Revision 18-0; Effective September 4, 2018

 

 

3100 Ancillary Member Resources

Revision 18-0; Effective September 4, 2018


 

 

3110 Medicaid, Medicare and Dual-Eligible Members

Revision 18-0; Effective September 4, 2018
 

 

 
3111 Dual-Eligible Members

Revision 18-0; Effective September 4, 2018
 
Members who receive both Medicaid and Medicare are called dual-eligible members. Dual eligible members choose a managed care organization (MCO), but are not required to choose a primary care provider (PCP) because dual-eligible members receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare eligibility or services. The STAR+PLUS MCO only provides Medicaid long-term services and supports (LTSS) to dual-eligible members.

STAR+PLUS Medicaid-only members are required to choose an MCO and a PCP in the MCO's network. These members receive all covered services, both acute care and LTSS from the MCO.

MCOs are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member in developing an appropriate plan of care (POC). MCOs are expected to provide innovative, cost-effective care in order to prevent or delay unnecessary institutionalization.
 

3112 Medicaid Eligibility

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must verify each applicant's current eligibility for Medicaid through the Texas Integrated Eligibility Redesign System (TIERS). PSU staff initiate the Medicaid financial eligibility determination process if there is no existing acceptable Medicaid coverage.

Refer to Section 3114, Applicants with Medicaid Eligibility, for Medicaid programs appropriate for STAR+PLUS HCBS.

Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200. PSU staff must check with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding the need for a new Form H1200.

Refer to Appendix V, Medicaid Program Actions, to determine if a program transfer by the MEPD specialist will be required. Refer to Section 3230, Financial Eligibility, for additional information regarding financial eligibility.

Note: The completion or signing of an application for an applicant or member does not automatically authorize a person to receive protected health information (PHI) from PSU staff or the managed care organization (MCO) regarding that applicant or member. Refer to Section 2240.1, Authorized Representative, for individuals who may receive or authorize the release of an applicant’s or member's personally identifiable information (PII) or PHI under Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.
 

3113 Transmittal of Form H1200

Revision 18-0; Effective September 4, 2018
 
When transmitting Form H1200, Application for Assistance – Your Texas Benefits, Program Support Unit (PSU) staff fax all pages of Form H1200 along with any supporting documentation and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. PSU staff will upload all pages of Form H1200 and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) with the applicant's valid signature.

The original Form H1200 must be kept for three years after the HEART case record is denied or closed. PSU staff must also retain a copy of the successful fax transmittal confirmation in the HEART case record. Scanning Form H1200 and sending by electronic mail is prohibited.
 

3114 Applicants with Medicaid Eligibility

Revision 18-0; Effective September 4, 2018
 
At the time of the initial intake for the STAR+PLUS HCBS program, Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. PSU staff must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or through inquiry in the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for the STAR+PLUS HCBS program, refer to the mandatory population described in Section 3221, STAR+PLUS Mandatory Groups.

An applicant who receives Supplemental Security Income (SSI) is financially eligible for Medicaid and does not require a financial determination; the Social Security Administration (SSA) has already made this determination.

An applicant receiving services through Community Attendant Services (CAS) (TP14) is not automatically eligible for the STAR+PLUS HCBS program.

MEPD specialists must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.
 

3115 Applicants Without Medicaid Eligibility

Revision 18-0; Effective September 4, 2018
 
The Code of Federal Regulations (CFR), Section 42 §431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas state plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for medical assistance only (MAO) cases.

Financial eligibility for non-Supplemental Security Income (SSI) STAR+PLUS Home and Community Based Services (HCBS) program is determined exclusively by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Program Support Unit (PSU) staff must not:

  • screen applicants from referral to MEPD due to apparent financial ineligibility; or
  • deny applications or the annual recertification based on financial eligibility criteria unless notified by the MEPD specialist of financial ineligibility.

If the applicant's individual income exceeds the SSI federal benefit rate (FBR) per month, the applicant applies for Medicaid through HHSC by completing Form H1200, Application for Assistance – Your Texas Benefits, for MAO. If the combined income of the applicant and the spouse exceeds the SSI FBR for a couple, the applicant may apply for MAO with HHSC. Refer to Appendix VIII, Monthly Income/Resource Limits, for the current SSI FBR.
 

3116 Monthly Income Below the SSI Standard Payment

Revision 18-0; Effective September 4, 2018
 
An applicant in the community (with no ineligible spouse) who has income less than the Supplemental Security Income (SSI) federal benefit rate (FBR) must apply for SSI through the Social Security Administration (SSA). The Texas Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except for cases in which the SSI application for disability has been pending more than 90 days and a decision is made by HHSC Disability Determination Unit (DDU) staff.

If there is a question whether the applicant should apply for SSI or medical assistance only (MAO), Program Support Unit (PSU) staff may consult the regional Medicaid for the Elderly and People with Disabilities (MEPD) specialist.
 

3117 Coordination with the MEPD Specialist

Revision 18-0; Effective September 4, 2018
 
The Program Support Unit (PSU) staff must inform the applicant or member without pre-existing Medicaid coverage and/or his or her authorized representative (AR) that the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will complete a financial eligibility (Medicaid) determination. PSU staff must encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program according to regional procedures. For those applicants or members already on an appropriate type of Medicaid program, PSU staff must fax:

  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form H1746-A, MEPD Referral Cover Sheet.

An applicant for the STAR+PLUS HCBS program who has medical assistance only (MAO) coverage type Medicaid services may only receive the STAR+PLUS HCBS program after a program transfer to Medicaid waivers is completed by the MEPD specialist. When an applicant or member for the STAR+PLUS HCBS program has MAO coverage type, as indicated in the Texas Integrated Eligibility Redesign System (TIERS), a completed Form H1200 must be sent to the applicant or member. The completed application must be forwarded to the MEPD specialist for processing.

PSU staff must also send an email to MEPD at the HHSC OES MEPD IC mailbox that includes the following information:

  • the applicant’s or member’s name;
  • applicant’s or member’s Medicaid identification (ID) number;
  • individual has MAO coverage-type Medicaid, which will require a program transfer; and
  • name and telephone number of the PSU staff contact.

The MEPD specialist will make the necessary changes to allow the MAO coverage-type Medicaid individual to receive the STAR+PLUS HCBS program.

ID of MAO Coverage-Type Medicaid

PSU staff can check TIERS to determine an applicant’s or member’s coverage type. In TIERS, the coverage type on the Search/Summary screen is displayed with the preface of MAO.

Form H1200 is not required for members receiving Supplemental Security Income (SSI).

Note: If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA.
 

3117.1 Income and Resource Verifications for MEPD

Revision 18-0; Effective September 4, 2018
 
Any information, including information on third-party insurance, obtained by Program Support Unit (PSU) staff, must be shared with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to prevent the applicant or member from having to provide the information twice. PSU staff will fax Form H1746-A, MEPD Referral Cover Sheet, with supporting documents to MEPD.

Inform medical assistance only (MAO) applicants of the importance of providing the most complete packet possible to the MEPD specialist. Explain that failure to submit the required documentation to the MEPD specialist could delay completion of the application or cause the application to be denied.

Ensuring the following items are included greatly facilitates the financial eligibility process:

  • Bank accounts – bank name, account number, balance and account verification (for example, a copy of the last three months of bank statements).
  • Award letters showing the amount and frequency of income payments.
  • Life insurance policy – company name, policy number, face value or a copy of the policy.
  • A signed and dated Form H0003, Agreement to Release Your Facts.
  • Preneed funeral plans – name of the company, policy or plan number and a copy of the preneed agreement.
  • Correct and up-to-date telephone numbers.
  • Power of Attorney or Guardianship – copy of the legal document.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS HCBS program, according to regional procedures. PSU staff should obtain a copy of the most recent Form H1200, Application for Assistance – Your Texas Benefits, for those applicants or members already on an appropriate type of Medicaid program. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

Note: If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA.
 

3117.2 MAO Applicants Not Previously Certified in TIERS

Revision 18-0; Effective September 4, 2018
 
A new application is defined as an application for a Medicaid for the Elderly and People with Disabilities (MEPD) household not previously certified in the Texas Integrated Eligibility Redesign System (TIERS).
 

3117.3 Unsigned Applications

Revision 18-0; Effective September 4, 2018
 
Unsigned applications received by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are returned to the sender. Program Support Unit (PSU) staff must ensure applications are signed prior to referring to the MEPD specialist; if not, PSU staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form H1200-A, Medical Assistance Only (MAO) Recertification.

If the MEPD specialist receives an unsigned application from HHSC with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns the application to PSU staff with an annotation on the cover form (Form H1746-A) that the application is unsigned and must be signed before PSU staff can establish a file date. Once PSU staff receive an unsigned application from the MEPD specialist, it is the responsibility of PSU staff to coordinate with the applicant or member to obtain a signed application and return it to the MEPD specialist for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to applicants or members.
 

3117.4 Medicaid Eligibility Decisions Pending Past the Program Due Date

Revision 18-0; Effective September 4, 2018
 
For most Medicaid for the Elderly and People with Disabilities (MEPD) applications, eligibility decisions are due by the 45th day. However, applications for individuals under the age of 65 may require a 90-day time frame to allow the agency to obtain a disability determination. This applies when the person's age is less than 65 and the person does not receive Retirement, Survivors and Disability Insurance (RSDI), Supplemental Security Income (SSI) or Railroad Retirement (RR). A disability determination by the Texas Health and Human Services Commission (HHSC) is required even if the person has received a Medical Necessity and Level of Care (MN/LOC) Assessment determination under the STAR+PLUS Home and Community Based Services (HCBS) program eligibility component criteria.

For other case actions (for example, program transfers) the MEPD specialist may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income or resources. Program Support Unit (PSU) staff will email MEPD at the HHSC OES MEPD IC mailbox, requesting a status update, if the case has been pending more than 45 days.
 

3117.5 Inquires and Complaints

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff can direct other general inquiries and complaints regarding Medicaid for the Elderly and People with Disabilities (MEPD) applications and programs to the HHSC OES MEPD IC mailbox.


3118 Address Changes for Supplemental Security Income Individuals

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must not send address change requests for Supplemental Security Income (SSI) individuals to the Document Processing Center (DPC). PSU staff must inform the individual or authorized representative (AR) to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System (TIERS) after SSA makes the change.

PSU staff must also send an email to the Enrollment Resolution Services (ERS) mailbox to notify ERS of the request for a change in address.
 

3120 Other Available Services

Revision 18-0; Effective September 4, 2018
 
 


3121 Prescription Drugs

Revision 18-0; Effective September 4, 2018
 
Prescription drugs are not part of the managed care organization's (MCO's) array of services. STAR+PLUS Medicaid-only members continue to have prescriptions filled by any pharmacist participating in the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP). The member will receive unlimited medically necessary prescriptions instead of the traditional three prescriptions per month limit. Drug coverage through VDP is limited to the state's formulary and may not cover all of the prescribed medications required for the individual.

Medicare prescription drug coverage (Medicare Part D) is insurance that covers both brand name and generic prescription drugs at participating pharmacies in the member's service area. Medicare prescription drug coverage provides protection for people who have very high drug costs. Medicare members are eligible for this coverage, regardless of income and resources, health status or current prescription expenses. Members who are eligible for both Medicaid and Medicare (dual-eligible) receive the majority of their drugs through Medicare Part D.

The MCO must inform individuals requesting the STAR+PLUS program of prescription coverage available through the STAR+PLUS program and the Medicare Part D program. The following information regarding the impact of the Medicare Part D program on members must be explained to the applicant:

  • If a member is considered dual-eligible (receiving both Medicare and Medicaid), the member obtains prescriptions first through Medicare Part D or, for certain prescribed drugs excluded from Medicare Part D, through the Medicaid VDP.
  • Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all of the prescribed medications required for the member. Prescriptions not covered by Medicare Part D may be paid by the Medicaid VDP; however, the Medicaid VDP formulary does not cover certain prescription drugs and over-the-counter medications.
  • Members who participate in Medicare Part D are responsible for purchasing any medications and copayments for medications not covered through Medicare Part D or the Medicaid VDP.
  • Members not participating, or those choosing private insurance over Medicare Part D, are also responsible for purchasing medications and copayments for medications not covered by Medicare Part D or the Medicaid VDP.
  • Members eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program. These members pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may not be authorized for prescriptions, copayments and costs if the member is eligible for Medicare Part D and chooses private insurance rather than participation in Medicare Part D. Non-covered medications cannot be billed through the STAR+PLUS program as medical supplies or adaptive aids.

Copayments for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through the STAR+PLUS program.

Members who contribute to the cost of their care may be eligible to count Medicare Part D costs as an incurred medical expense if they:

  • reside in the community and have a qualified income trust (QIT); or
  • receive adult foster care (AFC) or assisted living (AL) services.

For a member whose current Medicaid identification (ID) card does not include the statement "can receive more than three prescriptions," pharmacists may verify the STAR+PLUS program eligibility for more than three prescriptions by calling Pharmacy Billing at 800-435-4165.

Pharmacists must check the member's Your Texas Benefits Medicaid card monthly to ensure the member remains eligible for Medicaid.

STAR+PLUS Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs as incurred medical expenses. Refer to Section 3123, Incurred Medical Expenses.
 

3122 Over-the-Counter Drugs

Revision 18-0; Effective September 4, 2018
 
The STAR+PLUS Home and Community Based Services (HCBS) program does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

Medications, including over-the-counter drugs, not covered through the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP), Medicare Part D or other third-party resources (TPRs), cannot be paid for by the STAR+PLUS HCBS program. Refer to Section 3121, Prescription Drugs, for additional information.
 

3123 Incurred Medical Expenses

Revision 18-0; Effective September 4, 2018
 
Incurred medical expenses (IMEs) are out-of-pocket expenses a medical assistance only (MAO) member can incur for necessary medical services. IMEs include the cost of medically necessary items not covered by Medicaid, such as Medicare Part D premiums.

STAR+PLUS Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs (such as premiums, enhanced premiums, prescription drug copayments or deductibles, drugs not covered by Medicare Part D, the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP) and non-formulary drugs) as IMEs, if the member:

  • resides in the community and has a Medicaid copayment as a result of a qualified income trust (QIT); or
  • resides in an adult foster care (AFC) home or assisted living facility.

Members who wish to use IMEs to pay for Medicare Part D costs should report these costs to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist so the costs can be included in the calculation of copayment for the STAR+PLUS HCBS program. The member's statement of Medicare Part D expenses is acceptable. No written documentation is required from the member to support the declaration. The arrangement for payment of the prescriptions is between the member and the pharmacist.

Some drugs are not covered by Medicare Part D, Medicaid or private drug coverage. In order for these non-formulary drugs to be considered as IMEs, a member must request an exception from the Medicare Part D plan for the drugs. The member is expected to use the procedure for requesting an exception, as required by his or her Medicare Part D plan. The member can submit the results of the requested exception directly to the MEPD specialist. If an exception is not requested, the non-formulary drugs are not allowable IMEs and the cost will be the responsibility of the member.

The MEPD specialist applies the IME policy during the certification process to all new members who meet the above criteria. The MEPD specialist also reviews Medicare costs and IMEs once every six months as part of the regular case monitoring, or whenever the member makes a request to update IME costs. The member or his or her authorized representative (AR) may identify and request IMEs by contacting the MEPD specialist.
 

3124 Medical Transportation Program

Revision 18-0; Effective September 4, 2018
 
STAR+PLUS Home and Community Based Services (HCBS) program members, as recipients of Medicaid, are eligible to use the Medical Transportation Program (MTP) for Medicaid-covered medical appointments. The MTP is accessed by calling the MTP Support Line at 1-877-633-8747. Day activity and health services (DAHS) providers, adult foster care (AFC) and assisted living facility (ALF) providers are responsible for scheduling transportation for the residents.

The local medical transportation contractors have procedures regarding service area limitations, schedules for traveling to certain areas and requirements on the amount of notice required by STAR+PLUS HCBS program members. The AFC or ALF provider must provide an escort for the member, if necessary.

There may be questions about eligibility for residents who are living in AFC or ALF. In cases of difficulties in scheduling, or questions about eligibility for transportation, residents should contact the managed care organization (MCO) to intercede on the resident’s behalf with the local Medicaid medical transportation system.
 

3125 STAR+PLUS HCBS Program Members Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018
 
The STAR+PLUS Home and Community Based Services (HCBS) program is required to provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, Community Care Services Eligibility (CCSE) services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCO’s) service coordinator.
 

3126 STAR+PLUS Members Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018
 
Members receiving STAR+PLUS services are potentially eligible to receive a variety of services from the Texas Health and Human Services Commission (HHSC). For specific information, refer to Section 3126.1, Community Care Services Eligibility, below.
 

3126.1 Community Care Services Eligibility

Revision 18-0; Effective September 4, 2018
 
If STAR+PLUS members meet program requirements, they are eligible to receive the following Community Care Services Eligibility (CCSE) services:

  • adult foster care (AFC);
  • residential care;
  • Emergency Response Services (ERS);
  • home-delivered meals (HDM); or
  • special services to persons with disabilities.

Members may also be eligible for family care if the managed care organization (MCO) has denied their request for personal attendant services due to the:

  • lack of practitioner's statement of need for the services; or
  • lack of personal care tasks.

STAR+PLUS members may never receive the following services from the Texas Health and Human Services Commission (HHSC):

  • Day Activity and Health Services (DAHS);
  • community attendant services (CAS);
  • primary home care (PHC); or
  • assisted living (AL).

An individual requesting CCSE services should be added to any applicable interest lists at the time of the request, in order to protect the date and time of the request. Prior to processing an application, the CCSE case manager must verify the service array does not include a service equivalent of the Title XX, Community Care Programs, service requested. The CCSE case manager may view the STAR+PLUS Program Health Plan Comparison Charts and value-added services (VAS) on the HHSC website at: https://hhs.texas.gov/services/health/medicaid-and-chip/programs/starplus/comparison-charts.

VAS offered by an MCO are extra services approved by HHSC. VAS will vary by MCO. HHSC staff are not required to wait for appeal decisions from MCOs to process requests for Title XX, Community Care Program services if the service requested is not a VAS on the member’s plan. Once released from the interest list, the CCSE case manager verifies the applicant’s MCO does not offer an equivalent service as a VAS and proceeds with the eligibility determination for the requested Title XX, Community Care Program service.

