Effective September 2022

Appendix I, MCO Business Rules for SK-SAI & SK-ISP (PDF)

6-2017

 

The managed care organization (MCO) must require all providers rendering Long-Term Services and Support (LTSS), with the exception of atypical providers, to use the CMS 1500 Claim Form or the HIPAA 837 Professional Transaction when billing. Atypical providers are LTSS providers that render non-health or non-medical services to STAR+PLUS members.  Examples include pest control services and building and supply services.
 
Providers using the Paper CMS 1500

Providers billing on paper will provide complete information about the service event and will use the state assigned provider identification (ID) to represent the provider(s) involved in the service event. The provider ID (billing and/or rendering) will be located in Block 33 on the paper form.

• If the billing provider and the rendering provider are the same, then the state assigned provider ID will be populated in Block 33.
• If the rendering provider is different than the billing provider, then the billing provider state assigned provider ID will be populated in Block 33, and the rendering provider state assigned provider ID will be populated in Block 24K.
• Under specific scenarios, the additional usage of Block 17a (Referring Provider (Optional)) and Block 24k can be used to report additional information on providers that are involved in the service event.

Providers using the Electronic HIPAA 837

Providers billing electronically will comply with HIPAA 837 guidelines, including the accurate and complete conveyance of information pertaining to the provider(s) involved in the service event.
 
Atypical Providers

Atypical providers will submit appropriate documentation to the MCO.  The MCO must obtain sufficient documentation from the atypical provider to accurately populate an 837 professional encounter. Refer to the HIPAA-compliant 837 Professional Combined Implementation Guide and the 837 Professional Companion Guide for further information. (See “Claims Processing Requirements” in §2, Claims, in the UMCM.)

Providers and MCOs will bill and report LTSS in compliance with the STAR Kids Billing Matrix (Matrix).

Providers – LTSS providers must use the “designated position” of the modifiers, as indicated on the Matrix, when filing claims.

MCOs – MCOs must use the “designated position” of the modifiers, as indicated on the Matrix, when reporting encounters.

Nursing Facilities (NFs) – Services pertaining to a member entering a nursing facility will be filed (paper or electronic) through the state’s claims administrator under traditional Medicaid (fee for service) following the claims submission guidelines applicable to traditional Medicaid billing. Services that do not involve a member entering a nursing facility (i.e., respite care) will conform to normal LTSS billing procedures.

The LTSS Bulletin posted on the Texas Medicaid Health Partnership website (www.tmhp.com) provides additional information and updates.

Appendix VII, CDS Training Manual

Revision 23-1; Effective March 1, 2023

Overview of Home and Community-Based Services Settings Rule

The federal regulations at 42 Code of Federal Regulations (CFR) Sections 441.301(c)(4) and 441.530 (Home and Community-Based Services Settings Rule) require settings where Medicaid home and community-based services are delivered. This includes services provided to members in the STAR Kids and Medically Dependent Children Program (MDCP), to have certain qualities as described below. 

Services and Settings Subject to the Home and Community-Based Services Settings Rule 

The managed care organization (MCO) must ensure settings where the following STAR Kids and MDCP services are delivered comply with requirements of the Home and Community-Based Services Settings Rule: 

• Community First Choice (CFC) personal assistance services;
• CFC Habilitation;
• respite care;
• flexible family support services;
• employment assistance;
• supported employment; 
• adaptive aids; and
• minor home modifications.

Requirements for Home and Community Based Services Settings

All Settings

A managed care organization (MCO) ensures that the settings listed above have the following qualities described in the Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i-v) and Section 441.530(a)(1)(i-v):  

• The setting provides opportunities for members to seek employment and work in competitive, integrated settings. 
• The setting provides opportunities for members to engage in community life. 
• The setting gives opportunities for members to control personal resources.
• The setting gives opportunities for members to receive services in the community. 
• The member selects the setting from the setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the person-centered service plan and are based on the individual’s needs and preferences.
• The setting ensures the member’s rights of privacy, dignity and respect, and freedom from coercion and restraint.
• The setting optimizes, but does not regiment, the member’s individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.
• The setting facilitates member choice regarding services and supports, and who provides them. 

