Nursing Facility Frequently Asked Questions

The following are responses to questions nursing facility providers frequently ask. To submit questions for response, please email Managed_Care_Initiatives@hhsc.state.tx.us.

Readiness Review

How will HHSC oversee and enforce the access requirements defined in the managed care organization contracts to ensure the availability of resources and providers?

HHSC employs a process called "readiness review (RR)" to examine a contracted managed care organization’s preparedness and ability to fulfill its obligations under the Uniform Managed Care Contract (PDF) (UMCC). During RR, MCOs are required to submit a comprehensive plan for network adequacy that includes a list of all contracted and credentialed providers, in an HHSC-approved format. The plan must include a description of additional contracting and credentialing activities scheduled to be completed before the operational start date. The MCO must submit a listing of all contracted and credentialed providers to be included in the first provider directory 90 days prior to the first enrollment kit mail out, or as otherwise directed by HHSC.

On an ongoing basis, MCOs must submit quarterly reports to HHSC. HHSC:

  • Evaluates GeoAccess standards
  • Analyzes provider data (network panel status reports, provider turnover rates, and enrollment broker reports)
  • Considers access to care complaints
  • Reviews out-of-network utilization
  • Verifies the accuracy of provider directories

What process will be used to assess readiness for each of the MCOs in their respective service areas? What is being measured to determine readiness prior to implementation?

HHSC employs a process called "readiness review (RR)" to examine a contracted managed care organization’s preparedness and ability to fulfill its obligations under the Uniform Managed Care Contract (UMCC). Given how Medicaid MCOs vary in size, experience, and ability, HHSC takes a risk-based approach to RR. This means the RR process may be adjusted based on new client risks and needs. MCOs must satisfy all RR requirements prior to the operational start date for each applicable MCO program and service area. Areas reviewed by HHSC include:

  • Organizational (corporate background structure, material subcontractor information, etc.)
  • Financial (bond documentation, financial update report, affiliate report, etc.)
  • Systems (developing, installing, testing of systems; data extracts, transfers, and transmissions; test files for systems and interface testing; demonstration of systems capabilities and adherence to contract specifications; etc.)
  • Operations (policies and procedures, network adequacy, claims processing, staff and provider training, etc.)

Significant Traditional Provider (STP), Any Willing Provider, and Contracting

What is a Significant Traditional Provider (STP)?

STPs are providers identified by HHSC as having provided a significant level of care to Medicaid clients. The STAR+PLUS managed care organizations (MCOs) are obligated to offer STPs an opportunity to be a part of the contracted MCO network. STPs must accept the MCOs’ conditions for contracting and credentialing to participate in managed care.

Will the state require the MCOs to enroll any willing provider, at least during the initial two years of the carve-in?

Texas Government Code § 533.0251(d) requires HHSC "to ensure a nursing facility provider authorized to provided services under the medical assistance program on September 1, 2013, is allowed to participate in STAR+PLUS." HHSC added the following language to its Uniform Managed Care Contract:

"Nursing facilities that are licensed, certified, and have a valid DADS contract on September 1, 2013, will be included on the significant traditional provider or STP list. PCPs associated with Nursing Facilities must have admitting privileges to Network Hospitals. If any willing Nursing Facility Provider is not on the STP list but will agree to the MCO’s contract rates and terms, the MCO must also enter into a Network Provider Agreement with that provider if the Nursing Facility is licensed, certified, and has a valid DADS contract. Any willing Nursing Facility Provider includes Nursing Facility STPs who have gone through a change in ownership after September 1, 2013, and new Nursing Facility providers." The STP list will be in effect through February 28, 2018.

How long will the MCOs be required to maintain STPs within their provider networks?

The MCO will maintain the STP enrollment requirements for nursing facilities through February 28, 2018, as described in Texas Government Code § 533.00251. The MCO may not terminate a network provider agreement with a STP unless the MCO demonstrates, to the satisfaction of HHSC, good cause for earlier termination.

What will happen if a nursing facility chooses not to sign a contract with an MCO?

