Revision 20-3; Effective December 1, 2020

 

 

6050 Description

Revision 20-3; Effective December 1, 2020

 

Sections 6100 and 6200 provide information pertaining to denial of Medically Dependent Children Program (MDCP) services for active members, along with adequate notice of a member's rights and opportunities to due process.

Section 6300 provides information on member or managed care organization (MCO) requested disenrollment from the STAR Kids Program. 

1 Texas Administrative Code §353.1203, which is cited on Form H2065-D, Notification of Managed Care Program Services, is the basis for all STAR Kids case actions.

 

6100 Ten Business Day Adverse Determination Notification

Revision 20-3; Effective December 1, 2020

 

Texas Health and Human Services Commission (HHSC) requires a notice to be sent to the member at least 10 business days before the action effective date. The member must be given the full 10 business day adverse action period to allow time to file an MCO internal appeal or request an external medical review, and/or fair hearing, as described below:

(a) If the agency mails the 10 business day notice, or within the time frames specified, as required under 42 Code of Federal Regulations (CFR) §431.213 or §431.214, and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless—

(1) It is determined at the hearing that the sole issue is one of Federal or State law or policy; and

(2) The agency promptly informs the beneficiary in writing that services are to be terminated or reduced pending the hearing decision.

The managed care organization (MCO) must calculate time periods related to adverse actions in accordance with instruction provided in §311.014 of the Code Construction Act. It specifies that:

(a) In computing a period of days, the first day is excluded and the last day is included.

(b) If the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 10 business day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10 business day adverse action period requires the period to be extended. Legal holidays do not include holidays when HHSC offices are officially open, even with limited workforce.

The full adverse action period may be waived if the individual signs a statement to waive the adverse action period.

To ensure the member is provided the full 10 business day adverse action period, the MCOs must mail the adverse determination document no later than 10 business days prior to the date the adverse action is to occur.

 

6200 Denial/Termination of Medically Dependent Children Program

Revision 20-3; Effective December 1, 2020

 

Program level denials are initiated when the member does not meet one or more Medically Dependent Children Program (MDCP) eligibility criteria. 

MDCP may be denied or terminated for the following reasons, which will be included on Form H2065-D, Notification of Managed Care Program Services:

  • Residence in a nursing facility for more than 90 days;
  • Member voluntary withdrawal; 
  • Medicaid financial eligibility;
  • Exceeding the cost limit;
  • Medical necessity (MN); or
  • Inability to locate the member.

The managed care organization (MCO) must:

  • monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN denial notice; and
  • notify the Program Support Unit (PSU) of the reason for denial request by submitting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in accordance with the conventions identified in Chapter 16.2 of the Uniform Managed Care Manual. 

PSU will:

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

 

6210 Denial/Termination Due to Death

Revision 20-3; Effective December 1, 2020

 

Within two business days of verification of the death of a member, Program Support Unit (PSU) staff will post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization’s (MCO’s) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.


If a member's Medicaid eligibility has been denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries must be made to end enrollment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Services must be terminated once death of the member has been confirmed by PSU staff. 


A 10 business day adverse action period is not required for death denials.

 

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 20-3; Effective December 1, 2020

 

The process for members residing in a nursing facility (NF) (excluding Truman Smith*) is as follows:

  • For members enrolled in STAR Kids, the enrollment remains open while a member resides in an NF. 
    • For members with Supplemental Security Income (SSI) or SSI-related Medicaid, the member remains enrolled in STAR Kids but Medically Dependent Children Program (MDCP) services must be suspended per Section 3326, Suspension of Medically Dependent Children Program Services. 
    • For members without SSI or SSI-related Medicaid (i.e., medical assistance only (MAO) members), the member remains enrolled in STAR Kids but MDCP services must be suspended per Section 3326.
  • If a member enrolled in MDCP has resided in an NF for 90 days or more, the managed care organization (MCO) must notify Program Support Unit (PSU) staff within 14 days following the 90th day of residence. 
    • The MCO sends this notice to PSU staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Once a denial is complete, if a member decides to discharge from the NF, the member would be directed to pursue Money Follows the Person (MFP) found in Section 2100, Money Follows the Person.

