Revision 18-0; Effective September 4, 2018
 

 

3100 STAR Kids Screening and Assessment

Revision 18-0; Effective September 4, 2018
 
All children and young adults enrolled with 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 Community First Choice (CFC), Personal Care Services (PCS) and/or Medically Dependent Children Program (MDCP) 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, legally authorized representative (LAR) or authorized representative (AR) should notify the MCO of the intended provider of services and the MCO will reach out to the provider.
 

3110 Assessment of Medical Necessity for Community First Choice

Revision 18-0; Effective September 4, 2018
 
A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids 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 obtained by the MCO, maintained in the MCO member case file signed 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 attached to the MCO member case file.

If an individual who is released from the MDCP interest list is receiving 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 Z5a 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, legally authorized representative (LAR) or authorized representative (AR). A physician’s certification, Form 2601, is not required for a reassessment of MN.

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 the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and Emergency Response Services (ERS). 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 MCO member case file, 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 the PCAM and Section P, but leaves Field Z5a marked “No” (indicated by a “0”). The MCO must note when the member’s MN expires and arrange for a reassessment with the member, legally authorized representative (LAR) or authorized representative (AR). If a member meets MN and has a need for CFC services, the MCO prepares an individual service plan (ISP) for the member and provides an authorization to the network provider of the member, LAR or AR’s choice.

 

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018
 
A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids 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 on the STAR Kids Screening and Assessment Instrument (SK-SAI) for a determination of MN and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP).

An applicant or member coming off the MDCP interest list must be assessed using the SK-SAI no later than 30 days following notification from Program Support Unit (PSU) staff, of the MCO selection as detailed in Section 2220, 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 considered complete when the physician’s signed and dated certification is on file with the MCO. MCOs assessing applicants or members for MDCP services must complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate “Yes” on Field Z5a (indicated by a "1") when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be signed and dated by the physician and maintained by the MCO in the MCO member case file. Form 2601 must be signed and dated by the member’s physician prior to the submission of the SK-SAI when Field Z5a is marked “Yes” (indicated by a “1”) on initial assessments for MDCP.

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.
 

3200 Member Reassessment

Revision 18-0; Effective September 4, 2018
 
All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days prior to the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid eligibility. Before the end date of the annual SK-SAI, the MCO must initiate a reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the end of the ISP. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about the Consumer Directed Services (CDS) option and Service Responsibility Option (SRO). The MCO is expected to complete the same activities for each annual assessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member, legally authorized representative (LAR) or authorized representative (AR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive Personal Care Services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The MCO must also complete the NCAM at any time the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

 

3210 Reassessment of Medical Necessity or Level of Care

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI) no earlier than 90 days before, and no later than 30 days prior to, the expiration of the member’s current individual service plan (ISP) on file for members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services. The MCO must indicate “Yes” in Field Z5a (indicated by a “1”) to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the MCO member case file contains Form 2601 from a previous assessment and there has been no change to the member’s health status. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member, legally authorized representative (LAR) or authorized representative (AR) to schedule a reassessment prior to the expiration of the member’s LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member’s ISP is completed by the MCO annually. PSU staff must search the TMHP Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

  • check the TMHP LTC Online Portal to determine if the MCO has electronically submitted Form 2604, STAR Kids Individual Service Plan Service Tracking Tool, before the ISP end date;
  • verify the member has an approved SK-SAI in the TMHP LTC Online Portal;
  • verify the ISP is within the cost limit in the TMHP LTC Online Portal;
  • confirm ongoing Medicaid eligibility and managed care enrollment is active in the Texas Integrated Eligibility Redesign System (TIERS); and
  • upload Form 2604 to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of an MDCP denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting PSU staff to manually generate Form H2065-D. Form H2065-D is not generated in the TMHP LTC Online Portal at reassessment for denials; PSU staff must manually complete Form H2065-D. PSU staff mail Form H2065-D to the member and post Form H2065-D to the appropriate MCO STAR Kids folder in TxMedCentral, following the instructions in Appendix IX, Naming Conventions. See Section 3328, Reassessment Notification Requirements, for additional information.
 

