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STAR Kids Program Support Unit Operational Procedures Handbook

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STAR Kids Program Support Unit Operational Procedures Handbook

  • Section 1000, STAR Kids Overview and Eligibility
  • Section 2000, Medically Dependent Children Program Intake and Initial Application
  • Section 3000, STAR Kids Screening and Assessment and Service Planning
  • Section 4000, STAR Kids Community Services
  • Section 5000, Reserved for Future Use
  • Section 6000, Denials and Terminations
  • Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings
  • Section 8000, Utilization Management and Review by the State
  • Appendices
  • Glossary
  • Forms
  • Revisions
  • Policy Updates
  • Contact Us
  • Printer-friendly version

 

Section 1000, STAR Kids Overview and Eligibility

  • 1100 Legal Basis and Values
    • 1110 Mission Statement
    • 1120 Medically Dependent Children Program
    • 1130 Medically Dependent Children Program Goal
  • 1200 Medically Dependent Children Program Eligibility
    • 1210 Medical Necessity Determination
      • 1211 Medical Necessity Determination for an Applicant or Member Residing in a Nursing Facility
      • 1212 Medical Necessity Determination for an Applicant or Member Not Residing in a Nursing Facility
    • 1220 Individual Cost Limit
    • 1230 Unmet Need for at Least One Medically Dependent Children Program Service
    • 1240 Age
    • 1250 Citizenship and Identity Verification
    • 1260 Living Arrangement and Texas Residency
    • 1270 Financial Eligibility
  • 1300 STAR Kids Services and Service Delivery Options
    • 1310 Acute Care Services
    • 1320 Long Term Services and Supports
    • 1330 Service Delivery Options for Certain Long Term Services and Supports
  • 1400 Service Coordination through the Managed Care Organization
    • 1410 Service Coordination Requirements
    • 1420 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities
    • 1430 Service Coordination and the Youth Empowerment Services Waiver Program
    • 1440 Service Coordinators and Home and Community Based Services – Adult Mental Health
      • 1441 Program Point of Contact
      • 1442 Managed Care Organization Service Coordination Responsibility
  • 1500 Reserved for Future Use
  • 1600 Disclosure of Information
    • 1610 Confidential Nature of Medical Information – Health Insurance Portability and Accountability Act
      • 1611 Confidential Nature of a Case Record
      • 1612 Custody of Records
      • 1613 Responsible Party to Authorize Disclosure
        • 1613.1 Legally Authorized Representatives and Authorized Representatives
        • 1613.2 Unemancipated Minors
        • 1613.3 Adults and Emancipated Minors
        • 1613.4 Deceased Applicant or Member
      • 1614 Verifying the Identity of an Applicant, Member, LAR, AR or Third Party Individual
        • 1614.1 Telephone Communication
        • 1614.2 In-Person Communication
        • 1614.3 Electronic Mail Communication
      • 1615 Information That May Be Disclosed
      • 1616 Verification and Documentation of Disclosure
    • 1620 Alternate Means of Communication with the Applicant or Member
    • 1630 Confidential Information on Notifications
      • 1631 Program Support Unit Communications with Managed Care Organizations
    • 1640 Applicant or Member Correction of Information
    • 1650 Disposal of Records
  • 1700 Member Rights and Responsibilities
  • 1800 Notifications
    • 1810 Program Support Unit Staff Notification Requirements
    • 1820 Managed Care Organization Notification Requirements
    • 1830 Notifications with Medicaid for the Elderly and People with Disabilities or Texas Works Involvement

Section 2000, Medically Dependent Children Program Intake and Initial Application