If a nursing facility does not sign a contract with an MCO, the facility will be considered out-of-network. The MCO must reimburse an out-of-network, in-area service provider the Medicaid fee-for-service (FFS) rate in effect on the date of service, less five percent (1 TAC § 353.4).  However, the MCO must reimburse in-network nursing facilities contracted with the MCO at or above the prevailing nursing facility unit rates established by HHSC for the date of service.

Will an MCO be able to "drop" a nursing facility from its provider network?

To stay in a STAR+PLUS provider network, facilities must maintain certification of compliance with Medicaid nursing facility standards and program requirements. The contract between the provider and the MCO will automatically terminate for a facility on the date the facility’s certification of Medicaid compliance is terminated by the federal Centers for Medicare and Medicaid Services (CMS) or the Texas Department of Aging and Disability Services (DADS), and the Provider will not be entitled to payment for services provided to STAR+PLUS members during the time the facility does not have a certification of compliance with Medicaid standards and program requirements.

If a nursing facility does not sign an MCO agreement, will the Medicaid patient be moved to a network facility?

The MCO must pay for Nursing Facility Unit Rates at or above the prevailing rate established by HHSC for the date of service for nursing facilities contracted with MCOs. The MCO must reimburse an out-of-network, in-area service provider the Medicaid fee-for-service (FFS) rate in effect on the date of service less five percent.  The intent is to maintain residents in their existing nursing facility, and out-of-network, in-area facilities will be paid an out-of-network rate.

Resource Utilization Group (RUG), Minimum Data Set (MDS), and Long Term Care Medicaid Information (LTCMI)

How will the Resource Utilization Group (RUG) rate be established?

Under Medicaid managed care, establishment of the RUG rate for nursing facility residents will stay the same (see HHSC Rate Analysis for more information). The MCO will be required to pay the RUG rate, staff enhancement, and other applicable enhancements, at or above the prevailing rate established by HHSC for the date of service. 

Nursing facilities will continue to be paid based on the RUG level derived from the Minimum Data Set (MDS). Nursing facilities also will continue to be responsible for completing and timely submitting the 3618 and 3619 forms. In addition, TMHP will continue to approve medical necessity for nursing facility eligibility determination

Who will be responsible for completing the Minimum Data Set (MDS) and Long Term Care Medicaid Information (LTCMI)?

Nursing facilities will maintain responsibility for completing and submitting the MDS and LTCMI. There will be no changes to this process.

Who will be responsible for completing and submitting the 3618 and 3619 forms?

Nursing facilities will continue to be responsible for completion and timely submission of the 3618 and 3619 forms to the TMHP LTC Online Portal system.  There will be no changes to this process.

To facilitate care coordination under managed care, nursing facilities must provide notice to the MCO’s designated service coordinator via phone, fax, email or other electronic means no later than one business day after any of the following events:

  • Significant, adverse change in the member’s physical or mental condition or environment that could potentially lead to hospitalization.
  • Admission to or discharge from the nursing facility, including admission or discharge to a hospital or other acute facility, skilled bed, long term services and supports provider, non-contracted bed, another nursing or long term care facility.
  • Emergency room visit.

Notice will not be required when a member is absent from the facility for a therapeutic home visit.

Reimbursement, Billing, and Clean Claims

What is the Nursing Facility Unit Rate?

The Nursing Facility (NF) Unit Rate means the types of services included in the DADS daily rate for nursing facility providers, such as room and board, medical supplies and equipment, personal needs items, social services, and over-the-counter drugs.  The NF Unit Rate also includes applicable nursing facility staff rate enhancements and professional and general liability insurance. NF Unit Rates exclude NF Add-on Services.

  • NFs will continue to complete and submit Minimum Data Set (MDS) and Long Term Care Medical Information (LTCMI).
  • STAR+PLUS managed care organizations (MCOs) will not do reassessments for NF Unit Rate services, though they may bring to the NF’s attention items for consideration.
  • NFs will have up to 365 days from the begin date of service to submit a NF Unit Rate Claim.

The STAR+PLUS MCOs will be responsible for adjudicating the NF Unit Rate, including the daily rate, the staff rate enhancement, and insurance components, and clean claims must be adjudicated within ten days of submission.

