Form H2065-D, Notification of Managed Care Program Services

Instructions for Opening a Form

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Documents

Effective Date: 1/2019

Instructions

Updated: 10/2023

Purpose

To notify the applicant or member of:

  • initial or ongoing eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program or Medically Dependent Children Program (MDCP);
  • denial or termination of the STAR+PLUS HCBS program or MDCP;
  • the right to appeal decisions about eligibility room and board (R&B) and copayment charges, if applicable; and
  • member transfers from one service area to another service area.

Procedure

When to Prepare

Program Support Unit (PSU) staff must prepare Form H2065-D and Form H2065-DS when:

  • an applicant or member is determined eligible for the STAR+PLUS HCBS program or MDCP;
  • a member is determined eligible at reassessment for the STAR+PLUS HCBS program or MDCP;
  • an applicant is denied eligibility for the STAR+PLUS HCBS program or MDCP;
  • a member’s eligibility is terminated from the STAR+PLUS HCBS program or MDCP;
  • there is a change in a member’s R&B or copayment amount; or
  • a member transfers from one service area to another service area for STAR+PLUS HCBS program.

Copies and Transmittal

PSU staff mail the original Form H2065-D and Form H2065-DS to the applicant, member, authorized representative (AR), legally authorized representative (LAR) or medical consenter. PSU staff send one copy of Form H2065-D to the managed care organization (MCO) and, when applicable, one copy to the Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) specialist.

PSU staff must mail the following forms along with Form H2065-D and Form H2065-DS; when applicable:

  • STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment, for STAR+PLUS applicants and members denied or terminated for medical necessity (MN);
  • STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials, for MDCP members terminated for MN;
  • SKOPH Appendix XXVII, Fair Hearing Options for MDCP Denials, for applicants denied MN; or
  • SKOPH Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, for members denied due to not meeting the age requirement for MDCP.

Form Retention

Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is the electronic case record for STAR+PLUS HCBS program and MDCP. PSU staff upload a copy of the completed Form H2065-D and Form H2065-DS to the HEART case record within two business days of PSU staff mailing Form H2065-D and Form H2065-DS to the applicant, member, AR, LAR or medical consenter. PSU staff must not retain paper copies of Form H2065-D and Form H2065-DS. PSU staff dispose of paper copies of Form H2065-D and Form H2065-DS by following established procedures for destruction of confidential data, as described in the HHS Computer Usage and Information Security Training.

Supply Source

Form H2065-D and Form H2065-DS can be found in the  SPOPH, SKOPH, STAR Kids Handbook (SKH), STAR+PLUS Handbook (SPH), and Chapter 16.2 of the Uniform Managed Care Manual (UMCM) for STAR Health.

Detailed Instructions

Page 1 Upper Section (required for all forms)

Date of Notice — Enter the date PSU staff complete and mail the form to the applicant or member.

HHSC Staff — Enter the name of PSU staff completing the form.

Office Address and Telephone No. — Enter the mailing address for PSU staff, including the street address or post office box, mail code, city, state, ZIP code and direct phone number.

Name and Address — Enter the applicant’s, member’s, AR’s, LAR’s or medical consenter’s name and mailing address. For STAR Health, this will be the address of the medical consenter, as provided by the STAR Health MCO. PSU staff must also include the name of the applicant or member for identification purposes. 

STAR+PLUS Home and Community Based Services (HCBS) Program or Medically Dependent Children Program (MDCP) — Select the appropriate box to show which program the PSU staff approves, denies, or terminates an applicant or member.

Program Approvals — Block of check boxes that begin with “You are eligible . . .”
Follow the instructions per the appropriate program approval action the form is being prepared for.

1. Program Approval for Interest List Release and Upgrade (does not include Money Follows the Person (MFP)

You are eligible for ______ beginning ______ — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the first day of the month following all eligibility criteria being met. PSU staff processing does not delay the eligibility begin date.

