Revision 19-1; Effective June 3, 2019

 

 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-2; Effective September 3, 2018

 

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list according to the date and time of the request, regardless of the program's enrollment status. Each individual is released from the interest list in the order of the request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual's name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

 

2020 Individual Who Receives STAR Health

Revision 19-1; Effective June 3, 2019

 

See the Uniform Managed Care Manual (UMCM) for STAR Health members. The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

An individual enrolled with a STAR Health managed care organization (MCO) must remain enrolled with the STAR Health MCO.

Additional information on MDCP STAR Health members is located in the STAR Health MDCP Policy §16.2 of the UMCM.

 

2021 Individual Who Receives Other Types of Medicaid

Revision 18-2; Effective September 3, 2018

 

An individual who receives other types of Medicaid (i.e., non-Supplemental Security Income (SSI) and is either served in fee-for-service or enrolled with a STAR managed care organization (MCO) must select a STAR Kids MCO.

 

2030 Managed Care Organization Coordination

Revision 19-1; Effective June 3, 2019

 

The STAR Kids managed care organization (MCO) has 30 days following the initial notice from Program Support Unit (PSU) staff to complete all assessments for an individual enrolled in the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation, for a total of 60 days following the initial notice from PSU staff. The MCO must:

  • verify the individual meets all other eligibility criteria referenced in Section 1000, Overview and Eligibility;
  • complete Section B, Waiver Assessment Report, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
  • complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module and submit to Texas Medicaid & Healthcare Partnership (TMHP) following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP; and
  • complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and submit electronically to TMHP following the requirements in Appendix I.

If the MCO does not submit Form 2604 within 60 days after PSU staff uploaded Form H3676, Section A, Referral/Assessment Authorization, authorizing the MCO to begin the eligibility process, PSU staff must email Managed Care Compliance & Operations (MCCO).

The MCO must schedule and complete the SK-SAI, including the MDCP module, within 30 days of notice from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP, following the requirements in Appendix I within 72 hours of completion. For the purposes of this requirement, an SK-SAI is considered "complete" when the MCO has obtained the physician's signature on Form 2601, Physician Certification, and has retained this form in the individual's case file.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI. The MN determination must be made by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff process the SK-SAI for an individual to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for an individual or member and establish the service plan cost limit. The MDCP module of the SK-SAI (Section R, MDCP Related Items) is used to determine the RUG.

Once TMHP staff process an SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG value. This code may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A “BC1” code indicates the SK-SAI does not have all the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a “BC1” code. After 14 days, the MCO must inactivate the SK-SAI and submit a new SK-SAI in its place. Information about the process of transmitting, correcting and inactivating an SK-SAI is available in Appendix I.

As a part of the individual service plan (ISP) planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or RUG value assigned by TMHP. If the MCO does not properly establish this plan of care and the individual’s/member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual's/member's ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member's MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member or legally authorized representative (LAR) no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.

 

2100 Money Follows the Person

Revision 18-2; Effective September 3, 2018

 

 

2110 Traditional Money Follows the Person

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aged or who have disabilities live in the most integrated setting possible. The PI Initiative is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

  • state's treatment professionals determine the placement is appropriate;
  • affected persons do not oppose such treatment; and
  • placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Texas Government Code §531.151, as amended by Senate Bill 368, 77th Legislature, Regular Session, 2001).

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with an external vendor. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, in accordance with legislative direction, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another 1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other 1915(c) waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Reference the STAR Kids Contract, Section 8.1.15, for further information.

The MCO must have a protocol for quickly assessing the needs of members who have or will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

  • determine the member’s assigned permanency planner;
  • contact the member’s assigned permanency planner within seven days of the member’s facility admission;
  • collaborate with the member, the legally authorized representative (LAR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
  • contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC's contracted permanency planner to work with the member and the member's LAR to review community based options; and
  • work with the member, the LAR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid, and not enrolled in STAR Kids, requesting MDCP services through the MFP option must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff will authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because they meet the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference Section 2120, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

 

2111 Non-STAR Kids Individual Residing in an NF

Revision 19-1; Effective June 3, 2019

 

For requests to transition into the community under traditional Money Follows the Person (MFP) for a non-STAR Kids member, the individual's Texas Health and Human Services Commission (HHSC)-contracted permanency planner is the designated party responsible for the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the individual and the individual's family or legally authorized representative (LAR) as part of the permanency planning process;
  • lead the development of the individual's permanency plan;
  • educate the individual and LAR on 1915(c) Medicaid waiver options, including the Medically Dependent Children Program (MDCP);
  • document the individual's choice of the 1915(c) Medicaid waiver program; and
  • educate the individual about STAR Kids, including providing information about managed care and the importance of choosing a managed care organization (MCO).