3300 Member Service Planning and Authorization

Revision 18-0; Effective September 4, 2018
 
Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. For new Medically Dependent Children Program (MDCP) members, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). For existing MDCP members, the ISP must be completed within 60 days of completion of the SK-SAI at reassessment. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs and member preferences. The ISP must be used to communicate and help align expectations between the member, legally authorized representative (LAR), authorized representative (AR), MCO and key service providers. The STAR Kids individual service plan (ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member, LAR or AR, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The ISP is used for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the STAR Kids MCO;
  • documenting services received through third party sources, such as §1915(c) Medicaid waiver programs operated by the state;
  • identifying the member’s strengths, preferences, support needs and desired outcomes;
  • identifying what is important to the member;
  • identifying natural supports available to the member and needed supports;
  • documenting the member’s preferences for when and how to receive services;
  • identifying special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
  • documenting the member’s unmet needs.

For STAR Kids members receiving MDCP services, the ISP must fall within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member, LAR or AR following any significant update, and not less than annually, within five business days of meeting with the member, LAR or AR. The MCO must provide a copy of the ISP to the member’s providers and other individuals specified by the member, LAR or AR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member, LAR or AR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports (LTSS) no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member’s current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member’s MCO service coordinator, or a representative of the MCO, must review and update each member’s ISP with the member, LAR or AR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

 

3310 Service Planning

Revision 18-0; Effective September 4, 2018
 
All STAR Kids individual service plan (ISP) narratives must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

  • a summary document describing the recommended service needs identified through the SK-SAI;
  • covered services currently received;
  • covered services not currently received, but the member may benefit from;
  • a description of non-covered services that could benefit the member;
  • member and family goals and service preferences;
  • natural strengths and supports of the member including helpful family members, community supports or special capabilities;
  • a description of roles and responsibilities for the member, legally authorized representative (LAR), authorized representative (AR) or others in the member’s support network, key service providers, the member’s health home, the managed care organization (MCO), and the member’s school with respect to maintaining and maximizing the health and well-being of the member;
  • a plan for coordinating and integrating care between providers and covered and non-covered services;
  • short and long-term goals for the member’s health and well-being;
  • if applicable, services provided to the member through other §1915(c) Medicaid waiver programs not operated by the MCO or third-party resources (TPR), and the sources or providers of those services;
  • plans specifically related to transitioning to adulthood for members age 15 and older; and
  • any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the SK-SAI, in addition to input from the member, family and caretakers, providers and any other individual with knowledge and understanding of the member’s strengths and service needs who is identified by the member, LAR, AR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member to provide, a copy of the member’s Individualized Education Plan (IEP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by TPR, like Medicare or available community services. Form 2603 is updated, per Section 3311 below, and is maintained in the MCO member case file.
 

3311 Updates to the Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
Each member’s individual service plan (ISP) must be updated at least annually, or sooner in the following situations outlined in the STAR Kids Managed Care Contract, Section 8.1.39.1:

  • upon discharge from an inpatient stay;
  • upon discharge from a long-term care facility;
  • upon a significant change in the member’s condition that results in a need for additional or reduced services;
  • upon notification of a significant change in life circumstance (change in family structure, a physical move or death in the family); and
  • within seven calendar days of the member’s request.

 
3320 Service Planning for Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) service coordinator must work with the member, legally authorized representative (LAR) or authorized representative (AR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member’s cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member’s Resource Utilization Group (RUG), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG are found in Appendix VIII, RUG IPC Cost Limits.

The MCO service coordinator documents MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Agency Option (AO), Consumer Directed Services (CDS) option, or Service Responsibility Option (SRO), if applicable. Form 2603 must also include a brief rationale (i.e., why the service is needed or requested).

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the MCO completes and submits the electronic ISP within 60 days of the initial referral from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic ISP within 60 days following receipt of a Texas Medicaid & Healthcare Partnership (TMHP) response to the SK-SAI submission. The response file from TMHP contains the determination of medical necessity (MN) and the member’s RUG. The start date for the ISP must be the first day of the month following the MN approval date. If a Medicaid eligibility determination is required, the start of care (SOC) date on the ISP is the first day of the month following the applicant meeting all eligibility criteria. An ISP is valid for one year.

