Revision 17-3; Effective September 1, 2017

 

 

2010 Community Services Interest List Responsibilities for Initial Requests

Revision 17-1; Effective June 1, 2017

 

Individuals requesting Medically Dependent Children Program (MDCP) services must be placed on the MDCP interest list, regardless of the program's enrollment status, according to the date and time of the request. Individuals are released in order of the request date. An individual is placed on the MDCP interest list by calling the Community Services Interest List (CSIL) Unit toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the MDCP interest list and refer the individual directly to the CSIL Unit at 877-438-5658 for placement on the MDCP interest list.

The individual's name may only be added to the interest list if the individual is less than 21 years of age and resides in Texas.

 

2020 Community Service Interest List Unit Interest List Procedures

Revision 17-3; Effective September 1, 2017

 

The Texas Health and Human Services Commission (HHSC) Community Services Interest List (CSIL) Unit manages the following activities related to the Medically Dependent Children Program (MDCP) interest list:

  • Adds and updates individuals on the interest list;
  • Sends an initial notification to the individual, or individual's parent or guardian, added to the interest list;
  • Performs annual contacts of individuals on the interest list for more than one year;
  • Releases individuals from the interest list;
  • Confirms individuals in released status on the interest list are viable MDCP candidates before release by:
    • verifying the individual’s address, county, and all contact information is correct;
    • if Medicaid enrolled, identifying the individual's type of assistance in the Texas Integrated Eligibility Redesign System (TIERS);
    • checking if the individual is enrolled in STAR Health, then the individual or individual's parent or guardian will not receive an initial contact by the CSIL Unit. The CSIL Unit forwards the release to the Program Support Interest List (PSIL) to confirm current primary medical consenter information;
    • verifying the individual still wants to pursue MDCP services; and
  • Provides separate lists of released individuals to the PSIL email box MDCP_Interest_List@hhsc.state.tx.us for assignment to the appropriate Program Support Unit (PSU) staff.
    • The first list contains STAR Health members released from the MDCP interest list and the second list contains "all other" releases. When submitting the lists to the PSIL Unit, the CSIL Unit must submit each list with a separate title.
      • The title for STAR Health members released from the list must read: MDCP Interest List Releases for STAR Health Members.
      • The "all other" list for the remaining releases must read: MDCP Interest List Releases. The list of data elements for both lists will include:
        • Interest List number;
        • Assign to PSIL date;
        • Name;
        • Address;
        • Contact phone numbers;
        • County;
        • Social Security number; and
        • Medicaid number, if applicable.

Additional instructions on MDCP interest list releases for STAR Health members are located in the STAR Health Chapter 16.2 of the Uniform Managed Care Manual.

 

2030 Program Support Interest List Unit Responsibilities

Revision 17-1; Effective June 1, 2017

 

The Program Support Interest List (PSIL) Unit state office staff are responsible for coordinating and managing activities related to the release of an individual from the Medically Dependent Children Program (MDCP) interest list.

 

2031 Interest List Release and Initial Contact

Revision 17-3; Effective September 1, 2017

 

Within five business days of receiving the names of interest list releases from the Community Services Interest List (CSIL) Unit, the Program Support Interest List (PSIL) Unit staff must:

  • create a case in the HHS Enterprise Administrative Report and Tracking System (HEART);
  • check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program, and document the individual’s current Medicaid status and managed care organization (MCO) enrollment, if applicable, in HEART;
  • contact the individual to confirm continued interest and provide a general description of the Medically Dependent Children Program (MDCP) services (See the Uniform Managed Care Manual for specific instructions on outreach to STAR Health members);
  • discuss the MCOs operating in the individual's service delivery area and encourage the individual to contact the MCO for additional information and available services, if applicable;
  • discuss the importance of choosing an MCO so the assessment and initial individual service plan (ISP) are completed timely and to avoid delays in eligibility determination for MDCP services;
  • inform the individual the MCO in which he/she enrolls can be changed at any time after one full calendar month of MDCP service provision; and
  • discuss the importance of returning Form H1200, Application for Assistance - Your Texas Benefits, and other required documents, as applicable.

Within two business days of the initial contact with the individual, the PSIL must assign the HEART case to the appropriate Program Support Unit staff to take all necessary case actions.

 

2032 Program Support Unit Responsibilities

Revision 17-3; Effective September 1, 2017

 

The Program Support Unit (PSU) staff are regional Texas Health and Human Services Commission (HHSC) staff responsible for facilitating the required components of the Medically Dependent Children Program (MDCP) eligibility process by coordinating between HHSC, managed care organizations and MDCP individuals.

 

2100 Enrollment Following Release from the Interest List

Revision 17-3; Effective September 1, 2017

 

For individuals not enrolled in Medicaid, including individuals enrolled in the Children’s Health Insurance Program (CHIP), within three business days of the receipt of assignment, Program Support Unit (PSU) staff send the following forms to the Medically Dependent Children Program (MDCP) individual for completion:

  • Form 2602, Managed Care Organization Selection Acknowledgement, to confirm interest in applying for MDCP services;
  • Form H2053-B, Health Plan Selection, and Form H2053-BS (Spanish);
  • MDCP information and Appendix IV, MDCP Frequently Asked Questions;
  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • a postage-paid envelope.

Within 14 calendar days from the date the enrollment packet is mailed to the individual, PSU staff contact the individual regarding selection of a managed care organization (MCO) as quickly as possible to ensure the selected MCO can conduct an assessment and develop the initial individual service plan. PSU staff must remind the individual that a delay in selecting an MCO will result in a delay in eligibility determination for MDCP services.

Individuals Who Receive Supplemental Security Income (SSI) or SSI-Related Medicaid

Individuals with SSI or SSI-related Medicaid are already enrolled with an MCO and receive benefits through the STAR Kids or STAR Health program. Within three business days of the receipt of assignment, PSU staff send the following forms to the individual for completion:

  • Form 2602 to confirm interest in applying for MDCP services;
  • MDCP information and Appendix IV; and
  • a postage-paid envelope.

Individuals Who Currently Receive Other Types of Medicaid

Individuals who receive other types of Medicaid (i.e., non-SSI) and are either served in fee-for-service or are enrolled with a STAR MCO must select a STAR Kids MCO. Individuals enrolled with the STAR Health MCO will remain enrolled in STAR Health. Within three business days of the receipt of assignment, PSU staff send the following forms to the individual for completion:

  • Form 2602 to confirm interest in applying for MDCP services;
  • Form H2053-B and Form H2053-BS (Spanish);
  • MDCP information and Appendix IV; and
  • a postage-paid envelope.

Within 14 days from the date the enrollment packet is mailed to the individual, PSU staff contact the individual regarding selection of a STAR Kids MCO so the selected MCO can conduct the assessment and develop the initial individual service plan. PSU staff must remind the individual that any delay in selecting an MCO will result in a delay in eligibility determination for MDCP services.

 

2110 Managed Care Organization Selection

Revision 17-3; Effective September 1, 2017

 

The individual has 30 days from the date of the Medically Dependent Children Program (MDCP) interest list release notification letter to complete and return enrollment materials to Program Support Unit (PSU) staff. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services at the time of his or her interest list release, the individual may request to remain on the MDCP interest list but must be notified his or her name will be placed at the bottom of the list.

If the individual has not selected a managed care organization (MCO) within 30 days of contact by PSU staff, an MCO is assigned based on criteria developed by Texas Health and Human Services Commission from the list of available MCOs in the service area. PSU staff contact the individual within three business days of an MCO assignment, who informs him or her that:

  • an MCO has been assigned to the individual; and
  • the MCO in which the individual is enrolled can be changed at any time, but will not go into effect until after one full calendar month of MDCP service provision.

