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Effective Date: 
8/2020

Documents

 

Instructions

Effective: 8/2020

 

Purpose

Program Support Unit (PSU) staff may mail Form 2606 and Form 2606-S, Managed Care Enrollment Processing Delay, along with Form H1200, Application for Assistance - Your Texas Benefits, and a postage-paid envelope to provide notice to the applicant or member of the requirement to complete and return Form H1200.

 

Procedure

When to Prepare

Prepare and mail Form 2606 and Form 2606-S with Form H1200 to the applicant or member within two business days of:

  • The 30th day from the date the enrollment packet was mailed to an applicant who has not returned Form H1200 from the enrollment packet;
  • PSU staff receiving an unsigned Form H1200 from an applicant or member;
  • Medicaid for the Elderly and People with Disabilities (MEPD) specialist notifying PSU staff that an applicant or member’s Form H1200 has not been received;
  • PSU staff having determined that the applicant or member has lost Medicaid eligibility and Form H1200 is required; or
  • PSU staff notification of an upgrade request for the STAR+PLUS Home and Community Based Services (HCBS) program and Form H1200 is required.

Copies and Transmittal

PSU staff mail the original Form 2606 and Form 2606-S to the applicant, member, guardian, legally authorized representative (LAR), authorized representative (AR) or medical consenter. PSU staff upload an electronic copy of Form 2606 to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions for STAR+PLUS HCBS program or Appendix XVIII, STAR Kids HEART Naming Conventions, for MDCP.

Form Retention

HEART is the repository for the electronic case record. Paper copies of Form 2606 and Form 2606-S are not retained. PSU staff upload a copy of the completed Form 2606 to the HEART case record, following the instructions in Appendix XXXIII for STAR+PLUS HCBS program or Appendix XVIII for MDCP, the same date Form 2606 and Form 2606-S are mailed to the applicant, member, LAR, AR or medical consenter. PSU staff dispose of paper copies of Form 2606 and Form 2606-S by following established procedures for the destruction of confidential data as described in the HHS Computer Usage and Information Security Training.

Supply Source

Forms 2606 and 2606-S are found in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) and STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH).

Detailed Instructions

Date of Notice — Enter the date the form is completed and mailed to the applicant, member, LAR, AR or medical consenter. Once this field is entered, the 30th day from this date will auto-populate in the body of the form. The auto-populated date may be adjusted by entering a new date, if necessary.

HHSC Staff — Enter PSU staff name.

Office Address — Enter the mailing address for PSU staff.

Program Support Unit Phone Number — Enter the direct phone number of PSU staff mailing the form.

Program Support Unit Fax Number — Enter the direct fax number for PSU staff.

Name and Address — Enter the applicant, member, LAR, AR or medical consenter’s name and address. If the LAR, AR or medical consenter’s name is used, the applicant’s or member’s name must also be included for identification purposes. For STAR Health, this will be the address of the medical consenter, as provided by the STAR Health managed care organization (MCO).

Program Type — Select “STAR+PLUS Home and Community Based Services (HCBS) Program” or “Medically Dependent Children Program (MDCP).” Once the Program Type field is entered, the program will auto-populate in the body of the form.

There has been a delay in processing your application for — Select “STAR+PLUS HCBS Program” or “MDCP” from the drop-down box. Once the Program Type field has been selected, the program will auto-populate in the body of the form.

Failure to complete, sign and return Form H1200 to HHSC by [DATE] — Enter the date Form H1200 must be returned to HHSC by the individual, applicant or member. Once the Date of Notice field has been selected, a date will auto-populate in the body of the form. The Failure to complete, sign and return Form H1200 to HHSC by [DATE] field will auto-populate as the 30th day from the date entered in the Date of Notice field. The auto-populated date may be adjusted by entering a new date, if necessary.