*Members enrolled in STAR Kids who enter the Truman Smith NF or a state veteran's home are excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied.

 

6230 Denial/Termination of Medicaid Financial Eligibility

Revision 20-3; Effective December 1, 2020

 

A member's continued receipt of STAR Kids services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or Medicaid for the Elderly and People with Disabilities (MEPD) specialists for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

The chart below describes how to proceed if financial eligibility is denied.

 

When the individual is denied SSI: When the individual is denied MAO:
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to SSA is available to the individual.
  • The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS) (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to MEPD is available to the individual.
  • The individual can contact the local HHSC office to request other LTSS (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.

For SSI members, the termination date must match the SSA termination date.

For MAO members, the termination/denial date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past when PSU staff become aware of the denial.

6240 Denial/Termination as a Result of Exceeding the Cost Limit

Revision 20-3; Effective December 1, 2020

 

The Medically Dependent Children Program (MDCP) waiver is intended to serve individuals who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems in determining if the MDCP individual service plan (ISP) ensures the needs of the applicant or member. 


As part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid Healthcare Partnership (TMHP). HHSC expects this type of denial will occur rarely as MDCP members primarily receive state plan services.


When MDCP applicants or members exceed their assigned cost limit, the MCO must notify Program Support Unit (PSU) staff of the MDCP program denial request of MDCP and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial request is based on the inadequacy of the ISP, including both MDCP and non-MDCP services, to meet the needs of the individual within the RUG cost limit.

 

6250 Denial/Termination of Medical Necessity

Revision 20-3; Effective December 1, 2020

 

Medically Dependent Children Program (MDCP) services must be denied when an applicant or member fails to meet medical necessity (MN) criteria.

Notification can come from:

  • the monthly individual service plan (ISP) expiring report;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

The MCO must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for notification of a preliminary denial of medical necessity “MN Pending Denial.”


When the MN status is in the “MN Pending Denial” status, the MCO must: 

 

  • Verify with the TMHP nurse assessor what information is missing for MN;
  • Review Form 2605, Member SK-SAI MDCP Review Signature, Question 8. 
    • If the answer on Form 2605 is marked “Yes”:
      • Contact the member or Legally Authorized Representative (LAR) to confirm the request to have a peer-to-peer review;
      • Contact the listed physician of choice on Form 2605 to schedule and complete a peer-to-peer review; 
      • Submit any information obtained during the review to TMHP to support MN; and
      • Continue the denial process as outlined below.
    • If the answer on Form 2605 is marked “No”:
      • Contact the member or LAR and offer an opportunity to hold a peer-to-peer review with the treating physician of the member’s or LAR’s choice and the MCO medical director. 
      • If the member/LAR requests the peer-to-peer review:
        • Verify the physician of the member’s/LAR’s choice,
        • Contact the physician of the member’s/LAR’s choice to schedule and complete a peer-to-peer review; 
        • Submit any information obtained during the review to TMHP to support MN; and
        • Continue the denial process as outlined below.
      • If the member/LAR refuses the peer-to-peer review:
        • Document the refusal in the member’s file; and
        • Continue the MN denial process as outlined below.
           

The peer-to-peer review should cover specifically those items on the STAR Kids Screening and Assessment Instrument (SK-SAI) related to MN. The MCO must ensure that the member’s/LAR’s physician of choice has access to the completed SK-SAI before the peer-to-peer review. 

Any information obtained in the peer-to-peer review must be submitted to TMHP. 

The MCO is required to ensure that the peer-to-peer review does not affect member rights to appeal an initial assessment or reassessment through the MCO internal appeal process or the state fair hearing process. 

In addition, the MCO must monitor the TMHP portal through the final MN determination.

