Revision 17-3; Effective September 1, 2017

 

 

3100 STAR Kids Screening and Assessment

Revision 17-1; Effective June 1, 2017

 

All children and young adults enrolled in a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

 

3110 Assessment of Medical Necessity for Community First Choice

Revision 17-3; Effective September 1, 2017

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC. Field Z5a must be marked yes (indicated by a "1") to request TMHP review and determination of MN. A physician certification is required for all initial assessments for MN for CFC services. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Z5a is marked yes for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is on file in the member's case file.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and emergency response services. For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the member's file, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including the PCAM and Section P, but leaves Field Z5a as marked "no" (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative (LAR). If a member meets MN and has a need for CFC services, the MCO prepares a service plan for the member and provides an authorization to the network provider of the member's or LAR’s choice.

 

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 17-3; Effective September 1, 2017

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC.

Applicants or members coming off the MDCP interest list must be assessed for MN for eligibility for MDCP and the SK-SAI must be completed no later than 30 days following notification from Program Support Unit (PSU) staff, detailed in Section 2220, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered complete when the physician certification is on file. MCOs assessing applicants/members for MDCP services complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate yes on Field Z5a when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Z5a is marked yes on initial assessments for MDCP.

If a member comes off the interest list who is receiving Community First Choice (CFC) services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Z5a as a “no” (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative. A physician's certification is not required for a reassessment of MN.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.

 

3200 Member Reassessment

Revision 17-1; Effective June 1, 2017

 

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed. Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. Before the end date of the annual SK-SAI, including applicable modules, the MCO must initiate an annual reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the one year anniversary of the member's previous assessment using the SK-SAI. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member or member’s legally authorized representative (LAR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive personal care services, the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized personal care service hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The MCO must also complete the NCAM at any time it determines the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

 

3210 Reassessment of Medical Necessity or Level of Care

Revision 17-3; Effective September 1, 2017

 

For members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment and there has been no change to the member's health status. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member and/or the member's legally authorized representative (LAR) to schedule a reassessment prior to the expiration of the member's LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure that the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member's ISP is completed annually. PSU staff:

  • check the Long Term Care (LTC) Online Portal to determine if the MCO has electronically submitted Form 2604, STAR Kids Individual Service Plan (ISP) Service Tracking Tool, or through a 278 transaction before the ISP end date;
  • verify the case has an approved SK-SAI;
  • confirm ongoing Medicaid eligibility;
  • verify the ISP is within the cost limit; and
  • take a screenshot of the ISP and posts the screenshot to the HHS Enterprise Administrative Report and Tracking (HEART) system.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, asking PSU staff to manually generate Form H2065-D, Notification of Managed Care Program Services. This form is not generated in the LTC Online Portal at reassessment. PSU staff send Form H2065-D to the member and post a copy to the appropriate MCO STAR Kids folder in TxMedCentral. See Section 3328, Reassessment Notification Requirements, for additional information.

 

3300 Member Service Planning and Authorization

Revision 17-3; Effective September 1, 2017

 

Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. Except as provided below for members receiving Medically Dependent Children Program (MDCP) services, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The ISP must be completed within 60 days of completion of the SK-SAI for all subsequent reassessments. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The ISP must be used to communicate and help align expectations between the member, his legally authorized representative (LAR), the MCO and key service providers. The STAR Kids Individual Service Plan (SK- ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member and his LAR, on the member's behalf, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The STAR Kids ISP is for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the STAR Kids MCO;
  • documenting services received through third party sources, such as 1915(c) waivers operated by the state;
  • identifying the member or applicant’s strengths, preferences, support needs and desired outcomes;
  • identifying what is important to the member;
  • identifying available natural supports available to the member and needed service system supports;
  • documenting the individual’s preferences for when and how to receive services;
  • identifying any special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
  • documenting the member's unmet needs.

