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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.