Revision 18-2; Effective September 3, 2018

 

 

2100 Disclosure of Information

Revision 18-2; Effective September 3, 2018

 

 

2110 Confidential Nature of the Case Record

Revision 18-2; Effective September 3, 2018

 

Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify a member.

A member or authorized representative (AR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

 

2111 Establishing Identity for Contact Outside the Interview Process

Revision 18-2; Effective September 3, 2018

 

Keep all information that the Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) have about a member or authorized representative (AR) on the member's case confidential. Confidential information includes, member’s name, date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number or any other individually identifiable health information.

Before discussing or releasing information about a member or AR on the member's case, take steps to be reasonably sure the individual receiving the confidential information is either the member or an individual the member has authorized to receive confidential information (for example, an attorney or AR).

 

2111.1 Telephone Contact

Revision 18-2; Effective September 3, 2018

 

Establish the identity of an individual who identifies herself or himself as an applicant, member or authorized representative (AR) by verifying the individual’s knowledge of any of the following:

  • applicant's or member’s Social Security number (SSN) and date of birth (DOB);
  • member’s SSN and Medicaid ID number;
  • member’s SSN and answer to a security question;
  • member’s DOB and answer to a security question; or
  • answer two security questions.

Establish the identity of an AR by using the individual's knowledge of any of the above or the any of the following:

  • AR's SSN and DOB;
  • AR’s SSN and answer to a security question;
  • AR’s DOB and answer to a security question; or
  • answer two security questions.

Establish the identity of attorneys or AR by asking for the individual to provide Form 1826-D, Case Information Release, or a document that contains all of the information listed in Section 2114, When and What Information May Be Disclosed, completed and signed by the member. The managed care organization (MCO) must maintain this documentation in the member's case file.

Texas Health and Human Services Commission (HHSC) staff must use established regional procedures to confirm the identity of legislators or their staff. The MCO must use established HHSC procedures to confirm the identity of legislators or their staff.

 

2111.2 In-Person Contact Communication

Revision 18-2; Effective September 3, 2018

 

Establish the identity of the individual who presents herself or himself as an applicant, member or member's authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) or managed care organization (MCO) office by examining:

At least one form of government-issued photo identification (ID):

  • valid U.S. passport;
  • valid driver license or Department of Public Safety identification card; or
  • state agency employee badge; and

At least one form of other identification:

  • birth certificate or birth record;
  • Social Security Number (SSN) card;
  • hospital record;
  • work or school identification card;
  • voter registration card;
  • wage stub;
  • credit card;
  • department store credit card;
  • gas station credit card;
  • annual plastic membership identification card; or
  • utility bill.

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers or contractors by examining at least one source such as:

  • employee badge; or
  • government-issued identification card with a photograph.

Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access protected health information (PHI) through one of the following:

  • official correspondence or a telephone call from a state or regional office; or
  • contact with an HHSC Office of the Chief Counsel.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC or MCO staff come to the office without prior notification or adequate identification and request permission to access records.

Refer to Section 2111.3 below if the individual is requesting personally identifiable information (PII) or PHI.

 

2111.3 Verification and Documentation

Revision 18-2; Effective September 3, 2018

 

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, authorized representative (AR) or a third-party to whom the applicant, member, or AR have provided written consent for the release of PII or PHI information. If disclosing PII or PHI, document transactions and maintain documentation in the member’s case file pertaining to how the identity of the person was verified when contact is outside the interview and the method of how the information was released to the individual.

Verify the identity of the person who requests disclosure of PII or PHI by examining:

At least one form of government-issued photo identification (ID):

  • valid U.S passport;
  • valid driver license or Department of Public Safety identification card; or
  • state agency employee badge; and

At least one form of other ID:

  • birth certificate or birth record;
  • Social Security number (SSN) card;
  • hospital record;
  • work or school identification card;
  • voter registration card;
  • wage stub;
  • credit card;
  • department store credit card;
  • gas station credit card;
  • annual plastic membership identification card; or
  • utility bill.

Refer to Section 2111.1, Telephone Contact, Section 2111.2, In-Person Communication, and Section 2150, Alternate Means of Communication, for acceptable communication channels for external partners.

 

2112 Custody of Records

Revision 18-2; Effective September 3, 2018

 

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain, except as provided by Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) regulations.

Reasonable diligence for employees responsible for records includes keeping records:

  • in a locked office when the building is closed;
  • properly filed during office hours; and
  • in the office at all times, except when authorized to remove or transfer them.