For STAR Kids members receiving MDCP services, the ISP must establish an MDCP service plan that falls within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member or his LAR following any significant update and no less than annually within five business days of meeting with the member or LAR. The MCO must provide a copy of the ISP to the member's providers and other individuals specified by the member or LAR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member's current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member's service coordinator, or a representative of the MCO, must review and update each member's ISP with the member and his LAR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

 

3310 Service Planning

Revision 17-3; Effective September 1, 2017

 

All STAR Kids narrative individual service plans (ISPs) must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

  • A summary document describing the recommended service needs identified through the SK-SAI;
  • Covered services currently received;
  • Covered services not currently received, but that the member might benefit from;
  • A description of non-covered services that could benefit the member;
  • Member and family goals and service preferences;
  • Natural strengths and supports of the member including helpful family members, community supports or special capabilities;
  • A description of roles and responsibilities for the member, his legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the managed care organization (MCO), and the member's school with respect to maintaining and maximizing the health and well-being of the member;
  • A plan for coordinating and integrating care between providers and covered and non-covered services;
  • Short and long-term goals for the member's health and well-being;
  • If applicable, services provided to the member through waiver programs not operated by the MCO or third-party resources, and the sources or providers of those services;
  • Plans specifically related to transitioning to adulthood for members age 15 and older; and
  • Any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, his family and caretakers, providers and any other individual with knowledge and understanding of the member's strengths and service needs who is identified by the member, the member's LAR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but may not require the member, to provide a copy of the member's Individualized Education Plan (IEP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Consumer Directed Services or Service Responsibility Option, if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by third-party resources, like Medicare or available community services. This form is updated, per the section below, and is maintained in the member's case file.

 

3311 Updates to the Individual Service Plan

Revision 17-3; Effective September 1, 2017

 

Each member's individual service plan must be updated at least annually, or sooner in the following situations, within 14 days of the request or notification of a need or a change:

  • following a significant change in health condition that impacts service needs;
  • upon request from the member or his legally authorized representative;
  • at the recommendation of the member's primary care provider and/or health home; and
  • following a change in life circumstance.

 

3320 Service Planning for Medically Dependent Children Services

Revision 17-3; Effective September 1, 2017

 

The service coordinator must work with the member and/or member's legally authorized representative (LAR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member's Resource Utilization Group (RUG), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG are found in Appendix VIII, RUG IPC Cost Limits.

The service coordinator documents these MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Agency Option, Consumer Directed Services, or Service Responsibility Option, if applicable. The form must also include a brief rationale (i.e., why the service is needed or requested).

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the MCO completes and submits the electronic SK-ISP within 60 days of the initial notification from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic SK-ISP within 60 days following receipt of a response to the SK-SAI submission. The response file from Texas Medicaid & Healthcare Partnership (TMHP) contains the determination of medical necessity and the member's RUG. The start date for the SK-ISP must be the first day of the next month. If a Medicaid eligibility determination is required, the start date of the SK-ISP is the first day of the month following a determination of Medicaid eligibility. An ISP is valid for one year.

When the member's SK-ISP is complete and within the member's established cost limit, the MCO submits the SK-ISP as Form 2604  to the TMHP Long Term Care (LTC) Online Portal or through a 278 transaction. The MCO must submit the electronic SK-ISP prior to the start date of the member's ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must retain a copy of Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, in the member's file.

If the member is turning age 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member's cost limit. To calculate the prorated cost, the MCO must:

  • divide the cost limit by the total number of days (365) in a year;
  • determine the total number of days beginning with the start date of the individual plan of care (IPC) and ending with the date before the member's 21st birthday; and
  • multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.

Example: The member's 21st birthday is July 9, the ISP start date is April 1, and the end date will be on July 8. The member's cost limit is $25,000.

  • Step 1: $25,000 ÷ 365 days = $68.49 per day
  • Step 2: The number of days per month: April = 30, May = 31, June = 30, July 1-8 = 8, for a total of 99 days.
  • Step 3: $68.49 × 99 = $6,780.51

$6,780.51 is the prorated cost limit for the individual for the ISP.

 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 17-3; Effective September 1, 2017

 

If a member and/or his legally authorized representative (LAR) requests a change to the member's Medically Dependent Children Program (MDCP) service plan, but the member has not experienced a change in condition that affects his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 14 days.

To revise a member's MDCP individual service plan (ISP) when there is no change in the member's RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and submits the SK-ISP to the Long Term Care Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the member's file.

