3300, Member Service Planning and Authorization

Revision 23-3; Effective May 22, 2023

The managed care organization (MCO) must collaborate with the member and legally authorized representative (LAR) to create and update Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, also known as the STAR Kids individual service plan (SK-ISP). The MCO develops the SK-ISP using a person-centered process with the support of a group of people chosen by the member or LAR. 

The purpose of the SK-ISP is to articulate assessment findings from the STAR Kids Screening and Assessment Instrument (SK-SAI). It includes short and long-term goals, service needs and member preferences. 

The MCO uses the SK-ISP for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the MCO; 
  • documenting services received through third-party sources; 
  • identifying a member's strengths, preferences, support needs, and desired outcomes; 
  • identifying what is essential to the member; 
  • identifying natural supports available to the member and needed supports; 
  • documenting the member's preferences for when and how to receive services; 
  • identifying special needs, requests, or considerations the MCO or providers should know when supporting the member; and 
  • documenting the member's unmet needs. 

The MCO must:

  • write the SK-ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language; 
  • submit the electronic SK-ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, as applicable; 
  • create and update the SK-ISP at least annually, as applicable; 
  • ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility; 
  • provide a printed or electronic copy of the SK-ISP to the member or LAR following any significant update; 
  • retain any amended SK-ISP in an MCO member's case file;
  • provide the Texas Health and Human Services Commission (HHSC) staff with the SK-ISP upon request; 
  • not provide significant change SK-ISPs to Program Support Unit (PSU) staff; and
  • authorize all services identified on the SK-ISP.

The SK-ISP must be within the member's cost limit. PSU staff must not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP SK-ISP Annual Cost Limit field.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

3310 Service Planning

Revision 23-3; Effective May 22, 2023

Form 2603, STAR Kids Individual Service Plan (SK-ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and to develop the SK-ISP. The managed care organization (MCO) is responsible for completing Form 2603. The MCO maintains Form 2603 in the MCO's case file.

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 the member may 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, legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the 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;
  • services provided to the member through other third-party resources (TPR) and the sources or providers of those services;
  • plans specifically related to transitioning to adulthood for members 15 and older;
  • a list of Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable;
  • a brief rationale for the services; and
  • any other information to describe strategies to meet service objectives and member goals.

The MCO must include the items listed above in the SK-ISP.

3320 Service Planning for Medically Dependent Children Program Services

Revision 23-3; Effective May 22, 2023

The STAR Kids individual service plan (SK-ISP) contains a list of all the member's services, including Medically Dependent Children Program (MDCP) services. The managed care organization (MCO) lists MDCP services on Form 2603, STAR Kids Individual Service Plan Narrative. The list of MDCP services on Form 2603 must match the services listed on the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

The MCO must submit Form 2604 to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) before the start date of the member's SK-ISP following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MCO must collaborate with the member or legally authorized representative (LAR) to create the SK-ISP including MDCP services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. Program Support Unit (PSU) staff will not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field.

The MCO must initiate a reassessment for MDCP to determine and validate the need for continued services listed on the SK-ISP for each member before the end date of the annual STAR Kids Screening and Assessment Instrument (SK-SAI). The MCO must ensure all member reassessment activities, including submitting the SK-ISP to the TMHP LTCOP, are completed no earlier than 90 days and no later than 30 days before the expiration of the member's current SK-ISP on file. Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility. 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 23-3; Effective May 22, 2023

It may be necessary for the managed care organization (MCO) to revise the STAR Kids individual service plan (SK-ISP) within the SK-ISP period due to situations outlined in the STAR Kids Contract, Section 8.1.39.1.

The MCO must retain the amended SK-ISP in the MCO's member case file. 

The MCO must not submit the revised SK-ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to TxMedCentral.

3322 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3323 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3324 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

 

3325 Reserved For Future Use

Revision 23-4; Effective Aug. 21, 2023

 

3326 Suspension of Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018

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 (NF), 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 Plan Procedures

Revision 22-3; Effective Sept. 9, 2022

Program Support Unit (PSU) staff must ensure the member’s STAR Kids individual service plan (SK-ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for all SK-ISPs submitted on a daily basis. 

PSU staff must complete the following activities within five business days of receipt of the SK-ISP:

  • verify the member is under 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • verify the member is a Texas resident in TIERS;
  • check the TMHP LTCOP to determine if the managed care organization (MCO) has submitted the member’s SK-ISP before the SK-ISP end date;
  • verify the member has an approved medical necessity (MN) and STAR Kids Screening and Assessment Instrument (SK-SAI) in the TMHP LTCOP;
  • verify the member’s SK-ISP is within the cost limit;
  • confirm ongoing Medicaid financial eligibility and managed care enrollment is active in TIERS; 
  • verify the member has an SK-ISP with a least one Medically Dependent Children Program (MDCP) service;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and 
  • document the HEART case record.

The member’s MDCP services will continue using the existing SK-ISP until a decision is received from the hearings officer if:

  • a member’s reassessment SK-ISP is developed; and
  • not submitted due to the member's timely appeal of an MDCP denial. 

PSU staff and the MCO coordinate the submission of a reassessment SK-ISP to ensure:

  • the SK-ISP records are correct; and 
  • the reassessment SK-ISP processes correctly once the state fair hearing decision is reached.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox each month. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs being reported as a MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month].” 

The assigned PSU staff is not required to send a follow up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

  • Form H2067-MC, Managed Care Programs Communication; 
  • the SK-SAI; or 
  • the SK-ISP. 

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late reassessment activity. 

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) on a monthly basis to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that expire within the next 90 days.

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 ISP Expiring Report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update from the MCO.

The process for managing the ISP Expiring Report is as follows:

  • PSU staff provide the ISP Expiring Report to the MCO point of contact and to Managed Care Compliance & Operations (MCCO) staff by email five business days prior to the scheduled monthly call. 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 PSU staff within two business days prior to the monthly call.
  • PSU staff review the MCO 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 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 response is sufficient.

3328 Reassessment Notification Requirements

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, at reassessment as notification of continuing Medically Dependent Children Program (MDCP) eligibility if the member meets MDCP requirements. 

PSU staff must complete the following activities for an approved MDCP reassessment within five business days from verification that the member continues to meet all MDCP requirements:

  • electronically generate Form H2065-D in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • mail Form H2065-D to the member, legally authorized representative (LAR) or medical consenter; 
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR  Kids HEART Naming Conventions; and 
  • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, if the member does not meet MDCP requirements at reassessment.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, if the member, LAR or medical consenter files a state fair hearing within the adverse action notification time period.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements regarding the termination of MDCP for STAR Health members.