Revision 22-2; Effective September 1, 2022

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

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

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

3110 Assessment of Medical Necessity for Community First Choice

Revision 22-2; Effective September 1, 2022

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

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

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

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 22-2; Effective September 1, 2022

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

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

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

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

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

Revision 23-4; Effective Dec. 1, 2023

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

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

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

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

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

3210 Reassessment of Medical Necessity or Level of Care

Revision 23-3; Effective July 21, 2023

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

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

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

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

Revision 22-2; Effective September 1, 2022

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

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

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

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

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

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

3310 Service Planning

Revision 22-2; Effective September 1, 2022

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

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

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

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

3311 Updates to the Individual Service Plan

Revision 19-1; Effective September 3, 2019

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

3320 Service Planning for Medically Dependent Children Services

Revision 22-3; Effective Dec. 1, 2022

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

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

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

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

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

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

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

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

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

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

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 22-3; Effective Dec. 1, 2022

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

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

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 22-2; Effective September 1, 2022

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

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

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

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

Revision 22-2; Effective September 1, 2022

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

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

Revision 22-2; Effective September 1, 2022

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

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

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

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

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 22-2; Effective September 1, 2022

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

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

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

3326 Suspension of Medically Dependent Children Program Services

Revision 18-2; Effective September 3, 2018

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

The MCO must include in the documentation the:

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

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

3327 Reassessment Individual Service Plan

Revision 22-2; Effective September 1, 2022

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

3328 Process for Reviewing the Individual Service Plan Expiring Report

Revision 22-2; Effective September 1, 2022

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

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

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

3329 Reassessment Notification Requirements

Revision 23-3; Effective July 21, 2023

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

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

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

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

Revision 22-3; Effective Dec. 1, 2022

3410 Transfer from One Managed Care Organization to Another

Revision 23-3; Effective July 21, 2023

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

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

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

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

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

Examples:

Cutoff Date – April 12

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

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

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

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

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

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

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

Gaining MCO Responsibilities for Continuity of Care

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

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

3420 Member Transfer from Waiver Program to Medically Dependent Children Program

Revision 23-3; Effective July 21, 2023

If a STAR Kids member in another Medicaid waiver program comes up on the interest list for MDCP, a referral is made to Program Support Unit (PSU) staff.

PSU staff are responsible for completing the following activities within 14 days of the initial request for an MDCP assessment. All attempted contacts with the member or encountered delays must be documented.

PSU staff:

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

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

The MCO completes:

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

If the information from the MCO is not received within 60 days after the assessment is authorized, PSU staff email the assigned health plan manager as notification the time frame for completing the individual service plan (ISP) was not met.

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

3430 Member Transfer from MDCP to Another Waiver

Revision 22-2; Effective September 1, 2022

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

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

3440 Member Transfer from Community Services to STAR Kid

Revision 22-2; Effective September 1, 2022

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

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

Revision 22-2; Effective September 1, 2022

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

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

Revision 22-2; Effective September 1, 2022

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

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

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

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

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

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

3511 STAR+PLUS Transition Activities

Revision 23-4; Effective Dec. 1, 2023

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

3512 Intrapulmonary Percussive Ventilator Benefit

Revision 22-2; Effective September 1, 2022

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

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

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