When the member’s ISP is complete and within the member’s established cost limit, the MCO submits Form 2604 to the TMHP Long Term Care (LTC) Online Portal. The MCO must submit the electronic ISP prior to the start date of the member’s ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

If the member is turning age 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member’s cost limit. To calculate the prorated cost, the MCO must:

  • Step 1: divide the cost limit by the total number of days (365) in a year;
  • Step 2: determine the total number of days beginning with the start date of the ISP and ending the end of the month of the member’s 21st birthday; and
  • Step 3: multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.

Example: The member’s 21st birthday is July 9, the ISP start date is April 1, and the end date will be on July 31. The member’s cost limit is $25,000.

  • Step 1: $25,000 ÷ 365 days = $68.49 per day.
  • Step 2: The number of days per month: April = 30, May = 31, June = 30, July 31, for a total of 122 days.
  • Step 3: $68.49 × 122 = $8,355.78.

$8,355.78 is the prorated cost limit for the individual for the ISP.
 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 18-0; Effective September 4, 2018
 
If a member, legally authorized representative (LAR) or authorized representative (AR) requests a change to the member’s Medically Dependent Children Program (MDCP) individual service plan (ISP), but the member has not experienced a change in condition that affects his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 14 days.

To revise a member’s MDCP ISP when there is no change in the member’s RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and submits the ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the MCO member case file.
 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 18-0; Effective September 4, 2018
 
If a member, legally authorized representative (LAR), authorized representative (AR), service provider or service coordinator notify the managed care organization (MCO) about a change in the member’s condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days. The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, including the Medically Dependent Children Program (MDCP) module, and complete the following fields according to Appendix I, MCO Business Rules for SK-SAI and SK-ISP:

  • A10c = Medicaid number of the individual
  • A12 = 2 (Significant Change in Status Reassessment)
  • Z5a = 0 (No)
  • Z5b = 0 (No)

Following the MCO receipt of a TMHP response file indicating the member’s new RUG and associated cost limit, the MCO completes a new STAR Kids individual service plan (ISP) that reflects the member’s, LAR’s or AR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member’s new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the MCO member case file.

If a member will turn age 21 between the start and end date of the member’s ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or Transition Assistance Services (TAS) are provided prior to the end of the month of the member’s 21st birthday. If the MCO authorizes adaptive aids, minor home modifications or TAS, the MCO remains responsible for payment for those services, including applicable warranties.
 

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member, legally authorized representative (LAR) or authorized representative (AR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member, LAR or AR chooses to set aside funds, the MCO must document the member’s, LAR’s or AR’s preferences and maintain documentation in the MCO member case file. A member, LAR or AR may not carry forward funds between ISP periods.
 

3324 Individual Service Plan Exceeding the Cost Limit for MDCP Services

Revision 18-0; Effective September 4, 2018
 
If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits by email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

  • STAR Kids Screening and Assessment Instrument (SK-SAI);
  • STAR Kids individual service plan (ISP) and any Addendums; and
  • Medical records (nursing care plan, recent care notes, doctor’s orders and nursing notes).

HHSC UR may request a clinical review of the case to consider the use of state General Revenue (GR) funds to cover costs exceeding the 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and Program Support Unit (PSU) staff.

Note: MCOs must not discuss with applicants, members, legally authorized representatives (LARs) or authorized representatives (ARs), or request use of state GR funds for services above the cost ceiling.
 

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 18-0; Effective September 4, 2018
 
In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each member.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member’s care is based on his or her individual service plan (ISP) and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.
 