 

2113 Disposal of Records

Revision 18-2; Effective September 3, 2018

 

To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data. Managed care organizations (MCOs) must follow procedures contained in the Uniform Managed Care Contract.

 

2114 When and What Information May Be Disclosed

Revision 18-2; Effective September 3, 2018

 

Reasonable efforts must be made to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to determine eligibility and operate the program. The disclosure of the applicant’s or member’s PHI from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant or member.

PHI may only be disclosed to a person who has written permission from the applicant, member or authorized representative (AR) to obtain the information. The applicant, member or AR authorizes the release of information by completing and signing:

  • Form 1826-D, Case Information Release; or
  • a document containing all of the following information:
    • the applicant's or member's:
      • full name (including middle initial) and Medicaid identification number; or
      • full name (including middle initial) and either date of birth or Social Security number (SSN);
    • a description of the information to be released. Note: If a general release is authorized, provide the information that can be disclosed to the applicant, member or AR. Withhold PHI from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
    • a statement specifically authorizing HHSC or the MCO to release the information;
    • the name of the person or agency to whom the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the member, the purpose of the release or an expiration date of the release;
    • a statement about whether refusal to sign the release affects eligibility for delivery of services;
    • a statement describing the applicant's or member's right to revoke the authorization to release information;
    • the date the document is signed; and
    • the signature of the applicant, member or AR.

Note: If the case information to be released includes PHI, the document must also tell the applicant, member or AR that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and the members' survivors.

The Office of the General Counsel at HHSC handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to these offices. MCO staff should contact HHSC’s Managed Care Compliance & Operations (MCCO).

 

2115 Confidential Nature of Medical Information — HIPAA

Revision 18-2; Effective September 3, 2018

 

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of protected health information (PHI). PHI is information that identifies or could be used to identify an individual and that relates to the:

  • past, present or future physical, mental or behavioral health or condition of the individual;
  • provision of health care to the individual; or
  • past, present or future payment for the provision of health care to the individual.

PHI includes, but is not limited to, an individual's name, date of birth (DOB), address, Social Security number (SSN), Medicaid ID number, or any other individually identifiable information.

2116 Privacy Notice

Revision 18-2; Effective September 3, 2018

 

Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) staff must send each member the Health and Human Services Agencies' Notice of Privacy Practices, at https://hhs.texas.gov/health-and-human-services-agencies-notice-privacy-practices upon certification. This notice tells the member or authorized representative (AR) about:

  • the member's privacy rights;
  • the duties of HHSC and the MCO to protect health information; and
  • how HHSC and the MCO may use or disclose health information without the member's authorization. Examples of use or disclosure include health care operations (e.g., Medicaid), public health purposes, reporting victims of abuse, law enforcement purposes, sharing with HHSC or MCO contractors and coordinating government programs that provide benefits.

Notice of Privacy Practices – English
Notice of Privacy Practices – Spanish

 

2117 Member Authorization

Revision 18-2; Effective September 3, 2018

 

The member may authorize the release of health information from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records by using a valid authorization form. Form 1826-D, Case Information Release, includes all the authorization elements required by Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.

 

2118 Minimum Necessary Information Release

Revision 18-2; Effective September 3, 2018

 

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if a member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the member.

 

2119 Authorized Representatives

Revision 18-2; Effective September 3, 2018

 

Only the member's authorized representative (AR) can exercise the applicant's or member's rights with respect to protected health information (PHI). Therefore, only an applicant’s or member's AR may authorize the use or disclosure of PHI or obtain PHI on behalf of an applicant or member. Exception: Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) are not required to disclose the information to the AR if the member is subjected to domestic violence, abuse or neglect by the AR. Consult the Office of the Chief Counsel, as described in Section 2114, When and What Information May Be Disclosed, if it is believed that health information should not be released to the AR.

Note: A responsible party is not automatically an AR.

 

2119.1 Adults and Emancipated Minors

Revision 18-2; Effective September 3, 2018

 

If the member is an adult or emancipated minor, including married minors, the member's authorized representative (AR) is a person who has the authority to make health care decisions about the member and includes a:

  • person the member has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
  • court-appointed guardian for the member; or
  • person designated by law to make health care decisions when the member is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication.

Consult the Office of the Chief Counsel, as described in Section 2114, When and What Information May Be Disclosed, for approval.

