Revision 18-0; Effective September 4, 2018

 

 

1100 Program Overview

Revision 18-0; Effective September 4, 2018
 
The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living (ADLs), home modifications, respite (short-term supervision) and personal assistance services (PAS). These services are delivered through providers contracted with managed care organizations (MCOs).

The STAR+PLUS program provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.

Service coordination, available to all members, is the main feature of the STAR+PLUS program. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.

The STAR+PLUS Home and Community Based Services (HCBS) program is a program approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility (NF) care to receive LTSS in order to be able to live in the community.

Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to the STAR+PLUS program. For a dictionary of acronyms used in the STAR+PLUS Program, refer to Appendix VII, Acronyms.
 

1110 Legal Basis

Revision 18-0; Effective September 4, 2018
 
Statutory basis for the STAR+PLUS program:

  • Texas Administrative Code (TAC), Title 1, §353.601-607 and §353.1153; and
  • Government Code, Title 4, Executive Branch, Subtitle I, Health and Human Services, Chapter 533, Medicaid Managed Care Program.

 
1120 Values

Revision 18-0; Effective September 4, 2018
 
The principles and practices that form the foundation for the STAR+PLUS Home and Community Based Services (HCBS) program are based on the following values:

  • Members receive services based on their choices and ongoing assessment of their medical and functional needs.
  • The service delivery system is accessible to the member, responsive to his or her needs and preferences, and flexible in honoring choices regarding living arrangement, services and mode of service delivery.
  • Members use available family, community and third-party services and resources, as well as those provided through the STAR+PLUS HCBS program to meet their needs and identified goals.
  • Services provided to the member must provide safe, cost-effective, and medically or functionally necessary alternatives to nursing facility (NF) placement that allow the member the opportunity to use and maintain family and community contacts and services.
  • The individual service plan (ISP) reflects the member's active participation in the assessment and planning process and his or her responsibility to provide as much self-care as possible.
  • Services must support the member's efforts to retain or regain as much independence as possible in the activities of daily living (ADLs), living arrangement and other areas of personal choice, and in meeting any goals.
  • Individuals and members are provided the education, support and services needed to support the member's efforts to remain in or return to the community.
  • Within the constraints imposed by the cost limit on a member's ISP, the program promotes the member's active involvement and choices regarding the services provided.

 
1130 Service Model

Revision 18-0; Effective September 4, 2018

 

 

1131 Service Delivery Model

Revision 18-0; Effective September 4, 2018
 
Individuals enrolled in the STAR+PLUS program may select a service delivery model for personal assistance services (PAS) or Community First Choice (CFC) services identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H6516, Community First Choice Assessment, and Form H2060-A, Addendum to Form H2060. Individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services may reside alone, with family members or others at locations of their choice in the community, including adult foster care (AFC) homes or licensed assisted living facilities (ALFs).

The STAR+PLUS HCBS program provides individuals with an array of services necessary to allow the individual to remain in, or return to, a community setting. Providers contracted with managed care organizations (MCOs) provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists to determine financial eligibility for individuals not eligible for Supplemental Security Income (SSI). SSI eligible individuals are Medicaid eligible and can obtain STAR+PLUS HCBS program services without additional financial screening. (Refer to Section 3110, Medicaid, Medicare and Dual-Eligibles.)

STAR+PLUS members choose to participate in the agency option (AO), consumer directed services (CDS) option or service responsibility option (SRO) delivery models.

  • Members who choose the AO model work with the MCO to coordinate service delivery for each service in the ISP.
  • Members who choose the CDS model are given the authority to self-direct designated services. If the member chooses to self-direct designated services, the MCO coordinates delivery of non-member-directed designated services. In the CDS model, providers employed by the member or authorized representative (AR) must be qualified personnel to provide authorized services when services are necessary. These personnel may be employed directly by, or through, personal service agreements or subcontracts with the providers. A member's services and service providers must be based on an MCO assessment of the member’s individual needs. More information is available in Appendix XXVIII, CDS Training for Service Coordinators and CDS Training Manual.
  • In the SRO model, the provider is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The provider also orients attendants to provider policies and standards before sending them to members' homes. The member or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant.