3326 Suspension of Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018
 
To remain eligible for Medically Dependent Children Program (MDCP) services, a member must receive one MDCP service monthly. In the event that the member travels out of state, is admitted to a hospital or nursing facility (NF), or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. The MCO must document the:

  • dates during which services are suspended; and
  • reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

 
3327 Reassessment Individual Service Plan Provider Procedures

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must ensure the member’s individual service plan (ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

  • check the TMHP LTC Online Portal to determine if the managed care organization (MCO) has submitted Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool,  before the ISP end date;
  • verify the member has an approved STAR Kids Screening and Assessment Instrument (SK-SAI) in the TMHP LTC Online Portal;
  • verify the ISP is within the cost limit in the TMHP LTC Online Portal; and
  • confirm ongoing Medicaid eligibility and managed care enrollment is active in the Texas Integrated Eligibility Redesign System (TIERS); and
  • upload Form 2604 to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.
 

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) on a monthly basis to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that expire within the next 90 days.

PSU staff will provide this report to the managed care organizations (MCOs) prior to the monthly call with PSU staff. The MCOs must provide a status update for all members who have ISPs expiring within the next 45 days. Although the ISP Expiring Report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update from the MCO.

The process for managing the ISP Expiring Report is as follows:

  • PSU staff provide the ISP Expiring Report to the MCO point of contact and to Managed Care Compliance & Operations (MCCO) staff by email five business days prior to the scheduled monthly call. The day of the call is not considered one of the business days.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, completing the columns highlighted in red on the spreadsheet.
  • The MCO must return a completed report to PSU staff within two business days prior to the monthly call.
  • PSU staff review the MCO responses to determine if the MCO needs to provide clarification regarding any member’s ISP status. During the monthly call, only ISP statuses about which PSU staff have questions are reviewed. There is no need to review each member for the status of the ISP if the MCO response is sufficient. PSU staff use the columns in blue on the spreadsheet for internal tracking purposes.

Note: There will not be a need to review each member for the status of the ISP if the MCO response is sufficient.

 

3328 Reassessment Notification Requirements

Revision 18-0; Effective September 4, 2018
 
If the member continues to meet MDCP requirements, Program Support Unit (PSU) staff do not mail Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. PSU staff do not send any notification to the member. For an approved MDCP reassessment, PSU staff must upload into the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record:

  • Texas Integrated Eligibility Redesign System (TIERS) screenshot of Medicaid history;
  • TIERS screenshot of managed care enrollment;
  • Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal screenshot of medical necessity (MN) approval;
  • Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool;
  • all copies of Form H2067-MC, Managed Care Programs Communication, PSU staff sent to the managed care organization (MCO) and received from the MCO; and
  • screenshot of all PSU postings of Form H2067-MC to TxMedCentral.

If the member does not meet MDCP requirements, within two business days of receiving Form H2067-MC from the MCO, PSU staff must:

  • mail Form H2065-D to the member indicating why the case is being terminated;
  • terminate the individual service plan (ISP) through the TMHP LTC Online Portal;
  • manually generate Form H2065-D and upload to the MCO STAR Kids folder in TxMedCentral, following the instructions in Appendix IX, Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Coversheet, notifying the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of the program denial;
  • for MAO members, email Form H2065-D to Enrollment Resolution Services (ERS). The email to ERS must include the following information:
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (reassessment denial);
    • MN denial date;
    • ISP end date;
    • Form H2065-D; and
  • upload Form H2065-D, screenshot of Form H2065-D posting to TxMedCentral, screenshot of terminated ISP in TMHP LTC Online Portal, Form H1746-A, if applicable, and email sent to ERS, if applicable, to the HEART case record.

If the member files a state fair hearing within the 10-day adverse action period (refer to Section 6100, Ten Day Adverse Action Notification), within two business days of notification PSU staff must:

  • send an email to the to the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox, notifying the Centralized Representative Unit (CRU) specialist of the member’s request for an appeal and continued benefits;
  • post Form H2067-MC in TxMedCentral to the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions, informing the MCO to continue services due to the timely appeal (if services have already ended, the MCO reinitiates services immediately);
  • extend the end date of the current ISP in the TMHP LTC Online Portal for an additional four calendar months;
  • for MAO members, send an email to ERS as notification that a timely appeal was submitted and enrollment should remain open; and
  • upload a copy of the email sent to the AES Fair Hearing mailbox, Form H2067-MC, screenshot of Form H2067-MC posting to TxMedCentral, screenshot of TMHP LTC Online Portal ISP extension, and email sent to ERS, if applicable, to the HEART case record.