 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 17-3; Effective September 1, 2017

 

If a member and/or his legally authorized representative (LAR), the member's provider or the managed care organization (MCO) service coordinator notify the MCO about a change in the member's condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must reassess the member within 14 days. The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) in the Long Term Care Online Portal, including the MDCP module, and complete the following fields according to Appendix I, MCO Business Rules for SK-SAI and SK-ISP:

  • A10c = Medicaid number of the individual
  • A12 = 2 (Significant Change in Status Reassessment)
  • Z5a = 0 (No)
  • Z5b = 0 (No)

Following receipt of a response file indicating the member's new RUG and associated cost limit, the MCO completes a new STAR Kids individual service plan (SK-ISP) that reflects the member’s/LAR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member's new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the member's case file.

If a member will turn age 21 between the start and end date of the member's ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or transition assistance are provided prior to the member's birthday. If the MCO authorizes adaptive aids, minor home modifications or transition assistance, the MCO remains responsible for payment for those services, including applicable warranties.

 

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 17-1; Effective June 1, 2017

 

Managed care organizations may permit a Medically Dependent Children Program (MDCP) member or his legally authorized representative (LAR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member/LAR chooses to set aside funds, the MCO must document the member’s/LAR's preferences and maintain documentation in the member's case file. A member or LAR may not carry forward funds between ISP periods.

 

3324 Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services

Revision 17-3; Effective September 1, 2017

 

If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits via email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

  • STAR Kids Screening and Assessment Instrument (SK-SAI);
  • STAR Kids Individual Service Plan (SK-ISP) and any Addendums; and
  • Medical records (nursing care plan, recent care notes, doctor's orders and nursing notes).

HHSC UR may request a clinical review of the case to consider the use of state General Revenue funds to cover costs exceeding 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit.

Note: MCOs must not discuss with applicants or members, or request use of state General Revenue funds for services above the cost ceiling.

 

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 17-1; Effective June 1, 2017

 

In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each of those members.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member's care is based on his or her individual service plan and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.

 

3326 Suspension of Medically Dependent Children Program Services

Revision 17-1; Effective June 1, 2017

 

To remain eligible for Medically Dependent Children Program (MDCP) services, a member must receive one MDCP service monthly. In the event that the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. The MCO must document the:

  • dates during which services are suspended; and
  • reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

 

3327 Reassessment Individual Service Provider Procedures

Revision 17-3; Effective September 1, 2017

 

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is authorized annually. PSU staff:

  • check the Long Term Care (LTC) Online Portal to determine if the managed care organization (MCO) has submitted Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, electronically or through a 278 transaction, 30 days prior to expiration of the ISP end date;
  • verify the case has an approved Star Kids Screening and Assessment Instrument (SK-SAI);
  • confirm ongoing Medicaid eligibility; and
  • verify the ISP is within the cost limit.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

 

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 17-3; Effective September 1, 2017

 

Texas Health and Human Services Commission will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that will expire within the next 90 days.

Program Support Unit (PSU) staff will provide this report to the managed care organizations (MCOs) prior to the monthly call with PSU staff. The MCOs must provide a status update for all members who have ISPs expiring within the next 45 days. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.

The process for managing this report is as follows:

  • PSU staff provide the ISP Expiring Report to the MCO's point of contact via email five business days prior to the scheduled monthly call. For example, if the call is scheduled for June 16, PSU staff will provide the report to the MCO by close of business June 8. That provides five full business days for the MCO to respond to PSU staff. The day of the call is not considered one of the business days.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, completing the columns highlighted in red on the spreadsheet.
  • The MCO must return a completed report to the PSU staff within two business days prior to the monthly call. For example, if the call is scheduled for June 16, the MCO must return the report to the PSU staff by close of business on June 13.
  • PSU staff review the MCO's responses to determine if the MCO needs to provide clarification regarding any member's ISP status. During the monthly call, only ISP statuses about which PSU staff have questions are reviewed. There is no need to review each member for the status of the ISP if the MCO's response is sufficient. PSU staff use the columns in blue on the spreadsheet for internal tracking purposes.

Note: There will not be a need to review each member for the status of the ISP if the MCO's response is sufficient.

