Revision 18-2; Effective September 3, 2018

 

 

6050 Description

Revision 18-2; Effective September 3, 2018

 

This section provides information, procedures and references pertaining to denial or termination of Medically Dependent Children Program (MDCP) services for active members, along with adequate notice of a member's rights and opportunities to due process.

42 Code of Federal Regulations (CFR) Part 431, Subpart E, governs fair hearing rights for Medicaid applicants and beneficiaries. In general, the managed care organization must adhere to the federally-mandated 10-day adverse action period for denials and terminations related to MDCP services. However, 42 CFR § 431.213 specifies situations in which an adverse action period is not required. The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a beneficiary;

(b) The agency receives a clear written statement signed by a beneficiary that—

(1) He no longer wishes services; or

(2) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c) The beneficiary has been admitted to an institution where he is ineligible under the plan for further services;

(d) The beneficiary's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231(d) of this subpart for procedure if the beneficiary's whereabouts become known);

(e) The agency establishes the fact that the beneficiary has been accepted for Medicaid services by another local jurisdiction, state, territory, or commonwealth;

(f) A change in the level of medical care is prescribed by the beneficiary's physician;

(g) The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or

(h) The date of action will occur in less than 10 days, in accordance with §483.12(a)(5)(ii), which provides exceptions to the 30 days' notice requirements of §483.12(a)(5)(i).

1 Texas Administrative Code §353.1209, which is cited on Form H2065-D, Notification of Managed Care Program Services, is the basis for all STAR Kids case actions.

 

6100 Ten-Day Adverse Action Notification

Revision 18-2; Effective September 3, 2018

 

42 Code of Federal Regulations (CFR) §431.230 requires that the Texas Health and Human Services Commission (HHSC) provide a notice to the member at least 10 days before the action effective date. The member must be given the full 10-day adverse action period to give him or her time to file an appeal or request a fair hearing, as described below:

(a) If the agency mails the 10-day or five-day notice, as required under §431.211 or §431.214 of this subpart, 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.

(b) If the agency's action is sustained by the hearing decision, the agency may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary, to the extent they were furnished solely by reason of this section.

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-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-day adverse action period does not require 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-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.

 

6110 Denial of Medical Necessity/Individual Service Plan

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet medical necessity (MN) criteria or does not have a valid individual service plan (ISP), the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

 

Date Informed Eligibility Lost Date Form H2065-D Sent Current ISP End Date 10-Day Adverse Action Expiration Date Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal Data Entry
April 10 April 12 May 31 April 22 May 31 None
May 20 May 21 May 31 May 31 May 31 None
May 20 May 22 May 31 June 1 June 30 ISP must be extended to June 30.
June 5 June 7 May 31 June 17 June 30 ISP must be extended to June 30.
June 22 June 24 May 31 July 4 July 31 ISP must be extended to July 31.

 

6120 Denial of Medicaid Eligibility

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she does not meet Medicaid eligibility, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

 

Actual Date of Medicaid Eligibility Denial Date PSU Informed Eligibility Lost Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP)
Long Term Care (LTC) Online Portal Data Entry
12-31-2016 12-31-2016 5-31-2017 1-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 10-31-2016 5-31-2017 11-2-2017 12-31-2016 ISP must be corrected to 12-31-2016.
12-31-2016 2-5-2017 5-31-2017 2-7-2017 12-31-2016 ISP must be corrected to 12-31-2016.

Notes:

  • If eligibility for Medicaid is reestablished with a gap of over four months, this must be treated as an interest list release. The managed care organization (MCO) processes initial assessments.
  • If eligibility for Medicaid is reestablished with a gap of four months or less, the existing ISP and STAR Kids Screening and Assessment Instrument (SK-SAI) used to determine medical necessity (MN) are still valid. If the ISP and SK-SAI MN have expired, the MCO is allowed to do a reassessment without penalty.

