Revision 18-2; Effective September 3, 2018

 

Acute care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration. Exception: Some services for children are considered chronic and are covered under the State Medicaid Plan.

Agency option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

Applicant — A person who has applied for Medicaid benefits.

Authorized Representative — Any person or entity acting on behalf of individuals and with the individual’s written consent.

Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.

Code of Federal Regulations (CFR) — The codified federal regulations that govern most federal programs, including Medicaid.

Community First Choice (CFC) option — Personal assistance services; habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in STAR Kids who have received an institutional Level of Care (LOC) determination.

Community Living Assistance and Support Services (CLASS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities.

Comprehensive Care Program (CCP) — A package of Medicaid services available to individuals based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps benefit for individuals under age 21.

Consumer Directed Services employer — A member or legally authorized representative (LAR), parent, or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.

Consumer Directed Services (CDS) option — A service delivery option in which a member or LAR employs and retains service providers and directs the delivery of eligible STAR Kids program services. A member participating in the CDS option is required to use a financial management services agency (FMSA) chosen by the member or LAR to provide financial management services.

Day — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals who are deaf and blind and have a third disability.

Denial — Closure of an application with a finding of ineligibility.

Designated Representative (DR) – A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the employer. A DR, usually a family member, is not a paid service provider and is at least age 18.

Early and periodic screening, diagnosis and treatment (EPSDT) — Federally mandated Early and Periodic Screening, Diagnosis and Treatment program contained at 42 U.S.C. 1396d(r). The name has been changed to Texas Health Steps (THSteps) in the state of Texas.

Eligibility date — The first date all eligibility criteria are met.

Employee (service provider) – An individual who is hired, trained and managed by the employer to provide services authorized by the MCO.

Enrollment broker — A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP).

Family member — A person who is related by blood, affinity or law to an individual.

Financial management services (FMS) — Assistance provided to members who manage funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.

Financial management services agency (FMSA) – An agency that contracts with the MCO to provide FMS to members who choose the CDS option.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

Home and community-based services (HCS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities as cost-effective alternatives to institutional care.

Individual service plan (ISP) narrative — An individualized and person-centered plan in which a member enrolled in the STAR Kids and community-based services program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.

ISP Service Tracking Tool — This tool is developed at least annually by the member, the MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost ceiling. This is also known as Form 2604.

Intellectual and developmental disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social, and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.

Interdisciplinary team (IDT) — All individuals/entities involved in planning the member’s plan of care (POC). This typically includes the member, the member’s legal or authorized representative, the service coordinator, the primary care physician, etc.

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of a member, including a parent, guardian, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code Chapter 752.

Managed care organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with Chapter 843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.

Medically Dependent Children Program (MDCP) — A §1915(c) waiver program which provides respite, Flexible Family Support Services, minor home modifications, adaptive aids, Transition Assistance Services, and FMS to prevent placement of individuals in long-term care facilities who are medically dependent and under age 21 and support deinstitutionalization of nursing facility residents under age 21.

Medical necessity (MN) — The medical criteria a person must meet for admission to a Texas nursing facility (NF), as defined in Texas Administrative Code, Title 40, §19.2401.

Member — An individual who is enrolled in and receiving services through a STAR Kids MCO.

Money Follows the Person (MFP) — A process used when a member in a Medicaid-certified NF who requests to move to the community is Medicaid-eligible and approved for the STAR Kids program before leaving the NF.

Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and long-term services and supports (LTSS). The POC is not the same as the ISP service tracking tool used for MDCP services.

Program Support Unit (PSU) — An HHSC unit with staff who support and handle certain aspects of the STAR Kids program.

Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

Respite services — Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Responsible adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.

Responsible party — An individual who:

  • assists and/or represents an applicant or member in the application or eligibility redetermination process; or
  • is familiar with the applicant or member and his or her financial affairs and functional condition.

Service Coordinator – The MCO staff person with primary responsibility for providing service coordination and care management to STAR Kids members.

Service Plan – A POC developed by the MCO service coordinator authorizing tasks to be performed by the service provider (e.g., ISP).

Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services (PAS). The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

Social Security Administration (SSA) — U.S. government agency created in 1935 by President Franklin D. Roosevelt, the SSA administers the social insurance programs in the U.S. The agency covers a wide range of Social Security services, such as disability, retirement and survivors benefits.

STAR Kids — Managed care program for recipients under the age of 21 who receive SSI, SSI-related Medicaid, and/or 1915(c) waiver services.

STAR+PLUS program — State of Texas Access Reform Plus Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange, and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program.

Supplemental Security Income (SSI) — Federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter. Most individuals receiving SSI who are under the age of 21 are eligible for Medicaid and are required to enroll in STAR Kids.

Support advisor — An employee who provides support consultation to an employer, a DR, or a member receiving services through the CDS option.

Support consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.

Texas Administrative Code (TAC) — A compilation of all the state agency rules in Texas.

Termination — Closure of an ongoing case due to a finding of ineligibility.

Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code Chapter 531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.

Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service claims processing. TMHP is also responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for the MDCP waiver and CFC.

Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved state Medicaid plan, or as part of their caregiving arrangement without pay.

Texas Health Steps (THSteps) — The name adopted by the state of Texas for the federally mandated EPSDT program.

TxMedCentral — A secure internet bulletin board the state and MCOs use to share information.