Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 
3/2019

Documents

 

Instructions

Updated: 3/2019

 

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

Prepare and mail Form 2442 and Form 2442-S to an individual when their name has been released from the Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) program interest list in the Community Services Interest List (CSIL) database and has not responded to contact attempts or requests to withdraw from the enrollment process. Form 2442 and Form 2442-S are mailed within two business days of:

  • the individual, LAR, AR or medical consenter advising the ILM Unit or PSU staff he or she declines to apply for the MDCP or STAR+PLUS HCBS program; 
  • the 45th day from the date the individual was released from the interest list and the individual, LAR, AR or medical consenter fails to respond to contact attempts made by ILM Unit staff; 
  • the 30th day from the date the enrollment packet was mailed to the individual, LAR, AR or medical consenter and the individual, LAR, AR or medical consenter fails to respond to contact attempts made by PSU staff; or 
  • Managed care organization (MCO) notification on Section B of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, or Form H2067-MC, Managed Care Programs Communication, stating the individual did not allow the MCO to conduct the initial home visit to complete the assessment.

The interest list slot is closed in the CSIL database by ILM Unit or PSU staff within two business days of:

  • the individual, LAR, AR or medical consenter advising the ILM Unit or PSU staff he or she wants to withdraw from the enrollment process for MDCP or STAR+PLUS HCBS program; 
  • the 60th day from the date the individual was released from the interest list by ILM Unit staff and the individual, LAR, AR or medical consenter fails to respond to contact attempts made by ILM Unit staff; 
  • the 30th day from the date the enrollment packet was mailed to the individual, LAR, AR or medical consenter by PSU staff and the individual, LAR, AR or medical consenter fails to respond to contact attempts made by PSU staff; or 
  • PSU staff receiving Section B of Form H3676 or Form H2067-MC from the MCO stating the individual did not allow the MCO to conduct the initial home visit to complete the assessment.

PSU staff must mail Form H2065-D, Notification of Managed Care Program Services, to deny MDCP or STAR+PLUS HCBS program if the individual has submitted Form H1200, Application for Assistance - Your Texas Benefits, or if the MCO has conducted a home visit to complete the assessment. Form 2442 is not required if Form H2065-D is mailed.

Copies and Transmittal

ILM Unit or PSU staff mail the original Form 2442 and Form 2442-S to the individual, LAR, AR or medical consenter. ILM Unit or PSU staff upload an electronic copy of Form 2442 and Form 2442-S to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

Form Retention

HEART is the repository for the electronic case record. Paper copies of Form 2442 and Form 2442-S are not retained. ILM Unit and PSU staff dispose of paper copies of Form 2442 and Form 2442-S by following established procedures for destruction of 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 the same date Form 2442 and Form 2442-S are mailed to the individual, LAR, AR or medical consenter.

Supply Source

Form 2442 and Form 2442-S can be found in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH), STAR Kids Program Support Unit Operational Procedures Handbook (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 — 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.

Telephone No. — Enter direct telephone number of the ILM or PSU staff mailing the form. Once this field is entered, the telephone 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. If the LAR's, AR's or medical consenter’s name is used, the individual’s name must also be included for identification purposes. For STAR Health members, the address should be that 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 enter the date the individual’s interest list will be or was 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 staff have not been able to reach the individual, LAR, AR or medical consenter by telephone or mail within 60 days of the MDCP or STAR+PLUS HCBS program interest list release.
  • Select “we haven’t received the enrollment packet back from you” if PSU staff have not received the MDCP or STAR+PLUS HCBS program enrollment packet back from the individual, LAR, AR or medical consenter within 30 days of mailing the MDCP or STAR+PLUS HCBS program enrollment packet.  
  • Select “your health plan told us you didn’t let them complete the required assessment” if PSU staff have been informed by the MCO that the individual, LAR, AR or medical consenter would not allow the MCO to complete the MDCP or STAR+PLUS HCBS program assessment.
  • Select "you told us you don’t want to apply for services" if ILM Unit or PSU staff have been informed by the individual, LAR, AR or medical consenter 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 ILM Unit or PSU staff have been informed by the individual, LAR, AR, medical consenter or MCO 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 have been informed by the individual, LAR, AR or medical consenter that the individual will be aging out of eligibility before MDCP services can begin.
  • Select "you told us you’ll be accepting or are receiving services through another program" if ILM Unit or PSU staff have been informed by the individual, AR, LAR or medical consenter 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.

Note: For STAR Health members, refer to the instructions in STAR Health Chapter 16.2 of the Uniform Managed Care Manual (UMCM). Only the primary medical consenter may decline MDCP services on behalf of a child in conservatorship.