Once the individual selects a 1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the individual's 1915(c) Medicaid waiver selection under MFP and update the address on file to that of the LAR, if needed.

If the individual or LAR chooses a 1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the waiver program selected and immediately release the individual from the interest list in the Community Services Interest List (CSIL) database, using the bypass code “Residing in a Nursing facility.” ILM Unit staff will forward the request to the selected 1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, and selected 1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community. 

Prior to the individual's discharge from the NF, the individual's selected MCO service coordinator must perform the initial SK-SAI and establish the initial ISP to reflect both MDCP services and any other identified supports, such as nursing or personal care services (PCS). The MCO initiates contact with the individual or LAR to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

Within 15 business days from contact with the individual or LAR, the MCO service coordinator performs the SK-SAI, including the MDCP module (record SK-SAI items Z5a and Z5b as 1 (yes) to ensure processing for MN and RUG). The MCO service coordinator must submit the SK-SAI to TMHP), following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of the assessment’s completion.

Within one business day of completing Form 2604, STAR Kids Individual Service Plan (ISP) - Service Tracking Tool, the MCO service coordinator must:

  • submit Form 2604 electronically following the requirements in Appendix I;
  • complete Section B, Waiver Assessment Report, of Form H3676; and
  • upload Form H3676 and Form H2067-MC, Managed Care Programs Communication, to TxMedCentral.

Within one business day following communication from the MEPD specialist of the individual's Medicaid eligibility, PSU staff will upload Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TXMedCentral Naming Conventions.

Within one business day prior to the individual's discharge, PSU staff generate the final Form H2065-D in the LTC Online Portal containing the service effective date and:

  • mail the final Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload on TxMedCentral within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

  • generate Form H2065-D in the TMHP LTC Online Portal;
  • mail the original Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder following the instructions in Appendix IX.

If the individual chooses to leave the NF before being determined eligible for MDCP, the MDCP case must be denied and the above steps followed.

 

2112 STAR Kids Member Residing in an NF

Revision 19-1; Effective June 3, 2019

 

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

  • contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner within seven days of the member's admission;
  • coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
  • perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
  • update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the member and family or legally authorized representative (LAR) as part of the permanency planning process;
  • lead the development of the member's permanency plan;
  • coordinate with the MCO service coordinator in updating the member's ISP, if applicable;
  • educate the member and LAR on 1915(c) Medicaid waiver options, including MDCP; and
  • document the member's choice of the 1915(c) Medicaid waiver program;

Within two business days of the referral from ILM Unit staff, PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's STAR Kids folder.

The MCO initiates contact with the member or LAR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member or LAR, the MCO service coordinator performs the SK-SAI. The MCO service coordinator must submit the SK-SAI to TMHP following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member and LAR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to TMHP following the requirements in Appendix I within one business day of completion.

As needed, PSU staff collaborate with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays.

If within 30 days after the member’s or LAR's request to return to the community the MCO has not completed the MN process and submitted the ISP, PSU staff will email Managed Care Compliance & Operations (MCCO) to advise of the delay. PSU staff will continue to monitor TxMedCentral for receipt of Form H3676 or Form H2067-MC, Managed Care Programs Communication.

Within one business day following receipt of Form H2067-MC from the MCO, PSU staff will:

  • confirm MDCP eligibility by verifying the member:
    • is under age 21;
    • has an approved MN;
    • has an ISP with at least one MDCP service;
    • has an ISP that is within the individual’s cost limit; and
    • has an appropriate Medicaid Type of Assistance (TOA) in TIERS;
  • generate the initial Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTC Online Portal; and
  • mail the initial Form H2065-D to the member.

Within one business day prior to the member’s discharge from the NF, PSU staff will:

  • generate the final Form H2065-D in the TMHP LTC Online Portal containing the service effective date;
  • mail the original Form H2065-D to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

If MDCP eligibility is denied, PSU staff will manually complete Form H2065-D and will:

  • mail the original Form H2065-D to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

 

2113 MDCP MFP Applications Pending Due to Delay in NF Discharge

Revision 19-1; Effective June 3, 2019

 

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

An individual who has not made living arrangements to return to the community, cannot decide when to return to the community, or has no viable plan or support system in the community should be denied the Medically Dependent Children Program (MDCP). PSU staff deny the request for services and will:

  • send Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

 

2120 MFP Limited NF Stay Option for a Medically Fragile Individual

Revision 18-2; Effective September 3, 2018

 

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
  • renal dialysis;
  • 24-hour/day supplemental oxygen dependence;
  • total nutrition through enteral tube feeding;
  • total parenteral nutrition (TPN);
  • seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
  • congestive heart failure requiring hospitalization and routine medication within the past six months; or
  • hospice.

