Form 2442, Notification of Interest List Release Closure

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Documents

Effective Date: 1/2024

Instructions

Updated: 1/2024

Purpose

Interest List Management (ILM) Unit or Program Support Unit (PSU) staff must mail Form 2442 and Form 2442-S, Notification of Interest List Release Closure, to provide notice of interest list release closure to the individual, legally authorized representative (LAR), authorized representative (AR) or medical consenter.

Procedure

When to Prepare

ILM Unit or PSU staff prepare and mail Form 2442 and Form 2442-S to an individual when the individual: 

  • is released from the Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) program interest list; and 
  • fails to respond or opts out of the enrollment process.

ILM Unit staff must mail Form 2442 and Form 2442-S within two business days of:

  • the individual, LAR, AR or medical consenter declines to apply for the MDCP or STAR+PLUS HCBS program; 
  • the 45th day from the date of interest list release and the individual, LAR, AR or medical consenter fails to respond to contact attempts made by ILM Unit staff;  
  • the individual, LAR, AR or medical consenter advises the individual no longer resides in Texas; or
  • the individual, LAR, AR or medical consenter advises the individual will be turning 21 years of age and will no longer be eligible for MDCP.

ILM Unit staff must close the interest list release in the Community Services Interest List (CSIL) database within two business days of the 60th day from the date of release from the MDCP or STAR+PLUS HCBS program interest list.

STAR Kids PSU staff must mail Form 2442 and Form 2442-S within two business days from:

  • the date the individual, LAR or medical consenter declines to apply for MDCP;
  • the date the individual, LAR, medical consenter or managed care organization (MCO) advises PSU staff the individual no longer resides in Texas;
  • the date the individual, LAR, medical consenter or MCO advises PSU staff the individual will be turning 21 years old and will no longer be eligible for MDCP;
  • the 30th day from the date PSU staff mailed the enrollment packet and:
    • have been unable to contact the individual, LAR or medical consenter;
    • have been unable to confirm that the individual wishes to pursue MDCP; or
    • have not received Form H1200, Application for Assistance – Your Texas Benefits, from the individual;
  • the 30th day from the date PSU staff mailed Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to an individual and PSU staff have not received Form H1200, as applicable.

Note: STAR Kids PSU must mail Form 2442 with the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Appendix XX, MDCP Program Description.

STAR+PLUS PSU staff must mail Form 2442 and Form 2442-S within two business days from:

  • the date the individual or AR declines to apply for the STAR+PLUS HCBS program;
  • the date the individual, AR or MCO advises PSU staff that the individual no longer resides in Texas;
  • the 30th day from the date PSU staff received the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record from the enrollment broker and:
    • have been unable to contact the individual or AR;
    • have been unable to confirm that the individual wishes to pursue the STAR+PLUS HCBS program; or
    • have not received Form H1200 from the individual;
  • the 30th day from the date PSU staff mailed Form 2606 and Form H1200 to an individual and PSU staff have not received Form H1200, as applicable.

Note: STAR+PLUS PSU must mail Form 2442 with the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) Appendix XII, STAR+PLUS HCBS Program Description.

STAR Kids and STAR+PLUS PSU staff must close the interest list slot in the CSIL database within two business days from mailing Form 2442.

PSU staff must use Form H2065-D, Notification of Managed Care Program Services, to deny MDCP or STAR+PLUS HCBS program applicants. PSU staff are not required to generate Form 2442 when Form H2065-D is used.

Form 2442 is inappropriate for an individual applying for MDCP or the STAR+PLUS HCBS program through the Money Follows the Person (MFP) process.

Copies and Transmittal

ILM Unit or PSU staff mail the original Form 2442 and Form 2442-S along with SKOPH Appendix XX, MDCP Program Description, and SPOPH Appendix XII, STAR+PLUS HCBS Program Description, as applicable, to the individual, LAR, AR or medical consenter.

PSU staff must upload Form 2442 to TxMedCentral in the authorized MCO's folder using the naming conventions identified in the SKOPH and SPOPH.