 

6130 Unable to Locate

Revision 18-2; Effective September 3, 2018

 

When a member is denied Medically Dependent Children Program (MDCP) services because he or she cannot be located, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date PSU Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Texas Medicaid & Healthcare Partnership (TMHP)
Long Term Care (LTC) Online Portal Data Entry
12-31-2016 5-31-2017 1-2-2017 1-31-2017 ISP must be corrected to 1-31-2017.
5-3-2017 5-31-2017 5-5-2017 5-31-2017 None
5-25-2017 5-31-2017 5-27-2017 6-30-2017* ISP must be corrected to 06-30-2017.
6-9-2017 5-31-2017 6-11-2017 6-30-2017 Managed care organization (MCO) should have submitted an ISP and medical necessity (MN) for 6-1-2017.

*The 10-day adverse action period expires after the end of the month.

 

6200 Program Support Unit Initiated Denials/Terminations

Revision 18-2; Effective September 3, 2018

 

The following sections contain policy citations that must be included on Form H2065-D, Notification of Managed Care Program Services, when the denial or termination action is initiated by Program Support Unit (PSU) staff.

 

6210 Denial/Termination Due to Death

Revision 18-2; Effective September 3, 2018

 

Upon learning of the death of a member, Program Support Unit (PSU) staff must 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, within two business days of verification.

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-day adverse action period is not required for death denials.

 

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 18-2; Effective September 3, 2018

 

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 loses eligibility for Medically Dependent Children Program (MDCP) services. For members without SSI or SSI-related Medicaid (i.e., medical assistance only (MAO) members), loss of MDCP eligibility due to NF residence will result in loss of Medicaid eligibility.
  • For members enrolled in MDCP, the managed care organization (MCO) will notify Program Support Unit (PSU) staff within 14 days following the 90th day that the member is not returning to the community when a member resides in an NF for 90 days or more. 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.
  • PSU staff deny MDCP by the end of the month in which the 90th day occurred and will:
    • manually complete and send the member Form H2056-D, Notification of Managed Care Program Services; and
    • post Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

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).

*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 Due to Member Request

Revision 18-2; Effective September 3, 2018

 

When Program Support Unit (PSU) staff have been notified a member no longer wants Medically Dependent Children Program (MDCP) services, within two business day of becoming aware the member no longer wants services, 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.

 

6240 Denial/Termination of Financial Eligibility

Revision 18-2; Effective September 3, 2018

 

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. 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.

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 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.

 

6250 Denial/Termination of Medical Necessity

Revision 18-2; Effective September 3, 2018

 

Medically Dependent Children Program (MDCP) services must be denied or terminated when the member's medical necessity (MN) is denied. 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:

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

The MN status of "MN Denied" in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 buisness days to submit additional information. Once a STAR Kids Screening and Assessment Instrument (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 buisness 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 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 18-2; Effective September 3, 2018

 

The Medically Dependent Children Program (MDCP) must be denied/terminated when Program Support Unit (PSU) staff are notified that a member cannot be found. Within two business days, the 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;
  • Managed Care Operations;
  • an MCO; or
  • other reliable sources.

 

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

Revision 18-2; Effective September 3, 2018

 

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 Denial/Termination Initiated by the Managed Care Organization

Revision 18-2; Effective September 3, 2018

 

MCOs may request to disenroll a member from Medicaid managed Care. Reference the HHSC Uniform Managed Care Manual, Chapter 11.5, Medicaid Managed Care Member Disenrollment Policy. 

Sections 6310 through Section 6370 contain policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. Within two business days of the notification by the MCO, 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 MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

 

6310 Denial/Termination Due to Threats to Health and Safety

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) and provider staff must take special precautions when an applicant's or member's comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant or member, an MCO-contracted provider or an MCO employee. If an applicant or member exhibits such behavior, the staff member must immediately notify his or her manager.

The Texas Health and Human Services Commission (HHSC) reviews these situations on a case-by-case basis and determines the most appropriate action to be taken. If the applicant's or member's safety may be at risk, the MCO must follow current policy regarding notification to the Department of Family and Protective Services (DFPS). If the MCO or service provider staff believe there is a potential threat to others, HHSC management should determine the best method for notifying the MCO and/or the contracted provider and for addressing the applicant's or member's needs without placing an MCO or service provider staff at risk.

Within two business days of the notification by the MCO, 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 MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

The 10-day adverse action notification period does not apply in this situation.