 

2120 Inability to Contact the Individual

Revision 17-3; Effective September 1, 2017

 

If Program Support Unit (PSU) staff are unable to contact the individual by phone within 14 calendar days from the date the enrollment packet was mailed to the individual, PSU staff must complete and mail Form 2442, Notification of Interest List Release Closure, to the individual. Form 2442 must include the release date and release closure date, and must indicate that staff have not been able to contact the individual to begin the eligibility determination process. The release closure date is the 31st day after the date on the release notification letter.

PSU staff must make one additional attempt to contact the individual prior to the release closure date.

PSU staff should not attempt to contact an individual if the Texas Health and Human Services Commission receives information about the individual's death. The effective date of the release closure is the date staff received information of the individual's death. PSU staff must not send Form 2442 to the responsible party if the release was closed due to death of the individual.

PSU staff must close the release by the release closure date, if staff have not been able to contact the individual within 31 days from the date on the release notification letter.

Within three business days after closing the release, PSU staff must upload Form 2442 and document the closure date and reason in the HHS Enterprise Administrative Report and Tracking System (HEART).

If the individual mails the packet to the PSU within 90 days of the date of the closure letter; PSU staff will reopen the interest list case honoring the original request date. The individual will not be placed at the bottom of the interest list; PSU staff will proceed with processing the information provided by the individual.

 

2130 Declining Medically Dependent Children Program Services

Revision 17-1; Effective June 1, 2017

 

If the individual completes and mails Form 2602, Managed Care Organization Selection Acknowledgement, indicating no interest in applying for Medically Dependent Children Program (MDCP) services or declines MDCP services before the release closure date, the Program Support Unit (PSU) must close the release. The release closure date is the 31st day after the date on the release notification letter. Staff must complete and mail Form 2442, Notification of Interest List Release Closure, informing the individual the release was closed due to being informed the individual no longer wishes to apply for MDCP services.

PSU staff must:

  • upload Form 2442 and document the closure date and reason in the HHS Enterprise Administrative Report and Tracking (HEART) system; and
  • document the closure date and reason in the Community Services Interest List database.

See the Uniform Managed Care Manual for specific requirements around denial of MDCP for STAR Health members.

 

2200 Receipt of Enrollment Packet

Revision 17-3; Effective September 1, 2017

 

When the Program Support Unit (PSU) receives the enrollment packet back from the individual, PSU staff must review to ensure all documents are completed. If all documents are not completed, PSU staff must contact the individual to obtain completed forms within two business days of receipt of the incomplete information.

Unsigned applications received by Medicaid for the Elderly and People with Disabilities (MEPD) staff are returned to the individual. PSU staff must ensure applications are signed prior to referring to MEPD. If MEPD receives an unsigned application from PSU staff with Form H1746-A, MEPD Referral Cover Sheet, MEPD 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 the Texas Health and Human Services Commission can establish a file date.

Once PSU staff receive notice of an unsigned application from MEPD, PSU staff must contact the individual within two business days to inform the individual of the need to return a signed application for processing.

Sending unsigned applications delays the MEPD and PSU eligibility processes and could adversely affect service delivery to the individual.

 

2210 Income and Resource Verifications for Medicaid Eligibility

Revision 17-3; Effective September 1, 2017

 

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 individual from providing duplicate information.

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

  • Bank accounts – bank name, account number, balance and account verification (for example, a copy of the bank statement);
  • 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;
  • Correct and up-to-date phone numbers; and
  • Power of Attorney or Guardianship – copy of the legal document.

Form H1200, Application for Assistance - Your Texas Benefits, is not required for individuals receiving Supplemental Security Income (SSI) or SSI-related Medicaid, as these individuals already have Medicaid eligibility and are enrolled in STAR Kids.

Qualified Income Trust

An individual with a qualified income trust (QIT) may be determined eligible for the Medically Dependent Children Program (MDCP) even though his income is greater than the Medicaid income limit for waiver programs if he also meets all other MDCP eligibility criteria. Income diverted to the trust does not count for the purpose of financial eligibility determination, but is calculated for the determination of the co-payment for MDCP services.

Financial eligibility for an individual with a QIT is determined by MEPD staff. MEPD staff provide information to the individual about maintaining the QIT to remain eligible for Medicaid. A trustee is designated to manage the QIT and disburse payment to service providers on behalf of the member. The individual is informed that any funds deposited into the trust must be used toward the 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) using Form H2067-MC, Managed Care Programs Communication.

For an individual who is financially eligible based on a QIT, the eligibility based on the individual service plan (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 waiver 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 waiver eligibility. The MCO must ensure the individual meets the initial ISP cost limit requirement before deducting the copayment. If the MCO does not properly establish this plan of care and the member’s cost exceeds the individual limit, the MCO must continue to provide MDCP services to the member at the MCO’s expense. The MCO may not terminate MDCP services if a member exceeds his or her cost limit.

First, the ISP is developed by the MCO without consideration of the trust. Then, if the individual is eligible for MDCP within the cost limit, the copayment is allocated to purchase MDCP services identified on Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool. The ISP total and the amount of the provider's service authorizations are reduced by the amount of the copayment. The member must pay the provider(s) directly for the amount of services. The MCO must document the QIT in the ISP. Continuing Medicaid eligibility through the MDCP waiver is contingent upon copayment to the provider(s).

Refer to policy on QIT copayments for specific PSU staff and MCO procedures related to QIT copayments.

Non-Medicaid Individuals or Individuals Enrolled in the Children Health Insurance Program (CHIP)

Within two business days of receiving the enrollment packet or confirmed interest from the individual, PSU staff must:

  • upload enrollment packet documents into the HHS Enterprise Administrative Report and Tracking (HEART) system; and
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to the selected MCO's folder on TxMedCentral.

PSU staff must submit the following to the MEPD within two business days following the date of receipt of Form H1200:

  • Form H1200; and
  • Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken.

PSU staff must upload the enrollment documents into HEART and retain the original Form H1200 with the individual's valid signature in the HEART electronic case file.

PSU staff request financial eligibility determination for the MDCP on Form H1746-A. All available verification documents provided by the individual must be attached. PSU keeps a copy of all documents and records the date the application was faxed or mailed in the HEART electronic case file.

PSU staff must follow procedures in Section 2400, Money Follows the Person Option, regarding Medicaid eligibility for individuals transitioning from a nursing facility to the community.

Individuals Currently Enrolled in STAR Kids

An individual meets the Medicaid eligibility requirement for MDCP if the individual receives SSI or SSI-related Medicaid.

Within two business days of receiving the enrollment packet or confirmed interest from the individual, PSU staff must:

  • verify the individual receives SSI or SSI-related Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • verify the STAR Kids enrollment in TIERS;
  • upload enrollment packet documents into HEART; and
  • complete Section A of Form H3676 and upload to TxMedCentral. For Type Program (TP) 45, newborn children up to age one born to Medicaid-eligible mothers (if the individual does not have an established Social Security number), PSU will be required to indicate all zeros in Item No. 3, Social Security No., in Section A of Form H3676.

Individuals Currently Receiving Other Types of Medicaid

Within two business days of receiving the enrollment packet or confirmed interest from the individual, PSU must:

  • upload enrollment packet documents into HEART; and
  • complete Section A of Form H3676 and upload to TxMedCentral.

 

2220 Managed Care Organization Coordination

Revision 17-3; Effective September 1, 2017

 

The STAR Kids managed care organization (MCO) has 30 days to complete all assessments for individuals enrolled in the Medically Dependent Children Program (MDCP) and submit required forms to the Program Support Unit (PSU). The MCO has an additional 30 days to submit all required documentation, for a total of 60 days following the initial notice from PSU. The MCO:

  • verifies the individual meets all other eligibility criteria referenced in Section 1000, Overview and Eligibility;
  • completes Section B of Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
  • completes the STAR Kids Screening and Assessment Instrument (SK-SAI) tool, including Section R, MDCP Related Items; and
  • completes and submits Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, electronically through the Long Terms Care (LTC) Online Portal or through a 278 transaction.