  • 2010 Initial Requests for Medically Dependent Children Program
  • 2020 Interest List Management Unit Responsibilities
  • 2030 Program Support Unit Staff Responsibilities
  • 2100 Enrollment Following Release from the Interest List
    • 2100.1 Individuals Not Enrolled in Medicaid, Including an Individual Enrolled in the Children’s Health Insurance Program
    • 2100.2 Individual Who Receives Supplemental Security Income or SSI-Related Medicaid
    • 2100.3 Individual Who Receives STAR Health
    • 2100.4 Individual Who Receives Other Types of Medicaid
    • 2110 Managed Care Organization Selection
    • 2120 Inability to Contact the Individual
    • 2130 Declining Medically Dependent Children Program Services
  • 2200 Receipt of Enrollment Packet
    • 2210 Income and Resource Verifications for Medicaid Eligibility
      • 2210.1 Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program
      • 2210.2 Individual Enrolled in STAR Kids
      • 2210.3 Individual Enrolled in STAR Health
      • 2210.4 Individual Receiving Other Types of Medicaid
      • 2210.5 Individual with a Qualified Income Trust
    • 2220 Managed Care Organization Coordination
    • 2230 Program Support Unit Staff Coordination for an Applicant Enrolling in MDCP
    • 2240 Coordination for Program Denial
  • 2300 Interest List Release Closures
    • 2310 Contacting the Interest List Management Unit to Reopen a Closed Interest List Release
    • 2320 Earliest Date for Adding an Individual Back to the Interest List After Denial or Termination
  • 2400 Money Follows the Person
    • 2410 Traditional Money Follows the Person
      • 2410.1 Non-STAR Kids Individuals Residing in a Nursing Facility
      • 2410.2 STAR Kids Member Residing in a Nursing Facility
      • 2410.3 MDCP Money Follows the Person Applications Pending Due to Delay in NF Discharge
      • 2410.4 Money Follows the Person Demonstration (MFPD) References in STAR Kids
    • 2420 Money Follows the Person Limited NF Stay Option for a Medically Fragile Individual
      • 2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay
      • 2422 Money Follows the Person Limited Nursing Facility Stay Procedures
        • 2422.1 Processing Form 2406 and Medical Documents
      • 2423 HHSC Nurse or Physician Review of Medical Fragility
      • 2424 Physician Determination of Medical Fragility
      • 2425 Individual Not Meeting the Medically Fragile Criteria
      • 2426 ILM Unit Procedures for Assigning an Individual Approved for a Limited NF Stay to PSU Staff
      • 2427 PSU Procedures for an Individual Approved for a Limited NF Stay
        • 2427.1 PSU Procedures for an Individual Approved for a Limited NF Stay without Medicaid
        • 2427.2 PSU Procedures for an Individual Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids
        • 2427.3 PSU Procedures for an Individual Approved for a Limited NF Stay and Currently Enrolled in STAR Kids
      • 2428 PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay
      • 2429 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Section 3000, STAR Kids Screening and Assessment and Service Planning

  • 3100 STAR Kids Screening and Assessment
    • 3110 Assessment of Medical Necessity for Community First Choice
    • 3120 Assessment of Medical Necessity for the Medically Dependent Children Program
  • 3200 Member Reassessment
    • 3210 Reassessment of Medical Necessity or Level of Care
  • 3300 Member Service Planning and Authorization
    • 3310 Service Planning
      • 3311 Updates to the Individual Service Plan
    • 3320 Service Planning for Medically Dependent Children Program Services
      • 3321 Medically Dependent Children Program Individual Service Plan Revision
      • 3322 Medically Dependent Children Program Individual Service Plan and Budget Revision
      • 3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan
      • 3324 Individual Service Plan Exceeding the Cost Limit for MDCP Services
      • 3325 Multiple Medically Dependent Children Program Members in the Same Household
      • 3326 Suspension of Medically Dependent Children Program Services
      • 3327 Reassessment Individual Service Plan Provider Procedures
        • 3327.1 Process for Reviewing the Individual Service Plan Expiring Report
      • 3328 Reassessment Notification Requirements
  • 3400 Member Transfers
    • 3410 Transfer from One Managed Care Organization to Another
    • 3420 Transfer from Medicaid Waiver Program to Medically Dependent Children Program
    • 3430 Transfer from MDCP to Another Medicaid Waiver Program
    • 3440 Transfer from Community Care for Aged and Disabled Services to STAR Kids
  • 3500 Transition from Medically Dependent Children Program to Adult Programs
    • 3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC
      • 3511 Twelve Months Prior to the Member’s 21st Birthday
      • 3512 STAR+PLUS Transition Activities
      • 3513 Intrapulmonary Percussive Ventilator Benefit
    • 3520 Transition Policy for Non-Waiver Members Receiving PCS or CFC Only