The member should be asked if he or she has requested the service from the MCO, if the requested service is not a VAS but is part of the MCO's service array. If the answer to that question is:

  • No, the CCSE case manager refers the member to the MCO.
  • Yes, and services were approved, the CCSE case manager refers the member to the MCO to initiate service delivery.
  • Yes, and services were not approved or the member doesn't know if he or she was approved, the CCSE case manager contacts Program Support Unit (PSU) staff. Once PSU staff confirm services were not approved, the application can be processed.
  • Unsure, the CCSE case manager refers the member to PSU staff. PSU staff will contact the MCO to inquire about the request.

Note: Once released from the interest list, CCSE case managers may proceed to determine eligibility. CCSE case managers process applications for individuals who are enrolled in STAR+PLUS services managed care only if the individuals meet the criteria outlined above. Do not authorize Title XX, Community Care Programs, services for anyone receiving the STAR+PLUS Home and Community Based Services (HCBS) program.
 

3127 Health Insurance Premium Payment Program

Revision 18-0; Effective September 4, 2018
 
The Health Insurance Premium Payment (HIPP) program is a Medicaid program that reimburses eligible individuals for their share of an employer-sponsored HIPP. The Texas Health and Human Services Commission (HHSC) pays for copayments and deductibles for Medicaid-covered services provided by Medicaid providers. HIPP individuals also can receive Medicaid benefits (provided by a Medicaid-enrolled provider) not covered by their employer-sponsored health insurance.

In order to qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The reimbursement may pay for individuals and their family members to receive employer-sponsored health insurance benefits when it is determined the cost of insurance premiums and administration are less than the cost of projected Medicaid expenditures.

Individuals who participate in the HIPP program may participate in STAR+PLUS and remain enrolled in HIPP.
 

3200 Eligibility

Revision 18-0; Effective September 4, 2018
 

 

 

3210 Service Areas

Revision 18-0; Effective September 4, 2018
 
STAR+PLUS services are currently available statewide broken down by service areas:

Bexar Service Area: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties.
Dallas Service Area: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwell counties.
Harris Service Area: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller and Wharton counties.
El Paso Service Area: El Paso and Hudspeth counties.
Hidalgo Service Area: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy and Zapata counties.
Jefferson Service Area: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler and Walker counties.
Lubbock Service Area: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher and Terry counties.
Medicaid Rural Service Area (RSA) Central Texas Service Area (Waco): Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell and Washington counties.
Medicaid RSA Northeast Texas Service Area (Tyler): Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt and Wood counties.
Medicaid RSA West Texas Service Area (Abilene): Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young and Zavala counties.
Nueces Service Area: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kennedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties.
Tarrant Service Area: Denton, Hood, Johnson, Parker, Tarrant, and Wise counties.
Travis Service Area: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties.

 

3220 Eligible Groups

Revision 18-0; Effective September 4, 2018

 

 

3221 STAR+PLUS Mandatory Groups

The following groups of individuals must receive services through the STAR+PLUS program. The program designations are used in the following list.

  • Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) type of assistance (TA) 01, TA 02 and TA 22 — Individuals age 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
  • Pickle Amendment Group, TIERS type program (TP) 03 — Individuals age 21 or over who would continue to be eligible for SSI benefits if cost of living adjustment (COLAs) increases were deducted from his or her countable income.
  • Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), aged 60-65 and with a disability, who:
    • were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
    • are ineligible for Medicare; and
    • would continue to be eligible for SSI benefits in the absence of those early aged widow's or widower's benefits and any increases in those benefits.
  • Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), aged 50-60 and with a disability, who:
    • are ineligible for Medicare and were denied SSI due to an increase in widow's/widower's benefits as a result of the relaxing of disability criteria; and
    • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
  • Disabled Adult Children (DAC), TIERS TP 18 — Adults over age 21 with a disability that began before age 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
  • Medicaid Buy-In, TIERS TP 87 (designated in TIERS as "ME — Medicaid Buy In") — Disabled working adults over age 21 who receive full Medicaid benefits as a result of buying into the Medicaid program.
  • Medicaid for Breast and Cervical Cancer (MBCC) recipients, TIERS TA 67 — Individuals aged 18 to the 65th birth month who meet eligibility requirements defined in Texas Administrative Code (TAC), Title 1, Part 15, Chapter 366, Subchapter D.
  • STAR+PLUS Home and Community Based Services (HCBS) program members who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program.  
  • Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (medical assistance only (MAO)) — Most individuals residing in an NF.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact Program Support Unit (PSU) staff and provide the details for disenrollment from STAR+PLUS.
 

3222 STAR+PLUS Excluded Groups

Revision 18-0; Effective September 4, 2018
 
For excluded groups, refer to Texas Administrative Code (TAC), Title 1, §353.603, Member Participation.
 

3223 Hospice Services in STAR+PLUS

Revision 18-0; Effective September 4, 2018
 
Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF hospice services can be identified in the Service Authorization System Online (SASO) as service group (SG) 8, service code (SC) 31. The NF counter is activated by non-hospice NF authorizations, which appear in SASO as SG1/SC1 or SG1/SC3.

 

3230 Financial Eligibility

Revision 18-0; Effective September 4, 2018

STAR+PLUS Home and Community Based Services (HCBS) program applicants who are not already Medicaid eligible are required to complete Form H1200, Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed Form H1200 must be sent to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by close of business within two business days from receipt. The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Applicants have 30 days from the mail date of the application to complete, sign and return Form H1200. After 30 days, the application must be denied for failure to return the information needed to determine financial eligibility. Before denying the application, Program Support Unit (PSU) staff must check first to make sure the application Form H1200 was not mailed directly to the MEPD specialist.

If denial is necessary, document "Your application is being denied because you failed to return the application form mailed to you on [date]" in the comments section of Form H2065-D, Notification of Managed Care Program Services.

Refer to Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.
 

3231 Income Diversion Trust

Revision 18-0; Effective September 4, 2018
 
An applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit, if he or she also meets all other eligibility criteria. Income diverted to the trust does not count for the purposes of determining financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. An applicant may be eligible for services if all other eligibility criteria are met, even if the amount he or she has available for copayment equals or exceeds the total cost of his or her individual service plan (ISP).

Financial eligibility for an applicant with a QIT is determined by the MEPD specialist. He or she is informed that any funds deposited into the trust must be used as copayment for the cost of services delivered. The MEPD specialist calculates the amount of income available from the trust for copayment and provides the amount to Program Support Unit (PSU) staff. PSU staff notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication.

For an applicant who is financially eligible based on a QIT, the eligibility based on the ISP cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase STAR+PLUS HCBS program services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of STAR+PLUS HCBS program eligibility. A member with a QIT copayment that covers all STAR+PLUS HCBS program costs receives the benefit of contracted rates as opposed to private pay rates.

A plan of care (POC) is developed by the MCO without consideration of the trust. If the individual is eligible for the STAR+PLUS HCBS program based on the cost limit, the excess funds from the trust are allocated to pay for services identified on Form H1700-1, Individual Service Plan (Pg. 1), for the STAR+PLUS HCBS program. The ISP total, and therefore the amount of the authorizations to providers, is reduced by the amount of excess funds paid by the QIT. The member must pay the provider directly for the amount of services equivalent to the amount of excess funds. Use of the trust fund is documented on Form H1700-B, Non-STAR+PLUS HCBS Program Services. Continuing Medicaid eligibility through the STAR+PLUS HCBS program is contingent upon payment of the QIT copayment to the provider(s).

Refer to Section 3236, Copayment and Room and Board, and Section 3232, Payments from the Qualified Income Trust, for specific PSU and MCO staff procedures related to QIT copayments.
 

3232 Payments from the Qualified Income Trust

Revision 18-0; Effective September 4, 2018
 
Applicants or members with a qualified income trust (QIT) are responsible for a copayment in adult foster care (AFC), assisted living (AL) or the at-home setting. The managed care organization (MCO) must clearly explain to the applicant or member the funds from the QIT determined to be available for copayment must be used to purchase the STAR+PLUS HCBS program. Payments are made directly to the AFC, AL or other provider.

For applicants or members residing in AFC or AL settings, the copayment amount is usually applied to the cost of AFC or AL first. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other STAR+PLUS HCBS program services, such as nursing, personal assistance services (PAS) or medical supplies. For applicants or members at home, the copayment is first used to purchase nursing, PAS or medical supplies. The MCO calculates the type and amount of payment the applicant or member will make directly to the service provider using the following steps:

  • The MCO develops the individual service plan (ISP) showing the total requested services and total cost of the ISP without consideration of the amount of services the QIT copayment will purchase.
  • Once the ISP has been developed, the MCO uses the QIT copayment amount provided by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to determine the units of service to be purchased from the trust. The units of service are determined by dividing the monthly copayment amount by the unit rate for the service and rounding the result to the next lower half unit. The MCO documents the amount of services the applicant or member must pay directly to the provider(s) and obtains the applicant's or member's agreement. Refer to Section 3234, Qualified Income Trust Copayment Agreement, for specific details about documenting the agreement.
  • The MCO develops a second Form H1700-1, Individual Service Plan (Pg. 1), to reflect the amount of services reduced by the QIT copayment amount. The second Form H1700-1 is annotated in the top margin as "Adjusted ISP for QIT Copayment." For the service category where the QIT payment will be applied, the monthly units to be purchased through the copayment are multiplied by 12 to determine an annual amount of services to be purchased. This amount is subtracted from the total authorized amount to determine the new service units to be authorized and the new ISP total. Form H1700-B, Non-STAR+PLUS HCBS Program Services, is used to document the specific services provided through the QIT.
  • The amounts on the adjusted ISP are entered into the Service Authorization System Online (SASO). The total available QIT copayment amount is not entered on Form H1700-1 and is not reflected in SASO copayment screens for QIT members living at home. If the member lives in an AFC or AL setting, the calculated QIT copayment amount will be reflected in the copayment screens in SASO. Refer to the information in Section 3233, Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL, if the available QIT copayment amount is sufficient to fully pay for AFC or AL. The copayment amount for services other than AFC or AL is documented on Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and Form H2065-D, Notification of Managed Care Program Services.
  • The adjusted ISP and Form 1578 are sent to the service provider(s). The provider will review the adjusted ISP and attachments to determine the acceptance of a referral.
  • Form H2065-D is used to notify the member and provider(s) of the amount of copayment to be made directly to the provider(s). QIT copayment amounts to the MCO contracted provider are shown on Form H2065-D in the comments section.

 
3233 Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL

Revision 18-0; Effective September 4, 2018
 
If the available qualified income trust (QIT) copayment amount exceeds the daily rate for adult foster care (AFC) or assisted living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment funds remain after the monthly copayment is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to Section 3235, Refusal to Pay Qualified Income Trust Copayment.
 

3234 Qualified Income Trust Copayment Agreement

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

  • service purchased;
  • amount available for copayment;
  • unit rate;
  • units purchased; and
  • monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or an assisted living facility (ALF), the copayment amount is first applied to the cost of AFC or ALF. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase nursing, PAS or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.
 

3234.1 Calculation Example and Completion of Form 1578

Revision 18-0; Effective September 4, 2018
 
There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through the QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to be entered on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization (MCO) discusses the copayment with the applicant or member and the trustee of the trust. After explaining the requirements, the applicant, member, authorized representative (AR) and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant, member or AR and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant or member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.
 

3235 Refusal to Pay Qualified Income Trust Copayment

Revision 18-0; Effective September 4, 2018
 
The trustee of the qualified income trust (QIT) must pay the QIT copayment directly to the provider(s) by the 10th day of the month, or not later than 10 days after STAR+PLUS Home and Community Based Services (HCBS) program services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

  • write a letter to the member and the trustee explaining the consequences of continued failure to pay; and
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the trustee has refused to make the copayment.

If the copayment is not fully paid within 30 days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form H2067-MC.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify the MEPD specialist of the refund.

Refer to Section 7100, Adult Foster Care, for procedures related to failure to pay copayment.
 

3236 Copayment and Room and Board

Revision 18-0; Effective September 4, 2018
 
Members who are determined to be financially eligible based on the special medical assistance only (MAO) institutional income limit may be required to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for the STAR+PLUS HCBS program.

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the STAR+PLUS HCBS program and specified on the member's individual service plan (ISP). The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized STAR+PLUS HCBS program services.

To determine the room and board (R&B) amounts for members residing in adult foster care (AFC) or assisted living facility (ALF), apply the following post-eligibility calculations:

  • for individuals, the R&B amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance;
  • for SSI couples, the R&B amount is the SSI FBR [for a couple] minus the personal needs allowance for an individual multiplied by two; or
  • for couples with incomes that exceed the SSI FBR for couples, the R&B amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the R&B amount for an individual.

Some individuals will be responsible for contributing toward the cost of STAR+PLUS HCBS program services. This is referred to as copayment and/or R&B charges. The copayment amount is not a factor in determining the individual's eligibility for services.

The MEPD specialist calculates the copayment and deducts allowable incurred medical expenses (IMEs) for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a qualified income trust (QIT). Refer to Section 3123, Incurred Medical Expenses, and Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance (RSDI), are not required to make a copayment and no copayment calculation is necessary for them. STAR+PLUS HCBS program members who reside in AFC or ALF settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the individual, if it is determined the individual must pay a monthly copayment, that the copayment amount must be paid directly to the AFC or ALF provider. All STAR+PLUS HCBS program members, including SSI recipients, are required to pay R&B in an AFC and ALF.

The MCO must also explain to the individual that the individual is required to pay the AFC or ALF provider an R&B charge. If the member fails to pay the agreed-upon R&B charge and/or copayment, the member could be terminated from the STAR+PLUS HCBS program.

Program Support Unit (PSU) staff notify the member and MCO of new copayment amounts to be collected on Form H2065-D, Notification of Managed Care Program Services.

Refer to Section 3232, Payments from the Qualified Income Trust, and Section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.
 

3237 Determining Room and Board Charges

Revision 18-0; Effective September 4, 2018
 
All STAR+PLUS Home and Community Based Services (HCBS) program members must pay the room and board (R&B) charges to be eligible for an assisted living facility (ALF). R&B cannot be waived, but an ALF may choose to accept an individual for a lower amount. STAR+PLUS HCBS program policy does not direct the facility to accept or reject the individual.

The R&B charge for an individual is fixed at the amount remaining after subtracting $85 from the Supplemental Security Income (SSI) federal benefit rate (FBR). FBR current amounts are found in Appendix VIII, Monthly Income/Resource Limits, which is updated when the FBR changes.

For couples where both partners are residing in an adult foster care (AFC) or ALF, $170 is subtracted from the couple's income so each member of the couple keeps $85 a month for personal needs and the remainder is the R&B charge for the couple. Due to the difference in income between couples and individuals, the amount of R&B charge for a couple depends on income.

  • For SSI couples, the R&B charge is the FBR for a couple minus the $170 personal needs allowance.
  • For couples who are not SSI individuals, but whose income is less than the current FBR for an individual doubled, the R&B charge is for the monthly income minus the $170 for personal needs.
  • For couples whose income exceeds twice the SSI FBR for an individual, the full R&B charge for two individuals is required.

The AFC or ALF member will keep $85 a month for personal needs.

 
3238 Determining Copayment Amounts

Revision 18-0; Effective September 4, 2018
 
After determining financial eligibility for Medicaid, Medicaid for the Elderly and People with Disabilities (MEPD) specialists determine the amount of money available for copayment. MEPD specialists notify Program Support Unit (PSU) staff indicating the amount available for the monthly ongoing copayment to the appropriate mailbox designated for the MEPD specialist to submit to PSU staff through the MEPD Communications Tool. PSU staff forward this information to the managed care organization (MCO) by uploading Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.
 

3239 Copayment Changes

Revision 18-0; Effective September 4, 2018
 
A member's copayment may change during the time he or she is receiving the STAR+PLUS Home and Community Based Services (HCBS) program, typically due to a change in income or medical expenses. Copayment changes must always be effective on the first day of the month. If the copayment is increasing, Program Support Unit (PSU) staff must send the member and managed care organization (MCO) notification on Form H2065-D, Notification of Managed Care Program Services, and the increase is effective the first day of the month after the expiration of the adverse action period. The MCO is responsible for notifying the provider.

If the first day of the month occurs before the end of the adverse action period, the copayment increase is effective the first day of the subsequent month. Decreases in copayment require Form H2065-D notification, but can be effective the first day of the month after the notification is sent.

Copayments may also change due to other circumstances. Medicaid for the Elderly and People with Disabilities (MEPD) specialists are responsible for calculating and handling fraud referrals. Notices and letters on these issues are prepared by MEPD specialists with copies to PSU staff. MEPD specialists inform PSU staff of fraud referrals and determine whether any corrections are necessary to the member's copayment based on a change in the amount available for copayment. PSU staff upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, to inform the MCO of any change in the copayment amount.

Underpayments by the member that are not part of a fraud referral, such as those based on reconciliation of variable income, result in the MEPD specialist sending a letter to the member requesting that the member pay the MCO the amount of copayment that was underpaid. PSU staff are not responsible for determining if the underpayment is made to the MCO. The underpayment is not retroactively considered in the copayment calculation. The MEPD specialist notifies PSU staff if the ongoing copayment amount increases to the appropriate mailbox designated for the MEPD specialist to submit to PSU staff through the MEPD Communications Tool. If the amount does increase, PSU staff must upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, notifying the MCO of the increase in the monthly copayment amount. The increase in copayment is effective the first day of the month after the expiration of the adverse action period indicated on Form H2065-D.

Refunds due to the member require a new copayment calculation be completed. The copayment may be calculated to allow the refund to be deducted from the member's next copayment amount due to the provider or the member may be given a reimbursement by the adult foster care (AFC) or assisted living facility (ALF) provider if there are no future copayments. The MCO determines if the AFC or ALF provider should submit a negative billing. The decrease in copayment is effective the first of the following month, as indicated on Form H2065-D.

Example: The member's ongoing copayment is $100 per month. The MEPD specialist determines a copayment amount of $75 should have been effective February 1. A refund of $25 per month for the months of February, March, April and May total $100. PSU staff find out about the new amount on May 20 and immediately upload Form H2065-D notifying the MCO and mail Form H2065-D to the member. The MCO contacts the provider of the member's new copayment amounts: June – $0, July – $50, August – $75, ongoing.
 

3240 STAR+PLUS HCBS Program Requirements

Revision 18-0; Effective September 4, 2018
 
The STAR+PLUS Home and Community Based Services (HCBS) program is provided by virtue of authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility (NF). To be eligible for services under the STAR+PLUS HCBS program, the following criteria must be met:

  • medical necessity (MN) (Refer to Section 3241, Medical Necessity Determination);
  • services under the established cost limits (Refer to Section 3242.1, Maximum Limit);
  • the member's unmet need for at least one STAR+PLUS HCBS program service (Refer to Section 3242.2, Unmet Need for at Least One STAR+PLUS HCBS Program Service); and
  • approved Medicaid eligibility.