The MCO must schedule and complete the SK-SAI, including the MDCP module, within 30 business days of notice from PSU staff. Once the SK-SAI and MDCP module are complete, the MCO must submit the results from the SK-SAI to the Texas Health and Human Services Commission (HHSC) Administrative Services contractor, Texas Medicaid & Healthcare Partnership (TMHP), within 72 hours of completion. For the purposes of this requirement, an SK-SAI is considered "complete" when the MCO has obtained the physician's signature using Form 2601, Physician Certification, and has retained this form in the individual's case file.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI and MDCP module. An MN determination must be authorized through HHSC or its designee.

TMHP processes SK-SAI for individuals to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility staffing intensity and is used in waiver programs to categorize needs for individuals/members and establish the service plan cost limit.

When TMHP processes an SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG. This code may also be viewed in the TMHP Long Term Care (LTC) Online Portal. An SK-SAI with incomplete information will result with a BC1 code instead of a RUG value. An SK-SAI resulting with a BC1 code does not have all of the information necessary for TMHP to accurately calculate a RUG for the individual/member. Code BC1 is not a valid RUG to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a BC1 code. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. Information about the process of transmitting and correcting an SK-SAI is available in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MDCP module of the SK-SAI establishes an annual cost limit for each individual/member receiving MDCP services, which is based on the anticipated cost if the individual/member received services in a nursing facility.

As a part of the individual service plan (ISP) planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit. If the MCO does not properly establish this plan of care and the individual’s/member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual's/member's ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member's MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member and/or the member's legally authorized representative no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.

The MDCP STAR Kids member’s ISP must include the components of a person-centered service plan described in Title 42 of the Code of Federal Regulations §441.301(c)(2).

The MCO electronically submits Form 2604 to  the LTC Online Portal or through a 278 transaction. The MCO posts Form H3676 on TxMedCentral in the MCO's STAR Kids folder. If the MCO does not submit Form 2604 electronically within 60 days after PSU staff posted Form H3676, Part A, authorizing the MCO to begin the eligibility process, PSU staff email the health plan manager assigned to the MCO.

 

2230 Program Support Unit Coordination for Individuals Enrolling in the Medically Dependent Children Program

Revision 17-3; Effective September 1, 2017

 

Within two business days of receiving the Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, the Program Support Unit (PSU) ensures the individual has:

  • medical necessity;
  • financial eligibility;
  • services under the established cost limits; and
  • an unmet need for at least one waiver service.

For individuals needing a Medicaid eligibility financial decision, PSU staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the individual meets medical necessity. This notification must be documented on Form H1746-A, MEPD Referral Cover Sheet, and sent to the MEPD specialist. The start of care (SOC) date for Medically Dependent Children Program (MDCP) services is the first day of the month following the individual meeting the following eligibility criteria:

  • Approved medical necessity;
  • Receipt of an individual service plan (ISP) within the allowable cost limit; and
  • Medicaid eligibility.

For example, the SOC date is the same as the ISP begin date, and will always be the first day of the month. PSU staff must record MDCP eligibility begin date on Form H2065-D, Notification of Managed Care Program Services, and send to the member.

Eligibility must be approved within two business days of the individual meeting all eligibility criteria and receiving Form H3676 and Form 2604 from the MCO. PSU staff  must generate Form H2065-D in the Long Term Care (LTC) Online Portal and:

  • mail the original Form H2065-D to the individual;
  • email Enrollment Resolution Services (ERS) at HPO_Star_Plus@hhsc.state.tx.us;
  • document the closure date and reason in the Community Services Interest List (CSIL) database; and
  • upload all applicable case forms to the HHS Enterprise Administrative Report and Tracking System (HEART).

The MCO must monitor the LTC Online Portal to retrieve Form H2065-D.

 

2240 Coordination for Program Denial

Revision 17-3; Effective September 1, 2017

 

If the individual fails to meet any of the eligibility criteria for the Medically Dependent Children Program (MDCP) or Medicaid is denied by the Medicaid for the Elderly and People with Disabilities (MEPD) unit for financial eligibility, the MCO must post on TxMedCentral within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and Form H2067-MC, Managed Care Programs Communication, notifying Program Support Unit (PSU) staff of the program denial. PSU staff generate Form H2065-D, Notification of Managed Care Program Services, and:

  • mail the original Form H2065-D to the individual;
  • post Form H2065-D on TxMedCentral in the managed care organization's MDCP folder, following the instructions in Appendix IX, Naming Conventions;
  • send a copy to MEPD staff, if applicable;
  • document the closure date and reason in the Community Services Interest List database; and
  • upload all applicable case forms into the HHS Enterprise Administrative Report and Tracking (HEART) system.

 

2300 Interest List Release Closures

Revision 17-3; Effective September 1, 2017

 

Program Support Unit (PSU) staff must change the status of an interest list release in the Community Services Interest List (CSIL) database.

PSU staff will record the appropriate closure code in CSIL when an individual cannot complete the application process or when the individual receives a Medically Dependent Children Program (MDCP) determination. Interest list closures are documented in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking (HEART) system.

Closing the Interest Release for an Individual Choosing Community Living Assistance and Support Services (CLASS)

When an individual is offered both MDCP and CLASS, and the individual chooses CLASS, PSU staff must notify the Program Support Interest List (PSIL) Unit to close the MDCP release effective the date PSU staff are notified of the decision to apply for CLASS. PSU staff notify the PSIL Unit by emailing MDCP_Interest_List@hhsc.state.tx.us. The email's subject line must read: “MDCP Closure.” The following elements must be included in the email:

  • Individual's name;
  • Interest List ID;
  • Program to be closed;
  • Date of closure; and
  • Closure reason.

Within two business days of receiving notification of the individual’s choice to apply for CLASS, PSU staff must mail Form 2442, Notification of Interest List Release Closure, to the CLASS individual. A copy of Form 2442 must be recorded in the individual’s electronic case file in HEART. Once Form 2442 is sent to the CLASS individual, no follow-up contacts with the individual/family are necessary.

If the CLASS application is denied, Form 2442 instructs the individual to contact the Texas Health and Human Services Commission (HHSC) if he/she wishes to apply for MDCP. When the individual contacts HHSC, he/she will be reinstated on the MDCP interest list using the procedures in Section 2310 that follows.

 

2310 Contacting Program Support Interest List Unit to Reopen an Interest List Closure

Revision 17-3; Effective September 1, 2017

 

Program Support Unit (PSU) staff must submit a request to the Program Support Interest List (PSIL) Unit to reopen an individual’s closed interest list record for the following reasons:

  • PSU staff were not able to contact the individual before the release closure date.
  • The individual received a dual offer (an offer to select one of two waiver slots), did not meet eligibility for the alternate waiver program and wishes to apply for Medically Dependent Children Program (MDCP) services.

Within three business days of receiving the request to apply for MDCP services, PSU staff must email a completed Form H2067-MC, Managed Care Programs Communication, to MDCP_Interest_List@hhsc.state.tx.us and must include the:

  • release date;
  • release closure date;
  • reason for the closure; and
    • the reason for requesting to reopen an individual's closed CSIL record; or
    • a statement indicating that the application for an alternate waiver program was denied and the individual now wishes to apply for MDCP.

The PSIL Unit will notify PSU staff of the outcome of the request. If an exception is granted, PSU staff must contact the individual to begin the application process.

 

2320 Adding a Name Back to the Interest List

Revision 17-3; Effective September 1, 2017

 

An individual's name may be added back to the Community Services Interest List (CSIL) when the name has been removed because staff are unable to locate the individual, or because of the individual's failure to respond to attempted contacts. A name is added back if the individual contacts the:

  • Program Support Interest List Unit within 90 days of the closure date and expresses continued interest (the name will be added back with the original date of request); or
  • Program Support Unit more than 90 days following the closure date and expresses continued interest (the name will be added back with the current date as the request date).