 
1140 Program Services

Revision 18-0; Effective September 4, 2018

 

 

1141 Services Available Under STAR+PLUS

Revision 18-0; Effective September 4, 2018
 
If the service coordinator identifies a need, or the member requests additional services, the managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP). Since MCOs are at risk for paying for a range of acute care and long-term services and supports (LTSS), there is an incentive to provide innovative, cost effective care from the onset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS members who do not have Medicare are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals can choose a specialist to be their PCP and they receive all services, both acute care and LTSS, from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. The STAR+PLUS program does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

The STAR+PLUS program serves as an insurance policy if members have a need for LTSS at a future time. Refer to Section 3110, Medicaid, Medicare and Dual-Eligible, for additional information on dual-eligible coverage.

Medicaid-only members (those who do not receive Medicare) receive traditional Medicaid acute care services plus an annual check-up. For these members, the cost of acute care services is included in the capitation payment to the MCO. For dual-eligible members, the MCO’s capitation payment does not include the cost of acute care.

 

1142 Long-term Services and Supports

Revision 18-0; Effective September 4, 2018
 
Day Activity and Health Services (DAHS) and personal attendant services (PAS) are available to STAR+PLUS members who meet functional eligibility requirements. Community First Choice (CFC) services are available to STAR+PLUS members who meet an institutional level of care (LOC), meet functional eligibility requirements, and who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. Additional services are available under the STAR+PLUS Home and Community Based Services (HCBS) program. For a complete list of services provided under the STAR+PLUS program, refer to the managed care contracts governing the STAR+PLUS program at https://hhs.texas.gov/services/health/provider-information/managed-care-contracts-manuals.
 

1143 STAR+PLUS Services

Revision 18-0; Effective September 4, 2018
 
STAR+PLUS program members have access to medically and functionally necessary services available in the state plan. Some members are eligible for additional services available in the STAR+PLUS Home and Community Based Services (HCBS) program, in addition to their traditional state plan STAR+PLUS services. Refer to:
•    Section 1143.1, Services Available to STAR+PLUS Members, that follows; and
•    Section 1143.2, Services Available to STAR+PLUS Home and Community Based Services (HCBS) Program Members.

 

1143.1 Services Available to STAR+PLUS Members

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) contracts with Medicaid managed care organizations (MCOs) for the provision of STAR+PLUS services. These Medicaid MCOs are responsible for providing a benefit package to members that include all medically-necessary services covered under the traditional, fee-for-service (FFS) Medicaid programs, with the exception of non-capitated services provided to Medicaid members outside of the MCO capitation and listed in each managed care contract. (For example, Attachment B-1, Section 8.2.2.8, of the Uniform Managed Care Contract (UMCC).

STAR+PLUS members also receive enhanced benefits compared to the traditional FFS Medicaid coverage:

  • waiver of the three-prescription per month limit for members not covered by Medicare; and
  • waiver of spell illness limitation for members admitted to a facility as a result of the serious and persistent mental illness (SPMI).

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members age 18 and over and prescription drugs. STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual (TMPPM) and the Texas Medicaid Bulletin postings for a more inclusive listing of limitations and exclusions that apply to each Medicaid benefit category. (These documents can be accessed online at: www.tmhp.com.)

The services listed in the managed care contracts (for example, UMCC) are subject to modification based on federal and state laws and regulations and program policy updates.
 

1143.1.1 Services Included Under the MCO Capitation Payment

Revision 18-0; Effective September 4, 2018
 
Services included under the managed care organization (MCO) capitation payment include:

  • ambulance services;
  • audiology services, including hearing aids;
  • behavioral health services, including:
    • inpatient mental health services;
    • outpatient mental health services;
    • outpatient chemical dependency services;
    • mental health rehabilitation for non-duals;
    • mental health targeted case management for non-duals;
    • detoxification services;
    • psychiatry services; and
    • counseling services;
  • birthing services provided by a certified nurse midwife in a birthing center;
  • chiropractic services;
  • dialysis;
  • durable medical equipment (DME) and supplies;
  • Emergency Response Services (ERS);
  • family planning services;
  • home health care services for acute conditions;
  • hospital services;
  • laboratory;
  • long-term services and supports (LTSS) (Refer to Section 1143.1.2, Long-term Services and Support Listing, below);
  • medical checkups and Comprehensive Care Program (CCP) services for Medicaid for Breast and Cervical Cancer (MBCC) members under age 21;
  • oncology services;
  • optometry, glasses and contact lenses, if medically necessary;
  • podiatry;
  • prenatal care;
  • prescription drugs;
  • primary care services (PCS);
  • preventive services including an annual adult well check;
  • radiology, imaging and X-rays;
  • specialty physician services;
  • therapies, including physical, occupational and speech for acute conditions;
  • transplantation of organs and tissues; and
  • vision services.