 
3241 Medical Necessity Determination

Revision 18-0; Effective September 4, 2018
 
A STAR+PLUS Home and Community Based Services (HCBS) program applicant or member must have a valid medical necessity (MN) determination before admission into the STAR+PLUS HCBS program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant's or member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for STAR+PLUS HCBS program applicants or members. TMHP processes MN/LOC Assessments for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in the STAR+PLUS HCBS program to:

  • categorize needs for applicants or members; and
  • establish the ISP cost limit.

When TMHP processes an MN/LOC Assessment, a three-alphanumeric digit RUG appears in the Level of Service record in the Service Authorization System Online (SASO) and in the TMHP Long Term Care (LTC) Online Portal. An MN/LOC Assessment with incomplete information will result with a “BC1” code instead of a RUG value. An MN/LOC Assessment resulting with a “BC1” code does not have all of the information necessary for TMHP to accurately calculate a RUG for the applicant or member. Code “BC1” is not a valid RUG to determine STAR+PLUS HCBS program eligibility.

The MCO nurse must correct the information on the MN/LOC Assessment within 14 days of submitting the assessment that resulted in a “BC1” code. After 14 days, the MCO nurse must inactivate the MN/LOC Assessment and resubmit the Assessment with correct information to TMHP.

For applicants or members needing a Medicaid eligibility financial decision, Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the applicant or member meets MN. PSU staff fax Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist. The MEPD specialist may view the SASO or TMHP LTC Online Portal to confirm that the applicant or member has met the MN criteria.
 

3241.1 Medical Necessity Determination for Applicants Residing in NFs

Revision 18-0; Effective September 4, 2018
 
During the initial contact with the applicant or member, Program Support Unit (PSU) staff must explore the applicant's or member's status in the nursing facility (NF) and determine whether the applicant or member has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. Communication with the NF regarding plans for submittal of the MN/LOC Assessment may be necessary. PSU staff must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary and to avoid duplication of submittal to Texas Medicaid & Healthcare and Partnership (TMHP) for an MN determination.

Approved MNs for NF residents may be verified through the Service Authorization System Online (SASO). In this situation, the MCO must not complete a new MN/LOC Assessment. The MN on record will be accepted as a valid MN. The MCO should ask the NF for a courtesy copy of the Minimum Data Set (MDS) completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.

If an applicant or member is applying for Medicaid as a resident in the NF and is concurrently applying for the STAR+PLUS Home and Community Based Services (HCBS) program, the NF should complete the MDS. The MCO is instructed not to complete a new MN/LOC Assessment with the pre-enrollment assessment. PSU staff must notify the MCO that MN exists by entering the Resource Utilization Group (RUG) and expiration date in Section A, Item 6, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization. If the NF refuses to complete the MDS in a timely manner, PSU staff must authorize the MCO to complete the MN/LOC Assessment on the applicant or member by entering N/A in Section A, Item 6, of Form H3676 and uploading to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

A different situation exists when a STAR+PLUS HCBS program applicant or member enters the NF on Medicare. PSU staff must authorize the MCO to complete the MN/LOC Assessment, as described above, to expedite receiving an MN and avoid a delay for the applicant's or member's return to the community.

A denied MN decision resulting from an MN/LOC Assessment the MCO submitted is not used to deny a STAR+PLUS HCBS program applicant or member who has a current valid NF MDS. The NF MDS and RUG are used in the STAR+PLUS HCBS program eligibility determination.

An MN record must be located in the SASO so the individual service plan (ISP) registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
 

3241.2 Medical Necessity Determination for Applicants Not Residing in NFs

Revision 18-0; Effective September 4, 2018
 
For STAR+PLUS Home and Community Based Services (HCBS) program applicants not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) doing the pre-enrollment home health assessment.

The MCO must electronically submit the MN/LOC Assessment to TMHP after it has been signed by the physician. PSU staff upload a screenshot of the MN in the member's Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
 

3242 Individual Cost Limit Requirement

Revision 18-0; Effective September 4, 2018
 

 


3242.1 Maximum Limit

Revision 18-0; Effective September 4, 2018
 
The cost of the STAR+PLUS Home and Community Based Services (HCBS) program cannot exceed 202 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the STAR+PLUS HCBS program applicant must have an individual service plan (ISP) developed that is at or below 202 percent of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.
 

3242.2 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 18-0; Effective September 4, 2018
 
The Code of Federal Regulations (CFR) specifies individuals are not eligible to receive the STAR+PLUS Home and Community Based Services (HCBS) program unless they have a need for at least one STAR+PLUS HCBS program service per individual service plan (ISP) year. Therefore, the Texas Health and Human Services Commission (HHSC) cannot approve any ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan (Pg. 1). When Program Support Unit (PSU) staff receive an ISP from the managed care organization (MCO) with a $0.00 STAR+PLUS HCBS program cost, the following activities occur.

Within two business days:

PSU staff upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. This will inform the MCO to verify if the ISP, which has no services, is accurate.

  • If the ISP was submitted incorrectly:
    • the MCO must resubmit a corrected ISP within two business days (for example, the ISP uploaded correctly but is missing services); and
    • PSU staff must honor the original uploaded date if the MCO uploads the corrected ISP within two business days of notification by PSU staff; or
  • If the ISP was submitted correctly:
    • the MCO must upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, informing PSU staff the ISP reflects the member's needs; and
    • PSU staff:
      • begin denial procedures for these cases by completing Form H2065-D, Notification of Managed Care Program Services;
      • mail Form H2065-D to the applicant or member;
      • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV;
      • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable; and
      • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox.

 
3300 Administrative Procedures

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff operate in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. PSU staff provide support necessary for the coordination of long-term services and supports (LTSS), including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

  • nursing facilities (NFs) to the community, and
  • the Medically Dependent Children Program (MDCP) to the STAR+PLUS HCBS program.

Responsibilities of PSU staff include:

  • acting as an intermediary in relaying communications between Community Care Services Eligibility (CCSE) staff and the managed care organization (MCO);
  • receiving requests for services from CCSE staff performing intake tasks;
  • coordinating the application process for the STAR+PLUS HCBS program for NF residents who wish to transition to the community;
  • assisting applicants with enrollment through the Texas Health and Human Services Commission (HHSC) enrollment broker to select an MCO and primary care provider (PCP), if necessary;
  • coordinating with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding Medicaid eligibility, as appropriate;
  • sending service authorizations (Form H3676, Managed Care Pre-Enrollment Assessment Authorization) to the MCO to initiate STAR+PLUS HCBS program assessments for applicants;
  • serving as the primary contact for transitions in and out of STAR+PLUS service areas;
  • assisting CCSE case managers in processing applications for non-Medicaid services by verifying the MCO denied the equivalent service under STAR+PLUS (Refer to Section 3510, Money Follows the Person and Managed Care);
  • assisting MCO members requesting placement on an interest list for services excluded from managed care (Refer to Section 3222, STAR+PLUS Excluded Groups);
  • processing applicants released from the STAR+PLUS HCBS program interest list;
  • assisting members who are aging out of MDCP and/or Texas Health Steps (THSteps) Comprehensive Care Program (CCP) in transferring to the STAR+PLUS HCBS program (Refer to Section 3420, Individuals Transitioning Services for Adults);
  • coordinating continuity of care for members suspended or disenrolled from STAR+PLUS;
  • approving the STAR+PLUS HCBS program based upon eligibility;
  • making Service Authorization System Online (SASO) entries, as required for actions involving STAR+PLUS HCBS program members;
  • handling the administrative claims process;
  • researching and requesting disenrollment when the member is enrolled inappropriately;
  • denying eligibility for the STAR+PLUS HCBS program; and
  • handling requests for state fair hearings for applicants or members who are denied STAR+PLUS HCBS program eligibility.

 
3310 Intake and Enrollment

Revision 18-0; Effective September 4, 2018
 
When Community Care Services Eligibility (CCSE) staff receive a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

  • Intellectual or Developmental Disabilities (IDD) Program Eligibility and Support;
  • Texas Health and Human Services Commission (HHSC) enrollment broker;
  • Program Support Unit (PSU) staff;
  • Interest List Management (ILM) Unit staff; or
  • appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS.

Type of Individual Enrolled with a STAR+PLUS MCO? How does CCSE handle this request?
Full Medicaid individual applying for the STAR+PLUS HCBS program No.

Forward the request to the HHSC enrollment broker. Supplemental Security Income (SSI) or other full Medicaid program individuals never go on the STAR+PLUS HCBS program interest list, whether the individual is enrolled with STAR+PLUS or not.

The HHSC enrollment broker determines what is preventing MCO enrollment and takes action to resolve the issue, which may include referral to the HHSC or contact with the individual.

Full Medicaid individual applying for the STAR+PLUS HCBS program Yes. Refer the individual to the MCO for the STAR+PLUS HCBS program. This individual will never go on the interest list.
Medically Dependent Children Program (MDCP) member who is turning age 21 No. MDCP is excluded from STAR+PLUS. The MDCP_PDN Transition Report is emailed to the PSU supervisor identifying individuals who are turning age 21 within the next 18 months and who receive MDCP and/or PDN. See the procedures for transition from MDCP to the STAR+PLUS HCBS program in Section 3420, Individuals Transitioning Services for Adults. These individuals never go on the interest list.
Medical assistance only (MAO) applicant for the STAR+PLUS HCBS program No. CCSE staff receiving the request will place the individual on the STAR+PLUS HCBS program interest list.
Nursing facility (NF) resident applying for the STAR+PLUS HCBS program Yes. The resident must be referred to the MCO for an upgrade to the STAR+PLUS HCBS program.
NF resident applying for the STAR+PLUS HCBS program No. All Money Follows the Person (MFP) individuals are placed on the interest list by CCSE intake staff and immediately assigned. The Community Services Interest List (CSIL) database assignment automatically generates an email notifying PSU staff of the referral.


Due to member choice issues, MCOs are prohibited from contacting the applicant without the authorization from PSU staff to complete the required STAR+PLUS HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS program interest list, or MFP individuals, PSU staff:

  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
  • upload Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake staff must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the request and referral process when the individual requesting services is determined to be age 55 years or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.
CCSE intake staff must be aware of the PACE service areas (SAs) and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.
 

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 18-0; Effective September 4, 2018
 
While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care Services Eligibility (CCSE) program. Referrals to CCSE must be made for all active Medicaid individuals awaiting enrollment for managed care. CCSE case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.
 

3311.1 Interest List Procedures

Revision 18-0; Effective September 4, 2018
 
Requests from Supplemental Security Income (SSI) or other active Medicaid program individuals must be assigned immediately. Program Support Unit (PSU) staff will use the Community Services Interest List (CSIL) database to track active Medicaid individuals who are not SSI eligible, as well as non-Medicaid individuals who have expressed interest in the STAR+PLUS Home and Community Based Services (HCBS) program. Interest List Management (ILM) Unit or CCSE regional intake staff will record the date and time of the individual’s expressed interest in STAR+PLUS HCBS. Once the individual comes to the top of the interest list and a slot is available, ILM Unit staff may immediately release and assign the individual to the appropriate PSU staff.

ILM Unit staff must use the CSIL database to track nursing facility (NF) residents who are not SSI eligible and express an interest in the STAR+PLUS HCBS program. When ILM Unit staff receive the request for community transition to the STAR+PLUS HCBS program from the individual or authorized representative (AR), ILM Unit staff will check the CSIL database to see if the NF resident is on the STAR+PLUS HCBS program interest list. If not, and the individual is not SSI eligible, ILM Unit staff will add and immediately release the individual from the STAR+PLUS HCBS program interest list to pursue the money the person (MFP) process.

ILM Unit staff manage activities related to the STAR+PLUS HCBS program interest list, including:

  • placing individuals on the interest list;
  • maintaining annual contact updates when individuals are on the interest list for than one year;
  • releasing individuals from the interest list when funding is available;
  • tracking STAR+PLUS HCBS program slots allocated for use by individuals who are not mandatory participants; and
  • confirming individuals on the interest list are viable STAR+PLUS candidates before release by:
    • verifying all contact information is correct;
    • checking the Texas Integrated Eligibility Redesign System (TIERS) to determine the Medicaid eligibility status; and
    • verifying the individual is still interested in the STAR+PLUS HCBS program.

ILM Unit staff are responsible for sending Form 2398, Community Services Interest List Notification Letter, or Form 2398-S (Spanish), within five business days of placing individuals on the interest list. Form 2398 and Form 2398-S are available to ILM Unit staff on SharePoint.

ILM Unit staff are required to perform annual contacts for individuals on the STAR+PLUS HCBS program interest list to verify the current address, phone number and confirm continued interest in the program. ILM staff mail Form 2399, Interest List Annual Contact Letter, or Form 2399-S (Spanish), to the address on file one month prior to the contact due date. If no response is received from the individual within 120 days of the annual contact due date, the interest list status will automatically update to an inactive status until the individual notifies ILM Unit staff of continued interest. Form 2399 and Form 2399-S are available to ILM Unit staff on SharePoint.

Upon release from the STAR+PLUS HCBS program interest list, ILM Unit staff contact all individuals by phone to notify them of their names reaching the top of the list and slots have become available. All contact attempts will be documented in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

Once contacted, if the individual wishes to pursue STAR+PLUS HCBS program services, the individual will be added to a list sent to the HHSC enrollment broker for an enrollment packet to be mailed. If the individual does not wish to pursue STAR+PLUS HCBS program services, the individual can be added back to the bottom of the interest list for an offer in the future or the interest list release (ILR) will be closed with the appropriate closure code in the CSIL database.

The Texas Health and Human Services Commission (HHSC) enrollment broker will send a STAR+PLUS HCBS enrollment packet to all individuals released from the interest list and interested in pursuing STAR+PLUS HCBS program services. The STAR+PLUS HCBS enrollment packet includes:

  • Form H2053-A, STAR+PLUS Selection Letter, and Form H2053-AS (Spanish);
  • Form H3675, Application Acknowledgement, and Form 3675-S (Spanish);
  • Form H2053-B, Health Plan Selection, and Form H2053-BS (Spanish);
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • STAR+PLUS information; and
  • a postage-paid envelope.

The HHSC enrollment broker contacts the individual every seven days from the date the enrollment packet is mailed. All enrollment broker contacts will cease when the completed packet is received by the enrollment broker or the 30th day after mailing the enrollment packet, whichever is sooner. The enrollment broker contact attempts include the 14-day contact requirement.

The HHSC enrollment broker will contact the applicant or authorized representative (AR) to:

  • give a general description of STAR+PLUS HCBS program services;
  • provide a list of managed care organizations (MCOs) in their area and encourage the member to contact one for service information;
  • discuss the importance of choosing an MCO so an assessment and initial individual service plan (ISP) can be completed in order to avoid a delay in eligibility determination for the STAR+PLUS HCBS program; and
  • inform the individual the MCO in which he or she enrolls can be changed at any time after the first month of service.

Once Form H1200 is returned, the enrollment broker will fax the signed and completed Form H1200 to Medicaid for the Elderly and People with Disabilities (MEPD) within two business days of receipt. The applicant or AR will select an MCO by indicating on Form H3675, Application Acknowledgement, or may notify the HHSC enrollment broker verbally.

The HHSC enrollment broker will notify ILM Unit staff following receipt of the completed packet and will scan and send the documents to ILM staff. Upon receipt, ILM staff will update the HEART record with Form H3675, indicating the individual would like to apply for the STAR+PLUS HCBS program or document the verbal statement in HEART.

If the applicant does not want to decline the STAR+PLUS HCBS program by indicating they are no longer interested in the STAR+PLUS HCBS program on Form H3675, or want to be returned to the bottom of the interest list or provides a verbal statement declining STAR+PLUS HCBS, ILM staff will document the individual’s choice in HEART and close the interest list release. ILM Unit staff will mail Form 2442, Notification of Interest List Release Closure, within two days of the applicant or member advising staff he or she wants to withdraw from the enrollment process for STAR+PLUS HCBS program.

ILM Unit staff will notate all efforts to locate the individual in the HEART narrative. ILM Unit staff will mail Form 2442 to the individual’s last known address within 60 days of interest list release if staff are unable to locate or obtain a written or verbal response from the individual. The interest list release is closed on the 61st day following the release for individuals who do not respond to contact attempts.

Refer to Section 3312, Managed Care Enrollment, for steps to be taken after an individual is released from the STAR+PLUS HCBS program interest list.
 

3311.2 Enrollment Procedures Following Release from the Interest List

Revision 18-0; Effective September 4, 2018
 
Within two business days of the MCO selection, Program Support Unit (PSU) staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

The MCO completes:

  • Section B of Form H3676;
  • a Medical Necessity and Level of Care (MN/LOC) Assessment; and
  • Form H1700-1, Individual Service Plan (Pg. 1).

Note: The Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. The MCO has 45 days per the UMCC requirement to complete all assessments and submit the results on Section B on Form H3676 to PSU staff.

The MCO uploads Form H1700-1 to TxMedCentral in the MCO's ISP folder, following the instructions in Appendix XXXIV. The MCO uploads Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

If the MCO does not upload an ISP within 45 days after PSU staff uploaded Form H3676, Section A, PSU staff notify the Managed Care Compliance & Operations (MCCO) assigned to the MCO by email.

Within five business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff verify eligibility based on Medicaid eligibility, the Medical Necessity and Level of Care (MN/LOC) Assessment, and an ISP cost within the individual's assessed cost limit based on the established Resource Utilization Group (RUG) value.

The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month following receipt of the latter of:

  • an approved and valid MN/LOC Assessment submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal;

Note: A valid MN does not exceed 120 days from the date of TMHP approval. If MN exceeds 120 days from date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

  • the ISP; and
  • notification or verification of Medicaid eligibility.

Example: The MN/LOC Assessment is received at Texas Medicaid & Healthcare Partnership (TMHP) on May 15. The ISP is uploaded to TxMedCentral on June 2, and Medicaid eligibility is effective  May 1. The SOC date is July 1.

The SOC date is the same as the ISP begin date, and will always be the first day of the month. Because individuals are not eligible for any STAR+PLUS HCBS program benefits between the notification form signature date and the ISP begin date, PSU staff must take care in recording the correct date on the notification to the member.

If eligibility is approved, PSU staff complete Form H2065-D, Notification of Managed Care Program Services, and:

  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • fax Form H2065-D, along with Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox to request enrollment.