Any exceptions for adding names back to the CSIL with the original date after a 90 day period must be approved by the Texas Health and Human Services Commission Program Enrollment manager.

 

2321 Earliest Date for Adding an Individual Back to the Interest List After Denial

Revision 17-1; Effective June 1, 2017

 

The earliest date an individual may be added back to the Community Services Interest List (CSIL), for the same program the individual is denied, is the date the individual is determined to be ineligible for the program.

Examples:

  • The individual is released from the Medically Dependent Children Program (MDCP) interest list on Aug. 2. The individual is denied eligibility for MDCP on Aug. 28, and a notification is sent to the individual of ineligibility. The first date the denied individual can be added back to the MDCP interest list is Aug. 28. The earliest date an individual may be added back to the CSIL for the same program the individual is terminated is the first date the individual is no longer eligible for the program terminated.
  • An individual's MDCP services are terminated July 31st due to denial of medical necessity. The first date the individual can be added back to the MDCP interest list is Aug. 1.

 

2400 Money Follows the Person

Revision 17-1; Effective June 1, 2017

 

 

2410 Traditional Money Follows the Person

Revision 17-3; Effective September 1, 2017

 

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aging and have disabilities live in the most integrated setting possible. PI is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide Community-based Services for persons with disabilities who would otherwise be entitled to institutional services, when the:

  • state's treatment professionals determine that the placement is appropriate; and
  • affected persons do not oppose the treatment and placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Texas Government Code §531.151, as amended by SB 368, 77th Legislature, Regular Session, 2001).

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with HHSC. For NFs, permanency planners are contracted with EveryChild, Inc. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, in accordance with legislative direction, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another 1915(c) Home and Community Based Services Waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other 1915(c) waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care, as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. See the STAR Kids Contract, Section 8.1.15, for further information.

The MCO must have a protocol for quickly assessing the needs of members who have or will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary Personal Care Services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

  • determine the member’s assigned permanency planner;
  • contact the member’s assigned permanency planner within seven days of the member’s facility admission;
  • collaborate with the member, the member’s legally authorized representative (LAR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
  • contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC's contracted permanency planner to work with the member and the member's LAR to review community based options; and
  • work with the member, the member’s LAR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

Individuals without Medicaid, and not enrolled in STAR Kids, requesting MDCP services through the MFP option must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. Individuals cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. The Program Support Unit (PSU) staff and MCO must follow time frames for processing an application for MDCP. PSU staff will authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For individuals who cannot reside in an NF for 30 days because they meet the medically fragile criteria, Medicaid for the Elderly and People with Disabilities (MEPD) can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP waiver to meet the 30-day requirement. See Section 2420, Money Follows the Person Limited Nursing Facility Stay for Medically Fragile Individuals.

STAR Kids

When a STAR Kids member is admitted to a facility, the MCO service coordinator must do the following:

  • contact the designated permanency planner within seven days of the member's admission;
  • coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process if needed, including sharing the most recent screening and assessment instrument (SAI) and individual service plan (ISP);
  • perform a new SAI for a significant change in status upon discharge, unless one is required sooner for MDCP; and
  • update the individual's ISP to reflect changes in the SAI, if applicable.

For requests to transition to the community under MFP for a STAR Kids member, the individual's permanency planner is the designated party responsible for part of the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the member and the member's family/LAR as part of the permanency planning process;
  • lead the development of the member's permanency plan;
  • coordinate with the MCO service coordinator in updating the member's ISP, if applicable;
  • educate the member and LAR on 1915(c) waiver options, including MDCP; and
  • document the member's choice of the waiver program;

Once the individual selects a waiver program, the permanency planner will contact the HHSC Community Services Interest List (CSIL) Unit within two business days to notify the state of the individual's waiver selection under MFP, and update the address on file to that of the individual's LAR, if needed.

If the member/LAR chooses a 1915(c) waiver program other than MDCP, CSIL will forward the request to the selected waiver program. The permanency planner will also work with the individual, individual's LAR, MCO service coordinator, and selected waiver program to ensure program eligibility and transition to services in the community. Prior to member discharge, the MCO service coordinator must perform a new SAI for significant change in status and update the ISP to reflect the individual's addition of waiver services and any other identified supports, such as nursing or personal care services.

If the member chooses MDCP, CSIL will create a case in the HHS Enterprise Administrative Report and Tracking (HEART) system within one business day of the request and assign to the appropriate PSU staff to proceed with necessary case actions.

Within two business days of the referral from CSIL, PSU staff must:

  • check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program;
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the individual has a current medical necessity by entering the Resource Utilization Group (RUG) and expiration date in Item 6;
  • post Form H3676 to the MCO's STAR Kids folder on TxMedCentral using the appropriate naming convention; and
  • check the CSIL to see if the individual is already on the MDCP CSIL. If not, PSU staff add and immediately release the individual from the MDCP interest list.

If the individual or the individual's LAR chooses MDCP, the MCO initiates contact with the individual or individual's LAR to begin the assessment process within five business days of receipt of Form H3676.

Within seven business days from contact with the individual, the MCO service coordinator performs the SAI, including the MDCP module (SAI Section R). The MCO service coordinator must submit the SAI to HHSC's administrative services contractor, Texas Medicaid & Healthcare Partnership (TMHP), within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the individual meets medical necessity, the service coordinator, in conjunction with the permanency planner and the individual and individual's LAR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determines a discharge date for the individual and notifies PSU staff by using Form H2067-MC, Managed Care Programs Communication. The MCO service coordinator must submit Form 2604 electronically to the LTC Online Portal or use the 278 transaction within one business day of completion of Form 2604.

As needed, PSU staff collaborate with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays. PSU staff tracks all actions and communications in HEART until all MDCP enrollment activities are complete.

If within 30 days after the individual's/LAR's request to return to the community the MCO does not complete the process and post the above information, PSU staff send an email to the appropriate HHSC health plan manager. PSU staff continue to monitor for receipt of the above-referenced forms.

Within one business day following receipt of the Form H2067-MC from the MCO, PSU staff:

  • confirm MDCP eligibility based upon:
    • Medicaid eligibility for MDCP;
    • an approved medical necessity;
    • an ISP with at least one MDCP service and cost within the individual’s cost limit;
  • generate the initial Form H2065-D, Notification of Managed Care Program Services, in the LTC Online Portal, to the member and inform the MCO PSU staff have notified the individual of this determination; and
  • mail the initial form to the individual; and
  • upload Form H2065-D, Form H2604 and Form H2067-MC to HEART.

The MCO must monitor the LTC Online Portal to retrieve the initial Form H2065-D.

Within one business day prior to the individual's discharge, PSU staff generate the final Form H2065-D in the LTC Online Portal containing the service effective date and:

  • mail the final Form H2065-D to the individual;
  • update the CSIL, in accordance with Section 2300, Interest List Release Closures, ensuring accurate selection of the CSIL closure code(s); and
  • upload Form H2065-D to HEART.

If the individual fails to meet any of the eligibility criteria for the MDCP or Medicaid is denied by the Medicaid for the Elderly and People with Disabilities (MEPD) unit for financial eligibility, the MCO must post on TxMedCentral within two business days of receiving Form H3676 and Form 2067-MC notifying PSU staff of the program denial. PSU staff will generate Form H2065-D and:

  • mail the final Form H2065-D to the individual;
  • send a copy to MEPD staff, if applicable;
  • document the closure date and reason in the CSIL database; and
  • upload all applicable case forms into HEART.

Non-STAR Kids Individuals Residing in an NF

For requests to transition to the community under MFP for a non-STAR Kids member, the individual's permanency planner is the designated party responsible for the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the individual and the individual's family/LAR as part of the permanency planning process;
  • lead the development of the individual's permanency plan;
  • educate the individual and LAR on 1915(c) waiver options, including MDCP;
  • document the individual's choice of the waiver program; and
  • educate the individual about STAR Kids, including providing information about managed care and the importance of choosing an MCO.