Section 4000, STAR Kids Community Services

  • 4010 Outline
  • 4100 Community First Choice
    • 4110 Community First Choice Eligibility
      • 4111 Determining Institutional Level of Care
        • 4111.1 STAR Kids Screening and Assessment Instrument
        • 4111.2 Intellectual Disability or Related Condition Assessment
        • 4111.3 Child and Adolescent Needs and Strengths or Adult Needs and Strengths Assessment
    • 4120 Community First Choice Services
      • 4121 Community First Choice Personal Assistance
      • 4122 Community First Choice Habilitation
      • 4123 Community First Choice Emergency Response Services
      • 4124 Community First Choice Support Management
    • 4130 Community First Choice Assessment and Authorization
      • 4131 Assessment for a Nursing Facility Level of Care
        • 4131.1 Reassessment for a Nursing Facility Level of Care
      • 4132 Assessment for an Intermediate Care Facility Level of Care
      • 4133 Assessment for an Institution Providing Psychiatric Services Level of Care
        • 4133.1 Reassessment for an Institution for Mental Disease Level of Care
    • 4140 Functional Assessment for Community First Choice Services
      • 4140.1 Reassessment of Functional Need for Community First Choice
  • 4200 Personal Care Services
    • 4210 Assessment for Personal Care Services
      • 4211 Reassessment for Personal Care Services
    • 4220 Personal Care Services Providers
  • 4300 Private Duty Nursing
    • 4310 Assessment for Private Duty Nursing
      • 4311 Reassessment and Reauthorization
    • 4320 Providers of Private Duty Nursing
    • 4330 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services
  • 4400 Prescribed Pediatric Extended Care Centers
    • 4410 Assessment for Prescribed Pediatric Extended Care Center Services
      • 4411 Reassessment and Reauthorization of Prescribed Pediatric Extended Care Center Services
    • 4420 Providers of Prescribed Pediatric Extended Care Center Services
    • 4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services
  • 4500 Day Activity and Health Services
    • 4510 Assessment for Day Activity and Health Services
      • 4511 Reassessment for Day Activity and Health Services
    • 4520 Day Activity and Health Services Providers
  • 4600 Medically Dependent Children Program Services
  • 4700 Medically Dependent Children Program Respite and Flexible Family Support Services
    • 4710 Medically Dependent Children Program Respite
      • 4711 In-Home Respite
        • 4711.1 Attendant with Delegated Tasks
      • 4712 Out-of-Home Respite
    • 4720 Respite Limits
    • 4730 Flexible Family Support Services
      • 4731 Flexible Family Support Services in Child Care
      • 4732 Flexible Family Support Services for Independent Living
      • 4733 Flexible Family Support Services in Post-Secondary Education
      • 4734 Flexible Family Support Services Requiring Delegated Tasks
    • 4740 Flexible Family Support Services Limits
  • 4800 Adaptive Aids, Minor Home Modification and Transition Assistance Services
    • 4810 Adaptive Aids
      • 4811 Service Limits on Adaptive Aids
    • 4820 Minor Home Modifications
      • 4821 Service Limits on Minor Home Modifications
    • 4830 Transition Assistance Services
      • 4831 Deposits
      • 4832 Moving Expenses
      • 4833 Site Preparation
      • 4834 Limits on Transition Assistance Services
      • 4835 Transition Assistance Services Agency Responsibilities
      • 4836 Three-Day Monitor Requirement
      • 4837 Failure to Leave the Nursing Facility
  • 4900 Supported Employment and Employment Assistance
    • 4910 Employment Assistance
      • 4911 Coordination with Texas Workforce Commission for Employment Assistance
      • 4912 Employment Assistance Providers
    • 4920 Supported Employment
      • 4921 Coordination with Texas Workforce Commission for Supported Employment
      • 4922 Supported Employment Providers