ILM Unit or PSU staff upload an electronic copy of Form 2442 and Form 2442-S to the HEART case record, following the instructions in SKOPH Appendix XVIII, STAR Kids HEART Naming Conventions, for MDCP, or SPOPH Appendix XXXIII, STAR+PLUS HEART Naming Conventions for STAR+PLUS HCBS program.

Form Retention

HEART is the repository for electronic case records. ILM Unit or PSU staff must not retain paper copies of Form 2442 and Form 2442-S. ILM Unit and PSU staff dispose of paper copies of Form 2442 and Form 2442-S by following established procedures for destroying confidential data as described in the Health and Human Services (HHS) Computer Usage and Information Security Training. ILM Unit or PSU staff upload a copy of the completed Form 2442 and Form 2442-S to the HEART case record on the same date ILM Unit or PSU staff mails Form 2442 and Form 2442-S to the individual, LAR, AR or medical consenter.

Supply Source

ILM Unit and PSU staff may find Form 2442 and Form 2442-S in the following handbooks: 

  • SPOPH; 
  • SKOPH;
  • STAR+PLUS Handbook (SPH); 
  • STAR Kids Handbook (SKH); and 
  • Chapter 16.2 of the Uniform Managed Care Manual (UMCM) for STAR Health.

Detailed Instructions

Date of Notice — Enter the date the form is completed and mailed to the individual, LAR, AR or medical consenter.

Texas Health and Human Services Commission Staff — Enter ILM Unit or PSU staff name.

Office Address — Enter ILM Unit or PSU staff office address of the staff mailing the form .

Area Code and Phone No. — Enter the direct phone number of the ILM Unit or PSU staff mailing the form. Once this field is entered, the phone number field in the body of the form will auto-populate with the same number.

Name and Address — Enter the individual's, LAR's, AR's or medical consenter’s name and address. ILM Unit or PSU staff must include the individual’s name for identification purposes if the LAR's, AR's or medical consenter’s name is used. For STAR Health members, use the address of the primary medical consenter.

On ____, you came to the top of the interest list for: — Enter the date the individual was released from the interest list, as recorded in the CSIL database. Select “Medically Dependent Children Program (MDCP)” or “STAR+PLUS Home and Community Based Services (HCBS) program” interest list from the drop-down box. 

On ____, Texas Health and Human Services Commission staff closed or will close your release from the interest — ILM Unit or PSU staff must enter the date the individual’s interest list is closed in the CSIL database. Once this field is entered, the 90th day from this date will auto-populate in the body of the form.

We are closing your release because: — Select the appropriate reason from the drop-down box for the interest list release closure:

  • Select "we haven’t been able to contact you to begin the eligibility process" if ILM Unit or PSU staff have not been able to contact or locate the individual, LAR, AR or medical consenter within the timeframes described above. 

    Note: This includes if ILM Unit or PSU staff are able to contact the individual at one point in the enrollment process but then are not able to at a later date.
     
  • Select “we haven’t received the completed and signed enrollment packet back from you” if PSU staff have not received the completed Form H1200 from an individual, LAR, AR or medical consenter within the time frames described above. 
  • Select "you told us you don’t want to apply for services" if the individual, LAR, AR or medical consenter informs ILM Unit or PSU staff that the individual does not want to apply for MDCP or STAR+PLUS HCBS program.
  • Select “you told us you don’t live in Texas” if the individual, LAR, AR, medical consenter or MCO informs ILM Unit or PSU staff that the individual no longer resides in Texas. 
  • Select "you told us you’ll be turning 21 years old" if ILM Unit or PSU staff determine the individual will turn 21 before MDCP services can begin.
  • Select "you told us you’ll be accepting or are receiving services through another program" if the individual, LAR, AR, medical consenter or MCO informs ILM Unit or PSU staff that the individual does not want to apply for MDCP or STAR+PLUS HCBS program because the individual is pursuing or receiving services from another program that meets their needs.