PSU staff carry out the decision within 10 days of receiving the fair hearings officer’s decision.

 

3400 Member Transfers

Revision 18-0; Effective September 4, 2018

 

 

 
3410 Transfer from One Managed Care Organization to Another

Revision 18-0; Effective September 4, 2018
 
Once the initial enrollment period of one calendar month of service authorization has passed, a member is eligible to change managed care organization (MCO) plans. When a member, legally authorized representative (LAR) or authorized representative (AR) chooses to change from one MCO to another MCO in the same service area (SA), the member, LAR or AR must contact the state contracted enrollment broker by telephone at 800-964-2777 or via written correspondence.

The member can request to change MCOs as many times as the member wants, but the change cannot be made more than once per month. If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day of the month, the change will take place the first day of the second month following the change request.

Examples:

  • If the member calls on or before April 15, the change will take place on May 1.
  • If the member calls after April 15, the change will take place on June 1.

Texas Health and Human Services Commission (HHSC) Operations prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. PSU staff receive a full list and share MCO specific information with Managed Care Compliance & Operations (MCCO) staff by email. MCCO staff share the list with MCOs. The MCO receives a member-specific report that gives a list of STAR Kids members who have changed MCOs from the previous month.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning the result of the MCO assessment upon the gaining MCO request. Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the MCO member case file from the losing MCO, such as the member’s Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must ensure the member’s new service coordinator, once assigned, contacts the member’s former service coordinator at the losing MCO to ensure a seamless transition of service coordination. The gaining MCO must contact the losing MCO for additional information maintained in the MCO member case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify MCCO staff.

MCCO staff must contact the losing MCO and require the MCO to upload information contained in the MCO member file to TxMedCentral, including Form 2603 and any current authorizations, within two business days of notification. MCCO staff inform PSU staff by email, the date by which the MCO must upload the information to TxMedCentral. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from MCCO staff. The STAR Kids Screening and Assessment Instrument (SK-SAI) and electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, as well as historical SK-SAIs and ISPs, will be available to the gaining MCO upon enrollment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within five business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 15 business days of enrollment of the new member, the gaining MCO must conduct a home visit to assess the member’s needs. For continuity of care, this includes authorizations, additional assessments, and pending delivery of adaptive aids, minor home modifications or Transition Assistance Services (TAS). This home visit may include conducting the SK-SAI if the member is due for a new assessment, has experienced a significant change in condition, or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires a new assessment or until the gaining MCO is able to complete its own SK-SAI, update the ISP, and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs. If the gaining MCO is in a different SA because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member, LAR or AR. Out-of-network authorizations must continue until the existing ISP expires or the gaining MCO can provide comparable services to transition the member to a provider that will be able to meet the member’s needs.
 

3420 Transfer from Medicaid Waiver Program to Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018
 
Participants in other §1915(c) Medicaid waiver programs operated by the state may be on the interest list for the Medically Dependent Children Program (MDCP). If a STAR Kids member in another §1915(c) Medicaid waiver program comes up on the interest list for MDCP, Interest List Management (ILM) Unit staff make a referral to Program Support Unit (PSU) staff.

Within 14 days of the initial request for an MDCP assessment, PSU staff must:

  • contact the individual and explain MDCP services; and
  • mail a copy of the STAR Kids managed care organization (MCO) provider directories and STAR Kids Comparison Charts to the individual.

All attempted contacts with the individual or encountered delays must be documented in the Texas Health and Human Services (HHS) Enterprise Administrative Record and Tracking System (HEART) case record.

Within two business days of notification of the MCO selection by the §1915(c) Medicaid waiver applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post to the MCO STAR Kids folder on TxMedCentral, following the instructions in Appendix IX, Naming Conventions,.

The MCO completes:

  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module;
  • Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and submits it electronically in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal; and
  • Section B of Form H3676 and sends to PSU staff, once the SK-SAI is complete.