PSU staff make Service Authorization System Online (SASO) entries following procedures in Section 9000, Service Authorization System Online Help File, within five business days of receipt of all required eligibility verification.

All documentation must be uploaded in HEART, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

After the individual has been determined eligible for the STAR+PLUS HCBS program, ERS updates the member's TIERS record to indicate managed care enrollment.

If eligibility is denied, PSU staff complete Form H2065-D and:

  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV; and
  • fax Form H2065-D and Form H1746-A to the MEPD specialist.

 

3311.3 Interest List Slot Allocations

Revision 18-0; Effective September 4, 2018
 
Members receiving Medicaid services under any of the programs listed in the chart below must receive those services through managed care. This does not impact the STAR+PLUS member's right to access non-Medicaid services through the Texas Health and Human Services Commission (HHSC). STAR+PLUS Home and Community Based Services (HCBS) program members must receive all services through the STAR+PLUS HCBS program, excluding hospice care. Only STAR+PLUS HCBS members count against slot allocations, as the following table illustrates.

Texas Integrated Eligibility Redesign System (TIERS) Type of Assistance (TA) Program Description Counts Against Interest List Slot Allocation?
TP 03 Medical assistance only (MAO) Medicaid – Pickle No
TA 03 Manual Supplemental Security Income (SSI) recipient waivers No
TA 02  SSI recipient waivers No
TP 13  SSI Medicaid No
TA 10  Medicaid waivers Yes
TP 18 Medicaid for Disabled Adult Children (DAC) No
TP 21  Disabled Widows/Widowers Medicaid No
TA 01 SSI Denied Child No
TP 22  Early aged Widows/Widowers Medicaid No
TP 51  Rider 51 waivers No
TP 87 Medicaid Buy-in No

 

3311.4 Earliest Date for Adding a Member Back to the Interest List

Revision 18-0; Effective September 4, 2018
 
The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) database for STAR+PLUS HCBS is the date the applicant is determined to be ineligible for the program or the first date the member is no longer eligible for the program.

Example 1: The applicant is released from the STAR+PLUS HCBS program interest list on March 2, 2019. PSU staff send Form H2065-D, Notification of Managed Care Program Services, notifying the applicant is not eligible for the STAR+PLUS HCBS program on March 28, 2019. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2019.

Example 2: A STAR+PLUS HCBS program member is determined ineligible on March 28, 2019. PSU staff send Form H2065-D to the STAR+PLUS HCBS program member notifying of program termination. Termination is effective April 30, 2019. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2019.

If the applicant or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL database interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program.
 

3311.5 Updating Community Services Interest List Records

Revision 18-0; Effective September 4, 2018
 
The Community Services Interest List (CSIL) database must be updated to reflect accurate information. Program Support Unit (PSU) staff must complete data entry in the CSIL database for STAR+PLUS Home and Community Based Services (HCBS) program actions within five business days of the date:

  • PSU staff sign Form H2065-D, Notification of Managed Care Program Services, certifying or denying applications, except Money Follows the Person (MFP) certifications; and
  • the request for other CSIL database actions (updating information, transferring an individual to another region's interest list or removing a member from the interest list upon request by the individual).

For MFP certifications, the CSIL database is updated when the Service Authorization System Online (SASO) data entry is completed to register the initial individual service plan (ISP). Delaying data entry of the disposition in CSIL for an applicant certified through MFP provisions prevents removing the individual from the interest list before the actual discharge from the nursing facility (NF) is verified.

PSU staff must ensure CSIL database closures are recorded accurately by using the Community Services Interest List (CSIL) User's Guide, available to PSU staff on SharePoint.
 

3312 Managed Care Enrollment

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) enrollment broker mails enrollment packets to all Medicaid individuals who are candidates for STAR+PLUS. The enrollment packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the individual can choose. Individuals can return enrollment forms by mail, complete an enrollment form at an enrollment event or presentation, or call the HHSC enrollment broker and enroll by telephone at 800-964-2777.

Individuals have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the individual will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Individual assignments to an MCO or PCP are automatic, using a default process. Individuals assigned through the default process may change their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, the individual must receive Medicaid services through the assigned MCO and PCP until the individual contacts the MCO or the HHSC enrollment broker at 800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity (MN) determination is required.
 

3313 Termination of CCSE Services Upon STAR+PLUS HCBS Program Enrollment

Revision 18-0; Effective September 4, 2018

Code of Federal Regulations (CFR) §431.213, Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

  1. The agency has factual information confirming the death of a recipient;
  2. The agency receives a clear written statement signed by a recipient that —
    1. He no longer wishes services; or
    2. Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;
  3. The recipient has been admitted to an institution where he is ineligible under the plan for further services;
  4. The recipient's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);
  5. The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;
  6. A change in the level of medical care is prescribed by the recipient's physician.

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care Services Eligibility (CCSE) with the CCSE case manager so the individual does not experience a break in services and does not receive concurrent services through another waiver or CCSE service. The STAR+PLUS Home and Community Based Services (HCBS) program member must be encouraged to contact the managed care organization (MCO) to request any services being denied that are not included in the STAR+PLUS HCBS program individual service plan (ISP).

The 10-day adverse action prior notice requirement does not apply to individuals transferring from CCSE or other waiver programs to the STAR+PLUS HCBS program.
 

3313.1 Procedure for STAR+PLUS HCBS Program Applicants

Revision 18-0; Effective September 4, 2018
 
For individuals entering the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care Services Eligibility (CCSE) services with the waiver or CCSE case manager. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System Online (SASO).

CCSE services are terminated by the CCSE case manager no later than the day prior to STAR+PLUS HCBS program enrollment. This is crucial since no STAR+PLUS HCBS program individual may receive CCSE and STAR+PLUS HCBS program services on the same day. The CCSE case manager must send:

  • Form H2065-A, Notification of Community Care Services, denying ongoing Texas Health and Human Services Commission (HHSC) services to the member; and
  • Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring from CCSE to the STAR+PLUS HCBS program.

 
3313.2 Procedure for STAR+PLUS HCBS Program Members

Revision 18-0; Effective September 4, 2018
 
If it is determined an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care Services Eligibility (CCSE) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If CCSE services are authorized in SASO, the CCSE case manager must immediately send:

  • Form H2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to the STAR+PLUS HCBS program; and
  • Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring from CCSE to the STAR+PLUS HCBS program.

 
3314 Managed Care Organization Changes

Revision 18-0; Effective September 4, 2018
 
Members may change managed care organization (MCO) plans as often as monthly by contacting the Texas Health and Human Services Commission (HHSC) enrollment broker at 800-964-2777. The HHSC enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of each month. Depending on which day of the month (before or after the HHSC enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834 daily enrollment file, notifying the MCO of the new member. Program Support Unit staff, when notified by the member, HHSC or an MCO that a member has elected to change MCOs, will update the Service Authorization System Online (SASO) to change the previous MCO to the new MCO.
 

3315 STAR+PLUS HCBS Program Individuals Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018
 
Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for the STAR+PLUS HCBS program member. A STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's (MCO’s) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.
 

3315.1 Requests from Individuals Awaiting Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care Services Eligibility (CCSE) program. Referrals to CCSE must be made for all full Medicaid recipients awaiting enrollment for managed care. CCSE staff may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

 

3315.2 Requests from STAR+PLUS HCBS Program Members

Revision 18-0; Effective September 4, 2018
 
Requirements of the federal 1115 waiver dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCOs) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

 

3316 Requests for STAR+PLUS HCBS Program from Individuals in 1915(c) Medicaid Waivers

Revision 18-0; Effective September 4, 2018
 
Individuals in the following Intellectual or Developmental Disabilities (IDD) 1915(c) Medicaid waivers may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program at any time, if the individual has Supplemental Security Income (SSI) Medicaid or another active Medicaid program or is medical assistance only (MAO):

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

When a 1915(c) Medicaid waiver individual requests the STAR+PLUS HCBS program through the Texas Health and Human Services Commission (HHSC), a referral is made to Program Support Unit (PSU) staff.

PSU staff are responsible for completing the following activities within 14 days of the initial request for a STAR+PLUS HCBS program assessment. PSU staff must:

  • document in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) all attempted contacts with the member or encountered delays;
  • move the individual to the top of the STAR+PLUS HCBS program interest list with an "assessment requested" notation;
  • contact the 1915(c) waiver program member and explain STAR+PLUS HCBS program services; and
  • send a STAR+PLUS HCBS program enrollment packet to the 1915(c) Medicaid waiver member.

Within two business days of notification of the MCO selection by the applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

The MCO completes:

  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum, as applicable;
  • Medical Necessity and Level of Care (MC/LOC) Assessment;
  • Section B of Form H3676; and
  • Form H1700-1, Individual Service Plan (Pg. 1), and Form H1700-2, Individual Service Plan (Pg. 2), and attachments.

The MCO uploads Form H1700-1 and Form H3676 with Section B completed to TxMedCentral in the respective MCO’s ISP and SPW folder, following the instructions in Appendix XXXIV. If Form H1700-1 and Form H3676 are not received from the MCO within 45 days after the assessment is authorized, PSU staff email the assigned Managed Care Compliance & Operations (MCCO) as notification of the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff determine STAR+PLUS HCBS program eligibility based on medical necessity (MN) and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for the STAR+PLUS HCBS program is denied or the applicant decides not to accept the STAR+PLUS HCBS program, PSU staff complete Form H2065-D, Notification of Managed Care Program Services, and:

  • mail Form H2065-D to the 1915(c) Medicaid waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving; and
  • notify the MCO by uploading Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

If eligibility is approved and the individual chooses to accept STAR+PLUS HCBS program services, the individual is enrolled in the STAR+PLUS HCBS program the first day of the next month.

Within two business days of determining the start of care (SOC) date for the STAR+PLUS HCBS program, PSU staff complete Form H2065-D and:

  • mail Form H2065-D to the individual;
  • notify the MCO by uploading Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) Medicaid waiver services end the day before enrollment in the STAR+PLUS HCBS program.
 

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 18-0; Effective September 4, 2018

 
 

 

3321 General Eligibility Issues

Revision 18-0; Effective September 4, 2018
 
At the initial contact, Program Support Unit (PSU) staff must inform the medical assistance only (MAO) applicant, member or authorized representative (AR) that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by PSU staff, must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialists of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by faxing a completed and signed Form H1200, Application for Assistance – Your Texas Benefits, along with Form H1746-A, MEPD Referral Cover Sheet, following the guidelines provided in Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, within two business days of receipt. Form H1200 is not required for members receiving Supplemental Security Income (SSI).
 

3321.1 Disability Determinations

Revision 18-0; Effective September 4, 2018
 
The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have no role in this process.

If a STAR+PLUS HCBS program applicant or member's application for Supplemental Security Income (SSI) disability has been pending over 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

  • Form H3034, Disability Determination Socio-Economic Report;
  • Form H3035, Medical Information Release/Disability Determination; and
  • a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment.

 
3322 Actions Pending Past the MEPD Due Date

Revision 18-0; Effective September 4, 2018
 
Because Program Support Unit (PSU) staff depend on the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to determine eligibility for medical assistance only (MAO) applicants, there are times when PSU staff must check with the MEPD specialist regarding the status of an application or program change.

PSU staff must contact the MEPD specialist by sending an email to the HHSC OES MEPD IC mailbox. PSU staff must ensure the MEPD time frame has expired. MEPD specialists have 45 days to complete applications for individuals over age 65. MEPD specialists have 90 days for individuals under age 65 whose disability has not yet been determined by the Social Security Administration (SSA).  
 

3330 STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018
 
Medicaid members enrolled in STAR+PLUS qualify for Medicaid eligibility through various program types. Some members who request the STAR+PLUS Home and Community Based Services (HCBS) program may be Medicaid eligible through one of the following Medicaid programs:

  • Pickle (Type Program (TP)-03);
  • Disabled Adult Child (TP-18);
  • Disabled Widow(er) (TP-21);
  • Early Aged Widow(er) (TP-22);
  • Medicaid Buy-in (TP-87); or
  • Medicaid for Breast and Cervical Cancer (MBCC) (TA-67).

Although these Medicaid programs represent full Medicaid eligibility, they do not consider transfer of assets and substantial home equity reviews required to establish financial eligibility for the STAR+PLUS HCBS program. Therefore, these Medicaid types are not eligible for an upgrade and enrollment in the STAR+PLUS HCBS program until Medicaid for the Elderly and People with Disabilities (MEPD) specialists test for the additional criteria.

Managed care organizations (MCOs) must notify the Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within three business days of an upgrade request for a member who has one of these Medicaid program types. PSU staff must contact the member within three business days of receiving Form H2067-MC to advise the member Form H1200, Application for Assistance - Your Texas Benefits, must be completed and returned to PSU staff.  

Once the member returns Form H1200, PSU staff send the signed and completed application form within two business days of receipt to the MEPD specialist, along with Form H1746-A, MEPD Referral Cover Sheet, following the guidelines provided in Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet.

The MCO service coordinator must, within 45 days of a STAR+PLUS member's request for the STAR+PLUS HCBS program:

  • complete an assessment in order to prepare the individual service plan (ISP);
  • complete the Medical Necessity and Level of Care (MN/LOC) Assessment and submit it to Texas Medicaid & Healthcare Partnership (TMHP) to request medical necessity (MN); and
  • upload Form H1700-1, Individual Service Plan (Pg. 1), in TxMedCentral in the MCO’s ISP folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

Within five business days of receipt of Form H1700-1 from the MCO, PSU staff review Form H1700-1 to determine if the member meets eligibility criteria for the STAR+PLUS HCBS program.

If MN for a pending upgrade is denied, the MCO must inform PSU staff within three business days by uploading Form H2067-MC to TxMedCentral. Within three business days of PSU staff receiving Form H2067-MC from the MCO, PSU staff fax Form H1746-A to MEPD as notification of denial.

PSU staff must apply STAR+PLUS Program Support Unit Operational Procedures Handbook policy regarding upgrades to determine if the member meets the eligibility criteria for the STAR+PLUS HCBS program. This will include not only review of the functional criteria evaluated by the MCO, but also a determination that the member's Medicaid type is eligible for the STAR+PLUS HCBS program. For SSI-denied Medicaid program types referenced in this section, the Medicaid program type verification includes the MEPD certification that the additional required financial criteria have been met.

If not eligible, PSU staff must:

  • follow actions in Section 3632, Program Support Unit Initiated Denials or Terminations, to deny the request;
  • mail Form H2065-D, Notification of Managed Care Program Services, within three business days to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

If the member is eligible, PSU staff will process the member’s upgrade by:

  • completing Form H2065-D and mailing it to the member and (if applicable) the MEPD specialist;
  • uploading Form H2065-D in TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV; and
  • confirming Service Authorization System Online (SASO) entries to authorize eligibility for the STAR+PLUS HCBS program are complete and accurate. PSU staff will correct as needed.

 
3400 Transferring Into STAR+PLUS

Revision 18-0; Effective September 4, 2018
 
Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, Section 2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to his or her MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to Section 3125, STAR+PLUS HCBS Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants or members, the losing service area must inform the gaining service area of the GR status. The gaining service area must follow the GR process.
 

3410 Transfer Scenarios

Revision 18-0; Effective September 4, 2018
 
 
 

 

3411 Transferring to Another Service Area with Prior Knowledge

Revision 18-0; Effective September 4, 2018
 
When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS service area, within two business days, the losing PSU staff:

  • notify the gaining PSU staff a member is transferring to its service area and provides the following:
    • member name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • email Form H1700-1, Individual Service Plan (Pg. 1), to the gaining PSU staff;
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals;  
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address; and
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, and request Form H1700-1 and all forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan (Pg. 2);
    • Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form H1700-B, Non-STAR+PLUS HCBS Program Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the Medical Necessity and Level of Care (MN/LOC) Assessment;
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.

Once the gaining PSU staff receive Form H1700-1, PSU staff will confirm all STAR+PLUS HCBS program eligibility. The process is abbreviated since the member already has:

  • an MN/LOC Assessment;
  • a Resource Utilization Group (RUG); and
  • financial eligibility determination by MEPD specialist, if applicable.

The gaining PSU staff coordinates all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining service area.

The gaining PSU staff maintains contact with the member until the transfer is complete. Within five business days after the transfer is complete, PSU staff:

  • send an email to the ERS mailbox notifying ERS the member has moved;
  • manually close the current Service Authorization System Online (SASO) records for the losing MCO effective the end of the month the member moves;
  • manually update SASO with the gaining MCO's information effective the first day of the month after the move;
  • mail Form H2065-D, Notification of Managed Care Program Services, to the member and include the begin and end dates of the individual service plan (ISP) in the Comments section; and
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.
 

3412 Transferring to Another Service Area Without Prior Knowledge

Revision 18-0; Effective September 4, 2018
 
When Program Support Unit (PSU) staff are notified a transfer from one STAR+PLUS service area to another STAR+PLUS service area has already occurred, within one business day the losing PSU staff:

  • notify the gaining PSU staff a member has transferred to its service area and provides the member’s:
    • name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move;
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, and request Form H1700-1, Individual Service Plan (Pg. 1), and all forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan (Pg. 2);
    • Form H1700-3, Nursing Service Plan;
    • Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form H1700-B, Non-STAR+PLUS HCBS Program Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the Medical Necessity and Level of Care (MN/LOC) Assessment;
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;  
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.
  • notify Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals; and
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address.

Within two business days of notification from the losing PSU staff, the gaining PSU staff:

  • contact the member to select an MCO from the gaining service area;
  • send the enrollment packet containing the STAR+PLUS MCO list and a comparison chart; and
  • upload Form H2067-MC to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, requesting the MCO to inform the gaining MCO of the move.

Upon receipt of Form H2067-MC, the gaining MCO must contact the member within one business day and begin services within two business days.

Once the gaining PSU staff receive Form H1700-1, PSU staff will confirm all STAR+PLUS HCBS program eligibility criteria is met. The process is abbreviated since the member already has:

  • an MN/LOC Assessment;
  • a Resource Utilization Group (RUG); and
  • financial eligibility determination by the MEPD specialist, if applicable.

The gaining PSU staff coordinate all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining service area.

Within two business days after completing the steps above, the gaining PSU staff will:

  • send an email to the ERS mailbox notifying ERS the member has moved;
  • manually close Service Authorization System Online (SASO) records effective the end of the month the member moves;
  • manually update SASO with the gaining MCO's information effective the first of the following month in which the move occurred;
  • mail Form H2065-D, Notification of Managed Care Program Services, to the member (with the begin and end date of the ISP in the Comments section); and
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

Within two business days of notification of the move, ERS considers coordination of claims to limit provider impact.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.