Once the individual selects a waiver program, the permanency planner will contact the HHSC CSIL to notify the state of the individual's waiver selection under MFP, and update the address on file to that of the individual's LAR, if needed.

If the individual/LAR chooses a 1915(c) waiver program other than MDCP, CSIL will forward the request to the selected waiver program. The permanency planner will also work with the individual, individual's LAR, and selected waiver program to ensure program eligibility, STAR Kids MCO selection, and transition to services in the community.  Prior to the individual's discharge, the individual's selected MCO service coordinator must perform the initial SAI and establish the initial ISP to reflect both waiver services and any other identified supports, such as nursing or personal care services.

If the individual or individual's LAR chooses MDCP, CSIL will create a case in HEART within one business day of the request and assign to the appropriate PSU staff to proceed with necessary case actions.

Within two business days of the referral from CSIL, PSU staff must:

  • check TIERS to verify if Form H1200 has already been submitted for the NF stay, or the individual already has full Medicaid eligibility for a type program applicable to MDCP;
  • contact or attempt to contact the individual/LAR by phone to explain the Medicaid application process, when applicable, the selection of an MCO and the importance of promptly returning the forms that PSU staff mails to the individual/LAR;
  • inform the individual/LAR during the phone 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 MDCP service provision;
  • send Form H1200, when applicable, and the appropriate STAR Kids MCO enrollment packet to the individual and individual's LAR;
  • send Form 2602, Managed Care Organization Selection Acknowledgement, to confirm interest in applying for MDCP services;
  • send Form H2053-B, Health Plan Selection, and Form H2053-BS (Spanish); and
  • check the CSIL to see if the individual is already on the MDCP CSIL. If not, PSU adds and immediately releases the individual from the MDCP interest list.

PSU staff are responsible for completing the following activities 14 business days following the initial contact with the individual. PSU staff must document in HEART all attempted contacts with the NF resident and any encountered delays. PSU staff:

  • contact the individual if PSU staff have not received Form H1200, when applicable; and
  • discuss with the individual the importance of choosing an MCO if the individual did not select one during the initial contact, explaining the MCO conducts the assessment and service planning to facilitate an eligibility determination for MDCP services.

If Form H1200 is applicable, and during the 14-day follow-up contact the individual/LAR or the NF has already submitted a completed Form H1200, PSU staff must check TIERS to verify Form H1200 has been submitted. If the individual/LAR communicates Form H1200 has not been submitted, or if TIERS does not have a record Form H1200 has been submitted, PSU staff notify the individual/LAR to immediately return Form H1200 to PSU staff because the application for MDCP services will be denied for failure to return Form H1200 within 45 days from the date PSU staff sent the form to the individual/LAR. PSU staff must document in HEART all attempted contacts with the individual/LAR and any encountered delays. Upon receipt of the completed Form H1200, PSU makes a referral to MEPD within two business days by completing 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 the PSU sent it to the individual, PSU staff deny the application for MDCP by:

  • documenting in HEART Form H1200 was not received within 45 days;
  • sending the individual Form H2065-D; and
  • posting Form H2065-D to TxMedCentral using the appropriate naming convention.

Within two business days from when the individual, individual's LAR, or the permanency planner notifies PSU staff of the MCO selection verbally or in writing, or from when the individual is defaulted to an MCO, PSU staff must:

  • check the TMHP Long Term Care Online Portal to determine if the individual has a current medical necessity;
  • complete Section A of Form H3636, indicating whether the individual has a current medical necessity by entering the RUG and expiration date in Item 6; and
  • post Form H3676 to the MCO's STAR Kids folder on TxMedCentral using the appropriate naming convention.

The MCO initiates contact with the individual or individual's LAR to begin the assessment process within five business days of receipt of Form H3676. Within seven business days from contact with the individual or individual's LAR, the MCO service coordinator performs the SAI, including the MDCP module (SAI Section R). The MCO service coordinator must submit the SAI to HHSC's administrative services contractor (TMHP) within 72 hours of completion of the assessment. Within five business days of the MCO service coordinator receiving confirmation that the individual meets medical necessity, the service coordinator, in conjunction with the permanency planner and the individual and individual's LAR, must develop the ISP using Form 2604, and determine a discharge date for the individual and notify PSU by using Form H2067-MC. Within one business day of completing Form 2604, the MCO service coordinator must:

  • submit Form 2604 electronically through the LTC Online Portal or through a 278 transaction;
  • complete Section B of Form H3676; and
  • upload Form H3676 and Form H2067-MC to TxMedCentral.

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

If within 30 days after the individual's/LAR's request to return the community the MCO does not complete the process and post the above information, PSU staff send an email to the appropriate HHSC health plan manager. PSU staff continue to monitor for receipt of the above-referenced forms.

Within two business days following receipt of all MCO documentation required for MDCP eligibility, PSU staff complete and send Form H1746-A to notify MEPD staff of the approved ISP and SAI so MEPD staff can complete the Medicaid eligibility determination.

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

Within one business day following communication from MEPD of the individual's Medicaid eligibility, PSU staff:

  • confirm MDCP eligibility based upon:
    • Medicaid eligibility for MDCP;
    • an approved medical necessity;
    • an ISP with a least one MDCP service and a cost within the individual’s cost limit;
  • generate the initial Form H2065-D in the LTC Online Portal and inform the MCO PSU staff have notified the individual of this determination;
  • mail the initial form H2065-D to the individual; and
  • upload Form H2065-D, Form H2604 and Form H2067-MC to HEART.

The MCO must monitor the LTC Online Portal to retrieve the initial Form H2065-D.

Within one business day prior to the individual's discharge, PSU staff generate the final Form H2065-D in the LTC Online Portal containing the service effective date and:

  • mail the final Form H2065-D to the individual;
  • fax or email a copy, as well as Form H1746-A, to the assigned MEPD staff for generation of a pending task in TIERS;
  • update the CSIL, in accordance with Section 2300, ensuring accurate selection of the CSIL closure code(s);
  • email Enrollment Resolution Services (ERS) at HPO_STAR_PLUS@hhsc.state.tx.us, requesting enrollment effective the first of the month in which the individual is discharged, as required; and
  • upload Form H2065-D and Form H1746-A to HEART.

The MCO must monitor the LTC Online Portal to retrieve the final Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD unit for financial eligibility, the MCO must post on TxMedCentral within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will generate Form H2065-D and:

  • mail the final Form H2065-D to the individual;
  • post Form H2065-D on TxMedCentral in the MCO's MDCP folder following the instructions in Appendix IX, Naming Conventions;
  • notify MEPD of denial via Form H1746-A; and
  • upload Form H2065-D, Form 2604, Form H1746-A and Form H2067-MC to HEART;
  • update the CSIL, in accordance with Section 2300, ensuring accurate selection of the CSIL closure code(s); and
  • close the case in HEART.

If the individual chooses to leave the NF before being determined eligible for MDCP, PSU staff fax or email a copy of Form H2065-D to MEPD staff. Upon completion of all MDCP actions, PSU staff close the case in HEART.

Denial/Termination of MDCP Due to Residence in an NF

For members enrolled in STAR Kids, the enrollment remains open while a member resides in an NF.

For members enrolled in MDCP, the MCO notifies PSU staff within 14 business days following the 90th day that the member is not returning to the community when a member resides in an NF for 90 days or more. The MCO sends this notice to the PSU by posting Form H2067-MC in TxMedCentral.

PSU staff deny MDCP services by the end of the month in which the 90th day occurred by:

  • sending the member Form H2065-D;
  • posting the form on TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • sending to MEPD Form H1746-A and a copy of Form 2065-D, for Medical Assistance Only MDCP members; and
  • uploading Form H2065-D and Form H1746-A to HEART.

Once a denial is complete, if a member decides to discharge from the NF, the member would be directed to pursue MFP, if eligible.

See Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program.