Settings that are Provider-Owned and Controlled

A host family home where MDCP respite is delivered is considered a provider-owned or controlled setting. An MCO must ensure that a setting where a host family provides respite care has the following qualities as described in 42 CFR Section 441.301(c)(4)(vi):

• each member has privacy in their sleeping or living unit;
• the member has the freedom and support to control their own schedules and activities and has access to food at any time;
• the member is able to have visitors of their choosing at any time; and
• the setting is physically accessible to the member.

Any modifications to these requirements must be supported by a specific assessed need and documented in the person-centered service plan. Include the following criteria in the plan:

• a description of the specific and individualized assessed need that justifies the modification;
• a description of the positive interventions and supports that were tried but did not work;
• a description of less intrusive methods of meeting the need that were tried but did not work;
• a description of the condition that is directly proportionate to the specific assessed need;
• a description of routine collection and review of data to measure the ongoing effectiveness of the modification;
• the established time limits for periodic reviews to determine if the modification is still necessary or can be stopped;
• the member’s or legally authorized representative’s  signature showing evidence of informed consent to the modification; and
• the MCO service coordinator's assurance that the modification will cause no harm to the individual.

Access to the Community 

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i) and 42 CFR Section 441.530(a)(1)(i) require the member to have full access to the greater community. This includes opportunities to engage in community life, control personal resources, and receive services in the community to the same degree as a person not receiving Medicaid services.

The MCO must ensure that providers not have policies or practices in place that restrict or obstruct the member’s access to the community. The MCO must also ensure provider service and support practices do not create an environment that is institutional in nature. The MCO must support the member’s desire to participate in the community.

The MCO must use the person-centered planning process to: 

• ensure the member has opportunities and supports needed to participate in the community when they want, both individually and in groups; 
• identify, develop, and make available information on transportation options for community access; 
• assist the member with developing meaningful relationships with other members of the community; and
• ensure the member has services, resources, and supports to help them explore or maintain meaningful activities.

Employment 

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i) and 42 CFR Section 441.530(a)(1)(i) requires that the member has opportunities to seek employment and work in competitive integrated settings, in the same way a person not receiving Medicaid home and community-based services has.

As part of the person-centered planning process, the MCO must assess the member’s preferences and goals. This may include preferences and goals related to seeking employment and working in competitive integrated settings. The MCO is responsible for assessing and providing information to the member about employment assistance and supported employment services available through MDCP (STAR Kids Contract 8.3.2). 

Setting Choice

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(ii) and 42 CFR §441.530(a)(1)(ii) requires that the member is allowed to select a setting where services are delivered from setting options. Setting options should include non-disability specific settings. 

The MCO must facilitate the service planning process, including offering setting options that a member may choose. The MCO must identify and document the setting options and selection, based on the member’s needs and preferences, in the member’s individual service plan (ISP).

Privacy, Dignity and Respect, and Freedom from Coercion and Restraint

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iii) and 42 CFR Section 441.530(a)(1)(iii) require that the setting ensures the individual’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

The MCO must ensure the member is treated respectfully by providers and is free from coercion and restraint. 

The member has the right to privacy, in the same way as children and youth not receiving Medicaid home and community-based services. The right to privacy includes having their information kept private and having personal care provided in private. The MCO must ensure providers respect and protect the member’s privacy.

The MCO must also ensure licensed and certified providers meet applicable licensing and certification requirements about privacy, dignity and respect, and freedom from coercion and restraint.

Initiative, Autonomy, and Independence

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iv) and 42 CFR Section 441.530(a)(1)(iv) require that a setting optimize but not regiment, the member’s initiative, autonomy, and independence in making life choices. This includes, but is not limited to, daily activities, physical environment, and with who they interact. The managed care organization (MCO) and providers must maximize the member’s ability to make choices while minimizing the risk of endangering the member or others. 

The MCO must ensure providers support the member’s right to make choices about how they spend their time in any given setting, to the same degree as children and youth not receiving Medicaid home and community-based services. The MCO must ensure the member has opportunities to participate in community activities appropriate for children and youth. 

The MCO should coordinate with the member, LAR, other family members involved in service planning, and the provider to ensure: 

• the member is offered actual experiences to base future choices; 
• the member’s daily activities have the appropriate balance between autonomy and safety; 
• the member’s personal preferences are prioritized over a guardian’s or provider’s preferences, unless a health and safety reason is documented; and 
• the member feels supported in working toward their goals.