 

2119.2 Unemancipated Minors

Revision 18-2; Effective September 3, 2018

 

A parent is the authorized representative (AR) for a minor child except when:

  • The minor child can consent to medical treatment. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 or older, lives separately from the parents and manages her or his own financial affairs;
    • consent involves diagnosis and treatment of disease that must be reported to the local health officer or the Texas Department of State Health Services (DSHS);
    • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
    • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
    • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by the state;
    • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
    • consent involves suicide prevention or sexual, physical or emotional abuse.
  • A court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about health care decisions not made by the parent.

 

2119.3 Deceased Applicant or Member

Revision 18-2; Effective September 3, 2018

 

The authorized representative (AR) for a deceased applicant or member is an executor, administrator or other person with authority to act on behalf of the applicant, member or the member's estate. These include:

  • an executor, including an independent executor;
  • an administrator, including a temporary administrator;
  • a surviving spouse;
  • a child;
  • a parent; and
  • an heir.

Consult appropriate legal counsel, as described in Section 2114, When and What Information May Be Disclosed, if you have questions about whether a particular person is the AR of an applicant or member.

 

2120 Protected Health Information on Notifications

Revision 18-2; Effective September 3, 2018

 

The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member or authorized representative (AR) during the eligibility determination process. This includes inclusion of PHI by HHSC staff to third parties who receive a copy of a notification of eligibility form.

Staff must ensure they do not include PHI on the eligibility notice that should not be shared with the service provider or another third party. For example:

  • Notification is received from Medicaid for the Elderly and People with Disabilities (MEPD) that the member has lost Medicaid because the member's income of $2,892 exceeds the eligibility limit of $2,022. It is a violation of confidentiality to record on Form H2065-D, Notification of Managed Care Program Services, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "You are no longer eligible for Medicaid."
  • Another applicant is being denied STAR+PLUS Home and Community Based Services (HCBS) program services because the presence of weapons in the member's home presents a hazard to service providers. It is a violation of confidentiality to record on Form H2065-D, "The presence of weapons in your home presents a hazard to service providers." The comment should simply state, "Your services are being denied due to hazardous conditions in your home."

In the examples above, revealing specifics of the applicant’s or member's income or the condition of the home environment is a violation of the member's right to confidentiality. In all cases, HHSC staff must assess any information provided by the applicant or member to determine if its release would be a confidentiality violation.

 

2130 Applicant or Member Correction of Information

Revision 18-2; Effective September 3, 2018

 

An applicant, member or authorized representative (AR) has a right to correct any information that the Texas Health and Human Services Commission (HHSC) or the managed care organization (MCO) has about the applicant or member and any other individual on the member's case.

A request for correction must be in writing and:

  • identify the applicant or member asking for the correction;
  • identify the disputed information about the applicant or member;
  • state why the information is wrong;
  • include any proof that shows the information is wrong;
  • state what correction is requested; and
  • include a return address, telephone number or email address at which HHSC or the MCO can contact the applicant or member.

If HHSC or the MCO agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the member's request.

Notify the applicant, member or AR in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC or the MCO makes a correction to protected health information (PHI), ask the member for permission before sharing with third parties. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if they may have relied or could rely on it to the disadvantage of the member. HHSC staff must follow regional procedures to contact the HHSC Office of the Chief Counsel for a record of disclosures. MCOs must follow HHSC procedures as stated in the Uniform Managed Care Contract.

Note: Do not follow above procedures when the accuracy of information provided by an applicant, member or AR is determined by another review process, such as a:

  • fair hearing;
  • civil rights hearing; or
  • other appeal process.

The decision in the above review processes is the decision on the request to correct information.

 

2140 Communication with the Managed Care Organization

Revision 18-2; Effective September 3, 2018

 

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member's protected health information (PHI) to be shared only with the selected managed care organization (MCO). This makes it crucial that when documents containing member information are posted in the incorrect MCO folder in TxMedCentral, they be corrected immediately upon realization an error was made.

Send notification of all posting errors to txmedcentraladmin@tmhp.com. Include the document identifying information, the name of the folder in which it was erroneously posted and the name of the folder into which it should have been posted. Include the time the correction was made.

Example: Posted 9F_2067_123456789_ABCD_2S.doc in SUPSPW at 8:54 a.m. on December 20. Should have been posted to MOLSPW. Corrected at 9:22 a.m. December 20.

All emails containing member information must be sent using encryption software. No PHI may appear in the subject line.

See also:

 

2150 Alternate Means of Communication

Revision 18-2; Effective September 3, 2018

 

The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant's, member's or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations

The applicant, member or AR must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the applicant or member.