Services identified on your Individual Service Plan (ISP) are effective _______ through _______ as long as you are eligible for the program — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date will be the same as the eligibility begin date. The ISP end date will be 12 months from the ISP effective date, unless an MDCP applicant will be turning 21 years old in less than 12 months. If an MDCP applicant will be turning 21 years old, the ISP end date will be the last day of the applicant's 21st birth month.

2. Program Approval for Traditional MFP (does not include MDCP MFP limited nursing facility stay)
PSU staff must complete and send two forms for the STAR+PLUS HCBS program and MDCP MFP eligibility. The first form will provide the eligibility begin date and is issued while the applicant lives in the nursing facility (NF). The second form provides the ISP effective and end dates and is issued after the applicant discharges from the NF. The eligibility begin date will remain the same on both forms.

First Form Instruction for Traditional MFP Cases:

The first form is prepared when the applicant has met all eligibility criteria. The purpose of the first form is to notify the applicant he or she may discharge from the NF without an adverse impact to the STAR+PLUS HCBS program or MDCP eligibility.

You are eligible for ______ beginning _______ — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the day all eligibility criteria is met for STAR+PLUS HCBS program applicants. The eligibility begin date may be a mid-month date for STAR+PLUS HCBS program applicant. The eligibility begin date for MDCP applicants is the first day of the month that all eligibility criteria is met. PSU staff processing does not delay the eligibility begin date.

Second Form Instruction for Traditional MFP Cases:

The second form is prepared after the applicant discharges from the NF. Upon NF discharge, PSU staff can establish the ISP effective and end dates. The purpose of the second form is to advise the applicant of the service effective and end dates.

You are eligible for _______ beginning _______ — Select this box if the applicant is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the day all eligibility criteria is met for STAR+PLUS HCBS program applicants. The eligibility begin date may be a mid-month date for a STAR+PLUS HCBS program applicant. The eligibility begin date for an MDCP applicant is the first day of the month in which all eligibility criteria is met. The eligibility begin date must remain the same on both forms. PSU staff processing does not delay the eligibility begin date.

Services identified on your Individual Service Plan (ISP) are effective _____ through _____ as long as you are eligible for the program — Select this box on the second form prepared. Enter the ISP effective and end dates in the blanks provided. 

For STAR+PLUS HCBS program applicants, the ISP:

  • effective date is the day the applicant discharged from the NF; and
  • end date is the last day of the month 12 months from the date the STAR+PLUS HCBS program applicant discharged from the NF.

For MDCP applicants, the ISP:

  • effective date is the first day of the month in which the applicant discharged from the NF; and
  • end date is 12 months from the last day of the month the applicant discharged from the NF, unless an MDCP applicant will be turning 21 years old in less than 12 months. The ISP end date will be the last day of the applicant’s 21st birth month for MDCP applicants turning 21 years old.

The ISP effective date and the eligibility begin date may or may not be the same date, depending on the situation. 

MDCP Example:

  • The MDCP applicant discharged from the NF on March 20, 2020. The applicant’s ISP dates would be March 1, 2020, to Feb. 28, 2021. If the MDCP applicant is turning 21 years old on Jan. 12, 2021, the ISP dates are March 1, 2020, to Jan. 31, 2021.

STAR+PLUS HCBS Program Example:

  • If an applicant discharged from an NF on Jan. 15, 2019, their ISP dates are Jan. 15, 2019, through Jan. 31, 2020. 

3. Program Approval for MDCP MFP Limited NF Stay

You are eligible for _____ beginning _____ — Select this box if the applicant is eligible for MDCP. Select “MDCP” in the first blank provided. Enter the date the applicant is eligible for services in the second blank. The eligibility begin date is the first day of the month the applicant discharges from the NF.

Services identified on your Individual Service Plan (ISP) are effective ______ through ______ — as long as you are eligible for the program — Select this box if the applicant is eligible for MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the first day of the month that the applicant discharged from the NF. The ISP effective date is the same as the ISP effective date.