 

3413 Transferring from One MCO to Another Within the Same Service Area

Revision 18-0; Effective September 4, 2018
 
Once the initial enrollment period of one full calendar month is passed, a member is eligible to change managed care organization (MCO) plans. When a member chooses to change from one MCO to another in the same service area, the member or authorized representative (AR) must contact the Texas Health and Human Services Commission (HHSC) enrollment broker by telephone at 800-964-2777.

The HHSC enrollment broker will ask if the member is in a hospital or residing in a nursing facility (NF). If so, the member cannot change plans until the member has been discharged. The member can change MCOs as many times as the member wants, but not more than once per month.

If the member calls to change the MCO on or before the HHSC cutoff date day of the month, the change will take place on the first day of the next month. If the member calls after the HHSC cutoff date of the month, the change will take place the first day of the second month following the change request.

Examples:

  • If the member calls on or before April 15, the change will take place on May 1.
  • If the member calls after April 15, the change will take place on June 1.

Refer to the Uniform Managed Care Manual (UMCM), Chapter 3.4, Attachment C, to the Medicaid Managed Care Member Handbook Required Critical Elements, for more details.

Monthly Plan Changes Report

Texas Health and Human Services Commission (HHSC) – Enrollment Resolution Services (ERS) prepares and sends the Monthly Plan Changes Report to Program Support Unit (PSU) staff and the gaining MCOs. PSU staff receive a full list and the MCO receives a member-specific report. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month. PSU staff must correct the contract number in the Service Authorization System Online (SASO) to reflect all MCO changes. Refer to Appendix I-E, Monthly Plan Changes Report.

To prevent duplication of activities when a member changes MCOs, the losing MCO must provide the gaining MCO with information concerning the result of the MCO assessment upon the gaining MCO request. Within five business days of receiving the list of members changing MCOs, the gaining MCO must request Form H1700-1, Individual Service Plan (Pg. 1), and the Medical Necessity and Level of Care (MN/LOC) Assessment from the losing MCO. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must ensure the member’s new service coordinator, once assigned, contacts the member’s former service coordinator at the losing MCO to ensure a seamless transition of service coordination. The gaining MCO must contact the losing MCO for additional information maintained in the MCO member case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify Managed Care Compliance & Operations (MCCO) staff.

MCCO staff must contact the losing MCO and require the MCO to upload information contained in the MCO member file to TxMedCentral, including Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and any current authorizations, within two business days of notification. MCCO staff inform PSU staff the date by which the MCO must upload the information to TxMedCentral by email. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from MCCO staff. The STAR Kids Screening and Assessment Instrument (SK-SAI) and electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, as well as historical SK-SAIs and ISPs, will be available to the gaining MCO upon enrollment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within five business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 15 business days of enrollment of the new member, the gaining MCO must conduct a home visit to assess the member’s needs. For continuity of care, this includes authorizations, additional assessments and pending delivery of adaptive aids, minor home modifications or Transition Assistance Services (TAS). This home visit may include conducting the SK-SAI if the member is due for a new assessment, has experienced a significant change in condition or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in STAR Kids HandbookAppendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires a new assessment, or until the gaining MCO is able to complete its own SK-SAI, update the ISP and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs. If the gaining MCO is in a different service area because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member or AR. Out-of-network authorizations must continue until the existing ISP expires or the gaining MCO can provide comparable services to transition the member to a provider that will be able to meet the member’s needs.

 

3420 Individuals Transitioning Services for Adults

Revision 18-0; Effective September 4, 2018
 
STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults beginning the first day of the first month following the individuals 21st birthday. The following services end at the end of the month following the member’s 21st birthday.

  • Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
  • Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

In addition to the programs and services above, individuals for Community First Choice (CFC) services and personal care services (PCS) must transition to an adult program.

Members who receive MDCP, PDN, PPECC, CFC or PCS and transition to adult programs may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

 

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018
 
Members may receive a combination of the following services:

  • Medically Dependent Children Program (MDCP);
  • private duty nursing (PDN); or
  • prescribed pediatric extended care center (PPECC) services.

 
3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit provides a copy of the MDCP-PDN Transition Report, which lists members enrolled in STAR Kids or STAR Health receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

  • Program Support Unit (PSU) staff; and
  • UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice staff.

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including the authorized representative (AR), if applicable, to initiate the transition process.

During the home visit with the member, member’s  support person or AR, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to the STAR+PLUS program. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids Program Support Unit Operational Procedures Handbook, Appendix VI, STAR Kids Transition Activities, or for STAR Health, in the Uniform Managed Care Manual (UMCM).

The STAR Kids MCO must:

  • make a referral to Program Support Unit (PSU) staff by email at the Managed Care Program Support mailbox, using Form H2067-MC, Managed Care Programs Communication, and include, "PDN/PPECC and/or MDCP Transition” in the subject line;
  • monitor transition activities with the member or the support person, including the AR, every 90 days during the year before the member turns age 21; and
  • email the UR Unit mailbox indicating this may be a high needs member, if the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program.

The STAR Health MCO:

  • emails the UR Unit mailbox if the member appears to meet the high needs criteria below:
    • the member is on ventilator care; and/or
    • the member has high skilled nursing needs, such as tracheostomy care, wound care, suctioning or feeding tubes.

The UR Unit Transition/High Needs coordinator must:

  • monitor the MDCP-PDN Transition Report and identify all STAR Health members turning age 21 in 12 months and not enrolled in one of the following IDD 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); and
  • coordinate with UR Unit staff for the IDD waivers and PSU staff if it is determined the member has high needs and/or needs to be assessed for the STAR+PLUS HCBS program.

ILM Unit staff must:

  • monitor the Managed Care Program Support mailbox for referrals submitted with the subject line "PDN/PPECC and/or MDCP Transition”;
  • perform a search prior to assigning the referral to see if a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record has been created by PSU staff from monitoring the CCP Transition Report; and
  • if a HEART case record is found, upload the MCO’s referral and advise PSU staff by email; or
  • if a HEART case record is not found, create a HEART case record, upload the referral and assign to PSU staff for further action.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members receiving MDCP, PDN or PPECC services turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL;
  • create a case record in HEART noting:
    • if the MCO determines the member is high needs; the program type (MDCP, or PDN or PPECC) the member is transitioning from; and
    • the due date for the nine-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO’s SPW folder earlier than five months prior to the member’s 21st birthday.

The following chart outlines the responsibilities for monitoring the MDCP-PDN Transition Report and contacting members transitioning from STAR Kids or STAR Health who receive MDCP, PDN or PPECC 12 months prior to the member’s 21st birthday.

12-Month Transition Chart
Under Age 21 MDCP Under Age 21 Other Services Received Monitors  MDCP-PDN Transition Report 12-Month Contact
MDCP PDN-CCP or PPECC-CCP PSU Staff  MCO
MDCP None PSU Staff  MCO
Not Applicable PDN-CCP PSU Staff  MCO
Not Applicable PPECC-CCP PSU Staff  MCO

 

 

3421.2 Nine Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Nine months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO):

  • monitors transition activities with the member and the member’s available supports, including his or her authorized representative (AR), every 90 days during the year before the member turns age 21; and
  • notifies Program Support Unit (PSU) staff of any issues or concerns by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and PDN or PPECC turning age 21 in nine months and not enrolled in one of the following Intellectual or Developmental Disability (IDD) 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);

mail the STAR Kids member Form 2114, Nine-Month Transition Letter, along with a STAR+PLUS enrollment packet (including the STAR+PLUS MCO list and a comparison chart) to the member or AR. Form 2114 will serve as an introduction to the process and advise the member, support person or his or her AR. PSU staff will contact the member or member’s support person, or his or her AR, within 30 days to discuss the transition process and review the enrollment packet; and

  • update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record by:
    • documenting the date Form 2114 was sent out to the member or AR;
    • uploading Form 2114 to the HEART case record;
    • documenting the due date for the telephone contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
    • uploading Form H2067-MC to the HEART case record if the MCO documented any issues or concerns.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, earlier than five months prior to the member's 21st birthday.

Within 30 days of the enrollment packet mailing, PSU staff schedule and complete a telephone contact with the member or the member’s available supports, including his or her AR, to explain the following:

  • STAR Kids eligibility, MDCP, PDN and PPECC services will terminate on the last day of the month in which the member’s 21st birthday occurs.
  • The STAR+PLUS HCBS program is an option available to eligible members at age 21. PSU staff also present an overview of the array of services available within the STAR+PLUS HCBS program.
  • The STAR+PLUS HCBS program enrollment packet sent to the member is reviewed. The enrollment packet contains a list of the STAR+PLUS MCOs in the service area and a comparison chart to assist the member in making an MCO selection. The member will choose a STAR+PLUS MCO in his or her service area that will perform the assessment for services and oversee the delivery of services.
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid having a gap in services.
  • The member can change MCOs any time after the first month of enrollment.
  • The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the Medical Necessity and Level of Care (MN/LOC) Assessment. The assessment results in the cost limit for the individual service plan (ISP).
  • To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit that will meet the member's needs and ensure health and safety.
  • If an ISP cannot be developed within the cost limit that ensures member’s health and safety in the community, the STAR+PLUS HCBS program will be denied.
  • The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
  • The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. If an MCO has not been selected, then 30 days is allowed for a selection. After 30 days, an MCO is selected for the member.
  • After the MCO is selected, the MCO service coordinator will contact the member to begin the assessment for services and assist the member, the member’s support person, or his or her AR in identifying and developing additional resources and community supports to help meet the member's needs.
  • The MCO service coordinator will assist the member in determining the services needed within this service array to meet his or her needs and ensure health and safety. Example: If other needs are met, but the member primarily requires nursing, then an ISP can be developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
  • Reassure the member, member’s support person, or his or her AR that every effort will be made to help him or her make a successful transition to the STAR+PLUS HCBS program.
  • The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

PSU staff will update the HEART case record by noting the due date for the six-month contact.

The following chart outlines the responsibilities for monitoring the MDCP-PDN Transition Report and contacting members transitioning from STAR Kids or STAR Health and receiving MDCP and PDN or PPECC nine months prior to the member’s 21st birthday:

Nine-Month Transition Chart
Under Age 21 MDCP Under Age 21 Other Services Received Monitors  MDCP-PDN Transition Report: Nine-Month Contact:
MDCP PDN-CCP or PPECC-CCP PSU Staff  PSU Staff 
MDCP None PSU Staff  PSU Staff 
None PDN-CCP PSU Staff  PSU Staff 
None PPECC-CCP PSU Staff  PSU Staff 

 

 

3421.3 Six Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Six months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care (PPECC) services, the following process begins.
The Utilization Review (UR) Unit must:

  • monitor the MDCP-PDN Transition Report and identify all members turning age 21 in six months receiving CCP/PDN through fee-for-service (FFS) or STAR Health and not enrolled in one of the following Intellectual or Developmental Disability (IDD) 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).
  • coordinate with Program Support Unit (PSU) staff  if it is determined the member is high needs and/or will need to be assessed for the STAR+PLUS Home and Community Based Services (HCBS) program.

The IDD Waiver/Community Services/Hospice UR Unit staff will:

  • monitor the MDCP-PDN Transition Report for members enrolled in one of the following 1915(c) Medicaid waivers for IDD and who are turning age 21 in the next six months:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL; or
  • make a STAR+PLUS HCBS program referral to PSU staff by email using Form H2067-MC, Managed Care Programs Communication, for members requesting a STAR+PLUS HCBS program assessment, or whose proposed waiver plan exceeds the member cost limit for the IDD 1915(c) Medicaid waiver listed above.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members referenced in Section 3421, Children Transitioning from STAR Kids or STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC, turning age 21 in six months and not enrolled in one of the IDD 1915(c) Medicaid waivers listed above;
  • not reach out to members in CLASS, DBMD, HCS or TxHmL, unless the IDD Waiver/Community Services/Hospice UR Unit submits a referral, as documented above;
  • send Form H2116, Age-Out MDCP and PDN Contact Letter, to the member if the MCO choice has not been obtained;
  • contact the member or authorized representative (AR) if the MCO choice has not been obtained by telephone to:
    • review the STAR+PLUS enrollment packet discussed at the 12-month or the nine-month contact;
    • inform the member or AR of a 30-day time frame to choose a managed care organization (MCO) and a primary care physician (PCP);
    • explain if the member or AR does not timely choose an MCO, the Texas Health and Human Services Commission (HHSC) will assign an MCO for the member; and
    • explain that the member can change MCOs any time after the first month of enrollment.
  • email the UR Unit at the HHSC UR High Needs CCR mailbox regarding all possible high needs situations; and
  • update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, documenting the:
    • contact or contact attempt date;
    • MCO selection; and
    • due date for the five-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO’s SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for agency referrals and PSU staff action for members enrolled in STAR Kids or STAR Health and receiving MDCP, PDN or PPECC transitioning six months prior to the member’s 21st birthday.

Six-Month Transition Chart
Under Age 21 Current Program Under Age 21 Other Services Received PSU Staff Action
MDCP PDN-CCP or PPECC-CCP Monitors the MDCP-PDN Transition Report and contacts the member.
MDCP Not Applicable Monitors the MDCP-PDN Transition Report and contacts the member.
Not Applicable PDN-CCP Monitors the MDCP-PDN Transition Report and contacts the member.
Not Applicable PPECC-CCP Monitors the MDCP-PDN Transition Report and contacts the member.
CLASS, DBMD, HCS or TxHmL  Not Applicable, CCP/PDN or PPECC Contacts the member when the referral is received.

 

 

3421.4 Five Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018
 
Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

  • the member or AR receiving MDCP-PDN or PPECC informs PSU staff of the MCO choice; and
  • PSU staff inform the:
    • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
    • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions; and
    • MCO of members receiving 50 or more PDN hours, by noting the PDH hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

  • PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU staff contact, one will be assigned; and
  • if the selection is not made within seven days from the PSU staff contact, PSU staff:
    • select an MCO for the member;
    • inform the member that:
      • an MCO has been selected; and
      • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
  • inform the MCO of the choice by uploading Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

Note: Within 14 days of the PSU staff uploading date of Form H3676, the MCO must schedule the initial home visit with the MDCP or CCP or PDN member or AR.

 

3421.5 Within 45 Days of Receiving Notification of a Form H3676 Referral

Revision 18-0; Effective September 4, 2018
 
Within 45 days of receiving email notification of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, the managed care organization (MCO) must:

  • complete either Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment;
  • complete the Medical Necessity and Level of Care (MN/LOC) Assessment, using Service Group 19, and submit the form to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal (Note: The initial MN/LOC Assessment may not be submitted earlier than 120 days prior to the member's 21st birthday, unless the member is designated as having high needs status, as described in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program, in which case the MN/LOC Assessment may be submitted up to 180 days prior to the member’s 21st birthday);
  • make a referral to a Local Intellectual and Developmental Disability Authority (LIDDA), for members who may have an Intellectual or Developmental Disability (IDD), so the LIDDA can complete the necessary assessments used to determine whether the member meets the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) LOC necessary to qualify for Community First Choice (CFC);
  • complete Form H1700-1, Individual Service Plan (Pg. 1), and Form H1700-2, Individual Service Plan (Pg. 2), according to STAR+PLUS HCBS program eligibility referenced in Section 3421.6, Confirm STAR+PLUS HCBS Program Eligibility;
  • upload Form H1700-1 and Form H1700-2 to TxMedCentral in the MCO's ISP folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. An approved MN/LOC Assessment must be received before uploading Form H1700-1, if the member has a need for the STAR+PLUS HCBS program;
  • complete Section B of Form H3676; and
  • upload Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

 
3421.6 Confirm STAR+PLUS HCBS Program Eligibility

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff confirm eligibility within five business days of receipt of all required eligibility documentation from the managed care organization (MCO) and Texas Medicaid & Healthcare Partnership (TMHP), based on:

  • an approved and valid Medical Necessity and Level of Care (MN/LOC) Assessment was submitted through the TMHP Long Term Care Online Portal;

Note: A valid MN does not exceed 120 days from the date of TMHP approval. If MN exceeds 120 days from date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO, and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

  • at least one STAR+PLUS Home and Community Based Services (HCBS) program service is listed on the individual service plan (ISP); and
  • an ISP cost within 202 percent of the Resource Utilization Group (RUG) cost limit. Note: Refer to Section 3421.7, ISP Cost Exceeds 202% of the RUG Cost Limit, if the ISP exceeds 202 percent of the RUG.

PSU staff must request STAR+PLUS HCBS program enrollment from Enrollment Resolution Services (ERS) no later than 60 days prior to the individual's 21st birthdate so the Texas Health and Human Services Commission (HHSC) enrollment broker does not send a STAR+PLUS HCBS program enrollment packet to the individual.

If STAR+PLUS HCBS program eligibility is approved, within two business days of confirming eligibility, PSU staff must:

  • establish the start of care (SOC) date, which is the first of the month following the member’s 21st birthday;

For example, the 21st birthday of the member receiving the Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Centers (PPECC) services is March 3, 2019:

  • STAR+PLUS HCBS program registration is effective April 1, 2019;
  • ISP is entered for the STAR+PLUS HCBS program ISP period; and
  • STAR+PLUS HCBS program registration is April 1, 2019, to March 31, 2020;
  • complete Form H2065-D, Notification of Managed Care Program Services, and
    • mail Form H2065-D to the member;
    • upload Form H2065-D to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
    • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV; and
    • email Form H2065-D to the ERS mailbox, which includes the Medicaid identification (ID) number and primary care provider (PCP), for individuals who are Medicaid only and do not have Medicare; and
    • fax Form H1746-A, MEPD Referral Cover Sheet, to Medicaid for the Elderly and People with Disability (MEPD) of the program change from MDCP to STAR+PLUS HCBS program.
  • coordinate with the Intellectual or Developmental Disability (IDD) Waiver/Community Services/Hospice Utilization Review (UR) Unit staff on the termination date, if the individual is enrolled in one of the following IDD 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) Program; and
  • coordinate with ERS staff for STAR+PLUS HCBS program enrollment.

Within five business days of receipt of Form H2065-D from PSU staff, ERS staff will:

  • force enrollment of the member into STAR+PLUS in the Texas Integrated Eligibility Redesign System (TIERS); and
  • establish STAR+PLUS enrollment effective the first day of the month following the 21st birthday of the member receiving MDCP or PDN or PPECC services. Note: If the member's birthday is the first day of the month, enrollment is effective the same day and month following the 21st birthday of the member receiving MDCP or PDN or PPECC services.