 

2200 Citizenship and Identity Verification

Revision 10-0; Effective September 1, 2010

 

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long-term services and supports (LTSS) members whose financial eligibility is based on a determination from Medicaid for the Elderly and People with Disabilities (MEPD) staff.

This documentation must be provided at the initial determination. Verification of citizenship and identity for eligibility purposes is a one-time activity as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD staff, verification is no longer required even after a break in eligibility.

 

2210 Acceptable Documentation for Both Citizenship and Identity

Revision 10-0; Effective September 1, 2010

 

 

2211 Supplemental Security Income Recipients

Revision 10-0; Effective September 1, 2010

 

The State Data Exchange (SDX) contains the needed information to verify citizenship. For any active Supplemental Security Income (SSI) recipient, Medicaid for the Elderly and People with Disabilities (MEPD) staff are able to use the SDX as verification for both citizenship and identity. For any denied SSI recipient, the SDX can be used as a valid verification source of both citizenship and identity when the denial is for any reason other than citizenship. The SDX printout shows action code N13 if the denial is for citizenship.

 

2212 Medicare Recipients

Revision 10-0; Effective September 1, 2010

 

Active Medicare recipients are exempt from the requirement to provide evidence of citizenship and identity. The Social Security Administration (SSA) documents citizenship and identity for Medicare recipients.

For any individual entitled to or enrolled in Medicare Part A or B and subsequently denied Medicare, use the State On-Line Query (SOLQ) system or Wire Third Party Query (WTPY) system as documentation of both citizenship and identity when the denial is for any reason other than citizenship. If there is an end date listed for Medicare, the individual must provide documentation on the loss of Medicare.

 

2213 All Other Individuals

Revision 18-2; Effective September 3, 2018

 

The primary documents that may be accepted as proof of both identity and citizenship include:

  • U.S. passport;
  • Certificate of Naturalization (N-550 or N-570); or
  • Certificate of U.S. Citizenship (N-560 or N-561).

If an individual does not provide one of these primary documents that establish both U.S. citizenship and identity, the individual must provide two documents:

  • one document that establishes U.S. citizenship; and
  • one document that establishes identity.

See Evidence of Identity below for a list of documents that are acceptable.

Documents that establish citizenship are divided into second, third and fourth levels based on the reliability of the evidence.

Primary Evidence of Citizenship and Identity
  • U.S. passport.
  • Certificate of Naturalization.
  • Certificate of U.S. Citizenship.
  • State Data Exchange (SDX) for denied Supplemental Security Income (SSI) recipients when the denial reason is for any reason other than citizenship (N13).
  • State On-Line Query (SOLQ)/Wire Third Party Query (WTPY) and documentation on reason for Medicare denial.

Begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

Second Level of Evidence of Citizenship
(Use only when primary evidence is not available.)
  • A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (if born on or after Jan. 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (if born after Nov. 4, 1986). Contact the Bureau of Vital Statistics (BVS) for an individual born in Texas. If an individual's date of birth is earlier than 1903 or if the birth was out of state, accept a legible, non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; and usbirthcertificate.net or their toll-free number, 1-888-736-2692.
  • Report of Birth Abroad of a U.S. Citizen (FS-240).
  • Certification of Birth Abroad (FS 545 or DS-1350).
  • U.S. Citizen Identification card (Form I-179 or I-197).
  • Northern Mariana Identification card (I-873).
  • American Indian card (I-872) issued by the Department of Homeland Security with classification code "KIC".
  • Final adoption decree showing the child's name and U.S. place of birth.
  • Evidence of U.S. Civil Service employment before June 1, 1976.
  • U.S. military record showing a U.S. place of birth (Example: DD-214).

 

Third Level of Evidence of Citizenship
(Use only when primary and second level evidence is not available.)
  • Hospital record of birth showing the U.S. place of birth.
  • Life, health or other insurance record showing the U.S. place of birth.
  • Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual's age at the time the record was made.
  • Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and the name(s) and place(s) of birth of the applicant's or recipient's parents.

 

Fourth Level of Evidence of Citizenship
(Use only when primary, second and third level evidence is not available.)
Any listed documents used must include biographical information, including U.S. place of birth.
  • Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual's age (generally for individuals born 1900-1950).
  • Seneca Indian Tribal census record showing a U.S. place of birth.
  • Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth.
  • Bureau of Indian Affairs Roll of Alaska Natives.
  • U.S. state vital statistics official notification of birth registration showing a U.S. place of birth.
  • Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth.
  • Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth.
  • Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth.
  • Affidavits from two adults regardless of blood relationship to the individual. (Use only as a last resort when no other evidence is available.)