The MCO ensures a provider does not: 

• force or coerce the member to participate when they do not wish to participate in an activity; 
• punish the member for not participating in an activity; or
• make activity schedules without input from the members in the setting.

Member Choice

The Home and Community-Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(v) and 42 CFR Section 441.530(a)(1)(v) requires that the member has a choice about services and supports, and who provides them. 

The MCO ensures the member is free to choose who provides the services they receive and where they receive those services. The member must not be coerced or forced to get services in a particular setting. They may instead choose to go out into the community for the same services. 

The service plan is the central place where the MCO should document and honor the member’s choices for services, supports and who provides them. The MCO ensures the person-centered planning process addresses the member’s needs. The MCO must inform the member that they can request a change to their person-centered service plan if they are not happy with their services. The MCO requires providers to help the member with contacting their MCO to discuss possible changes to their service plan if they are unhappy with their services.  

Requirements for Host Family Settings Where MDCP Respite is Delivered

MDCP respite may be delivered in host family settings for members using the Consumer Directed Services (CDS) option. 

Note: As of November 2022, there are no host homes delivering respite services in MDCP. 

Privacy

The regulation at 42 CFR Section 441.301(c)(4)(vi)(B) requires that the member has privacy in their living unit or bedroom, in the same way a child or youth not receiving Medicaid home and community-based services does.

The member’s right to privacy includes:

• an entrance door to their bedroom or living unit that is lockable by the member;
• a choice of room and roommate, to the extent possible in the setting; and 
• ability to decorate their bedroom or living unit. 

Base any modifications or restrictions to the member’s  privacy on a specific, assessed need and documented in the member’s person-centered service plan.

Control of Daily Schedule and Access to Food

The regulation at 42 CFR Section 441.301(c)(4)(vi)(C) requires that the member has the freedom and support to control their own schedules and activities and has access to food at any time.

As part of the person-centered planning process, the MCO should discuss with the member their goals and preferences, including for daily schedules and activities. The MCO must also ensure the host family setting has processes in place to discuss with the member their preferences for their daily schedule and activities. 

The MCO must ensure the host family allows the member to access food at any time, in the same way a child or youth not receiving Medicaid home and community-based services can. This includes allowing the member to have food or snacks before or after scheduled mealtimes. As appropriate, the host family may leave the kitchen accessible to the member or may allow the member to keep their own food in their bedroom or another designated space, such as a pantry or cupboard, that they can access whenever they want. 

Base any modification to the member’s ability to control their daily schedule, including access to food at any time, on a specific assessed need and documented in the member’s person-centered service plan.

Visitation

The regulation at 42 CFR Section 441.301(c)(4)(vi)(D) requires that the member can have visitors of their choosing at any time. 

The MCO must ensure a host family allows the member to receive visitors at any time, in the same way as children and youth not receiving Medicaid home and community-based services. 

Base any modification to the member’s ability to have visitors at any time on a specific assessed need and documented in the members person-centered service plan.

Physical Accessibility

The regulation at 42 CFR Section 441.301(c)(4)(vi)(E) requires that the host family setting be physically accessible to the member. 

The MCO must ensure a host family setting is physically accessible to the member. 

Modifications to Home and Community Based Services Settings Rule Requirements

The regulation at 42 CFR Section 441.301(c)(4)(vi)(F) requires any modifications to the following conditions of the settings regulations be supported by a specific need and justified in the member’s person-centered service plan:

1. the member has privacy in their living unit or bedroom;
2. the member has a choice of roommates;
3. the member has the freedom to decorate their living space;
4. the member has freedom and support to control their schedules and activities, and has access to food at any time; 
5. the member is able to have visitors of their choosing at any time; and
6. the host family setting is physically accessible to the member.

The MCO ensures any modifications or restrictions to these conditions one through five above are based on an individualized, assessed need and documented in the person-centered service plan. Document the following information in the person-centered service plan: 

• a description of the specific and individualized assessed need that justifies the modification;
• a description of the positive interventions and supports that were tried but did not work;
• a description of the less intrusive methods of meeting the need that were tried but did not work;
• a description of the condition that is directly proportionate to the specific assessed need;
• a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;
• the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;
• the member’s or legally authorized representative’s  signature evidencing informed consent to the modification; and
• the MCO service coordinator's assurance that the modification will cause no harm to the individual.

The MCO must ensure that condition number six listed above is not modified.