10-2018

 

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Step 1: When a managed care organization (MCO) receives a request from, or becomes aware of, a STAR+PLUS member residing in a nursing facility (NF) who is requesting to move to the community in another service area (SA), the losing MCO service coordinator must contact the applicant or member within five business days. Within 14 business days of the request, the losing MCO service coordinator must:

  • meet with the member to explain the process of transitioning to the community; and
  • conduct the initial assessment.

If the member’s MCO operates in the gaining SA, the member has the option to remain enrolled with the same MCO in the gaining service area.

Step 2: Within three business days of meeting with the member, the losing MCO service coordinator must:

  • inform the losing Program Support Unit (PSU) staff of the request to transition to the community in a different SA, and provide PSU staff the losing MCO service coordinator contact information by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral using the appropriate naming convention for Money Follows the Person (MFP); 
  • determine if during the initial assessment the member voluntarily requests an MCO in the gaining SA, document the name of the requested MCO in the comments section on Form H2067-MC; and
  • determine if the individual requests assistance with relocation. Send a referral for relocation assistance to the relocation specialist in the losing SA by completing Form 1579, Referral for Relocation Service, if requested.

Step 3: Within two business days of the MCO uploading Form H2067-MC, the losing PSU staff must:

  • create a case in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • check the Community Services Interest List (CSIL) database to see if the member is on a Texas Health and Human Services Commission (HHSC) 1915(c) Medicaid waiver interest list;
  • determine, as directed by Section 3514, STAR+PLUS Members Residing in a Facility, if the member has either an open enrollment or services have been temporarily suspended in an HHSC 1915(c) Medicaid waiver;
  • inform the member to contact the Social Security Administration (SSA) or call 211 if medical assistance only (MAO) to update their address when they discharge and move to their new location;
    Note: It is imperative members with Supplemental Security Income (SSI) or SSI-related Medicaid notify SSA of a change in address. If SSA is not contacted in a timely manner, it could delay the member’s change of address in the Texas Integrated Eligibility Redesign System (TIERS).
  • inform the MCO if the member is on a 1915(c) Medicaid waiver interest list, in a 1915(c) Medicaid waiver notated as open enrollment or services temporarily suspended, or neither, by uploading Form H2067-MC to TxMedCentral;
  • indicate whether the member is potentially eligible to participate in Money Follows the Person Demonstration (MFPD) by indicating MFPD qualifying begin and end dates through December 31, 2018, if applicable, on Form H2067-MC;
  • provide the member a list of MCOs in the new SA and discuss the importance of choosing an MCO so the assessment and individual service plan (ISP) are transferred timely and there is no delay in STAR+PLUS HCBS program services when the member transitions to the new SA;
  • follow-up weekly with the member until the member makes an MCO selection, if one has not been selected;
  • determine if the Medicaid type program is MAO:
    • contact the resident and mail Form H1200, Application for Assistance – Your  Texas Benefits, to the member within two business days of the uploading date of Form H2067-MC;
    • advise the resident Form H1200 must be completed and returned to PSU staff;
    • once the resident returns Form H1200, send the signed and completed Form H1200 within two business days of receipt to Medicaid for the Elderly and People with Disabilities (MEPD) specialists, along with Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken, and Form H0003, Agreement to Release Your Facts; and
  • email the supervisor and administrative technician in the gaining PSU to notify of the upcoming transfer.

Step 4: Within 45 days of the NF resident's request to return to the community, the losing MCO must:

  • submit the Medical Necessity and Level of Care (MN/LOC) Assessment if there is no current Minimum Data Set (MDS), or completes its own MN/LOC assessment in lieu of using the NF's MDS and email or upload in TxMedCentral the following forms, depending on the Medicaid type and service needs:  
  • submit Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, if the member requested TAS;
  • complete an ISP series:
    • upload Form H1700-1, Individual Service Plan (Pg. 1) to TxMedCentral;
    • upload Form H1700-2, Individual Service Plan (Pg. 2) to TxMedCentral;
    • email Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services to the losing PSU;
    • Form H1700-B, Non-STAR+PLUS HCBS Program Services; and
  • upload to the losing PSU staff all assessment and service plan documentation via TxMedCentral.

The losing PSU staff must notify Managed Care Compliance & Operations (MCCO) of late assessments.

Step 5:  Within five business days of receipt of all required documents:

The losing PSU staff must:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • financial eligibility;
    • approved Medicaid;
    • approved medical necessity (MN); and
    • ISP with at least one STAR+PLUS HCBS program service within the member's cost limit;
  • mail an initial Form H2065-D, Notification of Managed Care Program Services, to the member as notification eligibility requirements for participation in STAR+PLUS HCBS program are met;
  • complete and upload Form H2065-D and Form H2067-MC to TxMedCentral within two business days of mailing Form H2065-D to the member to inform the losing MCO; and
  • email the assessment, ISP and Form H2065-D to the gaining PSU staff.

Step 6: The gaining PSU staff email the assessment packet to the MCO.

Step 7: Within 30 days of receipt of all required documents, if a member has not selected an MCO in the gaining SA, the member will be defaulted to an MCO by PSU staff. Within two business days of the member selecting or defaulting to an MCO in the gaining SA, the losing PSU staff notify the losing MCO and the gaining PSU staff of the member's decision or the default selection by uploading Form H2067-MC to TxMedCentral. Within two business days, the gaining PSU staff must notify the gaining MCO by uploading Form H2065-D to TxMedCentral. Upon confirmation of receipt by the gaining MCO, the gaining PSU staff must upload the ISP and Form H2065-D to the gaining MCO to TxMedCentral. The losing PSU staff must email all assessments to the gaining PSU staff.