If the information from the MCO is not received within 60 days after the assessment is authorized, PSU staff email the assigned Managed Care Compliance & Operations (MCCO) staff as notification the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required MDCP eligibility documentation, PSU staff determine MDCP eligibility based upon medical necessity (MN) and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for MDCP is denied or the individual decides not to accept MDCP services, PSU staff must:

  • generate Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTC Online Portal;
  • mail the original Form H2065-D to the §1915(c) Medicaid waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving; and
  • upload Form H2065-D to the applicant’s HEART case record.

The MCO must monitor the TMHP LTC Online Portal to check the status of the member’s ISP and to retrieve Form H2065-D.

If eligibility is approved and the individual chooses to accept MDCP services, the individual is enrolled in MDCP the first day of the next month. Within two business days of determining the start of care (SOC) date for MDCP services, PSU staff must:

  • generate Form H2065-D in the TMHP LTC Online Portal;
  • mail Form H2065-D to the §1915(c) Medicaid waiver member; and
  • notify Enrollment Resolution Services (ERS) by email. The email to ERS must include the following information:
    • the individual’s name;
    • Medicaid identification (ID) number;
    • type of request (waiver transfer);
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D.

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current §1915(c) Medicaid waiver services end the day before enrollment in MDCP. The MCO must monitor the TMHP LTC Online Portal for the status of the member’s ISP and to retrieve Form H2065-D.
 

3430 Transfer from MDCP to Another Medicaid Waiver Program

Revision 18-0; Effective September 4, 2018
 
STAR Kids members receiving Medically Dependent Children Program (MDCP) services may be on an interest list for another Medicaid program such as Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD) or Texas Home Living (TxHmL). The Texas Health and Human Services Commission (HHSC) informs the managed care organization (MCO) that a member receiving MDCP services has come to the top of the interest list for another program and is assessed as eligible for that program.

The MCO service coordinator or case manager must contact Program Support Unit (PSU) staff to assist in coordinating the end of MDCP services the day prior to the member’s enrollment in the new program. PSU staff must coordinate with the member’s MCO about the end of MDCP services and the member’s transition to another §1915(c) Medicaid waiver. The member remains in the same STAR Kids MCO he or she is currently enrolled for his or her state plan services.

PSU staff are responsible for completing the following activities within 14 days of the initial request for an MDCP assessment. All attempted contacts with the member or encountered delays must be documented in the member’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must:

  • create a case record in the HEART;
  • check the Community Services Interest List (CSIL) database to see if the member is on a §1915(c) Medicaid waiver program interest list;
  • confirm if the member has an open enrollment with another §1915(c) Medicaid waiver program according to the procedures below:
  • For either the TxHmL or HCS waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether a member is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
  • For the CLASS (Service Group 2) and DBMD (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waivers.
  • close the MDCP release in the CSIL database effective the date of the notification from the MCO informing of the member’s decision to transfer to another §1915(c) Medicaid waiver program; and
  • mail Form 2442, Notification of Interest List Release Closure, to the member as notification of the MDCP closure. If the CLASS or other §1915(c) Medicaid waiver program application is denied, Form 2442 will instruct the member to contact the Interest List Management (ILM) Unit staff if he or she wishes to apply for MDCP. When the member contacts ILM Unit staff, he or she will be reinstated on the MDCP interest list.

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that MDCP members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.
 

3440 Transfer from Community Care for Aged and Disabled Services to STAR Kids

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must coordinate the termination of Community Care for Aged and Disabled (CCAD) services with the CCAD case worker so the individual does not experience a break in services and does not receive concurrent services through another §1915(c) Medicaid waiver or CCAD.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), PSU staff coordinate the termination of CCAD services with the §1915(c) Medicaid waiver or CCAD case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through CCAD services.

CCAD services are terminated by the CCAD case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.
 

3500 Transition from Medically Dependent Children Program to Adult Programs

Revision 18-0; Effective September 4, 2018
 
Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are age 15 and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including the STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.
 