Examples:

  • The 21st birthday of the member receiving MDCP, PDN or PPECC services is March 3, 2019. STAR+PLUS enrollment is effective April 1, 2019.
  • The 21st birthday of the member receiving MDCP, PDN or PPECC services is April 1, 2019. STAR+PLUS enrollment is effective May 1, 2019.

If STAR+PLUS HCBS program eligibility is denied, PSU staff:

  • complete Form H2065-D;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the HEART case record;
  • upload Form H2065-D on TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • fax Form H1746-A to MEPD informing the member is not eligible for STAR+PLUS HCBS program; and
  • email a copy of Form H2065-D to the IDD Waiver/Community Services/Hospice UR Unit staff contact for members enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL.

 
3421.7 ISP Cost Exceeds 202% of the RUG Cost Limit

Revision 18-0; Effective September 4, 2018
 
If the individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits the documents below to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit Transition/High Needs coordinator:

  • Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H1700-1, Individual Service Plan (Pg. 1);
  • Form H1700-3, Nursing Service Plan;
  • Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services;
  • Form H1700-B, Non-STAR+PLUS HCBS Program Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H6516, Community First Choice Assessment, if applicable;
  • Form H2060-A, Addendum to Form H2060, if applicable;
  • Form H2060-B, Needs Assessment Addendum; and
  • two weeks of nursing notes, including Medication Administration Records.

The UR Unit will conduct a desk review once all the documents noted above are received and may request a clinical review by the HHSC Office of Medical Director of the case to consider the use of state of Texas General Revenue (GR) funds to cover costs exceeding the 202 percent cost limit.

Note: MCOs must not discuss with applicants or members, or request the use of, state of Texas GR funds for services above the cost limit.
 

3422 Transition Policy for Non-Waiver Members Receiving PCS or CFC Only

Revision 18-0; Effective September 4, 2018
 
STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs. The first day of the month following the members 21st birthday, the member will need to receive services through programs serving adults. Members must transition their personal care services (PCS) and Community First Choice (CFC) services to an adult program.

Depending on eligibility requirements, some members may continue to receive PCS or CFC through STAR Health until age 22.

The Texas Health and Human Services Commission (HHSC) enrollment broker will reach out to the member 30 days prior to the member’s 21st birthday and provide the member with a STAR+PLUS enrollment packet (containing the STAR+PLUS managed care organization (MCO) list). Fifteen days is allowed for the member to make an MCO selection. If the member has not made a selection after 15 days, the HHSC enrollment broker will select an MCO for the member, as outlined in Texas Administrative Code (TAC), Title 1,) §353.403(d)(3), Enrollment and Disenrollment.
 

3423 Intrapulmonary Percussive Ventilator

Revision 18-0; Effective September 4, 2018
 
Members who were approved for, and are using, an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by the Texas Health and Human Services Commission (HHSC) Office of the Medical Director (OMD).
 

3500 Money Follows the Person

Revision 18-0; Effective September 4, 2018
 
Refer to Section 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List (CSIL) database to track Money Follows the Person (MFP) applications from individuals who are not yet members of a managed care organization (MCO).
 

3510 Money Follows the Person and Managed Care

Revision 18-0; Effective September 4, 2018
 
The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). For residents who need the STAR+PLUS Home and Community Based Services (HCBS) program, the managed care organization (MCO) will perform the functional assessment and service planning.

Note: MCOs can use an NF's Medical Necessity and Level of Care (MN/LOC) Assessment, and Program Support Unit (PSU) staff can accept an NF’s MN/LOC Assessment for MFP applicants as long as the MN/LOC Assessments are approved and have not yet expired. The NF’s MN/LOC Assessment may not be used for upgrades. Refer to Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS HCBS Program, for more information about upgrades.

One of the eligibility requirements for MFP is that the individual be approved for the STAR+PLUS HCBS program prior to leaving the NF. Individuals must reside in the NF until a final determination is made indicating approval of the STAR+PLUS HCBS program. Individuals leaving before receiving Form H2065-D, Notification of Managed Care Program Services, for an approval, are denied using Denial Code 39 (Other) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

Once the assessment process has been completed and the resident is determined eligible for the STAR+PLUS HCBS program, the MCO must be prepared to initiate the individual service plan (ISP) upon notification of eligibility. Individuals are enrolled in managed care on the first day of the month in which discharge from the NF is planned. This flexible enrollment process only applies to MFP.

Refer to Section 3310, Intake and Enrollment, for more information about MFP.

The MCO participates in community planning groups (for example, the Community Transition Team) and other activities related to the state's Promoting Independence (PI) Initiative.
 

3511 Money Follows the Person Procedure

Revision 18-0; Effective September 4, 2018
 
A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) when a nursing facility (NF) resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. Community Care Services Eligibility (CCSE) intake staff must refer all Money Follows the Person (MFP) requests to Program Support Unit (PSU) staff. Referrals can be made by anyone, including family members, NF staff, relocation specialists and HHSC case managers.
 

3512 MFP Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018
 
In keeping with the Promoting Independence (PI) Initiative, the Program Support Unit (PSU) and managed care organizations (MCOs) staff are obligated to assist the nursing facility (NF) applicant or member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, PSU staff have the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four calendar month time frame is the guideline used in determining pending, or denying, requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the member is ready to discharge from the NF.

Examples:

  • A STAR+PLUS Home and Community Based Services (HCBS) program applicant has a definite date of discharge within four calendar months from the date services were requested. Allow the referral to remain open until the applicant is ready to discharge and coordinate the transfer to the community.
  • A STAR+PLUS HCBS program applicant is in the process of making living arrangements that will allow him to leave the NF within four calendar months from the date services were requested. Allow the application to remain open.

If the applicant has an estimated date of discharge that may or may not go beyond the four calendar month period, PSU staff should keep the request for services open. Refer to Section 3513, Applications Pending More than Four Calendar Months Due to Delay in NF Discharge, for information about applications pending more than four calendar months.
 

3513 Applications Pending More than Four Calendar Months Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but are not finalized. If the applicant has an estimated date of discharge that goes beyond the four calendar month period, PSU staff should keep the request for services open.

Applicants who have not made living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community, should be denied. PSU staff deny the request for services by mailing Form H2065-D, Notification of Managed Care Program Services, to the applicant within two business days after the end of the four calendar month pending period. PSU staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

If an assisted living (AL) applicant meets eligibility criteria but is on an interest list for a contracted STAR+PLUS HCBS program assisted living facility (ALF), PSU staff verify through the MCO that the applicant is on the list and may leave the service request pending until the slot opens.
 

3514 STAR+PLUS Members Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018
 
When a managed care organization (MCO) receives a request from, or becomes aware of, a STAR+PLUS member who is requesting to transition to the community, the MCO service coordinator must contact the applicant or member within five business days and must meet with the member within 14 business days to explain the process of transitioning to the community.  

Within three business days after meeting with the member, the MCO service coordinator must make a referral for relocation assistance by completing Form 1579, Referral for Relocation Service, if applicable.

The MCO service coordinator informs Program Support Unit (PSU) staff of the request to transition to the community by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, for Money Follows the Person (MFP).

Within two business days after the MCO has uploaded Form H2067-MC, PSU staff must:

  • create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program (TP);
  • check the Community Services Interest List (CSIL) database to see if the member is on an Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waiver interest list; or
  • determine, according to the procedures below, if the member has either an open enrollment or services have been temporarily suspended in an IDD 1915(c) Medicaid waiver:
    • For either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS), check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether a member is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
    • For the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to see if the service authorization record for these waivers has an end date and a termination code. If the service authorization has an end date and no termination code, this indicates the waiver has been temporarily suspended; and
  • inform the MCO if the member is on an IDD 1915(c) Medicaid waiver interest list, in an IDD 1915(c) Medicaid waiver notated as open enrollment or services temporarily suspended, or neither, by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

Within 45 days after becoming aware of a member requesting to transition to the community, the MCO service coordinator must have completed the assessment for the applicant or member for the appropriate services and community setting. The MCO completes the following activities:

  • The Medical Necessity and Level of Care (MN/LOC) Assessment if there is no valid Minimum Data Set (MDS) or has the option to complete its own MN/LOC Assessment in lieu of using the nursing facility's (NF’s) MDS.
    • The MCO should ask the NF for a courtesy copy of the MN/LOC Assessment completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC Assessment decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS Home and Community Based Services (HCBS) program applicant who has a valid NF MDS. The NF MDS and Resource Utilization Group (RUG) are used for STAR+PLUS HCBS program eligibility determinations.
    • An MN record must be located in the SASO so the individual service plan (ISP) registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
  • If a Supplemental Security Income (SSI) or SSI-related member will only be receiving state plan long-term services and supports (LTSS) (e.g., personal assistance services (PAS) or day activity and health services (DAHS)), the MCO must inform the PSU staff by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.
  • If the member meets functional criteria for the STAR+PLUS HCBS program, the MCO follows policy in Section 3514.1, Transition to Community with STAR+PLUS HCBS Program, below.

Note: PSU staff close the HEART case record if the member will only receive state plan services.
 

3514.1 Transition to Community with STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018
 
During the initial 45-day time frame for the assessment, if the member is temporarily suspended from a 1915(c) Medicaid waiver, the managed care organization (MCO) service coordinator explains the STAR+PLUS Home and Community Based Services (HCBS) program to the member so he or she can choose between the STAR+PLUS HCBS program or remain in his or her previous 1915(c) Medicaid waiver.

  • If the member chooses the STAR+PLUS HCBS program, the MCO service coordinator will:
    • review the current Form H1700-1, Individual Service Plan (Pg. 1), or develop a new individual service plan (ISP) if one previously did not exist or if the ISP has expired;
    • coordinate Transition Assistance Services (TAS) as part of the STAR+PLUS HCBS program, if needed;
    • notify Program Support Unit (PSU) staff the member has selected the STAR+PLUS HCBS program; and
    • notify PSU staff of the selection by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, for Money Follows the Person (MFP).
  • If the member chooses to remain with the 1915(c) Medicaid waiver, the MCO service coordinator will notify PSU staff of the selection by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, for MFP.

Within two business days of receipt of Form H2067-MC from the MCO notifying PSU staff of the member’s selection, PSU staff complete the following activities:

  • If the member chooses the STAR+PLUS HCBS program, PSU staff:
    • upload Form H2067-MC to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
    • add the member to the STAR+PLUS interest list, if applicable; and
    • immediately release the member from the interest list.
  • If the member chooses to return to the 1915(c) Medicaid waiver for services, PSU staff:
    • upload Form H2067-MC to the HEART case record; and
    • close the HEART case record.

For Medicare or Medicaid dually eligible individuals who became members during the nursing facility (NF) stay but have chosen to return to the 1915(c) Medicaid waiver, PSU staff email the Enrollment Resolution Services (ERS) Unit mailbox to request disenrollment at the time of discharge.

When the member chooses the STAR+PLUS HCBS program, the MCO coordinates with HHSC relocation contractors and Local Intellectual and Developmental Disability Authority (LIDDA) service coordinators, as needed, to ensure everything required for community living is in place at the time of discharge from the NF. Supplemental Transition Support (STS) services must be coordinated between the relocation specialist and MCO service coordinator when the relocation specialist determines the member may benefit from STS services. Refer to Appendix XXX, Relocation Function, for responsibilities of relocation specialists and MCOs. The MCO is not responsible for obtaining independent housing for the member, but is responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network.

For all members transitioning into the STAR+PLUS HCBS program, within 45 days, the MCO uploads the following information to TxMedCentral in the MCO’s ISP or SPW folder, following the instructions in Appendix XXXIV:

  • Form H1700-1, if the ISP has expired or one did not previously exist; and
  • Form H2067-MC, notifying PSU staff if the NF discharge date is known.

PSU staff send an email to the appropriate Managed Care Compliance & Operations (MCCO) Unit staff if the MCO does not upload the above information within 45 days after the member's request to return to the community. PSU staff continue to monitor for receipt of the above information when required. Within five business days after receipt of all required documentation, PSU staff:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility for STAR+PLUS;
    • an approved Medical Necessity and Level of Care (MN/LOC) Assessment; and
    • an ISP with:
      • at least one STAR+PLUS HCBS program service per ISP year; and
      • a cost within the individual's cost limit;
  • mail an initial Form H2065-D, Notification of Managed Care Program Services, to the applicant as notification he or she has met the eligibility qualifications to participate in the STAR+PLUS HCBS program; and
  • upload a copy of Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, within two business days to inform the MCO PSU staff sent the notice of initial eligibility determination to the member.

Once STAR+PLUS HCBS program eligibility is approved, the MCO, relocation contractor, NF, NF resident and PSU staff collaborate to identify a proposed discharge date. The MCO is responsible for notifying PSU staff of the discharge date by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, to determine if the date is acceptable. The MCO must respond with the correct scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of PSU staff's Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO uploads Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, to communicate the discharge to PSU staff. Within one business day, PSU staff complete a final Form H2065-D containing the service effective date and:

  • mail the final Form H2065-D to the member;
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • for medical assistance only (MAO) members, fax a copy of Form H2065-D, along with Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to facilitate the Medicaid program transfer; and
  • email Form H2065-D to the ERS Unit mailbox requesting enrollment from STAR+PLUS, if applicable.

Within one business day of mailing the final Form H2065-D to the member, PSU staff create Service Authorization System Online (SASO) entries documented in Section 9400, MFP Authorization for STAR+PLUS HCBS Program Applicant, with the exception of creating a one-day STAR+PLUS service authorization for the first day of the month in which an MFP individual is discharged from an NF. It is not necessary to complete a one-day service authorization record for members who discharge mid-month and begin receiving the STAR+PLUS HCBS program.

If the NF records in SASO do not reflect the NF end date within three business days of the individual's discharge date, PSU staff will contact the HHSC Long Term Care (LTC) Provider Claims Services department to request closure of the NF service authorization in SASO. The hotline for HHSC LTC Provider Claims Services is 512-438-2200. Select Option 1 when prompted to do so.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D and:

  • mail Form H2065-D to the applicant;  
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV; and
  • close the Community Services Interest List (CSIL), if applicable.

If a Medicaid eligibility NF MAO member chooses to leave the NF and return to the community before being determined eligible for the STAR+PLUS HCBS program, PSU staff perform the following steps additional to those referenced above:

  • fax Form H2065-D, along with Form H1746-A, to the MEPD specialist;
  • email Form H2065-D to the ERS Unit mailbox requesting disenrollment from STAR+PLUS; and
  • upload Form H2065-D to the HEART case record.

 
3515 Non-STAR+PLUS Members Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018
 
For requests to transition to the community for a non-STAR+PLUS member, the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) staff make a referral to Program Support Unit (PSU) staff. Within two business days of the referral from HHSC, PSU staff:

  • determine whether the individual has either an open enrollment or services have been temporarily suspended in a 1915(c) Medicaid waiver, according to the following:
    • For either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waivers, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information screens, to verify if the individual is enrolled in one of these programs. The Client ID screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
    • For the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to see if the service authorization record for these waivers has an end date and a termination code. If the service authorization has an end date and no termination code, this indicates the program has been temporarily suspended.
  • coordinate with the Local Intellectual and Developmental Disability Authority (LIDDA) to schedule a conference call with the individual to explain the benefits of the STAR+PLUS Home and Community Based Services (HCBS) program and the 1915(c) Medicaid waivers;
  • open a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document the member's STAR+PLUS HCBS program choice in the HEART case record.

Within two business days of receipt of the notification of the nursing facility (NF) resident's STAR+PLUS HCBS program selection, PSU staff immediately close the HEART case record if the individual has selected a 1915(c) Medicaid waiver program other than the STAR+PLUS HCBS program and email the LIDDA indicating PSU staff are closing the CSIL case record. The LIDDA is responsible for processing the CSIL case record if the individual chooses TxHmL or HCS. If the individual selects CLASS or DBMD, the LIDDA makes a referral to HHSC for processing. If the individual selects to apply for the STAR+PLUS HCBS program, PSU staff determine the individual's Medicaid status to evaluate for proper coordination with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

When the individual has elected to apply for the STAR+PLUS HCBS program, PSU staff must complete the following activities within two business days of notification of the selection:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify if either Form H1200, Application for Assistance – Your Texas Benefits, has already been submitted for the NF stay, or the individual already has full Medicaid eligibility for a type program applicable to the STAR+PLUS HCBS program.
  • Contact or attempt to contact the NF resident, responsible party or authorized representative (AR) by telephone to explain the Medicaid application process, when applicable, the selection of a managed care organization (MCO) and the importance of promptly returning the application packet that PSU staff mail to the individual.
  • Send Form H1200, when applicable, and the appropriate STAR+PLUS MCO enrollment packet to the NF resident, responsible party or AR.
  • Inform the NF resident during the telephone contact that he or she may change the MCO in which he or she is enrolled at any time after one full calendar month of the STAR+PLUS HCBS program provision.
  • Check the Community Services Interest List (CSIL) database to see if the resident is already on the STAR+PLUS HCBS program interest list. If not, add and immediately release the individual from the STAR+PLUS HCBS program interest list.
  • Refer the individual for relocation assistance by completing Form 1579, Referral for Relocation Services.

PSU staff are responsible for completing the following activities 14 days following the STAR+PLUS HCBS program selection. PSU staff must document in the HEART case record all attempted contacts with the NF resident and any encountered delays. PSU staff:

  • contact the NF resident if PSU staff have not received Form H1200; and
  • discuss with the NF resident the importance of choosing an MCO if the individual did not select one during the initial contact, explaining the MCO conducts the assessment, and develop the initial individual service plan (ISP) to facilitate an eligibility determination for the STAR+PLUS HCBS program.

If, during the 14-day follow-up contact, the NF resident states he or she, his or her AR, or the NF has already submitted a completed Form H1200, PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to verify Form H1200 has been submitted. If the NF resident communicates Form H1200 has not been submitted, or if TIERS does not have a record of Form H1200 being submitted, PSU staff notify the NF resident to immediately return Form H1200 to PSU staff because the application for STAR+PLUS HCBS program services will be denied for failure to return Form H1200 within 45 days from the date PSU staff sent the form to the NF resident. Upon receipt of the completed Form H1200, PSU staff make a referral to the MEPD specialist within two business days by faxing Form H1746-A, MEPD Referral Cover Sheet, to include submission of the returned Medicaid application.