Step 8: The gaining MCO service coordinator must:

  • inform the member who chooses to reside in an assisted living facility (ALF) or adult foster care (AFC) setting about room and board (R&B) and copayment requirements, as well as what type of furnishing to expect;
  • confirm the need for TAS, offer a choice of providers and coordinate the delivery of all services, including TAS;
  • communicate and coordinate with the losing MCO to assist the member in reviewing ALF and/or AFC homes available in the gaining SA to the extent possible, if member has not already requested a specific ALF/AFC home; and
  • confirm requested TAS items with member.

Step 9: Once STAR+PLUS HCBS program eligibility is approved and the gaining MCO has all required information outlined in Step 4, the gaining MCO service coordinator must:

  • coordinate with the losing MCO service coordinator, relocation specialist, NF, member and the gaining PSU staff to identify a proposed discharge date; and
  • within one business day of learning the discharge date, notify the losing PSU staff of the discharge date by uploading Form H2067-MC to TxMedCentral.

Should any other entity contact the losing PSU staff with a discharge date, the losing PSU staff must immediately upload Form H2067-MC to TxMedCentral, notifying the gaining MCO of a different date. The gaining MCO must respond with the correct scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of the losing PSU staff's Form H2067-MC uploading date.

Step 10: Within one business days of receipt of Form H2067-MC with the discharge date information, the gaining PSU staff must:

  • complete the final Form H2065-D and upload to TxMedCentral;
  • confirm the member's:
    • name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • notify MEPD to update Medicaid; if applicable; and
  • mail Form H2065-D to the member.

Step 11: Determining who pays for services depends on the start of care (SOC) date (indicated on the final Form H2065-D).

  • If the SOC date is between the 1st day and 10th day of the month (for example, April):
    • The gaining PSU staff send the final Form H2065-D to the losing MCO, the gaining MCO and the losing PSU staff.
    • The losing PSU staff coordinate with Enrollment Resolution Services (ERS) to enroll the member in the gaining MCO for the month (in this example, April).  
    • The MCO may need to notify providers so they hold claims with a date of service following the end of the previous month.
    • ERS retroactively enrolls the member in the gaining MCO for the month (in this example, April). 
    • The losing MCO is responsible for NF claims for the member until the end of the previous month (in this example, March).
    • The gaining MCO is responsible for claims once the individual is its member (in this example, April 1).  
  • If the SOC date is between the 11th day and the 25th day of the month (for example, April):
    • The gaining PSU staff send the final Form H2065-D to the losing MCO, the gaining MCO and the losing PSU staff.  
    • The losing MCO is responsible for claims until the individual transferring is no longer its member (in this example, until the end of April).
    • The losing PSU staff coordinate with ERS to prospectively enroll the individual in the gaining MCO for the next month (in this example, May).
    • The gaining MCO is responsible for claims once the individual is its member (in this example, May 1).
  • If the SOC date is between 26th day and last day of the month (for example, April):
    • The gaining PSU staff send the final Form H2065-D to the losing MCO, the gaining MCO and the losing PSU staff.
    • The losing PSU staff coordinate with ERS to prospectively or retroactively enroll the individual in the gaining MCO for the month following discharge (in this example, May).
    • The losing MCO is responsible for claims until the end of the month (in this example, April).
    • The gaining MCO is responsible for claims once the individual is its member (in this example, May 1).
    • The MCO may need to notify providers so they hold claims with a date of service following the end of the previous month.

Step 12: The gaining MCO service coordinator must:

  • coordinate all appropriate activities between the losing PSU staff, the losing MCO, the gaining PSU staff, the member and other key parties, including the relocation specialist, TAS provider and durable medical equipment (DME) provider, if needed, to ensure a successful transition;
  • facilitate communication and sharing of information between the current relocation specialist and the relocation specialist in the gaining SA; and
  • track each step of the process through the SOC date in the gaining SA.

Step 13: Once the member's plan change is effective, the gaining PSU staff manually update all Service Authorization System Online (SASO) records for the MCO to match the information in the TIERS managed care screen for that individual.

Step 14: Within five business days after the move, the gaining PSU staff must:

  • send an email to the ERS mailbox notifying ERS the member has moved;
  • send the final Form H2065-D to the member and include the begin and end dates in the Comments section; and
  • upload a copy of the final Form H2065-D to the gaining MCO's XXXSPW folder in TxMedCentral, using the appropriate naming convention.

Step 15: On the day of the relocation, the gaining MCO must:

  • be at the member's home to ensure services identified in the ISP begin on the day the member moves to the gaining SA and that all of the member's needs are met;
  • remind and assist the individual to call SSA or 211 (if MAO) to update the address; and
  • complete Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services.

For members transitioning who need only Community First Choice (CFC), the losing MCO must:

  • confirm CFC eligibility based upon:
    • approved MN or other institutional LOC;
    • eligible Medicaid type (not an MAO); and
    • documented need for at least one CFC service;
  • send the assessment and ISP to the gaining MCO; and
  • notify the losing PSU staff to close the STAR+PLUS HCBS program case. 

 

Shared Appendix 62

This appendix appears in the following handbooks:

STAR+PLUS Handbook (SPH): Appendix XXXI
STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH): Appendix XXXI