Section 5000, Reserved for Future Use

Section 6000, Denials and Terminations

  • 6050 Description
  • 6100 Ten-Day Adverse Action Notification
    • 6110 Denial of Medical Necessity/Individual Service Plan
    • 6120 Denial of Medicaid Eligibility
    • 6130 Unable to Locate
  • 6200 Program Support Unit Staff Initiated Denials/Terminations
    • 6210 Denial/Termination Due to Death
    • 6220 Denial/Termination Due to Residence in a Nursing Facility
    • 6230 Denial/Termination Due to Member Request
    • 6240 Denial/Termination of Financial Eligibility
    • 6250 Denial/Termination of Medical Necessity
    • 6260 Denial/Termination Due to Inability to Locate the Member
    • 6270 Denial/Termination Due to Failure to Meet Other Program Requirements
    • 6280 Denial/Termination for Other Reasons
  • 6300 Denial/Termination Initiated by the Managed Care Organization
    • 6310 Denial/Termination Due to Threats to Health and Safety
    • 6320 Denial/Termination Due to Hazardous Conditions or Reckless Behavior
    • 6330 Denial/Termination Due to Harassment, Abuse or Discrimination
    • 6340 Denial as a Result of Exceeding the Cost Limit
    • 6350 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions
    • 6360 Denial/Termination Due to Failure to Pay
    • 6370 Denial/Termination Due to Other Reasons

Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings

  • 7100 Managed Care Organization Procedures
    • 7110 Managed Care Organization Complaint Procedures
    • 7120 Internal Managed Care Organization Appeal Procedures
      • 7121 Expedited Managed Care Organization Internal Appeal
      • 7122 Request for a State Fair Hearing After Exhausting Internal Managed Care Organization Appeals
  • 7200 State Fair Hearing Procedures for Medically Dependent Children Program
    • 7201 Timely or Non-timely State Fair Hearing Request
    • 7210 Program Support Unit Staff Procedures for Completing Form H4800
      • 7211 Data Entry Representative Procedures for Entering the State Fair Hearing Request
      • 7212 Generation of the State Fair Hearing Packet
      • 7213 State Fair Hearing Packet
      • 7214 Changes to the State Fair Hearing Request Summary
    • 7220 Processing a State Fair Hearing Request
      • 7221 Type of Denials
        • 7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership
        • 7221.2 Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works
        • 7221.3 Supplemental Security Income Denial by the Social Security Administration
        • 7221.4 Other Denial Reasons
      • 7222 Continuation or Termination of Services
        • 7222.1 Continuation of Medically Dependent Children Program During a State Fair Hearing
        • 7222.2 Termination of MDCP Services Due to a Member Not Requesting a State Fair Hearing
    • 7230 State Fair Hearing Actions
      • 7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal
      • 7232 Presentation of the State Fair Hearing Evidence Packet
      • 7233 State Fair Hearing Decision
  • 7300 Post State Fair Hearing Actions
    • 7310 Action Taken on the State Fair Hearing Decision
  • 7400 Reserved for Future Use
  • 7500 State Fair Hearing Decision Actions
    • 7510 Sustained State Fair Hearing Decision
      • 7511 Sustained Decision – Termination Effective Date
    • 7520 Reversed State Fair Hearing Decision
      • 7521 Reversed Decision – Effective Date
      • 7522 New Assessment Required by State Fair Hearing Decision
      • 7523 Request to Withdraw a State Fair Hearing
  • 7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearings Officer

Section 8000, Utilization Management and Review by the State

  • 8100 Description
  • Section 1000, STAR Kids Overview and Eligibility
  • Section 2000, Medically Dependent Children Program Intake and Initial Application
  • Section 3000, STAR Kids Screening and Assessment and Service Planning
  • Section 4000, STAR Kids Community Services
  • Section 5000, Reserved for Future Use
  • Section 6000, Denials and Terminations
  • Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings
  • Section 8000, Utilization Management and Review by the State
  • Appendices
  • Glossary
  • Forms
  • Revisions
  • Policy Updates
  • Contact Us
Section 1000, STAR Kids Overview and Eligibility ›

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