summary
H4800-A Fair Hearing Request Summary (Addendum)
H4803 Notice of Hearing
H4807 Action Taken on Hearing Decision

Glossary

Revision 18-2; Effective September 3, 2018

 

Acute care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration. Exception: Some services for children are considered chronic and are covered under the State Medicaid Plan.

Agency option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

Applicant — A person who has applied for Medicaid benefits.

Authorized Representative — Any person or entity acting on behalf of individuals and with the individual’s written consent.

Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.

Code of Federal Regulations (CFR) — The codified federal regulations that govern most federal programs, including Medicaid.

Community First Choice (CFC) option — Personal assistance services; habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in STAR Kids who have received an institutional Level of Care (LOC) determination.

Community Living Assistance and Support Services (CLASS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities.

Comprehensive Care Program (CCP) — A package of Medicaid services available to individuals based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps benefit for individuals under age 21.

Consumer Directed Services employer — A member or legally authorized representative (LAR), parent, or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.

Consumer Directed Services (CDS) option — A service delivery option in which a member or LAR employs and retains service providers and directs the delivery of eligible STAR Kids program services. A member participating in the CDS option is required to use a financial management services agency (FMSA) chosen by the member or LAR to provide financial management services.

Day — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals who are deaf and blind and have a third disability.

Denial — Closure of an application with a finding of ineligibility.

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. A DR, usually a family member, is not a paid service provider and is at least age 18.

Early and periodic screening, diagnosis and treatment (EPSDT) — Federally mandated Early and Periodic Screening, Diagnosis and Treatment program contained at 42 U.S.C. 1396d(r). The name has been changed to Texas Health Steps (THSteps) in the state of Texas.

Eligibility date — The first date all eligibility criteria are met.

Employee (service provider) – An individual who is hired, trained and managed by the employer to provide services authorized by the MCO.

Enrollment broker — A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP).

Family member — A person who is related by blood, affinity or law to an individual.

Financial management services (FMS) — Assistance provided to members who manage funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.

Financial management services agency (FMSA) – An agency that contracts with the MCO to provide FMS to members who choose the CDS option.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

Home and community-based services (HCS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities as cost-effective alternatives to institutional care.

Individual service plan (ISP) narrative — An individualized and person-centered plan in which a member enrolled in the STAR Kids and community-based services program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.

ISP Service Tracking Tool — This tool is developed at least annually by the member, the MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost ceiling. This is also known as Form 2604.

Intellectual and developmental disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social, and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.

Interdisciplinary team (IDT) — All individuals/entities involved in planning the member’s plan of care (POC). This typically includes the member, the member’s legal or authorized representative, the service coordinator, the primary care physician, etc.

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of a member, including a parent, guardian, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code Chapter 752.

Managed care organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with Chapter 843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.

Medically Dependent Children Program (MDCP) — A §1915(c) waiver program which provides respite, Flexible Family Support Services, minor home modifications, adaptive aids, Transition Assistance Services, and FMS to prevent placement of individuals in long-term care facilities who are medically dependent and under age 21 and support deinstitutionalization of nursing facility residents under age 21.

Medical necessity (MN) — The medical criteria a person must meet for admission to a Texas nursing facility (NF), as defined in Texas Administrative Code, Title 40, §19.2401.

Member — An individual who is enrolled in and receiving services through a STAR Kids MCO.

Money Follows the Person (MFP) — A process used when a member in a Medicaid-certified NF who requests to move to the community is Medicaid-eligible and approved for the STAR Kids program before leaving the NF.

Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and long-term services and supports (LTSS). The POC is not the same as the ISP service tracking tool used for MDCP services.

Program Support Unit (PSU) — An HHSC unit with staff who support and handle certain aspects of the STAR Kids program.

Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

Respite services — Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Responsible adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.

Responsible party — An individual who:

Service Coordinator – The MCO staff person with primary responsibility for providing service coordination and care management to STAR Kids members.