 
1143.1.2 Long-term Services and Support Listing

Revision 18-0; Effective September 4, 2018
 
The following is a non-exhaustive, high-level listing of community-based long-term services and supports (LTSS) included under the STAR+PLUS program:

  • Community First Choice (CFC) - Available to all Medicaid-eligible members (members who are considered medical assistance only (MAO) are not eligible for CFC who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or psychiatric hospital (also called an institution for mental disease) (under age 21 or 65 or older). CFC services include:
    • Emergency Response Services (ERS), which are backup systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports;
    • habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
    • personal assistance services (PAS), which provide assistance with ADLs, IADLs and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks; and
    • support management, which is training provided to members or authorized representatives (ARs) on how to manage and dismiss their attendants.
  • Day Activity and Health Services (DAHS) — All members of a STAR+PLUS managed care organization (MCO) may receive medically and functionally necessary DAHS. DAHS includes nursing and PAS, therapy extension services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed by the state.
  • Nursing facilities (NFs) — Institutional care to a member whose physician has certified that the member has a medical condition that requires 24-hour nursing care that meets medical necessity (MN) requirements. The need for custodial care solely does not constitute MN for an NF placement. Institutional care includes coverage for the medical, social and psychological needs of each resident, including room and board, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.
  • PAS, formerly known as Primary Home Care (PHC) PAS — All members may receive medically and functionally necessary PAS. PAS includes assisting the member with the performance of ADLs and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member's need and the plan of care (POC). To be eligible for state plan PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. In order to be eligible for PAS through programs other than CFC or the STAR+PLUS Home and Community Based Services (HCBS) program, members must score at least 24 on Form H2060. PAS includes three service delivery options:
    • Agency Option (AO);
    • Consumer Directed Services Option (CDS); and
    • Service Responsibility Option (SRO).
  • STAR+PLUS HCBS program — This is for those members who qualify for such services. The state also provides an enriched array of services to members who would otherwise qualify for NF care through the STAR+PLUS HCBS program. The MCO must also provide medically necessary services that are available to members who meet the functional and financial eligibility for the STAR+PLUS HCBS program.

 
1143.2 Services Available to STAR+PLUS HCBS Members

Revision 18-0; Effective September 4, 2018
 
Services necessary for the member to remain in or return to the community are identified from the array of services available through the STAR+PLUS Home and Community Based Services (HCBS) program. STAR+PLUS HCBS program services include:

  • Adaptive aids and medical supplies — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable individuals to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live.
  • Adult foster care (AFC) — A 24-hour living arrangement for persons who, because of physical or mental limitations, are unable to continue residing in their own home. Services may include meal preparation, housekeeping, personal care, help with ADLs, supervision and the provision of, or arrangement of, transportation.
  • Assisted living (AL) services — A 24-hour living arrangement in licensed personal care facilities in which personal care, home management, escort, social and recreational activities, 24-hour supervision, provision or arrangement of transportation, and supervision of, assistance with and direct administration of medications are provided. Under the STAR+PLUS HCBS program, personal care facilities may contract to provide services in two distinct types of living arrangements:
    • AL apartments; or
    • AL non-apartment settings.
  • Cognitive rehabilitation therapy (CRT) — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells or chemistry in order to enable the individual to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. CRT is provided in accordance with the POC developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
  • Dental services — Services provided by a dentist to preserve teeth and meet the medical need of the member. Allowable services include:
    • emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection;
    • preventative procedures required to prevent the imminent loss of teeth;
    • the treatment of injuries to teeth or supporting structures;
    • dentures and the cost of preparation and fitting; and
    • routine procedures necessary to maintain good oral health.
  • Emergency Response Services (ERS) — An electronic monitoring system for use by functionally impaired individuals who live alone or are isolated in the community or at high risk of institutionalization. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week capability, helps insure that the appropriate persons or service provider respond to an alarm call from the member.
  • Employment Assistance Services (EAS) — Services that assist the member with locating competitive employment or self-employment.
  • Financial Management Services (FMS) — Assistance to members with managing funds associated with services elected for the Consumer Directed Services (CDS) option and is provided by the financial management services agency (FMSA). The service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
  • Home-Delivered Meals (HDM) — Services that provide nutritionally sound meals delivered to the member’s home.
  • Minor home modifications (MHMs) — Services that assess the need for, arrange for and provide modifications or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility.
  • Nursing services — Includes assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing (BON), developing the nursing POC and teaching individuals about proper health maintenance.
  • Occupational therapy (OT) services — Interventions and procedures to promote or enhance safety and performance in instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant (OTA) under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
  • Personal assistance services (PAS) — Includes assisting the member with the performance of ADLs and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member’s needs and the POC. Services may also include the provision of nursing tasks delegated by a registered nurse (RN) in accordance with state rules promulgated by the Texas BON and protective supervision provided solely to ensure the health and welfare of a member with cognitive/memory impairment and/or physical weakness. To be eligible for STAR+PLUS HCBS program PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. STAR+PLUS HCBS program PAS eligibility only requires that the applicant or member needs assistance with at least one personal care task identified on Form H2060. The 24-point scoring eligibility for state plan PAS does not apply to STAR+PLUS HCBS program PAS.
  • Physical therapy (PT) services — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Services include the full range of activities provided by a physical therapist or a licensed physical therapist assistant (PTA) under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
  • Respite care services — Temporary relief to persons caring for functionally impaired adults in community settings other than adult AFC homes or assisted living facilities (ALFs). Respite services are provided in-home and out-of-home and are limited to 30 days per individual service plan (ISP) year. Room and board (R&B) is included in the payment for out-of-home settings.
  • Speech and/or language pathology services — The evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by speech and language pathologists under the scope of the therapist’s state licensure.
  • Supported Employment Services — Services that assist the member with sustaining competitive employment or self-employment.
  • Transition Assistance Services (TAS) — Assists members with non-recurring set-up expenses for transitioning from nursing homes to the community. Services may include assistance with security deposits for leases on apartments or homes, essential household furnishings, set-up fees for utilities, moving expenses, pest eradication or one-time cleaning.

 
1200 Service Coordination Through the MCO

Revision 18-0; Effective September 4, 2018
 
Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. If a member receives long- term services and supports (LTSS), has a history of behavioral health issues or substance use disorders (SUD), or is dual eligible, the identified MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year. If the member receives the STAR+PLUS Home and Community Based Services (HCBS) program, or has a complex medical condition, the identified MCO service coordinator must visit with the member face-to-face at least twice a year. If a member resides in a nursing facility (NF), the MCO service coordinator must meet with the member face-to-face at a minimum of four times per year.

All applicants or members of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the applicant or member and his or her acute care and LTSS providers to ensure all of an applicant’s or member's medically and functionally necessary services are provided. This includes referring and assisting the applicant or member in obtaining appointments with specialists, participating in discharge planning for applicants or members in hospitals or the NF, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving the STAR+PLUS HCBS program can be found in Section 3000, STAR+PLUS HCBS Program Eligibility and Services, Section 6000, Specific STAR+PLUS HCBS Program, Section 5000, Automation and Payment Issues in STAR+PLUS, and Appendices. Service coordination requirements for members receiving Medicaid state plan LTSS can be found in the Uniform Managed Care Contract (UMCC).

The following sections detail MCO service coordinator responsibilities for applicants or members in certain facilities or programs.
 

1210 Service Coordinators and Nursing Facilities

Revision 18-0; Effective September 4, 2018
 
Members residing in a nursing facility (NF), except members receiving hospice care or living outside the managed care organization (MCO) service area, must receive at least quarterly face-to-face visits for assessment purposes. NF staff should invite MCO service coordinators to their resident care planning meetings or other interdisciplinary team meetings, as long as the resident does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or by telephone. The MCO must maintain and make available upon request documentation verifying the occurrence of required face-to-face service coordination visits, which may coincide with, or include participation in, care planning or other interdisciplinary team meetings.