The ISP end date is 12 months from the last day of the month the applicant discharged from the NF, unless the applicant is turning 21 years old in less than 12 months. For applicants turning 21 years old in less than 12 months, the ISP end date will be the last day of the applicant’s 21st birth month.

4. Annual Reassessment

You are eligible for _____ beginning _____ — Select this box if the member continues to be eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the member is eligible for services in the second blank. The eligibility begin date is the first day of the month following the historical ISP’s end date.

Services identified on your Individual Service Plan (ISP) are effective ____ through ____ as long as you are eligible for the program — Select this box if the member remains eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the first day of the month following the historical ISP’s end date. The ISP effective date is the same as the eligibility begin date. The ISP end date is 12 months from the ISP effective date, unless an MDCP member is turning 21 years old in less than 12 months. If an MDCP member is turning 21 years old, the ISP end date will be the last day of the MDCP member’s 21st birth month.

5. Program Approval due to Medicaid Reinstatement

PSU staff must reinstate STAR+PLUS HCBS program or MDCP eligibility when a member regains their eligibility with a gap of six calendar months or less in Medicaid financial eligibility. Refer to the SPOPH and SKOPH for specific reinstatement eligibility criteria.

You are eligible for ______ beginning _____ — Select this box if a member is eligible for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the date the member regains Medicaid eligibility for services in the second blank. The eligibility begin date is the first day of the month the MEPD specialist reinstates Medicaid eligibility. PSU staff must verify all other STAR+PLUS HCBS program or MDCP eligibility criteria continue to be met.

Services identified on your Individual Service Plan (ISP) are effective _____ through _____ as long as you are eligible for the program — Select this box if a member is eligible for the STAR+PLUS HCBS program or MDCP. Enter the ISP effective and end dates in the blanks provided. The ISP effective date is the first day of the month the MEPD specialist reinstates Medicaid eligibility. The ISP effective date is the same as the eligibility begin date. The ISP end date will match the historical ISP end date.

Examples:

  • Medicaid reinstatement without a gap in Medicaid financial eligibility — A member’s historical ISP effective and end dates are Nov. 1, 2018, through Oct. 31, 2019. The member lost Medicaid eligibility Jan. 31, 2019. PSU staff is notified March 15, 2019, that the member regained Medicaid eligibility Feb. 1, 2019, with no gap in Medicaid eligibility. PSU staff reinstate the STAR+PLUS HCBS program or MDCP with an eligibility begin date of Feb. 1, 2019. The ISP effective and end dates are Feb. 1, 2019, through Oct. 31, 2019.
  • Medicaid reinstatement with a gap of six months or less — A member’s historical ISP effective and end dates are Nov. 1, 2018, through Oct. 31, 2019. The member lost Medicaid eligibility Jan. 31, 2019. PSU staff is notified July 22, 2019, that the member regained Medicaid eligibility effective May 1, 2019. This created a three-month gap in Medicaid eligibility from Feb. 1, 2019, through April 30, 2019. PSU staff reinstate the STAR+PLUS HCBS program or MDCP with an eligibility begin date of May 1, 2019. The ISP effective and end dates are May 1, 2019, through Oct. 31, 2019.
  • Medicaid reinstatement with a gap of over six months — A member’s historical ISP effective and end dates are Nov. 1, 2018, through Oct. 31, 2019. The member lost Medicaid eligibility Dec. 31, 2018. PSU staff is notified Sept. 10, 2019, that the member regained Medicaid eligibility on Aug. 1, 2019. This created a seven-month gap in Medicaid eligibility from Jan. 1, 2019, through July 30, 2019. PSU staff does not reinstate the STAR+PLUS HCBS program or MDCP. 

R&B and Copayment (applicable to specific approvals)

PSU staff must complete this section of the form to notify a STAR+PLUS HCBS program or MDCP member of R&B and copayment.