HHSC will continue to set the RUG rates paid to nursing facilities under STAR+PLUS, including the staff rate enhancement.

What are Nursing Facility Add-on Services?

Nursing Facility Add-on Services means the types of services that are provided in the facility setting by a provider or another network provider, but are not included in the NF Unit Rate. NF Add-on Services “NF Add-on Services” include but are not limited to emergency dental services, physician-ordered rehabilitative services, customized power wheel chairs, and augmentative communication devices.

The STAR+PLUS MCOs will contract directly with providers of NF Add-on Services. In addition, the MCOs will be responsible for authorizing NF Add-on Services. Providers will have up to 95 days from the date of service to submit a claim for a NF Add-on Service.

STAR+PLUS MCOs also will be responsible for adjudicating claims for NF Add-on Services (MCOs must adjudicate a clean claim for NF Add-on Services within 30 days of submission).

How will the Resource Utilization Group (RUG) rate be established?

Under Medicaid managed care, establishment of the RUG rate for nursing facility residents will stay the same (see HHSC Rate Analysis for more information). The MCO will be required to pay the RUG rate, staff enhancement, and other applicable enhancements, at or above the prevailing rate established by HHSC for the date of service. 

Nursing facilities will continue to be paid based on the RUG level derived from the Minimum Data Set (MDS). Nursing facilities also will continue to be responsible for completing and timely submitting the 3618 and 3619 forms. In addition, TMHP will continue to approve medical necessity for nursing facility eligibility determination

What are acute care services?

Acute care means preventive care, primary care, and other medical care provided under the direction of a physician for a condition having a relatively short duration.

The STAR+PLUS MCOs will contract directly with acute care providers. In addition, the MCOs will be responsible for authorizing Medicaid-covered acute care services provided to nursing facility residents (for example psychiatry, podiatry, etc.). Providers will have up to 95 days from date of service to submit an acute care claim.

STAR+PLUS MCOs will be responsible for adjudicating claims for Medicaid-covered acute care services provided to NF residents and must adjudicate a clean claim within 30 days of submission.

The legislation directing HHSC to add nursing facility services into STAR+PLUS stated that nursing facility providers with signed contracts will be paid within 10 days of submitting a clean claim. With this being the shortest time period for payment that MCOs manage in Texas, what effort is HHSC making to maintain compliance with timeliness of payment?

Prior to implementation, HHSC will conduct an extensive readiness review of the MCOs’ claims processes, with a concentrated focus on their ability to properly adjudicate nursing facility claims.  A clean claim for a Nursing Facility Unit Rate claim submitted by a contracted provider must be adjudicated within 10 days of submission, and clean claim for a Nursing Facility Add-on Service submitted by a contracted provider must be adjudicated within 30 days. HHSC will make a "go or no-go" determination based on the readiness findings for Nursing Facility Unit Rate claims. Ongoing, HHSC staff will monitor provider complaints and track trends to identify and address billing concerns. Finally, STAR+PLUS MCOs will pay a network nursing facility provider interest at a rate of 18 percent per annum on all Nursing Facility Unit Rate clean claims that are not adjudicated within the ten day requirement.

Will the nursing facility be able to bill as frequently as needed?

The nursing facility may bill as often as needed. The MCO must adjudicate a clean claim for a Nursing Facility Unit Rate within 10 days of submission, and a clean claim for a Nursing Facility Add-on Service must be adjudicated within 30 days.

What is the HHSC definition of a clean claim?

The HHSC definition for a clean claim matches the DADS definition of a clean claim for nursing facilities. A clean claim is a claim for services rendered to a member with the data necessary for the MCO to adjudicate and accurately report the claim.

An MCO's claims and adjudication requirements may not exceed or be more restrictive than the following DADS claims adjudication requirements.

  • The Nursing Facility resident must be Medicaid eligible for the dates of service billed;
  • The Nursing Facility resident must be in the Nursing Facility for the dates of service billed;
  • The Nursing Facility resident must have a current Medicaid Necessity determination for the dates of service billed; and
  • The Nursing Facility Provider had to be in good standing for the dates of service billed (i.e., not on vendor payment hold for any reason).