 

Evidence of Identity
  • Driver license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color.
  • School identification card with a photograph.
  • U.S. military card or draft record.
  • Identification card issued by the federal, state or local government with the same information that is included on a driver license
  • Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color.
  • Birth certificate.
  • Hospital record of birth.
  • Military dependent's identification card.
  • Native American Tribal document.
  • U.S. Coast Guard Merchant Mariner card.
  • Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information.
  • Data matches with other state or federal government agencies (Example: Employee Retirement System (ERS) and Teacher Retirement System (TRS)).
  • Three or more supporting documents such as a marriage license, divorce decree, high school diploma or employer identification card (use only with second and third level evidence of citizenship).
  • Adoption papers or records.
  • Work identification card with photograph.
  • Signed application for Medicaid (accept signature of an authorized representative or a responsible person acting on the individual's behalf).
  • Health care admission statement.
  • For children under age 16, school records (may include nursery or day care records).
  • For children under age 16, doctor, clinic or hospital records.
  • For children under age 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).
  • For disabled individuals in residential care facilities who cannot provide any document on this list, an affidavit signed by the facility director or administrator attesting the identity of the individual (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).

In the hierarchy of approved documentation sources, some documents listed to verify citizenship are also acceptable to verify identity. When using the hierarchy of approved documentation sources, the same document cannot be the source to verify both citizenship and identity.

If an individual is unable to provide any other documentary evidence of citizenship, an affidavit signed under penalty of perjury is only accepted as a last resort. Medicaid for the Elderly and People with Disabilities (MEPD) specialists are required to document the reason another source is not available to verify citizenship. If managed care organization (MCO) or Program Support Unit (PSU) staff are provided an affidavit, ensure the reason the applicant or recipient is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form H1746-A, MEPD Referral Cover Sheet, along with the affidavit. The copies of the affidavit form are to be made available in all Texas Health and Human Services Commission (HHSC) benefits offices. Form H1097, Affidavit for Citizenship/Identity, and Form H1097-S (Spanish), also may be used.

 

2220 Reserved

Revision 10-0; Effective September 1, 2010

 

 

2230 Member Rights and Responsibilities

Revision 12-3; Effective October 1, 2012
 

 

2231 Notifications

Revision 18-2; Effective September 3, 2018

 

 

2231.1 Program Support Unit Notification Requirements

Revision 18-2; Effective September 3, 2018

 

The Program Support Unit (PSU) is responsible for preparing and sending notifications to the applicant, member or authorized representative (AR) advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member or AR of the actions taken regarding STAR+PLUS Home and Community Based Services (HCBS) program services. Form H2065-D must be completed in plain language that can be understood by the applicant, member or AR. The language preference of the applicant, member or AR must be considered.

The applicant, member or AR must be notified on Form H2065-D within two business days of the date a case is certified. Form H2065-D also includes information on the individual's room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is denied or terminated. The PSU staff must notify the applicant, member or AR on Form H2065-D of the denial of application within two business days of the decision. Refer to Section 3630, Denial or Termination Procedures.

Depending on when the notification is generated, it will either be posted to the managed care organization’s (MCO’s) STAR+PLUS folder in TxMedCentral or generated in the Long Term Care (LTC) Online Portal on the case action date.

 

2231.2 MCO Notification Requirements

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) is responsible for notifying the member or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member or AR has a right to appeal. Appeal rights of STAR+PLUS members are in the Uniform Managed Care Manual (UMCM), which can be found at: https://hhs.texas.gov/services/health/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

 

2232 Notifications with MEPD Involvement

Revision 18-2; Effective September 3, 2018

 

Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialist. The Program Support Unit (PSU) must coordinate changes, approvals and denials of Home and Community Based Services (HCBS) program services with the MEPD specialist.

Although the MEPD specialist is required to notify the applicant, member or authorized representative (AR) of all Medicaid eligibility decisions, the PSU is required to send the STAR+PLUS HCBS program applicant, member or AR the notification of denial of STAR+PLUS HCBS program services on Form H2065-D, Notification of Managed Care Program Services. PSU staff also fax the MEPD specialist a copy of Form H2065-D at initial certification and denial for case actions that involve Medicaid eligibility.

 

2233 Rights and Responsibilities Reference

Revision 10-0; Effective September 1, 2010

 

Member rights and responsibilities are included in the Member Handbook. The required critical elements for member handbooks can be found at:

https://hhs.texas.gov/services/health/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the member at application. This document is shared in the language preference expressed by the applicant/member.