1. STAR+PLUS HCBS Program or MDCP Applicant or Member R&B

You must pay ______ for room and board by ______ — Select this box if the STAR+PLUS HCBS program or MDCP applicant or member is moving into or lives in an adult foster care (AFC) home or if the STAR+PLUS HCBS program applicant or member is moving into or lives in an assisted living facility (ALF), and must pay R&B. Enter the R&B amount to be paid by applicants at initial eligibility or by members at annual reassessment for the upcoming ISP year. The begin date for the initial R&B for an interest list release (ILR) or upgrade case will match the MDCP or STAR+PLUS HCBS program eligibility effective date. The begin date for the initial R&B for an MFP case will match the date of relocation from the NF to the AFC home or ALF. The begin date for a reassessment case will match the ISP effective date for the upcoming ISP year.

And then pay _____ per month, beginning ______ — Enter the applicant’s or member’s ongoing R&B amount. For applicants, enter the first day of the second month of eligibility. For members, enter the first day of the second month of the upcoming ISP year. 

You must pay _____ for copayment by _____ — Select this box if the STAR+PLUS HCBS program or MDCP applicant or member is moving into or lives in an AFC home or an ALF, as applicable, and must pay a copayment. Enter the copayment amount to be paid by applicants at initial eligibility or by members at annual reassessment for the upcoming ISP year. PSU staff must enter “pending” in the copayment amount field if the MEPD specialist has not provided the copayment amount at the time the initial Form H2065-D is generated. Refer to the SPOPH Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, and SKOPH Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, for more information on the use of “pending” on Form H2065-D. The begin date for the initial copayment for an ILR or upgrade case will match the MDCP or STAR+PLUS HCBS program eligibility effective date. The begin date for the initial copayment for an MFP case will match the date of relocation from the NF to the AFC home or ALF. The begin date for a reassessment case will match the ISP effective date for the upcoming ISP year.

And then pay _____ per month, beginning ______ — Enter the applicant’s or member’s ongoing copayment amount. For applicants, enter the first day of the second month of eligibility. For members, enter the first day of the second month of the upcoming ISP year.

2. STAR+PLUS HCBS Program or MDCP Applicant or Member Qualified Income Trust (QIT)

You must pay _____ for room and board by _____ — Select this box if the STAR+PLUS HCBS program or MDCP applicant or member has a QIT and is moving into or lives in an AFC or if the STAR+PLUS HCBS program applicant or member lives in or is moving to an ALF, and must pay R&B. Enter the R&B amount to be paid by the applicants at initial eligibility or by members at annual reassessment for the upcoming ISP year. The begin date for the initial R&B for an ILR or upgrade case will match the MDCP or STAR+PLUS HCBS program eligibility effective date. The begin date for the initial R&B for an MFP case will match the date of relocation from the NF to the AFC home or ALF. The begin date for a reassessment case will match the ISP effective date for the upcoming ISP year.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing R&B amount. For applicants, enter the first day of the second month of eligibility. For members, enter the first day of the second month of the upcoming ISP year. 

You must pay _____ for copayment by _____ — Select this box if the STAR+PLUS HCBS or MDCP applicant or member has a QIT and is moving into or resides in an AFC or an ALF, ap applicable, and must pay a copayment. Enter the copayment amount to be paid by applicants at initial eligibility or by members at annual reassessment for the upcoming ISP year. The begin date for the initial copayment for an ILR or upgrade case will match the MDCP or STAR+PLUS HCBS program eligibility effective date. The begin date for the initial copayment for an MFP case will match the date of relocation from the NF to the AFC home or ALF. The begin date for a reassessment case will match the ISP effective date for the upcoming ISP year.

And then pay _____ per month, beginning _____ — Enter the applicant’s or member’s ongoing copayment amount. For applicants, enter the first day of the second month of eligibility. For members, enter the first day of the second month of the upcoming ISP year.

Program Denials and Terminations - Block of check boxes that begin with “Based on a review of . . .”