Service Plan – A POC developed by the MCO service coordinator authorizing tasks to be performed by the service provider (e.g., ISP).

Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services (PAS). The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

Social Security Administration (SSA) — U.S. government agency created in 1935 by President Franklin D. Roosevelt, the SSA administers the social insurance programs in the U.S. The agency covers a wide range of Social Security services, such as disability, retirement and survivors benefits.

STAR Kids — Managed care program for recipients under the age of 21 who receive SSI, SSI-related Medicaid, and/or 1915(c) waiver services.

STAR+PLUS program — State of Texas Access Reform Plus Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange, and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program.

Supplemental Security Income (SSI) — Federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter. Most individuals receiving SSI who are under the age of 21 are eligible for Medicaid and are required to enroll in STAR Kids.

Support advisor — An employee who provides support consultation to an employer, a DR, or a member receiving services through the CDS option.

Support consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.

Texas Administrative Code (TAC) — A compilation of all the state agency rules in Texas.

Termination — Closure of an ongoing case due to a finding of ineligibility.

Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code Chapter 531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.

Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service claims processing. TMHP is also responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for the MDCP waiver and CFC.

Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved state Medicaid plan, or as part of their caregiving arrangement without pay.

Texas Health Steps (THSteps) — The name adopted by the state of Texas for the federally mandated EPSDT program.

TxMedCentral — A secure internet bulletin board the state and MCOs use to share information.

Revisions

18-2, Miscellaneous Changes

Revision Notice 18-2; Effective September 3, 2018

 

The following change(s) were made:

Revised Title Change
Section 1000 Overview and Eligibility Deletes Section 1360, Section 1930 and Program Support Unit (PSU) language. Clarifies and adds language in Section 1530.
Section 2000 Medically Dependent Children Program Intake and Initial Application Deletes Section 2020 and PSU language. Clarifies other language.
Section 3326 Suspension of Medically Dependent Children Program Services Adds language for members who do not receive Community First Choice (CFC) and also have MAO Medicaid.
Section 4600 Medically Dependent Children Program Services Adds language pertaining to members utilizing CFC.
Section 6000 Denials and Terminations Deletes PSU language and clarifies other language.
Glossary Glossary Clarifies and adds new language.

18-1, Miscellaneous Changes

Revision Notice 18-1; Effective March 1, 2018

 

The following change(s) were made:

Revised Title Change
1000 Overview and Eligibility Clarifies and adds new language.
3000 STAR Kids Screening and Assessment and Service Planning Clarifies and adds new language.
Appendix I MCO Business Rules for SK-SAI & SK-ISP Clarifies language.
Appendix IV MDCP Frequently Asked Questions Adds a Spanish version of the questions and answers.
Appendix VI STAR Kids Transition Activities Clarifies and adds new language.

SKH, 17-3, Miscellaneous Changes

Revision Notice 17-3; Effective September 1, 2017

The following changes were made:

 

Revised Title Change
Section 2000 Medically Dependent Children Program Intake and Initial Application Updates the electronic individual service plan (ISP) process, name change and miscellaneous edits. Revises the limited nursing facility stay in Section 2426.3.
Section 3000 STAR Kids Screening and Assessment and Service Planning Updates the electronic ISP process, name change and miscellaneous edits.
Appendix I MCO Business Rules for SK-SAI and SK-ISP Updates the electronic ISP process.

SKH, 17-2, Appendix VI Updated

Revised Title Change
Appendix VI STAR Kids Transition Activities Updates the information

SKH, HHSC Policy Updates

The purpose of this section is to make the most current policy and procedures readily available via a single resource. Memoranda containing policy or procedural information will be placed on this list at the time of distribution. They will remain on the list until the information contained is completely incorporated into the handbook.

Release Date Title
 

 

SKH, Contact Us

For questions about the STAR Kids Handbook, email: MCO_Handbooks@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us