If Form H1200 is not received within 45 days from the date PSU staff mailed Form H1200 to the NF resident, PSU staff deny the application for the STAR+PLUS HCBS program by:

  • documenting in the HEART case record Form H1200 was not received within 45 days;
  • mailing the NF resident Form H2065-D, Notification of Managed Care  Program Services; and
  • uploading Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

Within two business days from when the NF resident notifies PSU staff of the MCO selection verbally or in writing, or from when the member is defaulted to an MCO, PSU staff must:

  • check SASO to determine if the applicant has a current Medical Necessity and Level of Care (MN/LOC) Assessment;
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the applicant has a current MN by entering the Resource Utilization Group (RUG) and expiration date in Item 6;
  • upload Form H3676 to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, notating whether or not the applicant is on a 1915(c) Medicaid waiver interest list; and
  • ensure the appropriate items on Form H3676 are completed and faxed to the relocation specialist, if the NF resident requires assistance transitioning to the community because of lack of supports, lack of housing or other barriers.

The MCO initiates contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. Within 45 days from receipt of Form H3676, the MCO service coordinator assesses the applicant for the appropriate services and community settings. The MCO completes the following activities:

  • The Medical Necessity and Level of Care (MN/LOC) Assessment if there is no valid Minimum Data Set (MDS) or has the option to complete its own MN/LOC Assessment in lieu of using the NF’s MDS. If there is no valid MDS, the MCO completes the MN/LOC Assessment for an MN determination.
    • The MCO should ask the NF for a courtesy copy of the MDS Assessment completed by the MDS. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC Assessment decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS HCBS program applicant who has a valid NF MDS. The NF MDS and RUG are used for STAR+PLUS HCBS program eligibility determinations.
    • An MN record must be located in SASO so the ISP registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
  • If the applicant requires services through the STAR+PLUS HCBS program, the MCO completes Section B of Form H3676 and develops the ISP using Form H1700-1, Individual Service Plan (Pg. 1).
  • If a referral for relocation services is not indicated in Section A of Form H3676 and the applicant needs these services, the MCO updates Form H3676, Section B, and sends Form 1579 to the relocation specialist.
  • If the applicant is not eligible for the STAR+PLUS HCBS program, the MCO must inform PSU staff by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV.

When the MCO has determined the applicant meets the functional eligibility requirements for the STAR+PLUS HCBS program, the MCO coordinates with relocation specialist to ensure everything needed for community living is in place at the time of discharge from the NF. The MCO must coordinate Transition Assistance Services (TAS) when needed by the applicant as part of the STAR+PLUS HCBS program. The MCO is not responsible for obtaining independent housing for the NF resident, but is responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network. When the applicant needs Supplemental Transition Support (STS) services, the relocation specialist must coordinate these through the MCO service coordinator.

As needed, PSU staff collaborate with involved parties throughout the STAR+PLUS HCBS program eligibility determination process to assist with problem resolution and to document any delays. PSU staff track all actions and communications in the HEART case record until all STAR+PLUS HCBS program enrollment activities are complete.

Within 45 days of receiving Form H3676 with Section A, the MCO uploads the following information to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV:

  • Form H1700-1;
  • Form H3676 with Section B completed; and
  • Form H2067-MC, notifying PSU staff of the NF proposed discharge date.

PSU staff send an email to the appropriate Managed Care Compliance & Operations (MCCO) staff if the MCO does not upload the above information within 45 days after the NF resident's request to return to the community. PSU staff continue to monitor for receipt of the above-referenced forms. Within two business days of receipt of this information, if Medicaid is pending, PSU staff complete and fax Form H1746-A to notify the MEPD specialist of the approved ISP and MN/LOC Assessment so the MEPD specialist can complete the Medicaid eligibility determination.

Upon completion of the evaluation for financial eligibility, the MEPD specialist notifies PSU staff of the determination by sending an email to the appropriate mailbox designated for the MEPD specialist to submit communications to PSU staff through the MEPD Communications Tool.

Within five business days after receipt of all MCO documentation required for STAR+PLUS HCBS program eligibility, as well as communication from the MEPD specialist of the applicant's Medicaid eligibility, PSU staff:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility for STAR+PLUS;
    • an approved MN/LOC Assessment;
    • an ISP with:
      • at least one STAR+PLUS HCBS program service per ISP year; and
      • a cost within the individual's cost limit.
  • mail the initial Form H2065-D to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, to inform the MCO that PSU staff notified the individual of this determination.

The MCO collaborates with the relocation specialist, NF, NF resident and PSU staff to identify a proposed discharge date. Once the discharge date has been determined, the MCO must notify PSU staff of the discharge date within two business days by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV to determine if the date is acceptable. The MCO resolves this discrepancy and must confirm the scheduled discharge date by uploading Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, within two business days of PSU staff’s Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO will upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, to communicate the discharge to PSU staff. Within one business day, PSU staff complete the final Form H2065-D containing the service effective date and:

  • mail initial Form H2065-D to the member;
  • upload Form H2065-D on TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • fax or email Form H2065-D, along with Form H1746-A, to the assigned MEPD specialist for generation of a pending task in TIERS; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) Unit mailbox requesting enrollment from STAR+PLUS, if applicable.

Within one business day of mailing the second Form H2065-D to the member, PSU staff:

  • verify that NF records in the SASO reflect the NF end date;
  • contact HHSC Long Term Care (LTC) Provider Claims Services at 512-438-2200 and select option 1 to request closure of the NF service authorization in SASO, if the NF end date reflecting the discharge has not processed;
  • update CSIL database, in accordance with Section 3311.4, Earliest Date for Adding a Member Back to the Interest List, ensuring accurate selection of CSIL closure code(s); and
  • email the ERS mailbox requesting enrollment effective the first of the month in which the applicant is discharged, as required by Section 3510, Money Follows the Person and Managed Care.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D, and:

  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • upload Form H2065-D to the HEART case record;  
  • close the HEART case record; and
  • close CSIL.

If the applicant chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program, PSU staff deny the STAR+PLUS HCBS program and fax Form H2065-D, along with Form H1746-A, to the MEPD specialist. Upon completion of all STAR+PLUS HCBS program actions, PSU staff close the HEART case record.

 

3520 Money Follows the Person Demonstration Entitlement Period Tracking

Revision 18-0; Effective September 4, 2018
 
Individuals who choose to enroll in and meet the eligibility requirements for Money Follows the Person Demonstration (MFPD) must be designated in the Service Authorization System Online (SASO) using the following procedures:

  • Enrollment Record — Enrolled From Field: Choose "12-Rider 37/28 (FAC to COMM)."
  • Service Authorizations:
    • Force Box — Check the Force box for each service authorization.
    • Fund Type — Choose "19MFP-Money Follows the Person." This code applies only to MFPD recipients.
    • Force Comment — Enter "MFP Demonstration Member" and select "Force."

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD period is over or if the member withdraws from MFPD. If a member enters a nursing facility (NF) and then re-enters the community setting before the MFPD ISP period is over, the MFPD entitlement period resumes until the end of the ISP or the month of a new ISP period if the 365-day period extends beyond the current ISP period.

Program Support Unit (PSU) staff must maintain a list of MFPD participants. This list must contain the participant's:

  • name;
  • Medicaid identification (ID) number; and
  • ISP start date.

The member may withdraw from MFPD at any time by completing Form 3632, Withdrawal Confirmation, and sending it to PSU staff. Although MFPD eligibility may end, the member continues to receive the STAR+PLUS Home and Community Based Services (HCBS) program if all eligibility criteria are met.

Time spent in an institutional setting does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) Initiative members receive the full 365-day entitlement period. The entitlement period begins the date the member who agrees to participate in the demonstration is enrolled in the STAR+PLUS HCBS program.

In order to assure that the member has been put on the SASO as an MFPD applicant, PSU staff must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TXMedCentral Naming Conventions, that Fund Code 19MFP has been entered.

Example: The applicant chooses to participate in MFPD and is enrolled in the STAR+PLUS HCBS program effective June 1. If there are no institutional stays during the initial individual service plan (ISP) period, the MFPD period ends on May 31. If the MFPD member is institutionalized for 10 days in April, the MFPD period is extended to June 10, following the ISP end date of May. If the MFPD member is authorized for a new MFPD service during the initial ISP period, the 365-day period would still end on May 31, if there were no institutional stays.

Tracking is required to ensure MFPD members receive the full 365-day entitlement period unless the member withdraws from MFPD. The MCO is responsible for tracking the MFPD entitlement period because PSU staff have no way of knowing when STAR+PLUS HCBS program members are admitted and released from nursing facilities (NFs). Once the 365-day period has passed, the MCO is responsible for uploading Form H2067-MC to TxMedCentral to inform PSU staff of the date the member's entitlement period ended. Once received, this information must be forwarded to the regional MFPD reporting coordinator within two business days.

It is essential that complete and accurate records are maintained because MFPD tracking is subject to audit by the Centers for Medicare and Medicaid Services (CMS). PSU staff must follow policy in Section 5120, Maintenance Requirements for Member Information and Forms, which requires a daily backup of TxMedCentral files to compact disk.
 

3530 High or Complex Needs Members

Revision 18-0; Effective September 4, 2018
 
 

 

 

3531 Designation of High Needs Members

Revision 18-0; Effective September 4, 2018
 
The Uniform Managed Care Contract (UMCC), Attachments A and B-1, Section 8.1.12, specifies the managed care organization (MCO) must develop and maintain a system and procedures for identifying members with special health care needs (MSHCN), including people with disabilities or chronic or complex medical and behavioral health conditions and children with special health care needs (CSHCN).

The MCO must contact members pre-screened by the Texas Health and Human Services Commission (HHSC) Administrative Services contractor as MSHCN to determine whether the members meet the MCO's MSHCN assessment criteria, and to determine whether the members require special services. The MCO must provide information to the HHSC Administrative Services contractor identifying members who the MCO has assessed to be MSHCN, including any members pre-screened by the HHSC Administrative Services contractor and confirmed by the MCO as MSHCN. The information must be provided in a format and on a time line to be specified by HHSC in the Uniform Managed Care Manual (UMCM), and updated with newly identified MSHCN by the 10th day of each month. In the event that an MSHCN changes MCOs, the MCO must provide the receiving contractor information concerning the results of the MCO's assessment of that member's needs to prevent duplication of those activities.

CSHCN means a child (or children) who:

  • ranges in age from birth up to age 19;
  • has a serious ongoing illness, a complex chronic condition or a disability that has lasted or is anticipated to last at least 12 continuous months or more;
  • has an illness, condition or disability that results (or without treatment would be expected to result) in limitation of function, activities or social roles in comparison with accepted pediatric age-related milestones in the general areas of physical, cognitive, emotional, and/or social growth and/or development;
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel; and
  • has a need for health and/or health-related services at a level significantly above the usual for the child's age.

MSHCN includes a CSHCN and any adult member who:

  • has a serious ongoing illness, a chronic or complex condition, or a disability that has lasted or is anticipated to last for a significant period of time; and
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel.

 
3532 Determination of High Needs Status for Ongoing Members

Revision 18-0; Effective September 4, 2018
 
If, during the individual service plan (ISP) period, the managed care organization (MCO) determines the member's subsequent ISP may have the potential to exceed the cost limit, that member is considered to have high needs status. Once designated as having a high needs status, the MCO must initiate in the ninth month of the ISP period plans to bring the ISP at or under the cost limit.

If it appears the subsequent ISP will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the MCO initiates a request for a staffing with the Texas Health and Human Services Commission (HHSC) to determine whether a request for the use of General Revenue (GR) funds is appropriate.
 

3600 Ongoing Service Coordination

Revision 18-0; Effective September 4, 2018
 
Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

  • revising the individual service plan (ISP) as necessary to meet the needs of the member, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services (ERS), respite or requests for service suspension;
  • coordinating and consulting with MCO-contracted providers regarding delivery of services;
  • reminding the member to complete and return Medicaid renewal eligibility documents sent by Program Support Unit (PSU) staff or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • monitoring services delivered to members, evaluating the adequacy and appropriateness of the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program, and documenting monitoring activities;
  • assisting the member in accessing and using community, Medicare, family and other third-party resources (TPR);
  • assisting with crisis intervention; and
  • responding to situations of potential denial of an active member whose ISP costs exceed the individual's assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of the STAR+PLUS HCBS program.

 
3610 Revising the Individual Service Plan

Revision 18-0; Effective September 4, 2018
 
It may be necessary to revise the individual service plan (ISP) within the ISP period due to changes in the needs of the member, or changes in the services offered or emergency situations. The managed care organization (MCO) documents revisions to the ISP on Form H1700-1, Individual Service Plan (Pg. 1). A revised ISP is not submitted to the Program Support Unit (PSU) through TxMedCentral, but is kept in the member's case record.
 

3611 MCO Required Notifications from the Provider

Revision 18-0; Effective September 4, 2018
 
The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

  • the member leaves the service area for more than 30 days;
  • the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • the member is not financially eligible for Medicaid benefits;
  • providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
  • the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
  • the member fails to pay his or her qualified income trust (QIT) copayment;
  • the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
  • the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
  • the member requests that services end.

 
3611.1 Immediate Suspension or Reduction of Services

Revision 18-0; Effective September 4, 2018
 
If the member or someone in the member's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the managed care organization (MCO) and MCO contracted provider are required to make an immediate referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) and/or the police and suspend services. The MCO must immediately provide written notice of temporary suspension of service to the member, and the right of appeal to a state fair hearing must be explained to the member. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference and the right of appeal.

The provider must verbally inform the MCO by the following business day of the reason for the immediate suspension, and follow up with written notification to the MCO within two business days of verbal notification. The MCO must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the STAR+PLUS Home and Community Based Services (HCBS) program provider may continue providing services to assist in the resolution of the crisis. If the crisis is not satisfactorily resolved, the MCO follows the established denial procedures. Services do not continue during the appeal process.
 

3611.2 Required Notification of Service Denial from the MCO

Revision 18-0; Effective September 4, 2018
 
If the managed care organization (MCO) determines that documentation supports initiation of denial, the MCO provides written notification of denial to the member within five business days.

The MCO’s denial notice must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal. The MCO forwards a copy of the denial notice to the provider within two business days.

If the member appeals the notification of denial within the 10-day adverse action period, the MCO must continue the STAR+PLUS Home and Community Based Services (HCBS) program until notification of the decision by the state fair hearings officer. The MCO must not reduce the STAR+PLUS HCBS program until the outcome of the appeal is known.
 

3620 Reassessment

Revision 18-0; Effective September 4, 2018
 
 

 

 

3621 Reassessment Procedures

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System Online (SASO) annually. PSU staff:

  • check TxMedCentral to determine if the managed care organization (MCO) has submitted Form H1700-1, Individual Service Plan (Pg. 1), before the ISP end date;
  • verify the SASO case record has an approved Medical Necessity and Level of Care (MN/LOC) Assessment (both must have the same end date as the ISP being registered; if not, extend the MN/LOC Assessment record through the end of the ISP being registered);
  • confirm ongoing Medicaid eligibility;
  • verify continuing enrollment in SASO reflects any plan change;
  • verify the ISP is within the cost limit;
  • determine if the ISP was submitted on time and if:
    • on time, enters service group (SG) 19 service code (SC) 12;
    • not on time, enters SG 19 SC 13 for the month(s) for which the ISP was late and SG 19 SC 12 for the remaining ISP period; and
  • confirm the ongoing ISP is entered in SASO.  If PSU staff must manually enter the ISP, PSU staff must enter the ongoing ISP into SASO within five business days of receipt, not to exceed the ISP end date.

The Supplemental Security Income (SSI)-denied Medicaid program types referenced in Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS HCBS Program, do not change in the Texas Integrated Eligibility Redesign System (TIERS) either during the initial or annual review by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. As part of reassessment procedures, PSU staff will remain responsible for confirming ongoing Medicaid eligibility, but are not required to request an MEPD specialist test an individual for the additional criteria, or request a change in the Medicaid type program (TP).

If the reassessment ISP is being submitted due to the member’s timely appeal of a STAR+PLUS HCBS program denial, PSU staff enter the information from the initial ISP, extending the end date an additional four months. Services continue using this ISP until a decision is received from the hearings officer. At that time, changes are made, if necessary, to comply with the hearings officer's decision.
 

3622 Reassessment Notification Requirements

Revision 18-0; Effective September 4, 2018
 
If the member continues to meet STAR+PLUS Home and Community Based Services (HCBS) program requirements, it is not necessary for Program Support Unit (PSU) staff to mail Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. If the member does not meet STAR+PLUS HCBS program requirements, PSU staff must, within two business days of notification:

  • mail Form H2065-D to the member indicating why the case is being terminated;
  • upload a copy of Form H2065-D to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox after the effective date of the action; and
  • fax Form H1746-A, MEPD Referral Cover Sheet, to MEPD, if applicable.

If no appeal is filed, ERS staff disenroll the member from STAR+PLUS effective the date of the action on Form H2065-D.

If the member files an appeal timely, PSU staff, within two business days of notification:

  • fax Form H1746-A for cases in the Centralized Representation Unit (CRU), which forwards the information to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, informing the MCO to continue services due to the timely appeal (if services have already ended, the MCO reinitiates services immediately);
  • extend the end date of the current ISP an additional four months; and
  • send an email to ERS staff for medical assistance only (MAO) cases as notification that a timely appeal was submitted and enrollment should remain open.

Within 10 days of receiving the fair hearings officer's decision, ERS staff must carry out the fair hearing decision. Refer to Section 4233, State Fair Hearing Decision.
 

3623  Eligibility Date on Form H2065-D

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

  • upgrades and interest list releases;
  • members transitioning out of children's programs; and
  • transfers from a nursing facility (NF) using the Money Follows the Person (MFP).
     

3623.1 Upgrades and Interest List Releases

Revision 18-0; Effective September 4, 2018
 
The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant being released from the interest list, or a member requesting or being processed for an upgrade, is based on the:

  • notification or verification of Medicaid eligibility;
  • date the approved and valid Medical Necessity and Level of Care (MN/LOC) Assessment was submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal; and
  • date the member's individual service plan (ISP) was uploaded to TxMedCentral.

Note: A valid MN does not exceed 120 days from the date of Texas Medicaid & Healthcare Partnership (TMHP) approval. If MN exceeds 120 days from the date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO, and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

Program Support Unit (PSU) staff determine the eligibility and effective date based on the later of the above dates. If the date falls on the first day of the month, the eligibility and ISP effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month. If the date falls between the second and the last day of the month, the eligibility and ISP effective date is the first date of the following month.

 

3623.2 Members Transitioning Out of Children's Programs

Revision 18-0; Effective September 4, 2018
 
The eligibility and the individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the first day of the month following their 21st birthday:

  • Medically Dependent Children Program (MDCP)
  • Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC)

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP through STAR Health until age 22. In this scenario, the eligibility and ISP effective date is the first day of the month following their 22nd birthday.
 