Follow the instructions according to the appropriate program denial or termination action the form is being prepared for.

Based on a review of your current situation, it has been determined that — Select one of the following boxes if PSU staff denies or terminates the applicant or member from the STAR+PLUS HCBS program or MDCP.

The last day you can get services for ______ is ______ — Select this box if PSU staff terminates the STAR+PLUS HCBS program or MDCP eligibility. Select “STAR+PLUS HCBS Program” or “MDCP” in the first blank provided. Enter the last day the MCO is authorized to deliver services in the second blank provided.

You are not eligible for ______ — Select this box if PSU staff denies an applicant for the STAR+PLUS HCBS program or MDCP. Select “STAR+PLUS HCBS Program” or “MDCP” in the blank provided.

Reason for denial — Select this box for all denials and terminations. PSU staff must enter the reason for denying or terminating the applicant or member. Refer to SPOPH Appendix IV for appropriate language to use for the STAR+PLUS HCBS program. Refer to SKOPH Appendix II for appropriate language to use for MDCP.

Note: PSU staff must generate Form H2065-D and Form H2065-DS through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for MN denials.

Legal Basis for the Action (required for all forms)

The above decision is based on: — Select the boxes associated with the appropriate program.

STAR+PLUS HCBS Program Rule §353.1153 — Select this box for all STAR+PLUS HCBS program notices.

STAR+PLUS Program Support Unit Operational Procedures Handbook reference: — Select this box for all STAR+PLUS HCBS program denial and termination notices. Enter the associated handbook reference supporting the denial or termination. Refer to SPOPH Appendix IV for the appropriate handbook section.

MDCP Program Rule §353.1155 — Select this box for all MDCP notices.

STAR Kids Program Support Unit Operational Procedures Handbook reference: — Select this box for all MDCP denial and termination notices. Enter the associated handbook reference supporting the denial or termination. Refer to SKOPH Appendix II for the appropriate handbook section.

UMCM Chapter 16.2, STAR Health MDCP — Select this box if the applicant or member is enrolled in STAR Health.

Comments — Refer to SPOPH Appendix IV for appropriate language to enter (if any) for the STAR+PLUS HCBS program. Refer to SKOPH Appendix II for appropriate language (if any) for MDCP. 
Do not enter comments language not listed in the SPOPH Appendix IV or SKOPH Appendix II without first obtaining supervisor approval. Any comments entered by PSU staff on Form H2065-D must also appear in Spanish on Form H2065-DS. PSU staff must avoid the use of confidential information as indicated in the SPOPH and SKOPH.

Medicaid No. — Enter the applicant’s or member's Medicaid identification (ID) number. Leave blank if the applicant does not have a Medicaid ID number.

Page 2

Name — Enter the applicant’s or member's full name. 

Medicaid No. — Enter the applicant’s or member's Medicaid ID number. Leave blank if the applicant does not have a Medicaid ID number.

You might be able to get free legal help from outside HHSC. Call — Enter the area code and phone number of the legal aid office in the applicant’s or member’s county of residence using the Attachment — Legal Aid List.

Right to a Fair Hearing

I request a state fair hearing and want my services to continue during the fair hearing process — The member selects this box if he or she is requesting a state fair hearing and would like his or her STAR+PLUS HCBS program or MDCP services to continue during the state fair hearing process.

I request a state fair hearing. — The applicant or member selects this box if he or she is requesting a state fair hearing and does not want services to continue during the fair hearing process.

Services are not provided to applicants requesting a fair hearing.

Signature – Applicant/Member — The applicant, member, AR, LAR or medical consenter must sign in the blank provided.

Print Name – Applicant/Member — The applicant, member, AR, LAR or medical consenter must print his or her name in the blank provided.

Date — The applicant, member, AR, LAR or medical consenter must enter the date the form was signed in the blank provided and return the form to PSU staff.

Attachment — Legal Aid List