MDCP MFP Applications Pending Due to Delay in NF Discharge

This situation is unlikely to occur as the permanency planner will be assisting the family with relocation. However, if this situation does occur, the following steps will take place. When specific eligibility criteria for either the MDCP waiver or Medicaid in general will not be met within four calendar months, PSU staff have the option to deny the request for services. This time frame serves as a guideline for denying requests, pending service arrangements.

The assessment process does not stop during this period; however, eligibility cannot be established until the individual is ready to discharge from the NF.

If the individual 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. See the two paragraphs below for information about applications pending more than four calendar months.

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

PSU staff and MCO staff must use their judgment and work with individuals who have community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge that goes beyond the four calendar month period, PSU staff should keep the request for services open.

Individuals who have not made any 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 MDCP. PSU staff deny the request for services by:

  • sending Form H2065-D to the individual within two business days after the end of the four calendar month pending period;
  • posting the form on TxMedCentral in the MCO's STAR Kids folder using the appropriate naming convention; and
  • uploading it to HEART.

MFP Demonstration (MFPD) References in STAR Kids

MFPD not apply to individuals enrolled in MDCP STAR Kids. Children will transition to the least restrictive setting under MFP. Therefore, MCO service coordinators will not be required to track the enrollment period or seek informed consent from the member or the member's LAR. The "MFPD" check box should be disregarded on Form 2604 and the electronic 278 transaction.

 

2420 Money Follows the Person Limited Nursing Facility Stay for Medically Fragile Individuals

Revision 17-1; Effective June 1, 2017

 

The limited nursing facility (NF) stay process applies to individuals who request Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but are too medically fragile to reside in an NF for an extended period of time and request to complete a limited NF stay. Individuals are either already enrolled in STAR Kids or new to the program. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care.

The Texas Health and Human Services Commission (HHSC) nurse will review the medical fragility criteria and physician's attestation documented on Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, for an individual requesting a limited NF stay. Medical judgment of the HHSC physician will be applied when the individual's physician does not check two or more of the below criteria and the individual's physician's attestation is "too medically fragile and cannot reside in an NF setting for an extended period of time without impact to his/her health and safety" on Form 2406. Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • Ventilator dependent (not Bi-level Positive Airway Pressure (BiPap));
  • Renal dialysis;
  • 24 hour/day oxygen dependence;
  • Total nutrition via enteral tube feeding;
  • Total parenteral nutrition (TPN);
  • Tracheostomy;
  • Seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • Documented immune deficiency confirmed by lab findings (i.e., IgA or IgG deficiency) or on immunosuppressive drug therapy;
  • Congestive heart failure requiring hospitalization within the past six months; or
  • Hospice.

Individuals determined medically fragile by the HHSC nurse or physician and approved for a limited NF stay must stay at least part of two days in the NF. Admission and discharge from the facility must be on different days. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services (and establish Medicaid in an NF).

 

2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 17-3; Effective September 1, 2017

 

Individuals requesting Medically Dependent Children Program (MDCP) services through the limited nursing facility stay Money Follows the Person (MFP) option may contact the Community Services Interest List (CSIL) Unit at 877-438-5658, a Texas Health and Human Services Commission (HHSC) regional office, or his or her managed care organization (MCO) service coordinator. If an individual contacts an HHSC regional office, or his or her MCO service coordinator, the HHSC regional office or MCO service coordinator will refer the individual to the CSIL Unit to add the individual's name to the interest list. This request will not be considered a release from the interest list, but a referral of an individual interested in by-passing the interest list through the MFP option.

The CSIL Unit must explain the following to the individual requesting to by-pass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • An overview of MDCP services;
  • The limited stay enrollment process, including an explanation to the individual on completing a limited nursing facility stay if the individual is determined to be too medically fragile to complete an extended nursing facility stay which must first be approved;
  • The facility may charge individuals a fee for the stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, regarding the physician's recommendation for the length of stay the individual can safely complete in a nursing facility;
  • Required medical documentation within 12 months of the date the documentation is being submitted; and
  • Admission and discharge documentation from the nursing facility.

The CSIL Unit informs the individual, or the individual's parent or guardian, that the individual's physician must complete Form 2406 with supporting documentation, and return the form to the CSIL Unit within 30 days of the initial contact with the individual, or the individual's parent or guardian. The CSIL Unit will send Form 2406 to the individual, or individual's parent or guardian, within one day of the contact, along with a self-addressed stamped envelope to the individual to return back to the CSIL Unit.

If the individual, or individual's parent or guardian, is reapplying after being denied the limited stay in the past, the CSIL Unit must inform the individual, parent or guardian a new Form 2406 must be completed and a new copy of medical records obtained. Previous medical documentation will not be considered.

 

2422 Community Services Interest List Unit Receipt of Form 2406

Revision 17-3; Effective September 1, 2017

 

Attachments to Form 2406

Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed by an individual's physician to be considered for a limited nursing facility (NF) stay. The physician must attach documentation (such as a visit note or hospital discharge summary) of chronic conditions to Form 2406. The medical documentation provided must:

  • document the individual's chronic conditions, the current health status of the individual and substantiate the boxes checked on the form; and
  • be within 12 months of the date the documentation is submitted

Note: Medical documentation over 12 months old will not be considered in the limited stay determination. If all the medical documentation submitted is over 12 months old, the request is incomplete. The Community Services Interest List (CSIL) Unit must contact the individual, parent or guardian within three days of receipt, to inform them of the requirement that medical documentation must be within 12 months of the date being submitted. The CSIL Unit documents delays in obtaining medical documentation, and conversations with the individual regarding the Money Follows the Person (MFP) Limited Stay option.

Upon receipt of Form 2406 and the medical documentation, the CSIL Unit identifies the physician's recommendation. If the physician attests that the patient does not meet the medically fragile criteria for a limited NF stay, within two days of receipt of Form 2406, the CSIL Unit must contact the individual by phone to inform him of the physician's recommendation, and of the option to transition from an NF as described in Section 2410, Traditional Money Follows the Person, to access the Medically Dependent Children Program (MDCP) through the MFP option. If the individual does not choose to transition from an NF, his name will remain on the interest list.

If the individual, or the individual's parent or guardian, decides not to pursue services through the MFP Limited Stay option and requests to access services through the traditional MFP option, refer to procedures outlined in Section 2410.

If the individual's physician attests that the individual does meet the medically fragile criteria or is too medically fragile and cannot reside in an NF setting for an extended period of time without impact to his/her health and safety on Form 2406, within two days the CSIL Unit will verify the:

  • form is completed in its entirety; and
  • individual's name printed on the form is legible and the physician's name, address, license number, signature and date are on the form.

If Form 2406 does not contain the required information, the CSIL Unit contacts the individual, or the individual's parent or guardian, within two days of receipt of the notice to discuss the elements of the form that are incomplete. The CSIL Unit informs the individual, or the individual's parent or guardian, that the form is being returned for completion by the individual's physician and must be returned to the CSIL Unit within 30 days of contact. The CSIL Unit returns Form 2406 to the individual, or the individual's parent or guardian, within two days of contact with the individual, or the individual's parent or guardian. If Form 2406 has not been returned by the 30th day, the CSIL Unit calls the individual to notify him that his request to access MDCP services through the MFP option is closed.

If Form 2406 does contain all required information, the CSIL Unit will forward Form 2406, along with the completed legible medical records required for the limited stay packet, to the Program Support Interest List (PSIL) Unit.

PSIL Receipt of Limited Stay Referral and Processing

Upon receipt of the limited stay referral, the PSIL Unit will:

  • create a case in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking (HEART) system documenting the date of the individual's MFP limited stay request;
  • inform the Texas Health and Human Services Commission (HHSC) nurse via HEART assignment of the need to access Form 2406 and medical documentation for review.
  • check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program and managed care organization (MCO) enrollment;
  • if the individual is enrolled in STAR Kids, notify the member's MCO the member is requesting to access MDCP through the limited stay process by posting Form H2067-MC, Managed Care Programs Communication, to the member's STAR Kids folder in TxMedCentral; and
  • upload a copy of Form H2067-MC in HEART.

