Revision 16-1; Effective March 1, 2016

 

Acute care — Medical care designed to treat or cure disease or injury, usually within a limited time period. Acute care usually refers to physician and/or hospital services of less than three months' duration. All the covered services in the State Medicaid Plan for adults that are considered acute in nature are available to members of the STAR+PLUS members that are Medicaid only. Exception: Some services for children are considered chronic and are covered under the State Medicaid Plan.

Agency Option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

Consumer Directed Services (CDS) — A service delivery option in which a member or legally authorized representative employs and retains service providers and directs the delivery of HCBS STAR+PLUS Waiver (SPW) personal assistance services and respite services. A member participating in the CDS option is required to use a CDS agency chosen by the member or legally authorized representative (LAR) to provide financial management services.

Community First Choice (CFC) Option — CFC enables Texas Medicaid to provide the most cost effective approach to basic attendant and habilitation service delivery so members can remain in the community. The services available in CFC are personal assistance services, habilitation services, emergency response services and support management.

Denial — Closure of an application with a finding of ineligibility.

Developmental Disability — As defined in the Developmental Disabilities Assistance and Bill of Rights Act of 200, Section 102(8) [42 USC 15002], a severe, chronic disability of an individual five years of age or older that is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the individual attains 22 years of age; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency; and reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.

Eligibility date — The first date all waiver eligibility criteria are met, as described in Section 3240, Waiver Requirements.

Enrollment broker — A contracted entity that assists individuals in selecting and enrolling with a managed care organization (MCO). If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP). Members of STAR+PLUS may request to change MCOs at any time after the first month of enrollment by contacting the enrollment broker. The change is effective the first day of the subsequent month if the request is made prior to state cut-off or the first of the following month if the request is made after the cut-off date.

Health and Human Services Commission (HHSC) — The state agency responsible for Medicaid. Certain functions related to SPW eligibility and coordination between trading partners are delegated to the Department of Aging and Disability Services (DADS).

Health Maintenance Activity (HMA) — A task that may be exempt from delegation based on registered nurse assessment that enables the member to remain in an independent living environment, and goes beyond activities of daily living because of the higher skill level required to perform.

Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) — Authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility. This is also known as the SPW.

Individual service plan (ISP) — A plan of care developed for the HCBS STAR+PLUS Waiver (SPW) member by the MCO.

Intellectual and Developmental Disability (IDD) — A significant sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the development period.

Interdisciplinary team (IDT) — All individuals/entities involved in planning the SPW member’s plan of care. This typically includes the member, the member’s legal/authorized representative, the service coordinator, the primary care physician, etc.

Legally authorized representative (LAR) — A person authorized by law to act on behalf of an HCBS SPW member, including a parent, guardian, managing conservator of a minor or the guardian of an adult.

Long-term Services and Supports (LTSS) — Services, including Primary Home Care, Day Activity and Health Services, and the HCBS STAR+PLUS Waiver (SPW), that assist members in living in the community.

Managed Care Operations (HMCO) — A unit within the Medicaid/Children's Health Insurance Program Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.

Managed Care Organization (MCO) — An insurer licensed by the Texas Department of Insurance as a Health Maintenance Organization in accordance with Chapter 843 of the Texas Insurance Code. The MCO provides Medicaid benefits to individuals who are enrolled in STAR+PLUS.

Medicaid Estate Recovery Program (MERP) — A program that requires HHSC, as the State Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients. For further information, see the MERP website at http://dadsview.dads.state.tx.us/merp/index.html.

Member — An individual who is enrolled in and receiving services through a STAR+PLUS MCO.

Money Follows the Person (MFP) — A process whereby the funds used for payment of institutional care follows the person when transitioning to the community under the SPW.

Money Follows the Person Demonstration (MFPD) — A federal grant program that provides additional services to members who utilize the MFP process.

Mutually exclusive services — Two or more services that may not be authorized for the same individual during the same time period.

Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and long-term services and supports. The POC is not the same as the individual service plan for SPW services.

Program Support Unit (PSU) — An HHSC unit of with staff who support and handle certain aspects of the STAR+PLUS program, as described in Section 3300, Administrative Procedures.

Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

PSU staff — An HHSC employee who works in PSU.

Responsible party — An individual who:

  • assists and/or represents an applicant or member in the application or eligibility redetermination process; and/or
  • is familiar with the applicant/member and his/her financial affairs and functional condition.

Service coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR+PLUS members.

Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services. The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

STAR+PLUS Program — The umbrella designation that includes both the STAR+PLUS services and HCBS STAR+PLUS Waiver (SPW).

STAR+PLUS Program specialist — The staff person responsible, along with Managed Care Operations, for STAR+PLUS policy development.

STAR+PLUS Services — Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute care, Primary Home Care, and Day Activity and Health Services through a managed care delivery system statewide.

STAR+PLUS staff — The Managed Care Operations staff person working with policy and operational issues.

Termination — Closure of an ongoing case due to a finding of ineligibility.

Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid claims processing and the Medicaid primary care case management services program. TMHP is responsible for processing medical necessity/level of care assessments for the waivers.

Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for any medical assistance provided to a recipient under the approved state Medicaid plan.

TxMedCentral — A secure Internet bulletin board the state and MCOs use to share information, as described in Section 5110, TxMedCentral Naming Convention and File Maintenance.

Unlicensed Assistive Person (UAP) — A paraprofessional who assists individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living, and provides bedside care. A UAP may perform nursing tasks only in specific situations, as governed by the Texas Administrative Code for the Texas Board of Nursing, Title 22, Part 11, Rules 224 and 225.

Upgrade — An existing STAR+PLUS member enrolled in the STAR+PLUS services who requests and is granted SPW services after meeting waiver eligibility criteria.