An individual determined to be medically fragile and who is approved for a limited NF stay must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress that in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday because services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

 

2121 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-2; Effective September 3, 2018

 

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual's name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in by-passing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to by-pass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • an overview of MDCP services;
  • the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
  • the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
  • required medical documentation must be within 12 months of the date the documentation is submitted to ILM Unit staff, from the individual’s clinical record at the physician’s office, hospital, or clinic (not from a patient portal); and
  • admission and discharge documentation from the NF will be required.

ILM Unit staff will send Form 2406 to the individual, parent, guardian or legally authorized representative (LAR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian or LAR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian or LAR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

 

2130 Physician Determination of Medical Fragility

Revision 19-1; Effective June 3, 2019

 

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

 

2131 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Not Enrolled in Medicaid/Without Medicaid (including an individual enrolled in CHIP)

Revision 19-1; Effective June 3, 2019

 

When an individual who is not enrolled in STAR Kids Medicaid is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

A STAR Kids managed care organization (MCO) must be selected prior to the limited nursing facility (NF) stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option.

Within two business days of the MCO selection, orally or in writing, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral in the MCO's STAR Kids folder.

 

2132 PSU Procedures for an Individual Who is Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

When an individual with Medicaid eligibility, but who is not enrolled in STAR Kids, is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

A STAR Kids MCO must be selected prior to the limited NF stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option. Within two business days of the MCO selection, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral in the MCO's STAR Kids folder.

 

2133 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A, Referral/Assessment Authorization, of Form H3676 stating the member resides at home and, in the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option, and upload the form to TxMedCentral in the MCO's STAR Kids folder.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian or legally authorized representative (LAR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator.

 

2134 PSU and MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 19-1; Effective June 3, 2019

 

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian or legally authorized representative (LAR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral informing the individual of the decision to complete a limited NF stay. The MCO must initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian or LAR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual or NF must present a completed paper copy of Form 3618, Resident Transaction Notice, to the MCO service coordinator or the individual's parent, guardian or LAR showing the time and date of the limited NF stay admission and discharge. Form 3618 must be received by the MCO and uploaded to TxMedCentral the same date as the NF discharge or MDCP services cannot be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay option funding requirements. MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

The MCO has 60 days to complete all assessments and submit required forms to Program Support Unit (PSU) staff. The MCO must complete:

  • Section B, Waiver Assessment Report, of Form H3676, noting "MFP Limited NF Stay Assessment Completed" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module;
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool; and
  • Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.

The MCO must upload Form H3676 to TxMedCentral in the MCO's STAR Kids folder and submit the electronic Form 2604 to TMHP, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must maintain a copy of Form 2603 in the member’s or applicant's case file.

If the MCO does not submit an ISP within 60 days after PSU staff uploaded Form H3676, Part A, PSU staff notify Managed Care Compliance & Operations by email.

For STAR Kids members accessing MDCP through the limited NF stay process for the limited NF stay, PSU staff upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, to notify the MCO of the approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff upload Form H2067-MC to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by uploading Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator or the individual's parent, guardian or LAR on the date of discharge. The NF must understand the importance of processing and providing Form 3618 to the family and/or MCO service coordinator prior to NF discharge.

MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

Within 24 hours of the limited NF stay, the following activities must occur:

  • the MCO must notify PSU staff that the limited NF stay occurred by uploading Form H2067-MC in TxMedCentral, following the instructions in Appendix IX, requesting PSU staff approve MDCP services;
  • the MCO must upload Form 3618 to TxMedCentral (on the date of discharge) in the MCOs STAR Kids folder; and
  • PSU staff must respond to the MCO on Form H2067-MC by uploading to TxMedCentral in the MCOs STAR Kids folder, following the instructions in Appendix IX, noting that the applicant or member is pending approval of Medicaid eligibility; however, the applicant or member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services.

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff will upload Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, if the form was manually completed.

The MDCP effective date will be the first of the month in which the MFP individual was discharged from the NF.

MCOs must monitor the TMHP LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

  • manually complete Form H2065-D;
  • mail the final Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

 

2135 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request that the MEPD specialist delay certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and fax Form H1746-A to the MEPD specialist. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.”

If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny MDCP eligibility by:

  • manually completing Form H2065-D, Notification of Managed Care Program Services;
  • mailing the original Form H2065-D to the applicant or member; and
  • uploading Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

MCOs must monitor the TMHP LTC Online Portal for the status of the member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian or legally authorized representative (LAR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting Interest List Management (ILM) Unit staff, as described in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian or LAR requesting to reopen the Medicaid application. The MCO must upload the letter on TxMedCentral in the MCO’s STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request that the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by uploading Form H2067-MC in TxMedCentral, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian or LAR that a new Form H1200 must be completed.