Service coordination activities for members residing in an NF include:

  • visiting members at least quarterly;
    • assessing the member within 30 days of entry in an NF or enrollment into the health plan;
    • visiting within 14 days of hearing that a significant change in condition of the member has occurred;
    • visiting within 14 days of learning that a resident requests a transition to the community;
  • developing a plan of care (POC) to transition the individual to the community (if appropriate and the resident’s choice);
    • if initial review doesn’t support return to the community, a second assessment will be conducted 90 days after the initial assessment;
  • transitioning the member to the community in adherence with the Texas Promoting Independence Initiative, including Money Follows the Person (MFP), as appropriate;
    • notifying the Relocation Contract specialist within three business days after meeting with the member;
    • notifying the Local Authority for residents meeting Pre-Admission Screening and Resident Review (PASRR) requirements, Local Intellectual and Developmental Disability Authority (LIDDA) or Local Mental Health Authority (LMHA), as appropriate;
    • working in conjunction with the NF discharge planning team;
    • coordinating transition with community partners;
    • coordinating transition if the resident is moving into a service area not served by this MCO, by setting up Single Case Agreements, as needed;
  • identifying and addressing residents’ physical, mental or long term needs;
  • assisting residents and families to understand benefits;
  • ensuring access to and coordination of needed services;
  • finding providers to address specific needs;
  • coordinating and notifying of add-on services not included in the daily rate; and
  • assisting with collection of applied income. The NF business office manager (BOM) is responsible for collecting applied income.
    • The BOM can notify the MCO service coordinator for assistance in collecting the applied income after two collection attempts are made with no success.  
    • The BOM’s role is to educate the resident and his or her responsible party on the rules regarding payment of applied income to the NF and the potential ramifications of not doing so. The MCO service coordinator may reinforce the BOM's education regarding payment of applied income to ensure the member understands.

If a member participating in the STAR+PLUS Home and Community Based Services (HCBS) program is admitted to an NF, the NF service coordinator must notify Program Support Unit (PSU) staff within three business days of the admission using Form H2067-MC, Managed Care Programs Communication.

 

1220 Service Coordinators and Programs Serving Members with IDD

Revision 18-0; Effective September 4, 2018
 
Members who have intellectual or developmental disabilities (IDD) and live in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who receive services through one of the following IDD waivers receive their acute care services only through the STAR+PLUS program and continue to receive their long- term services and supports (LTSS) through the 1915(c) Medicaid waivers:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL).

Members who receive services through one of these four programs and receive Medicare Part B (dual eligible) are not included in the STAR+PLUS program.

Members with IDD that meet the above criteria have a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member's or authorized representative's (AR’s) personal preference.

These members also have a Local Intellectual and Developmental Disability Authority (LIDDA) provider that is a person outside of the MCO who develops and implements an individual service plan (ISP) and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member's waiver case manager or service coordinator. The member's waiver case manager or service coordinator should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or by telephone. The MCO service coordinator is responsible for the coordination of the member's acute care services.

 

1230 Service Coordinators and HCBS - Adult Mental Health Program

Revision 18-0; Effective September 4, 2018
 
The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves members who have serious and persistent mental illness (SPMI) and:

  • a history of extended (three cumulative or consecutive years of the past five years) institutional stays in psychiatric facilities;
  • SPMI and frequent visits to the emergency department; and
  • SPMI and frequent arrests and stays in a correctional facility.

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program's population. HCBS-AMH is operated on a fee-for-service (FFS) basis through the Texas Health and Human Services Commission (HHSC). Each member is assigned a recovery manager (RM), who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive acute care services through their managed care organization (MCO) and enhanced community-based services from providers contracted with HHSC. Additional information about HCBS-AMH can be found at: https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

Program Point of Contact (PPOC)

  • Each MCO must have a designated PPOC for the HCBS-AMH program. The PPOC is responsible for the following:
    • Ensuring the MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
    • Responding within three business days to concerns from HHSC or RMs to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the AMH program.

MCO Service Coordination Responsibility

  • MCO service coordination must participate in telephonic recovery plan meetings, as scheduled by HHSC or RMs, and provide any requested member-specific information prior to the meeting. MCO service coordinators must:
    • send requested information to the HHSC or RM three business days prior to the scheduled recovery plan meeting. This information includes the following:
      • updates regarding member condition;
      • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
      • upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
      • relevant member treatment documents as requested by the HHSC or RM.
    • respond to ad-hoc requests from the HHSC or RM with "Urgent" in the subject line within one business day.
    • respond to non-urgent ad-hoc requests in a timely manner.
    • coordinate with Program Support Unit (PSU) staff and HHSC or RM when a member transfers from the STAR+PLUS Home and Community Based Services (HCBS) program to HCBS-AMH.