 

3328 Reassessment Notification Requirements

Revision 17-3; Effective September 1, 2017

 

If the member continues to meet waiver requirements, Program Support Unit (PSU) staff do not send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. PSU staff upload appropriate documentation into the HHS Enterprise Administrative Report and Tracking (HEART) system to record the approved reassessment.

If the member does not meet waiver requirements, PSU must, within two business days of receiving Form H2067-MC, Managed Care Programs Communication, from the managed care organization (MCO):

  • send Form H2065-D to the member indicating why the case is being terminated;
  • terminate the individual service plan (ISP) through the Long Term Care (LTC) Online Portal;
  • manually generate Form H2065-D and post it to the MCO's STAR Kids folder in TxMedCentral;
  • send a copy of Form H1746-A, MEPD Referral Coversheet, for Medical Assistance Only (MAO) members notifying Medicaid for the Elderly and People with Disabilities (MEPD) of the denial; and
  • send a copy of Form H2065-D to Enrollment Resolution Services (ERS) for MAO members (HPO_STAR_PLUS@hhsc.state.tx.us).

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

  • send an email notification regarding the request for appeal to the Centralized Representative Unit (CRU) for continued benefits. PSU staff send the email to the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox at OESFairHearings@hhsc.state.tx.us;
  • post Form H2067-MC in TxMedCentral to the MCO's STAR Kids folder, using the appropriate naming convention, 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 in the LTC Online Portal an additional four calendar months; and
  • send an email to ERS for MAO members as notification that a timely appeal was submitted and enrollment should remain open.

PSU staff carry out the decision within 10 days of receiving the fair hearings officer's decision.

 

3400 Member Transfers

Revision 17-1; Effective June 1, 2017

 

 

3410 Transfer from One Managed Care Organization to Another

Revision 17-3; Effective September 1, 2017

 

Once the initial enrollment period of one calendar month has passed, a member is eligible to change managed care organization (MCO) plans. When a member or his legally authorized representative (LAR) chooses to change from one MCO to another MCO in the same delivery area, the member or responsible party must contact the state contracted enrollment broker via phone at 1-800-964-2777 or via written correspondence.

The member can request to change MCOs as many times as the member wants, but the change cannot be made more than once per month. If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day 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.

Texas Health and Human Services Commission (HHSC) Operations prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. PSU staff receive a full list and share MCO specific information with Health Plan Management (HPM) staff, who share it with MCOs. The MCO receives a member-specific report that gives a list of STAR Kids members who have changed MCOs from the previous month.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning the results of the MCO’s identification and assessment upon the gaining MCO's request. Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the member's case file from the losing MCO, such as the member's Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. 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 member's case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify HPM.

HPM must contact the losing MCO and require the MCO to upload information contained in the member's file, including Form 2603 and any current authorizations, within two business days of notification. HPM informs PSU staff by email the date by which the MCO must upload the information to TxMedCentral. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from HPM. 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 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. 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 the SK-SAI business rules.

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 delivery area because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member or his LAR. Out-of-network authorizations must continue until the existing service plan 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 complex needs.

 

3420 Member Transfer from Waiver Program to Medically Dependent Children Program

Revision 17-3; Effective September 1, 2017

 

Participants in other 1915(c) Medicaid waivers operated by the state may be on the interest list for the Medically Dependent Children Program (MDCP). If a STAR Kids member in another Medicaid waiver program comes up on the interest list for MDCP, 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 an MDCP assessment. All attempted contacts with the member or encountered delays must be documented.

PSU staff:

  • contact the member and explain MDCP services; and
  • send a copy of the STAR Kids managed care organization (MCO) provider directories and comparison chart to the 1915(c) waiver member.

Within two business days of notification of the MCO selection by the waiver member, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and post it in the MCO's STAR Kids folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module; and
  • Form 2604, STAR Kids Individual Service Plan - Service Tracking, and submits it electronically in the Long Term Care (LTC) Online Portal or through a 278 transaction.

If the information from the MCO is not received within 60 days after the assessment is authorized, PSU staff email the assigned health plan manager as notification the time frame for completing the individual service plan (ISP) was not met.

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

If eligibility for MDCP is denied or the individual decides not to accept MDCP services, PSU staff:

  • generate Form H2065-D, Notification of Managed Care Program Services, in the LTC Online Portal;
  • mail the original Form H2065-D to the 1915(c) waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving; and
  • upload Form H2065-D to the Texas Health and Human Services (HHS) Enterprise Administrative Record and Tracking (HEART) system.