The PSIL must submit Form 2406 to the HHSC nurse within three days of receipt to determine if the individual meets the medically fragile criteria.

 

2423 Texas HHSC Nurse Determination

Revision 17-3; Effective September 1, 2017

 

A Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and medical documentation within two days to determine if an individual meets the limited stay criteria.

If the individual's physician attests the individual meets the medically fragile criteria, the HHSC nurse may approve the limited stay request if the physician's documentation clearly substantiates the individual meets two or more criteria on Form 2406. Within two days of the decision, the HHSC nurse will document the determination status in the HHS Enterprise Administrative Report and Tracking (HEART) system and notify the Program Support Interest List (PSIL) Unit via an appointment notice of the need to check HEART for further action.

If the documentation does not substantiate the individual meets two or more criteria on Form 2406, the HHSC nurse will document the decision to "submit to the HHSC physician" in the HEART case and follow procedures in Section 2424 below.

 

2424 Submission of Form 2406 to the Physician

Revision 17-3; Effective September 1, 2017

 

The Texas Health and Human Services Commission (HHSC) nurse emails Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and all medical documents dated within the past 12 months to the HHSC physician for review within two days of the decision. The Program Support Interest List (PSIL) Unit that received Form 2406 must be included in the email.

When submitting Form 2406 to the HHSC physician, the HHSC nurse must submit each request in a separate email. The email's subject line must read: Medically Dependent Children Program Form 2406 for XX. The "XX" in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "Medically Dependent Children Program Form 2406 for AS."

 

2425 Physician Determination of Medical Fragility

Revision 17-3; Effective September 1, 2017

 

The Texas Health and Human Services Commission (HHSC) physician will determine if the individual meets the medically fragile criteria. The HHSC physician will respond via email to the HHSC nurse and the Program Support Interest List (PSIL) Unit. The response will be either “meets criteria” or “does not meet criteria.” The PSIL Unit contacts the individual, or the individual's parent or guardian, by phone within two days of receipt of the HHSC physician email to advise the individual of the outcome of the limited stay request. If the physician has a comment regarding the information submitted, this will be noted in the physician response to the PSIL Unit. The PSIL Unit must include this comment when advising the individual of the outcome of the limited stay request.

If the limited nursing facility (NF) stay is approved, or the individual chooses to transition from the NF as described in Section 2410, Traditional Money Follows the Person, within two days of being notified of the individual's choice, the PSIL Unit will place the individual in a Medically Dependent Children Program (MDCP) assigned status by using the bypass code "Residing in a Nursing Facility" in the Community Services Interest List (CSIL) database.

If the HHSC physician determines the individual does not meet the medically fragile criteria, the PSIL Unit contacts the individual, or the individual's parent or guardian, by phone within two days of receipt of the physician's email. The PSIL Unit will inform the individual that a limited NF stay is not approved, and the individual has the option to transition from an NF stay, as described in Section 2410, to access MDCP through the Money Follows the Person (MFP) option. If the individual does not choose to complete an NF stay as described in that section, his or her name will remain on the interest list. The PSIL should explain the individual may re-apply in the future by contacting the CSIL Unit as described in Section 2420, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay for Medically Fragile Individuals, to begin the process again. Once a determination has been rendered by the HHSC physician, additional information regarding an individual's condition will not be considered as part of the original request.

The PSIL Unit will:

  • if the individual is a member of STAR Kids, inform the member's managed care organization (MCO) that he or she has not been approved for a limited stay by posting Form 2067-MC, Managed Care Programs Communication, in the MCO's STAR Kids folder in TxMedCentral;
  • upload a copy of Form H2067-MCand immediately close the HHS Enterprise Administrative Report and Tracking (HEART) system; and
  • remove the "Residing in a Nursing Facility" bypass code and place the individual's name in open status.

 

2425.1 Program Support Interest List Procedures for Assigning Individuals Approved for a Limited Nursing Facility Stay to Program Support Unit Regional Staff

Revision 17-3; Effective September 1, 2017

 

Within two days of an individual approved for a limited nursing facility stay, as outlined in the sections above, the Program Support Interest List Unit must assign the HHS Enterprise Administrative Report and Tracking (HEART) system case to the appropriate Program Support Unit staff to take all necessary case actions.

 

2426 Program Support Unit Procedures for Individuals Who Are Approved for a Limited Nursing Facility Stay and Currently Enrolled in STAR Kids

Revision 17-3; Effective September 1, 2017

 

When an individual enrolled in STAR Kids is approved for a limited nursing facility stay, as outlined in the sections above, within five days of case assignment, Program Support Unit staff must:

  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post it on TxMedCentral in the managed care organization's (MCO’s) STAR Kids folder; and
  • ensure the individual understands the limited stay must be coordinated with his or her MCO service coordinator and cannot be completed until notified by his or her service coordinator.

 

2426.1 Program Support Unit Procedures for Individuals Who Are Approved for a Limited Nursing Facility Stay and Not Enrolled in Medicaid (including Individuals Enrolled in Children's Health Insurance Program)

Revision 17-3; Effective September 1, 2017

 

When an individual who is not enrolled in STAR Kids is approved for a limited nursing facility stay as outlined in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of case assignment, Program Support Unit (PSU) staff take the following steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

PSU staff contact the applicant, or the applicant's parent or guardian, to:

  • explain the Medicaid application process;
  • discuss a list of managed care organizations (MCOs) and encourage the applicant to contact one for service information;
  • discuss the importance of choosing an MCO so assessments and initial individual service plans (ISPs) can be completed timely in order to avoid a delay in eligibility determination for MDCP services;
  • inform the applicant the MCO in which he or she enrolls can be changed at any time after the first month of service; and
  • ensure the applicant understands the limited stay must be coordinated with his or her MCO service coordinator and cannot be completed until notified by his or her service coordinator.

PSU staff send the following forms to the applicant for completion:

  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Form H3034, Disability Determination Socio-Economic Report; and
  • Form H3035, Medical Information Release/Disability Determination;
  • Form H2053-B, Health Plan Selection, and Form H2053-BS (Spanish);
  • Form 0003, Authorization to Furnish Information; and
  • a postage-paid envelope.

Once the forms are returned to PSU staff, PSU staff upload the forms to the HHS Enterprise Administrative Report and Tracking (HEART) system. PSU staff send the signed and completed application forms, including all medical documentation previously submitted with Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, within two days of receipt to Medicaid for the Elderly and People with Disabilities (MEPD) staff, along with Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken. PSU staff must also notify MEPD by sending an email to OESMEPDIC@hhsc.state.tx.us, when sending Form H1200 to ensure the application is assigned immediately. The email's subject line must read: MDCP Request for Expedited Processing for XX. The "XX" in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for AS." These assignments will be special assigned by an MEPD complaint resolution staff, to the region in which the individual resides in, requesting the processing be expedited. MEPD will notify PSU staff using the MEPD to PSU Communication when the Medicaid application has been approved pending the limited stay and 30 days of MDCP service via Form H1746-A.

The individual chooses an MCO and notifies PSU staff verbally or in writing using Form H2053-B.

Within two days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post it on TxMedCentral in the MCO's STAR Kids folder.

 

2426.2 Program Support Unit Procedures for Individuals Who Are Approved for a Limited Nursing Facility Stay with Medicaid and Not Enrolled in STAR Kids

Revision 17-3; Effective September 1, 2017

 

When an individual with Medicaid eligibility, but who is not enrolled in STAR Kids, is approved for a limited nursing facility stay as outlined in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of case assignment, Program Support Unit (PSU) staff take the following steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

PSU staff contact the applicant, or the applicant's parent or guardian, to:

  • explain the application process;
  • discuss a list of managed care organizations (MCOs) and encourage the individual to contact one for service information;
  • discuss the importance of choosing an MCO so assessments and initial individual service plans (ISPs) can be completed timely in order to avoid a delay in eligibility determination for MDCP services;
  • inform the applicant the MCO in which he or she enrolls can be changed at any time after the first month of service; and
  • ensure the applicant understands the limited stay must be coordinated with his or her MCO service coordinator and cannot be completed until notified by his or her service coordinator.