HCBS-AMH may provide transitional planning for members who reside in an institution and who are also enrolled in a STAR+PLUS MCO. MCO service coordinators must participate in planning meetings with an RM, telephonically or in person, during the member's stay. Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR+PLUS MCOs must follow all discharge planning requirements as outlined in Uniform Managed Care Contract (UMCC), Section 8.3.2.5.

 

1240 Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 18-0; Effective September 4, 2018
 
The Section 811 Project Rental Assistance (PRA) program provides subsidized rental housing in coordination with supports to individuals with disabilities. Each tenant in the Section 811 PRA program has a “Section 811 service coordinator.” Managed care organization (MCO) service coordinators are the Section 811 service coordinators for STAR+PLUS members discharging from nursing facilities (NFs).

Provision of Services

Once an individual has occupied a Section 811 PRA housing unit, the MCO service coordinator must ensure the STAR+PLUS Home and Community Based Services (HCBS) program is in place so that the member will be successful in maintaining his or her tenancy. Continued participation in these services is voluntary and not a prerequisite for remaining in Section 811 PRA housing.

The Section 811 PRA program relies on Medicaid services and service coordination to provide the supports an individual needs to remain safely in the community. The MCO service coordinator is responsible for informing individuals in NFs about the availability of this program and if they are interested, to assist them in submitting an application and required documentation. The MCO may delegate this responsibility to the relocation specialist. If eligible, the MCO service coordinator must assist eligible individuals in accessing funding available to assist with relocations.

Communication between the MCO and Texas Health and Human Services Commission (HHSC)

The MCO service coordinator must coordinate with the HHSC Section 811 Point of Contact (HHSC POC) on an ongoing basis regarding members participating in the Section 811 PRA program. The HHSC POC is listed on the Texas Department of Housing and Community Affairs (TDHCA) Section 811 PRA webpage: https://www.tdhca.state.tx.us/section-811-pra/contact.htm.

MCO Responsibilities – Helping Potential Applicants

Information on such laws and requirements will be conveyed at training provided by TDHCA and in the Texas Section 811 PRA Program Service Coordinator Manual. Specific responsibilities of the Section 811 PRA program service coordinator are listed below:

  • assist in recruiting and pre-screening potential participants;
  • assist individuals in accessing Section 811 PRA housing;
  • inform NF residents who have indicated an interest in moving to the community about the availability of the Section 811 PRA program;
  • inform individuals who transition from an NF to the community within the past months about the availability of the Section 811 PRA program;
  • assist interested individuals in reviewing available properties and their leasing criteria on the TDHCA website (http://tdhca.state.tx.us/section-811-pra/participating-properties.htm);
  • using information provided by TDHCA, inform interested individuals about the potential wait time for an available unit;
  • assist interested individuals in completing an application for tenancy and compiling necessary documentation;
  • ensure that all methods of outreach and referral are consistent with fair housing and civil rights, laws and regulations, and affirmative marketing requirements; and
  • assist residents in maintaining their housing.

MCO Point of Contact Requirements – for Potential Applicants

For members who have applied to the Section 811 PRA program, the MCO must update information that was collected at the time of application to the program, if anything changes. This will ensure the member can be contacted and the information on file with TDHCA is accurate. The MCO must ensure the HHSC Section 811 POC and the TDHCA POC have the means to identify and contact the member within one business day of receiving a notice that a Section 811 PRA program unit is available.

MCO Responsibilities – for Existing Tenants

Once an individual has been accepted for tenancy in a Section 811 PRA program unit, the MCO service coordinator will provide the following support to assist individuals in maintaining their housing:

  • Subject to an individual's agreement to share this information, respond to any inquiry from the HHSC Section 811 POC relating to an individual participating in the Section 811 PRA program, including the services the individual is receiving and who the service providers are; and
  • Fulfill the obligations of the Section 811 service coordinator in the Conflict Management process set forth in the Texas Section 811 PRA Program Service Coordinator Manual (http://www.tdhca.state.tx.us/section-811-pra/docs/ServiceCoordinatorManual.doc), including:
    • working with the Section 811 POC and the Section 811 PRA program property owner or the property owner's designated agent (such as the property management company) in the event there is an incident, including a lease violation which could jeopardize the individual's ability to maintain his or her tenancy in a Section 811 PRA program; and
    • working with the Section 811 POC and the Section 811 PRA program owner or the owner's designated agent to support the member in such a way that they do not lose his or her housing as a result of a lack of services or a lack of coordination of services. As a tenant in a Section 811 PRA program unit, a member may refuse services and this does not place his or her housing at risk.