 

6320 Denial/Termination Due to Hazardous Conditions or Reckless Behavior

Revision 18-2; Effective September 3, 2018

 

When there is no immediate threat to the health or safety of the service provider, but the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, appropriate documentation of denial is essential. For example, a situation where the member has a large dog that may bite if let loose could be resolved if the member or a neighbor or family member will agree to restrain the dog during times of service delivery.

However, if the provider shows up on numerous occasions at the designated time and the dog is loose, and the provider has documented a substantial pattern of being unable to deliver services due to this, services could be terminated.

Similarly, if there are illegal drugs in the member's home used by the member or others, the service provider may not be in immediate danger, yet the situation still may pose a threat. It is imperative that all available interventions are presented and the opportunity offered for the member to get rid of the illegal drugs and/or users, and agree to refrain and not allow the illegal drug use to resume. The managed care organization (MCO) should convene an interdisciplinary team meeting if the illegal drug usage occurs again, and the member must be warned in writing of the potential loss of services for allowing this activity to continue.

Within two business days of the notification by the MCO, the Program Support Unit staff must:

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

The 10-day adverse action notification period does not apply in this situation.

 

6330 Denial/Termination Due to Harassment, Abuse or Discrimination

Revision 18-2; Effective September 3, 2018

 

A substantial demonstrated pattern of verbal abuse or discrimination must be clearly established and documented by the managed care organization (MCO) before services can be denied for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the member and/or his or her family or legally authorized representative (LAR), explaining that the MCO does not condone discrimination, harassment and/or verbal abuse.

Appropriate interventions must be sought. This may include counseling, referral to other case management agencies and possibly changes to the individual service plan (ISP), such as attending Day Activity and Health Services (DAHS) for nursing.

There must be meetings of the Texas Health and Human Services Commission (HHSC) staff that include outside agencies, when appropriate, such as the Texas Department of Family and Protective Services (DFPS) Child or Adult Protective Services. The results must be documented in letters sent to the member that offer an opportunity to stop the behavior, with clear indication that failure may result in loss of service. Copies of written warnings must be sent to all who attend the meetings and a copy must be retained in the case file.

If the situation persists and results in an inability to deliver services, the MCO may request disenrollment from HHSC. After HHSC approves the disenrollment, HHSC notifies the Program Support Unit (PSU) supervisor via email. PSU staff send Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if appropriate.

Within two business days of the notification from the HHSC staff, PSU staff must:

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

The 10-day adverse action notification period does not apply in this situation.

If the denial or termination is being considered due to verbal abuse or harassment of the service provider, HHSC must determine if this behavior is directly related to the member's disability. If the member produces a letter from his physician indicating the behavior stems from the member's disability, services cannot be denied for this reason. Appropriate interventions to ensure service delivery, as noted above, should still be pursued.

 

6340 Denial as a Result of Exceeding the Cost Limit

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) must consider all available support systems in determining if the Medically Dependent Children Program (MDCP) is a feasible alternative that ensures the needs of the applicant are adequately met. If MDCP is not a feasible alternative, the MCO must notify Program Support Unit (PSU) staff of the denial and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial is based on the inadequacy of the plan of care, including both MDCP and non-MDCP services, to meet the needs of the individual within the cost limit.

If the individual service plan (ISP) is over the cost limit, within two business days of receipt of the ISP, PSU staff must:

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

 

6350 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions

Revision 18-2; Effective September 3, 2018

 

If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, services may be denied or terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member's home that prevent determining eligibility, carrying out the service plan or monitoring services. Within two business days of the notification, 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 MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

 

6360 Denial/Termination Due to Failure to Pay

Revision 18-2; Effective September 3, 2018

 

If the member refuses to pay a required copayment, room and board payment or Qualified Income Trust (QIT) payment, the Medically Dependent Children Program (MDCP) must be denied. After notification by the managed care organization (MCO), within two business days of notification, 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 MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

The 10-day adverse action period does apply in this situation.

 

6370 Denial/Termination Due to Other Reasons

Revision 18-2; Effective September 3, 2018

 

Use this denial or termination citation if initiating denial for a reason not covered above. After notification by the managed care organization (MCO), within two business days of notification, 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 MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.