The MCO must monitor the LTC Online Portal to check the status of the member's ISP and to retrieve Form H2065-D and file in the MCO’s case file.

If eligibility is approved and the individual chooses to accept MDCP services, the individual is enrolled in MDCP the first day of the next month. Within two business days of determining the start of care date for MDCP services, PSU staff:

  • generate Form H2065-D in the LTC Online Portal;
  • mail the original Form H2065-D to the 1915(c) waiver individual; and
  • notify Enrollment Resolution Services (ERS) by emailing HPO_Star_Plus@hhsc.state.tx.us.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) waiver services end the day before enrollment in MDCP. The MCO must monitor the LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D and file in the MCO’s case file.

 

3430 Member Transfer from MDCP to Another Waiver

Revision 17-3; Effective September 1, 2017

 

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may be on an interest list for another Medicaid program such as Community Living Assistance and Support Services (CLASS) or Home and Community-based Services (HCS). The Texas Health and Human Services Commission (HHSC) informs the managed care organization (MCO) that a member receiving MDCP services has come to the top of the interest list for another program and is assessed as eligible for that program.

The service coordinator or case manager must contact Program Support Unit (PSU) staff to assist in coordinating the end of MDCP services the day prior to the member's enrollment in the new program. PSU staff must coordinate with the member's MCO about the end of MDCP services and the member's transition to another waiver. The member remains in the same STAR Kids MCO he is currently enrolled in for his state plan services.

PSU staff are responsible for completing the following activities within 14 days of the initial request for an MDCP assessment. All attempted contacts with the member or encountered delays must be documented. PSU staff:

  • create a case in the HHS Enterprise Administrative Report and Tracking (HEART) system;
  • check the Community Services Interest List (CSIL) to see if the member is on a 1915(c) interest list;
  • confirm if the member has an open enrollment with another 1915(c) waiver program according to the procedures below:
    • For either the Texas Home Living (TxHmL) or HCS waivers, 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 CLASS (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System (SAS) to verify the service authorization record for these waivers.
  • move the interest list with an "assessment requested" notation;
  • close the MDCP release in the CSIL system effective the date of the notification from the MCO informing of the member's decision to transfer to another waiver program; and
  • send Form 2442, Notification of Interest List Release Closure, to the member notifying of the MDCP closure. If the CLASS or other waiver program application is denied, Form 2442 will instruct the member to contact the CSIL if he/she wishes to apply for MDCP. When the member contacts CSIL, he/she will be reinstated on the MDCP interest list.

 

3440 Member Transfer from Community Services to STAR Kids

Revision 17-3; Effective September 1, 2017

 

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the CCAD case worker so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), PSU staff coordinate the termination of other waiver or CCAD services with the waiver or CCAD case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

CCAD services are terminated by the CCAD case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.

 

3500 Member Transition to Adult Programs

Revision 17-1; Effective June 1, 2017

 

Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are 15 years of age and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.

 

3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN, PPECC or CFC

Revision 17-1; Effective June 1, 2017

 

Possible waiver and service combinations the member may be receiving prior to transition:

  • Medically Dependent Children Program (MDCP) only;
  • Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services only;
  • MDCP with either or both of the following services:
    • Personal Care Services (PCS);
    • PDN/PPECC
  • MDCP with Community First Choice (CFC) services;
  • PDN/PPECC with PCS; and
  • PDN/PPECC with CFC services.

 

3511 Twelve Months Prior to the Member's 21st Birthday

Revision 17-3; Effective September 1, 2017

 

Twelve months prior to the 21st birthday of a member receiving services from the Medically Dependent Children Program (MDCP), Private Duty Nursing (PDN), Prescribed Pediatric Extended Care Center (PPECC) services or Community First Choice (CFC) services, the following process begins.

Each quarter, Program Support Unit (PSU) staff and the Utilization Review department provide a copy of the STAR Kids Transition Report, which lists individuals enrolled in STAR Kids and receiving MDCP and/or PDN/PPECC and/or CFC who may transition to STAR+PLUS or the STAR +PLUS Home and Community Based Services (HCBS) program in the next 18 months, to the:

  • PSU Operations specialist; and
  • Utilization Management and Review (UMR) department for the Intellectual and Developmental Disability (IDD) 1915 (c) waivers.