3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018
 
Possible §1915(c) Medicaid waiver and service combinations the member may be receiving prior to transition:

  • Medically Dependent Children Program (MDCP) only;
  • private duty nursing (PDN) only;
  • Prescribed Pediatric Extended Care Center (PPECC) services only;
  • MDCP with either or both of the following services:
  • personal care services (PCS);
  • PDN/PPECC;
  • MDCP with Community First Choice (CFC) services;
  • PDN/PPECC with PCS; and
  • PDN/PPECC with CFC services.

 
3511 Twelve Months Prior to the Member’s 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Twelve months prior to the 21st birthday of a member receiving services from the Medically Dependent Children Program (MDCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, Utilization Review (UR) Unit staff provide a copy of the Comprehensive Care Program (CCP) Transition Report, which lists individuals enrolled in STAR Kids and receiving MDCP and/or PDN/PPECC and/or CFC services who may transition to STAR+PLUS or the STAR +PLUS Home and Community Based Services (HCBS) program in the next 18 months, to the:

  • PSU supervisor; and
  • Utilization Management (UR) Unit staff for the intellectual and developmental disability (IDD) §1915(c) Medicaid waiver programs.

Procedures for managing this report, including time frames, can be found in Appendix VI, STAR Kids Transition Activities.

The managed care organization (MCO) identifies all members turning age 21 within the next 12 months and schedules a face-to-face visit with the member and the member’s available supports, including the legally authorized representative (LAR) or authorized representative (AR), if applicable, to initiate the transition process.

During the home visit with the member, LAR or AR, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member’s 21st birthday. The transition activity points to be discussed by the MCO include:

  • STAR Kids eligibility will terminate on the last day of the month in which the member’s 21st birthday occurs and the individual will need to receive services through programs serving adult populations.
  • Individuals who meet STAR+PLUS enrollment criteria will transition to STAR+PLUS the first of the month following their 21st birthday.
  • The STAR+PLUS HCBS program may be an option available to the member at age 21. The MCO must also present an overview of the array of services available in the STAR+PLUS HCBS program.
  • Children’s services, such as PDN and MDCP, are not available to adults. For members receiving PDN, the STAR+PLUS HCBS program or an IDD waiver will need to cover medically necessary nursing services that are not intermittent or part time at age 21, which may not be the same level of nursing the member receives through STAR Kids. To be eligible for the STAR+PLUS HCBS program or an IDD waiver, the member’s health and safety must be ensured under the cost limit for the IDD waiver program.
  • Assist the member with looking for an adult primary care physician (PCP), specialists (as necessary) and a dentist.
  • Provide information and referral to community organizations that are important to the health and well-being of the member. These organizations include but are not limited to:
    • State/federal agencies (e.g., those agencies with jurisdiction over aging, public health, substance abuse, mental health, IDD, rehabilitation, income support, nutritional assistance, family support agencies, etc.). For members with progressive vision loss, a referral is made to explore services offered through the Texas School for the Blind and Visually Impaired;
    • Social service agencies (e.g., area agencies on aging, residential support agencies, independent living centers, SE agencies, etc.);
    • City and county agencies (e.g., human services, housing programs, etc.);
    • Civic and religious organizations; and
    • Consumer groups, advocates and councils (e.g., legal aid offices, consumer/family support groups, permanency planning, etc.).
  • Current and possible future community living options, and coordinating visits with potential providers or facilities, if applicable.
  • Assess the member’s needs for adaptive aids and new equipment due to growth and development, and minor home modifications, as necessary.
  • Guardianship and provide contact information.
  • Transition activities that begin no later than nine months prior to the member’s 21st birthday.
  • STAR+PLUS enrollment packets (containing the STAR+PLUS MCO list and a comparison chart).
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid being assigned an MCO or having a gap in services.
  • Member’s available supports and that the member can change MCOs any time after the first month of enrollment.
  • STAR+PLUS HCBS program cost limit based on a medical assessment and the Medical Necessity/Level of Care (MN/LOC) Assessment. The limit is 202% of the member’s Resource Utilization Group (RUG).The assessment results in the cost limit for the annual individual service plan (ISP).
  • To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit that will meet the member’s needs and ensure health and safety.
  • If an ISP cannot be developed within the cost limit that ensures the health and safety, the STAR+PLUS HCBS program will be denied.
  • The ISP considers all resources available to meet the member’s needs, including community supports, other programs, and what the member’s informal support system can provide to meet the member’s needs.
  • The STAR+PLUS HCBS program assessment process begins six months before the member’s 21st birthday. PSU staff will contact the member to begin the assessment process and find out which STAR+PLUS MCO has been selected. If an MCO has not been selected, then 30 days is allowed for a selection. After 30 days, an MCO is selected for the member.
  • After the STAR+PLUS MCO is selected, the MCO will contact the member to begin the assessment for services and assist the member and available supports in identifying and developing additional resources and community supports to help meet the member’s needs.