3623.3 MFP Initiative Nursing Facility Releases

Revision 18-0; Effective September 4, 2018
 
The ISP effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program through the Money Follows the Person (MFP) process is the date of discharge. The STAR+PLUS HCBS eligibility date on Form H2065-D for members transferring from NFs to the STAR+PLUS HCBS program through the MFP process, is the date used on the initial Form H2065-D. Service Authorization System Online (SASO) registration for MFP releases from NFs must occur as follows:

  • NF Service Group 1 SASO registrations must be closed the day before the discharge.
  • STAR+PLUS HCBS program service group (SG) 19 SASO registration covers the entire individual service plan (ISP) period. The ISP effective date on Form H2065-D is the date of discharge.

 

3630 Denial or Termination Procedures

Revision 18-0; Effective September 4, 2018
 
This section provides information, procedures and references pertaining to denial or termination of the STAR+PLUS Home and Community Based Services (HCBS) program for active members, along with adequate notice of members' rights and opportunities to appeal.

The following citation from the Code of Federal Regulations (CFR) specifies situations in which an adverse action period is not required:

CFR §431.213, Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

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

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

1) He no longer wishes services; or

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

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

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

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

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

The citation for the following rule, which appears in Texas Administrative Code (TAC), Title I, Part 15, Chapter 353, Subchapter G, §353.607, appears on Form H2065-D, Notification of Managed Care Program Services.

The STAR+PLUS Program Support Unit Operational Procedures Handbook includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR+PLUS program services to eligible members.

 

3631 10-Day Adverse Action Notification

Revision 18-0; Effective September 4, 2018
 
The Code of Federal Regulations (CFR) requires the Texas Health and Human Services Commission (HHSC) provide a notice to the member at least 10 days before the action effective date. The member must be given the full 10-day adverse action period to give him or her time to file an appeal.

CFR, Subpart E, Sec. §431.230, Maintaining services.

a) If the agency mails the 10-day or 5-day notice as required under Sec. §431.211 or Sec. §431.214 of this subpart, and the member requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless:

1) It is determined at the hearing that the sole issue is one of federal or State law or policy; and

2) The agency promptly informs the member in writing that services are to be terminated or reduced pending the hearing decision.

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

Instructions on how to calculate time periods is provided in §311.014 of the Code Construction Act. This act specifies:

  • in computing a period of days, the first day is excluded and the last day is included; and
  • if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 10-day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when HHSC offices are officially open, even with limited workforce.

The full adverse action period may be waived if the member signs a statement to waive the adverse action period.

 

3631.1 Denial of MN/LOC Assessment of ISP

Revision 18-0; Effective September 4, 2018

When a member is denied STAR+PLUS Home and Community Based Services (HCBS) program services because he or she does not meet medical necessity (MN) criteria or does not have a valid individual service plan (ISP), the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date Informed Eligibility Lost Date Form H2065-D Sent Current ISP End Date 10-Day Adverse Action Expiration Date Form H2065-D Termination Date Service Authorization System Online (SASO) Action
April 10 April 12 May 31 April 22 May 31 None
May 20 May 21 May 31 May 31 May 31 None
May 20 May 22 May 31 June 1 June 30 ISP must be extended to June 30.
June 5 June 7 May 31 June 17 June 30 ISP must be extended to June 30.
June 22 June 24 May 31 July 4 July 31 ISP must be extended to July 31.

 

3631.2 Denial of Medicaid Eligibility

Revision 18-0; Effective September 4, 2018

When a member is denied STAR+PLUS Home and Community Based Services (HCBS) program services because he or she does not meet Medicaid eligibility, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Actual Date of Medicaid Eligibility Denial Date Informed Eligibility Lost Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Online (SASO) Action
December 31 December 31 May 31 January 2 December 31 ISP and Medical Necessity and Level of Care (MN/LOC) Assessment must be corrected to December 31.
December 31 October 31 May 31 November 2 December 31 ISP and MN/LOC Assessment must be corrected to December 31.
December 31 February 5 May 31 February 7 December 31 ISP and MN/LOC Assessment must be corrected to December 31.

Notes:

  • If eligibility for Medicaid is reestablished with a gap of over four months, the individual must go back on the interest list.
  • If eligibility for Medicaid is reestablished with a gap of four months or less, the individual may resume services. The existing ISP and MN/LOC Assessment can be used if they are still valid. If the ISP and MN/LOC Assessment have expired, the MCO is allowed to do a reassessment without penalty.

 

3631.3 Members No Longer in the Service Area

Revision 18-0; Effective September 4, 2018
 
When a member is denied STAR+PLUS Home and Community Based Services (HCBS) program services because he or she is no longer in the service area, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions. Refer to Section 3410, Transfer Scenarios, for members transferring to another service area with and without prior knowledge.

Actual Date of Move Date Health and Human Services Commission (HHSC) Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Online (SASO) Action
December 31 December 31 May 31 January 2 December 31 ISP and Medical Necessity and Level of Care (MN/LOC) Assessment must be corrected to January 31.
October 31 December 31 May 31 January 2 January 31 ISP and MN/LOC Assessment must be corrected to January 31.
April 22 June 9 May 31 June 11 June 30 ISP and MN/LOC Assessment must be corrected to June 30.
May 22 May 22 May 31 May 24 June 30* ISP and MN/LOC Assessment must be corrected to June 30.
June 30 June 9 May 31 June 11 June 30 Managed care organization (MCO) should have submitted an ISP and MN/LOC Assessment for June 1. If these forms are not submitted, enter Service Group 19/Service Code 13 for June 1 through June 30.

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

 

3631.4 Unable to Locate

Revision 18-0; Effective September 4, 2018
 
When a member is denied STAR+PLUS Home and Community Based Services (HCBS) program services because he or she cannot be located, the following chart depicts an example of the dates Program Support Unit (PSU) staff use when completing case actions.

Date HHSC Informed Current Individual Service Plan (ISP) End Date Date Form H2065-D Sent Form H2065-D Termination Date Service Authorization System Online (SASO) Action
December 31 May 31 January 2 January 31 ISP and Medical Necessity and Level of Care (MN/LOC) Assessment must be corrected to January 31.
May 3 May 31 May 5 May 31 None
May 5 May 31 May 27 June 30* ISP and MN/LOC Assessment must be corrected to June 30.
June 9 May 31 June 11 June 30 Managed care organization (MCO) should have submitted an ISP and MN/LOC Assessment for June 1. If these forms are not submitted, enter Service Group 19/Service Code 13 for June 1 through June 30.

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

 

3632 Program Support Unit Initiated Denials or Terminations

Revision 18-0; Effective September 4, 2018

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

3632.1 Denial or Termination Due to Death

Revision 18-0; Effective September 4, 2018
 
Upon learning of the death of a member, Program Support Unit (PSU) staff must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, within two business days of verification.

Form H1746-A, MEPD Referral Cover Sheet, must be faxed to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if no notification was received by PSU from MEPD. PSU staff do not send a notice to the member's address or family. The effective date is the date of death.

PSU staff upload Form H2067-MC and Form H1746-A to Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

If the member was receiving Supplemental Security Income (SSI) and the eligibility records reflect SSI has been denied, PSU staff must use the same effective date of denial as the SSI denial date. If the eligibility records reflect SSI is still active, it is the member’s family’s responsibility to notify the Social Security Administration (SSA) of the member's death.

If a member's Medicaid eligibility has been denied in the Texas Integrated Eligibility Redesign System (TIERS) due to death, the appropriate entries must be made to end enrollment in the Service Authorization System Online (SASO). Refer to Section 9700, Terminations, for the termination process.
Services must be denied or terminated once death of the member has been confirmed by PSU staff by:

  • TIERS;
  • obituaries in the local newspaper;
  • contact with family or friends;
  • notification from the MCO; or
  • other reliable sources.

A 10-day adverse action period is not required for death denials.
 

3632.2 Denial or Termination Due to Residence in an NF

Revision 18-0; Effective September 4, 2018
 
Following the 90th day of a member not returning to the community when a member resides in a nursing facility (NF) for 90 days or more, the managed care organization (MCO) or Medicare-Medicaid Plan (MMP) notifies Program Support Unit (PSU) staff within 14 days. The MCO sends this notice to PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

PSU staff deny the STAR+PLUS Home and Community Based Services (HCBS) program by the end of the month in which the 90th day occurred by:

  • mailing the member Form H2065-D, Notification of Managed Care Program Services;
  • uploading Form H2065-D to TxMedCentral in the MCO or MMP's SPW folder, following the instructions in Appendix XXXIV;
  • faxing Medicaid for the Elderly and People with Disabilities (MEPD) Form H1746-A, MEPD Referral Cover Sheet, and a copy of Form H2065-D, for medical assistance only (MAO) STAR+PLUS HCBS program members; and
  • uploading Form H2065-D and Form H1746-A to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

 

3632.3 Denial or Termination Due to Member Request

Revision 18-0; Effective September 4, 2018
 
When Program Support Unit (PSU) staff have been notified a member no longer wants STAR+PLUS HCBS program services, within two business days of notification, PSU staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 
3632.4 Denial or Termination of Financial Eligibility

Revision 18-0; Effective September 4, 2018
 
A member's continued receipt of STAR+PLUS services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI, or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for MAO. The member may appeal the financial denial using SSA or MEPD processes, as appropriate. Within two business days of notification, Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D on TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for MAO members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Notification can come from:

  • monthly loss of eligibility reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

The chart below describes how to proceed if financial eligibility is denied.

When the individual is denied SSI: When the individual is denied MAO:
  • disenrollment from the STAR+PLUS program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • the right to appeal to SSA is available to the individual.
  • the individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS) (for example, Community Attendant Services (CAS), Family Care, Title XX programs or state-funded programs).
  • depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.
  • disenrollment from the STAR+PLUS program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • the right to appeal to the MEPD specialist is available to the individual.
  • the individual can contact the local HHSC office to request other LTSS (for example, CAS, Family Care, Title XX programs or state-funded programs).
  • depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.

 

For SSI members, the termination date must match the SSA termination date. For SSI denials, the 10-day adverse action notification period does not apply.

 

For MAO members, the termination date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past because PSU was not aware of the denial in advance.
 

3632.5 Denial or Termination of MN/LOC Assessment

Revision 18-0; Effective September 4, 2018
 
The STAR+PLUS Home and Community Based Services (HCBS) program must be denied or terminated when the member's Medical Necessity and Level of Care (MN/LOC) Assessment is denied. Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Services, within two business days of notification. Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • a managed care organization (MCO); or
  • other reliable sources.

MCOs must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN status through completing a current activity query in the TMHP LTC Online Portal every seven days, at minimum. If an MN status appears as "MN Denied" in the TMHP LTC Online Portal, the STAR+PLUS HCBS program applicant's or member's physician has 14 business days to submit additional information to the TMHP physician. If a member’s MN status enters “MN Denied,” the MCO must assist the member and physician with collecting and submitting any additional information pertinent to the member’s MN determination. The MCO must assist by calling the member and physicians and obtaining necessary documents to TMHP for consideration within the 14-business day time frame.

Once an MN/LOC Assessment status is in "MN Denied" status, several actions may occur:

  • MN Approved: The status changes to "MN Approved" if the TMHP physician overturns the denial because additional information is received;
  • Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14-business day period for the TMHP physician to overturn the denied MN has expired. No additional information was submitted for the physician review. The denied MN remains in this status unless a fair hearing is requested; or
  • Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP physician does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

PSU staff must not complete and mail Form H2065-D to the applicant or member to deny the STAR+PLUS HCBS program case until after 14 business days from the date the "MN Denied" status appears in the TMHP LTC Online Portal. After the 14-business day period has expired, PSU staff must not deny MDCP services unless the TMHP LTC Online Portal status is either “MN Denied,” “Overturn Doctor Review Expired” or “Doctor Overturn Denied.” PSU staff must meet initial certification and annual assessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented.

PSU staff must monitor the TMHP LTC Online Portal every five business days until a status of “MN Denied,” “Overturn Doctor Review Expired” or “Doctor Overturn Denied” is assigned.

After 14 business days from the “MN Denied” status initially appeared in the TMHP LTC Online Portal has expired, if the TMHP LTC Online Portal shows a status of “MN Denied,” “Overturn Doctor Review Expired,” or “Doctor Overturn Denied,” then within two business days PSU staff must:

  • mail the member Form H2065-D;  
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • upload Form H2065-D, screenshot of Form H2065-D uploading to TxMedCentral, screenshot of TMHP LTC Online Portal MN status, and Form H1746-A, if applicable, to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
  • for non-MAO members, email Enrollment Resolution Services (ERS) the following information:
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (STAR+PLUS HCBS program);
    • MN denial date;
    • ISP end date;
    • effective date of disenrollment;
    • MCO selection; and
    • Form H2065-D.

 
3632.6 Denial or Termination Due to Inability to Locate Member

Revision 18-0; Effective September 4, 2018
 
The STAR+PLUS Home and Community Based Services (HCBS) program must be denied or terminated when Program Support Unit (PSU) staff are notified that a member cannot be found. Within two business days of notification, PSU staff must:  

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

 
3632.7 Denial or Termination Due to Failure to Meet Other Requirement

Revision 18-0; Effective September 4, 2018
 
Use this denial citation if the applicant does not meet a STAR+PLUS Home and Community Based Services (HCBS) program requirement mentioned in Section 3632.1 through Section 3632.6. For example, this citation would be used if the applicant applying for services does not require at least one STAR+PLUS HCBS program service. Within two business days of notification, Program Support Unit (PSU) staff must:

  • mail the applicant or member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 
Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

 
3632.8 Denial or Termination for Other Reasons

Revision 18-0; Effective September 4, 2018
 
Use this citation if initiating denial or termination for a reason not covered in Section 3632.1 through Section 3632.7. Within two business days of notification, Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

 
3633 Denial or Termination Initiated by the MCO

Revision 18-0; Effective September 4, 2018
 
Section 3633.1 through Section 3633.7 contains policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. Within two business days of notification by the MCO, Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 

3633.1 Denial or Termination Due to Threats to Health and Safety

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) and provider staff must take special precautions when an applicant’s or member's comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant or member, an MCO-contracted provider or an MCO employee. If an applicant exhibits such behavior, the MCO staff member must immediately notify his or her manager.

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

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

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload the Form H2065-D on TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

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

3633.2 Denial or Termination Due to Hazardous Conditions

Revision 18-0; Effective September 4, 2018
 
When there is no immediate threat to the health or safety of the service provider, but the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, appropriate documentation of denial is essential. For example, a situation where the member has a large dog that may bite if let loose could be resolved if the member or a neighbor or family member will agree to restrain the dog during times of service delivery.

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

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

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

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload the Form H2065-D on TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

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


3633.3 Denial or Termination Due to Harassment, Abuse or Discrimination

Revision 18-0; Effective September 4, 2018
 
A substantial demonstrated pattern of verbal abuse or discrimination must be clearly established and documented by the managed care organization (MCO) before services can be denied for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the member and/or his or her family or authorized representative (AR), explaining that the MCO does not condone discrimination, harassment and/or verbal abuse.

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

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

If the situation persists and results in an inability to deliver services, the MCO may request disenrollment from HHSC, as described in the Uniform Managed Care Manual (UMCM), §11.5. After HHSC approves the disenrollment, HHSC notifies the Program Support Unit (PSU) supervisor by email. PSU staff fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

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

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload the Form H2065-D on TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

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

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

3633.4 Denial as a Result of Exceeding the Cost Limit

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) must consider all available support systems in determining if the STAR+PLUS Home and Community Based Services (HCBS) program is a feasible alternative that ensures the needs of the applicant are adequately met. If the STAR+PLUS HCBS program is not a feasible alternative, the MCO must notify Program Support Unit (PSU) staff of the denial and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial is based on the inadequacy of the plan of care (POC), including both the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program services, to meet the needs of the member within the cost limit.

If Form H1700-1, Individual Service Plan (Pg. 1), is over the cost limit, within two business days of receipt of Form H1700-1, PSU staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 
3633.5 Denial or Termination Due to Failure to Comply

Revision 18-0; Effective September 4, 2018
 
If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his or her home and thus refuses more than three times to comply with service delivery provisions, services may be denied or terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member's home that prevent determining eligibility, carrying out the service plan or monitoring services. Within two business days of notification, Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 
3633.6 Denial or Termination Due to Failure to Pay Copay R&B or QIT

Revision 18-0; Effective September 4, 2018
 
If the member refuses to pay a required copayment, room and board (R&B) payment or qualified income trust (QIT) payment, the STAR+PLUS Home and Community Based Services (HCBS) program must be denied. Within two business days of notification, the Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

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

3633.7 Denial or Termination Due to Other Reasons

Revision 18-0; Effective September 4, 2018
 
Use this denial or termination citation if initiating denial for a reason not covered above. After notification by the managed care organization (MCO), within two business days of notification, Program Support Unit (PSU) staff must:

  • mail the member Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; and
  • upload Form H2065-D and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

 
3640 Disenrollment Request Policy

Revision 18-0; Effective September 4, 2018
 
Mandatory STAR+PLUS members may request a case review for disenrollment from STAR+PLUS. Disenrollment of a mandatory member is only approved if a determination is made that a member would be better served under fee-for-service (FFS) than participating in managed care.

Members who request to disenroll from STAR+PLUS must submit a written request with supporting documentation of medical condition and extenuating circumstances. This written request must be submitted to the Texas Health and Human Services Commission (HHSC) at the following address:

Texas Health and Human Services Commission Managed Care
P.O. Box 149030, Mail Code W-516
Austin, TX 78714-9030

HHSC conducts a case review and makes a final determination. The member and Program Support Unit (PSU) staff will be notified in writing of the decision and any available alternatives. If the member is disenrolled, HHSC will make the necessary adjustments in the Service Authorization System Online (SASO) and notify the respective managed care organization (MCO) and HHSC enrollment broker.

The member can only re-enter the STAR+PLUS HCBS program using Money Follows the Person (MFP) procedures. Refer to Section 3510, Money Follows the Person and Managed Care, for additional information.
 

3641 Services for Members Disenrolled from STAR+PLUS

Revision 18-0; Effective September 4, 2018
 
In some situations, a STAR+PLUS member or his or her managed care organization (MCO) may request, and be granted, disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled members can receive available services from the Texas Health and Human Services Commission (HHSC) Medical and Social Services (MSS) Division, if determined eligible. Refer to Section 3640, Disenrollment Request Policy, for additional information.