Procedures for managing this report, including time frames, can be found in Appendix VI, STAR Kids Transition Activities.

The managed care organization (MCO) identifies all members turning age 21 within the next 12 months and schedules a face-to-face visit with the member and the member's available supports, including the legally authorized representative (LAR), if applicable, to initiate the transition process.

During the home visit with the member/LAR/supports, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member's 21st birthday. The points to be discussed are:

  • STAR Kids eligibility, MDCP or PDN terminate on the last day of the month in which the member’s 21st birthday occurs.
  • STAR+PLUS HCBS may be an option available to the member at age 21. The MCO must also present an overview of the array of services available in STAR+PLUS HCBS.
  • Children's services, such as PDN and MDCP, are not available to adults. Members receiving PDN, STAR+PLUS HCBS or an IDD waiver will need to cover medically necessary nursing services that are not intermittent or part-time at age 21, which may not be the same level of nursing the member receives through STAR Kids. To be eligible for STAR+PLUS or the IDD waiver, the member's health and safety must be ensured under the cost limit for the waiver program.
  • Assisting the member with looking for an adult primary care physician, specialists (as necessary), and a dentist.
  • Providing information and referrals to community organizations that are important to the health and well-being of members. These organizations include but are not limited to:
    • State/federal agencies (e.g., those agencies with jurisdiction over aging, public health, substance abuse, mental health, IDD, rehabilitation, income support, nutritional assistance, family support agencies, etc.). For members with progressive vision loss, a referral is made to explore services offered through the Texas School for the Blind and Visually Impaired;
    • Social service agencies (e.g., area agencies on aging, residential support agencies, independent living centers, supported employment agencies, etc.);
    • City and county agencies (e.g., welfare departments, housing programs, etc.);
    • Civic and religious organizations; and
    • Consumer groups, advocates, and councils (e.g., legal aid offices, consumer/family support groups, permanency planning, etc.).
  • Current and possible future community living options, and coordinating visits with potential providers or facilities, if applicable.
  • Assessing the member's needs for adaptive aids, new equipment due to growth and development, and minor home modifications, as necessary.
  • Guardianship.
  • Transition activities that begin no later than nine months prior to the member’s 21st birthday.
  • STAR+PLUS enrollment packets (containing the STAR+PLUS MCO list and a comparison chart) PSU staff send nine months prior to the member’s 21st birthday.
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid being assigned an MCO or having a gap in services.
  • Member’s available supports and that the member can change MCOs any time after the first month of enrollment.
  • STAR+PLUS HCBS program cost limit based on a medical assessment and the Medical Necessity/Level of Care (MN/LOC) Assessment. The limit is 202% of the member's Resource Utilization Group (RUG).The assessment results in the cost limit for the annual 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 the health and safety, 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 begins six months before the member's 21st birthday. PSU staff will contact the member to begin the assessment process and find out which STAR+PLUS 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 STAR+PLUS MCO is selected, the MCO will contact the member to begin the assessment for services and assist the member and available supports in identifying and developing additional resources and community supports to help meet the member's needs.

The STAR Kids MCO:

  • Makes a referral to PSU staff via email at ManagedCareProgramSupport@hhsc.state.tx.us using Form H2067-MC, Managed Care Programs Communication, and includes "PDN and/or MDCP" Transition in the subject line;
  • Monitors service planning with the member/available supports every 90 days during the year before the member turns age 21;
  • Notifies the Texas Health and Human Services Commission (HHSC) Program Support and Utilization Review Transition/High Needs coordinator by email this may be a high needs individual, if the member appears to meet the criteria in the STAR+PLUS Handbook, Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program.

PSU staff for STAR+PLUS HCBS:

  • monitor the STAR Kids Transition Report and identifies all individuals referenced in Section 3510, Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN, PPECC or CFC, turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); and
    • Texas Home Living (TxHmL); and
  • create a case in the HHS Enterprise Administrative Report and Tracking (HEART) system noting:
    • if the MCO determines the individual is high needs;
    • the program type (MDCP, CFC or PDN/PPECC) transitioning from; and
    • the due date for the nine month contact.