The STAR Kids MCO must:

  • Make a referral to PSU staff via email using Form H2067-MC, Managed Care Programs Communication, and includes "PDN and/or MDCP Transition” in the subject line;
  • Monitor transition activities with the member or the support person every 90 days during the year before the member turns age 21; and
  • Notify the  UR Unit staff via email indicating this may be a high needs member, if the member appears to meet the criteria in the STAR+PLUS Handbook, Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program.

PSU staff for the STAR+PLUS HCBS program must:

  • monitor the CCP Transition Report and identify all individuals referenced in Section 3510, Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC, turning age 21 in 12 months and not enrolled in one of the following IDD §1915(c) Medicaid waiver programs:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL); and
  • create a case in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) noting:
    • if the MCO determines the member is high needs;
    • the program type (i.e., MDCP, CFC or PDN/PPECC) transitioning from; and
    • due date for the nine month contact.

The following chart outlines the responsibilities for monitoring the STAR Kids Transition Report and contacting members transitioning from STAR Kids who receive MDCP, PDN or PPECC, or CFC within the next 12 months:

Twelve Month Transition Chart
Under Age 21 MDCP Under Age 21 Other Services Received Monitors STAR Kids Report: 12-Month Contact:
MDCP PDN/PPECC PSU Staff STAR Kids MCO
MDCP CFC PSU Staff STAR Kids MCO
MDCP PCS PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP None PSU Staff STAR Kids MCO
None PDN/PPECC PSU Staff STAR Kids MCO
None PDN/PPECC and CFC PSU Staff STAR Kids MCO
None PDN/PPECC and PCS PSU Staff STAR Kids MCO

 

3512 STAR+PLUS Transition Activities

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines as outlined in the STAR+PLUS Handbook, Section 3420, Individuals Transitioning to an Adult Program.
 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 18-0; Effective September 4, 2018
 
Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity (MN) criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

  • Children and young adults who have been approved for and are currently utilizing IPV in traditional Medicaid will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of the child/young adult when he transitions to a STAR Kids MCO.
  • When a member turns age 21 and transitions into STAR+PLUS, young adults who have been approved for and are currently utilizing IPV will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of a young adult. The member will not be subjected to an abrupt removal of equipment. The member will continue to receive ongoing treatment until the final decision is made, on a case-by-case basis, with thorough review and documentation by the managed care organization (MCO) and explicit approval by HHSC administration.
  • STAR Kids MCOs will address a new request for IPV on a case-by-case basis based on MN criteria for the member.

 
3520 Transition Policy for Non-Waiver Members Receiving PCS or CFC Only

Revision 18-0; Effective September 4, 2018

STAR Kids eligibility will terminate the last day of the month in which the member’s 21st birthday occurs, after which the member will need to receive services through programs serving adults. Members must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program.

The Texas Health and Human Services Commission’s (HHSC’s) state contracted enrollment broker will reach out to the member 30 days prior to the member’s 21st birthday and provide the member with a STAR+PLUS enrollment packet (containing the STAR+PLUS managed care organization (MCO) list). The member must make an MCO selection within 15 days. If the member has not made an MCO selection after 15 days, the state contracted enrollment broker will select an MCO for the member, as outlined in Title 1 Texas Administrative Code (TAC) §353.403(3).