PSU staff send the following to the applicant for completion:

  • Form H2053-B, Health Plan Selection, and Form H2053-BS (Spanish); and
  • a postage-paid envelope.

The individual chooses an MCO and notifies PSU staff verbally or in writing using Form H2053-B.

Within two days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and posts it on TxMedCentral in the MCO's STAR Kids folder.

 

2426.3 Program Support Unit and Managed Care Organization Coordination Procedures for Medically Dependent Children Program Applicants Approved for a Limited Nursing Facility Stay

Revision 17-3; Effective September 1, 2017

 

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, or the individual's parent or guardian, within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, informing the individual of the decision to complete a limited NF stay. The STAR Kids Managed Care Contract requires the MCO to initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, or the individual's parent or guardian, of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the overnight limited stay, and that the individual must present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the limited stay admission and discharge before MDCP services can be authorized. The MCO must explain the individual must not proceed with the limited stay until he is authorized to do so. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) funding requirements.

The MCO has 60 days to complete all assessments and submit required forms to the Program Support Unit (PSU). The MCO completes:

  • Section B of Form H3676, noting "MFP Limited Stay" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI) tool, including Section R, MDCP Related Items; and
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool.

The MCO posts Form H3676 on TxMedCentral in the MCO's ISP folder and submits the electronic Form 2604 in the Long Term Care (LTC) Online Portal or through a 278 transaction to the LTC Online Portal. The MCO maintains a copy of Form 2603 STAR Kids Individual Service Plan Narrative, in the member’s or applicant's case file.

If the MCO does not submit an electronic Form 2604 within 60 days after PSU staff posted Form H3676, Part A, PSU staff notify  the health plan manager assigned to the MCO by email.

Within two days of receiving Form H3676 and electronic Form 2604, PSU staff ensure the member has:

  • medical necessity (MN);
  • ongoing financial eligibility or Form H1746-A, MEPD Referral Cover Sheet, from Medicaid for the Elderly and People with Disabilities (MEPD) stating Medicaid is approved pending the limited stay and 30 days of MDCP services;
  • services under the established cost limits; and
  • an unmet need for at least one waiver service.

For STAR Kids members accessing MDCP through the limited stay process, if the above criteria are met except for the limited stay, PSU staff post Form H2067-MC, Managed Care Programs Communication, to the MCO's ISP folder, notifying them of the approval pending completion of the limited stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited stay, PSU staff can approve the individual to move forward to complete the limited stay as long as all other eligibility criteria are met. PSU staff post Form H2067-MC in the MCO's ISP folder, notifying the MCO to proceed with the limited stay.

The MCO service coordinator must coordinate the limited stay in the NF with the MDCP applicant, or his or her parent or guardian, and PSU staff to ensure PSU staff are available to determine eligibility and for the MCO service coordinator to authorize MDCP services within 24 hours after discharge. Form 3618 must be completed by the NF and submitted to the MCO service coordinator within 24 hours of the time of discharge. Service coordinators must stress that in order to ensure compliance with MFP policy for continuity of services, an applicant may not discharge, under the limited stay process, from an NF on a Friday, Saturday, Sunday, or any day preceding or the day of a state holiday, and that services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP policy.

Once the date of the limited stay is known, but prior to it occurring, the MCO service coordinator informs the assigned PSU staff of the limited stay date by posting Form H2067-MC to TxMedCentral in the MCOs STAR Kids folder.

Within 24 hours of the limited stay, the following activities occur:

  • The MCO must notify PSU staff that the limited stay occurred on Form H2067-MC requesting PSU staff approve MDCP services and post the form on TxMedCentral in the MCO's ISP folder.
  • The MCO must post Form 3618 on TxMedCentral in the MCOs STAR Kids folder.
  • PSU staff must respond to the MCO on Form H2067-MC by posting to TxMedCentral in the MCOs STAR Kids folder that the applicant or member is pending approval of Medicaid eligibility; however, the member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services.

Once the individual is receiving MDCP services, the service coordinator notifies PSU staff by posting Form H2067-MC to TxMedCentral in the MCO's ISP folder.

Once the MCO notifies PSU staff the member is authorized to receive MDCP services, within two days, PSU staff:

  • Notify the Program Support Interest List (PSIL) Unit by emailing the MDCP_Interest_List@hhsc.state.tx.us requesting MDCP interest list closure and documenting the reason.
  • Notify MEPD, via Form H1746-A, that the member has transferred from an NF to the MDCP waiver, if applicable.
  • Determine the MDCP effective date and complete Form H2065-D, Notification of Managed Care Program Services. The effective date will be the first of the month in which the MFP individual was discharged from the NF.

Example: An individual who is not enrolled in STAR Kids leaves the NF and begins MDCP services Dec. 25, 2016. The eligibility date of Form H2065-D will be Dec. 25, 2016, through Dec. 25, 2017. The enrollment date with the MCO will be Dec. 1, 2016.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD unit for financial eligibility, the MCO must post within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will generate Form H2065-D and:

  • mail the final Form H2065-D to the individual;
  • send a copy to MEPD staff, if applicable;
  • notify Enrollment Resolution Services (ERS) by emailing HPO_Star_Plus@hhsc.state.tx.us, if applicable;
  • document the closure date and reason in the Community Services Interest List (CSIL) database; and
  • upload all applicable case forms into HHS Enterprise Administrative Report and Tracking System (HEART).

The MCO must monitor the LTC Online Portal to retrieve the final Form H2065-D.

After the individual has been determined eligible for MDCP, Enrollment Resolution Services updates the member's Texas Integrated Eligibility and Redesign System (TIERS) record to indicate managed care enrollment, if applicable.

 

2427 Delays in Limited Nursing Facility Stay for Applicants Not Enrolled in STAR Kids

Revision 17-3; Effective September 1, 2017

 

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify the Program Support Unit (PSU) by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s STAR Kids folder.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD), PSU staff must request that MEPD delay certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, submit the form to MEPD, and upload the form to the HHS Enterprise Administrative Report and Tracking (HEART) system. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of waiver services is pending.” The delay request, if approved, will extend the MEPD time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for applicants requiring a disability determination, MEPD will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny Medically Dependent Children Program (MDCP) eligibility by completing Form H2065-D, Notification of Managed Care Program Services, and:

  • notify the Program Support Interest List (PSIL) Unit by email, stating that the applicant or member was denied and the reason for the denial;
  • mail the original Form H2065-D to the applicant or member;
  • post the form on TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions;
  • email a copy to MEPD staff; and
  • upload Form 2065-D to HEART.

If the individual, parent or guardian chooses to continue to pursue the Money Follows the Person (MFP) limited stay option after program eligibility has been denied, the MFP limited stay application process must start over. To begin the process again, the individual may re-apply by contacting the Community Services Interest List (CSIL) Unit, as described in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity has expired due to the delay in the NF stay, the MCO must complete a new screening and assessment instrument (SAI). If the SAI is completed within 90 days of the MEPD denial, PSU staff may request that the MCO obtain a letter signed by the individual, parent or guardian requesting to reopen the Medicaid application. The MCO must post the letter on TxMedCentral in the MCO’s STAR Kids folder. PSU staff must send the letter with Form H1746-A marked “Application.” The MEPD time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to MEPD, PSU staff must request that MEPD delay certification. However, MEPD may not approve the additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If MEPD denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent or guardian they must complete a new Form H1200. If MEPD approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by posting Form H2067-MC in TxMedCentral.