The MN status of "MN Denied" in the TMHP LTC Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 business days to submit additional information. Once an SK-SAI MN status is in "MN Denied" status, several actions may follow:

  • MN Approved: The status changes to "MN Approved" if the TMHP doctor overturns the denial because additional information is received;
  • Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14 business day period for the TMHP doctor to overturn the denied MN has expired. No additional information was submitted for the doctor review. The denied MN remains in this status unless a fair hearing is requested; or
  • Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

While the MN is in the MN Denied status, the MCOs must monitor the TMHP LTC Online Portal for the MN status through completing a current activity or Form Status query in the TMHP LTC Online Portal every seven days, at a minimum.

If a member’s MN status enters the period when the MDCP waiver applicant or member’s physician has 14 business days to submit additional information, listed in the TMHP LTC Online Portal as “MN Denied,” the MCO must assist the member to obtain from their physician any additional medical information pertinent to the member’s MN determination. The MCO must assist through calling the member and physicians to obtain necessary documents for provision to TMHP within the 14 business day time frame for consideration.

 

6260 Denial/Termination Due to Inability to Locate the Member

Revision 20-3; Effective December 1, 2020

 

The Medically Dependent Children Program (MDCP) must be denied when Program Support Unit (PSU) staff are notified that a member cannot be found.

Prior to notifying PSU, the managed care organization (MCO) must make at least three efforts to contact members by telephone. The telephone contact attempts must be made on separate days, over a period of no more than five business days and must be made at a different time of day upon each attempt. 


If an MCO is unable to reach a member or a member’s legally authorized representative (LAR) by telephone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible. 


If the MCO has not made any contact with the member or LAR 15 business days after sending the written correspondence, the MCO must attempt to contact the member or LAR in person by visiting the member’s address on file. 

Notification can come from:

  • monthly reports;
  • Managed Care Compliance Operations (MCCO);
  • an MCO; or
  • other reliable sources.

 

6270 Denial/Termination Due to Failure to Meet Other Program Requirements

Revision 20-3; Effective December 1, 2020

 

Use this denial citation if the applicant or member does not meet a Medically Dependent Children Program (MDCP) requirement mentioned in Sections 6210 through Section 6260 above. For example, this citation would be used if the applicant or member does not require at least one service. Within two business days of the denial, Program Support Unit (PSU) staff must:

  • send the applicant or member Form H2065-D, Notification of Managed Care Program Services; and
  • post Form H2065-D to TxMedCentral in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

 

6280 Denial/Termination for Other Reasons

Revision 18-2; Effective September 3, 2018

 

Use this citation if initiating denial or termination for a reason not covered in Sections 6210 through Section 6270. Within two business days of the denial, Program Support Unit (PSU) staff must:

  • send the member Form H2065-D, Notification of Managed Care Program Services; and
  • post Form H2065-D to TxMedCentral in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

 

6300 Disenrollment from Managed Care

Revision 20-3; Effective December 1, 2020

 

Texas Health and Human Services Commission (HHSC) conducts member disenrollment activities. Although a STAR Kids member may request disenrollment from managed care, membership in managed care is mandatory with limited exceptions.


See Chapter 533 of the Government Code and Title 1 of the Texas Administrative Code Sections 353.1201 and 353.1203 (related to STAR Kids Medicaid managed care) and Section 353.403 (related to enrollment and disenrollment standards for Medicaid managed care).


Members who receive HHSC approval to disenroll from managed care and who maintain Medicaid eligibility may continue to receive services available through fee-for-service (FFS) Medicaid.  All members who transition to FFS Medicaid lose any value-added services provided by the managed care organization (MCO). Those members who were receiving services under the STAR Kids Medically Dependent Children Program (MDCP) waiver may also lose some, if not all, of their MDCP waiver services in the transition to FFS Medicaid.  

 

6310 Disenrollment Request by the Managed Care Organization

Revision 20-3; Effective December 1, 2020

 

A managed care organization (MCO) has a limited right to request a member be disenrolled from the MCO’s plan without the member’s consent pursuant to 42 C.F.R. § 438.56. Refer to the HHSC Uniform Managed Care Manual, Chapter 11.5, Medicaid Managed Care Member Disenrollment Policy, for procedures to request the involuntary disenrollment of members.