The MCO must ensure the HHSC POC and the TDHCA POC have the means to identify and contact an individual's Section 811 service coordinator within one business day of receiving notice of a concern from the Section PRA program owner, owner's designee or TDHCA POC.

MCO Point of Contact Requirements – for Existing Tenants

MCO service coordinators serving members who are participating in the Section 811 PRA program must ensure that the HHSC POC has the MCO service coordinator’s contact information. If the MCO service coordinator information changes or is no longer fulfilling the roles and responsibilities associated with the Section 811 PRA program for a member, the MCO service coordinator must notify the HHSC POC.

Additional References for Section 811 Program Requirements for MCOs

MCO service coordinators serving members exiting an NF or other institution and who are participating in the Section 811 PRA program must comply with the roles and responsibilities assigned to them in the Inter-Agency Partnership Agreement (HHSC Contract No. 529-12-0134-00001) as amended and as applicable, and MCO service coordinators agree to fulfill the obligations assigned to Section 811 service coordinators in accordance with the Texas Section 811 PRA Program Service Coordinator Manual.

MCO service coordinators serving members who are participating in the Section 811 PRA program may download and read the Texas Section 811 PRA Program Service Coordinator Manual, available on TDHCA's webpage: http://www.tdhca.state.tx.us/section-811-pra/referral-agents.htm.

If requested by HHSC, the MCO service coordinator or designee must attend training on the Section 811 PRA program. Trainings can include in-person training, webinars, conference calls or responding to requests via email.

 

1250 Service Coordinators and the Medicaid for Breast and Cervical Cancer Program

Revision 18-0; Effective September 4, 2018
 
Individuals eligible for Medicaid through the Medicaid for Breast and Cervical Cancer (MBCC) program are a mandatory population in the STAR+PLUS program. The MBCC program provides Medicaid services including the treatment of cancer and precancerous conditions for individuals with qualifying diagnoses between the age of 18 and their 65th birth month. An MBCC program member 18 to 20 years of age will be enrolled in STAR+PLUS. Eligibility for the MBCC program allows an individual under the age of 21 to participate in the STAR+PLUS program. Individuals in the MBCC program receive their Medicaid services through their STAR+PLUS managed care organization (MCO). The individual will be assigned a named MCO service coordinator and receive at a minimum one telephonic contact and one face-to-face visit annually, unless otherwise requested by the MBCC member.

The MCO service coordinator assists the MBCC member with coordinating care. Coordination can include assistance with renewing Medicaid eligibility by reminding and assisting with paperwork. Continued participation in the MBCC program requires a completed MBCC renewal application and physician attestation the individual requires continued, active treatment for breast or cervical cancer or pre-cancer. The physician attestation and eligibility paperwork must be submitted every six months.

An MBCC individual under age 21 can also be on the Medically Dependent Children Program (MDCP) interest list. If the individual reaches the top of the MDCP interest list, the individual can transfer from STAR+PLUS into MDCP since MDCP provides additional services not available in STAR+PLUS or the STAR+PLUS HCBS programs. Upon release from the MDCP interest list, the individual will be processed as a STAR member transitioning to MDCP.

When the individual reaches age 21, the MDCP member will transfer to the STAR+PLUS HCBS program as a medical assistance only (MAO) upgrade using the high needs transition process.

MBCC members age 21 or older requesting STAR+PLUS HCBS program services can be upgraded to STAR+PLUS HCBS program without going on the interest list. However, PSU staff must send an enrollment packet that includes Form H1200, Application for Assistance – Your Texas Benefits, as Medicaid for the Elderly and People with Disabilities (MEPD) is required to assess the Medicaid application using ME-Waiver eligibility rules.

After the enrollment packet is received, PSU staff will send Form H1200 along with Form H1746-A, MEPD Referral Cover Sheet, to MEPD. If the individual is eligible as an MAO applicant, MEPD will change the individual’s Medicaid from MBCC to ME-Waivers in the Texas Integrated Eligibility Redesign System (TIERS).