The following chart outlines the responsibilities for monitoring the STAR Kids Transition Report and contacting members transitioning from STAR Kids who receive MDCP Waiver, PDN or PPECC, or CFC within the next 12 months:

Twelve Month Transition Chart

 

Under Age 21 MDCP Waiver Under Age 21 Other Services Received Monitors STAR Kids Report: 12-Month Contact:
MDCP PDN/PPECC PSU Staff STAR Kids MCO
MDCP CFC PSU Staff STAR Kids MCO
MDCP

PCS

PSU Staff STAR Kids MCO
MDCP PDN/PPECC and CFC PSU Staff STAR Kids MCO
MDCP PDN/PPECC and PCS PSU Staff STAR Kids MCO
MDCP None PSU Staff STAR Kids MCO
None PDN/PPECC PSU Staff STAR Kids MCO
None

PDN/PPECC and CFC

PSU Staff STAR Kids MCO
None PDN/PPECC and PCS PSU Staff STAR Kids MCO

 

3512 STAR+PLUS Transition Activities

Revision 17-3; Effective September 1, 2017

 

Program Support Unit staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines as outlined in the STAR+PLUS Handbook, Section 3420, Individuals Transitioning to an Adult Program.

 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 17-3; Effective September 1, 2017

 

Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

  • Children and young adults who have been approved for and are currently utilizing IPV in traditional Medicaid will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of the child/young adult when he transitions to a STAR Kids MCO.
  • When members turn age 21 and transition into STAR+PLUS, young adults who have been approved for and are currently utilizing IPV will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of young adult will not be subjected to an abrupt removal of the equipment. The member will continue to receive the ongoing treatment until the final decision is made, on a case-by-case basis, with a thorough review and documentation by the managed care organization (MCO) and explicit approval by HHSC administration.
  • STAR Kids MCOs will address a new request for IPV on a case-by-case basis based on medical necessity criteria for the individual member.

 

3520 Procedures for Non-Waiver Members Transitioning from STAR Kids with Only Personal Care Services Twelve Months Prior to the Member's 21st Birthday

Revision 17-1; Effective June 1, 2017

 

 

3521 Twelve Months Prior to the Member's 21st Birthday

Revision 17-3; Effective September 1, 2017

 

The managed care organization (MCO) identifies all members turning age 21 and receiving only Personal Care Services (PCS) within the next 12 months and schedules a face-to-face visit with the member and available supports to initiate the transition process.

During the home visit with the member and available supports, the MCO must present an overview of the STAR+PLUS program, including STAR+PLUS Home and Community Based Services (HCBS), and the changes that will take place the first of the month following the member's 21st birthday. The points to be discussed are:

  • STAR Kids eligibility will terminate on the last day of the month in which the member’s 21st birthday occurs.
  • PCS is a benefit of the STAR+PLUS program.
  • An enrollee in STAR+PLUS may request an upgrade to STAR+PLUS HCBS. Supplemental Security Income (SSI) members do not have to go on the STAR+PLUS HCBS Interest list.
  • MAXIMUS will reach out to the member 30 days prior to the member’s 21st birthday and provide the member with STAR+PLUS enrollment packets (containing the STAR+PLUS MCO list).
  • If an MCO has not been selected within 15 days of the enrollment packet being mailed, an MCO is selected for the member.
  • The effective date for the STAR+PLUS enrollment will be the first day of the month following the member’s 21st birthday.

 

3522 Thirty Days Prior to the Member's 21st Birthday

Revision 17-3; Effective September 1, 2017

 

MAXIMUS will reach out to the member 30 days prior to the member's 21st birthday and provide the member with STAR+PLUS enrollment packets (containing the STAR+PLUS managed care organization (MCO) list). If an MCO is not selected within 15 days of the enrollment packet being mailed, an MCO is selected for the member.

The Program Support Unit will update the monthly Personal Care Services (PCS) Authorization Report with the MCO selection and send PCS authorization information to the STAR+PLUS plan prior to the enrollment effective date. The STAR+PLUS MCO must honor the existing prior authorization as required by the contract.