2013 Texas Legislature Senate Bill 7

The Health and Human Services Commission (HHSC) is expanding the STAR+PLUS Medicaid managed care system to include:

  • Medicaid acute care services to individuals with intellectual and developmental disabilities (IDD)
  • Nursing facility services
  • Effective September 1, 2014

Expansion of Medicaid Acute Care Services

  • Effective September 1, 2014
  • Individuals receiving services in community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID)
  • Individuals receiving services in ICF-IID 1915 (c) waivers, such as Deaf Blind with Multiple Disabilities (DBMD), will receive their Medicaid acute care services through the STAR+PLUS managed care system.

The ICF-IID 1915 (c) waiver programs are:

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

Not included:

  • Individuals residing in a state supported living center
  • Individuals dually eligible for Medicare and Medicaid

Voluntary:

  • Children and young adults under age 21 receiving Supplemental Security Income (SSI) or SSI-related services

Medicaid Acute Care:

  • primary care or specialty doctor’s office
  • hospital, or emergency room
  • isolated event or part of routine health maintenance
  • access to prescription medications

Long Term Services and Supports (LTSS):

  • LTSS received through Medicaid in addition to Medicaid acute care, or Medicaid card services
  • Services an individual receives through an ICF/IID or one of the ICF-1915 (c) waiver programs, including DBMD

Certain individuals may qualify for LTSS through STAR+PLUS

How does this affect me or the individuals in my program?

Prevent loss of Medicaid acute care for individuals in your program by:

  • Maintaining a continuously authorized Level of Care (LOC) through an Intellectual Disability/Related Conditions (ID/RC) approved by DADS
  • Maintaining continuous authorizations of service through an Individual Plan of Care (IPC) approved by DADS
  • Assisting individuals and their representatives to prevent loss of financial eligibility for the waiver program

If a lapse in LOC or IPC authorizations occurs

  • Risks for the Individual include:
    • Denied doctor, clinic, or hospital visits
    • Denied prescription medications
    • Loss of financial eligibility for DBMD waiver program due loss of Medicaid or, in some cases auto-enrollment into STAR+PLUS for their LTSS
  • Risks for the Program Provider Include:
    • Difficulty accessing necessary acute care services and prescriptions on behalf of an individual
    • Non-payment for services due to the individual’s loss of financial eligibility for DBMD waiver program

Annual Renewal of the ID/RC (LOC) and IPC:

Title 40, Part 1, Chapter 42, §42.223 describes that the DBMD case manager must:

  • convene a service planning team (SPT) to develop a renewal ID/RC and IPC at least annually, but within 90 calendar days before the end of the IPC period and
  • submit the renewal documents to DADS within 10 business days after the SPT meeting but at least 30 calendar days before the end of the current IPC period.

Prevent lapses in LOC and IPC authorizations by:

  • avoiding the need to submit a Purpose Code E ID/RC and
  • submitting proposed renewal packets (ID/RC and IPC) as early as possible.

Recommendations:

  • Develop a tracking method, such as a spreadsheet, to record ID/RC (LOC) and IPC expiration dates
  • Begin working on ID/RC (LOC) and IPC renewals early enough to allow sufficient time for DADS to make an authorization determination before the previous authorizations expire
  • Schedule SPT meetings well in advance when possible to account for difficulty in coordinating schedules for all SPT members.
  • Encourage families and individuals to avoid delaying SPT meetings.
  • Prior to submitting a LOC or IPC packet to DADS for review, conduct a thorough quality check of the submission to ensure it is accurate and complete to avoid delays in authorization determinations.

Preventing the Loss of Financial Eligibility

HHSC mails a Medicaid recertification packet to the individuals last known address at least 90 days in advance of their recertification due date.

Individuals or their authorized representative may call§ 2-1-1 to find out their Medicaid recertification due date.

NOTE: This only applies to non-SSI Medicaid recipients. Individuals enrolled in a waiver program who receive Supplemental Security Income (SSI) are categorically eligible for SSI Medicaid and would not receive an annual Medicaid recertification packet from HHSC.

Recommendations:

  • Develop a tracking method to record Medicaid recertification due dates for individuals served in your program.
  • Assist the individual or their authorized representative to complete the Medicaid recertification packet and submit all required documentation to HHSC before the deadline.
  • Educate individuals and their families about the importance of informing their DBMD case manager when they receive any communication from HHSC.

Expansion of Nursing Facility Services

Effective September 1, 2014

Nursing facility services will be provided through STAR+PLUS for:

  • Adults (age 21 and over) who are in a nursing facility, who have been determined eligible for Medicaid, and who meet STAR+PLUS criteria

Excluded:

  • Children and young adults (under age 21)

Suspensions of Waiver Services

  • The capitated rate a Managed Care Organization (MCO) receives for an individual’s acute care services will increase during the individual’s nursing facility stay.
  • The program provider must§ immediately submit a request for suspension to DADS when an individual’s DBMD services need to be suspended because the individual is in a nursing facility.
  • If the individual’s DBMD services are not suspended timely, the individual may be at risk of early discharge from the nursing facility

Managed Care Expansion

Program providers must comply with:

  • applicable state laws and rules;
  • program standards and requirements; and
  • instructions from DADS.

Where can I find more information?

  • Visit the HHSC Medicaid Managed Care Initiatives website: http://www.hhsc.state.tx.us/medicaid/mmc.shtml
  • Visit the DADS DBMD program website: http://www.dads.state.tx.us/providers/DBMD/index.cfm
  • Read Information Letters! http://www.dads.state.tx.us/providers/communications/letters.cfm?ftype=DBMD
  • Register for email alerts! Have your employee’s register too! https://public.govdelivery.com/accounts/TXHHSC/subscriber/new?qsp=307

Questions?