Authorizations

Will the MCO require authorizations? How frequently?

MCOs will not authorize services related to the Nursing Facility Unit Rate. NF Unit Rate authorizations will be provided to the MCOs by DADS as a result of 3618 and MDS Assessment processing -- there will be no changes to this process. The MCOs will require authorizations for Nursing Facility Add-on Services and acute care services. Authorizations and claims processing will vary between MCOs for Nursing Facility Add-on and acute care services.

Will the MCO deny a claim based on authorization?

MCOs may deny a Nursing Facility Add-on or acute care services claim based on authorization.

Will the MCO be able to move a patient into a lower level of care if they meet Medicaid level of care for a nursing facility?

If a nursing facility resident indicates in Section Q of the MDS, or otherwise indicates to the MCO that they would like to move into the community, the MCO will work with the resident, the nursing facility, and other involved parties regarding the request.  However, the MCO is contractually obligated to honor the choice of a resident who chooses to remain in the nursing facility and meets level of care.

Claims Submission Portals

What are the differences between using the TMHP portal vs. MCO portals for reimbursement that are being developed?

Nursing facilities will continue to be responsible for completion and timely submission of the 3618 and 3619 forms to the TMHP LTC Online Portal system. 

Nursing facilities may submit Nursing Facility Unit Rate or Nursing Facility Add-on Services claims to the STAR+PLUS MCOs through the TexMedConnect portal. The state portal will act as a router, ensuring claims are redirected to the appropriate STAR+PLUS MCO for adjudication. Nursing facilities should not submit corrections or adjustments to the state portal.

Other providers who serve nursing facility residents should submit their claims directly to the MCO.

The MCO provider portal functionality will include:

  • Client eligibility verification
  • Submission of electronic claims
  • Authorization requests
  • Claims appeals and reconsiderations
  • Exchange of data and other documentation necessary for authorization and claim processing

Regardless of whether the MCO receives a claim for adjudication directly from the provider or through the TexMedConnect portal, the MCOs must adjudicate a clean claim for Nursing Facility Unit Rates or Medicare coinsurance within 10 days of receipt through the MCO or the state portal, whichever occurs first.

Applied Income

What roles will the STAR+PLUS MCOs play in assisting providers with the collection of applied income from its members?

Nursing facilities will continue to make reasonable efforts to collect applied income (1 TAC § 19.2316) and document those efforts. A nursing facility should notify the MCO service coordinator or the MCO's designated representative when it has made two unsuccessful attempts to collect applied income in a month. The MCO service coordinator will assist by contacting the family and ensuring family members and the resident understand that if applied income remains unpaid, then the resident may not be allowed to stay in the nursing facility.

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Service Coordination

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What is STAR+PLUS service coordination?

STAR+PLUS service coordinators (SC) are the MCO representatives with primary responsibility for providing service coordination and care management to STAR+PLUS program members. All nursing facility residents will have a named MCO service coordinator who will work as part of the team to support nursing facility care planning. MCO service coordinators will have responsibility for coordinating and ensuring the delivery of Nursing Facility Add-on Services and acute care services. MCO service coordinators are required to conduct a substantive face-to-face visit with each member at least quarterly. MCO service coordinators also will work with the resident, families, and other service coordinators/case managers to ensure smooth transition to the community (when appropriate).

What is a nursing facility’s responsibility to the MCO service coordinator (SC)?

The NF is responsible for all of the following:

  • Inviting the MCO SC to provide input for the development of the NF care plan, subject to the member's right to refuse, by notifying the MCO SC when the interdisciplinary team is scheduled to meet. NF care planning meetings should not be contingent on MCO SC participation.
  • Notifying the MCO SC if a member is discharged to return home.
  • Notifying the MCO SC within one business day of unplanned admission or discharge to a hospital or other acute facility, skilled bed, or another nursing home.
  • Notifying the MCO SC if a member moves into hospice care.
  • Notifying the MCO SC within one business day of an adverse change in a member's physical or mental condition or environment that could potentially lead to hospitalization.
  • Coordinating with the MCO SC to plan discharge and transition from a NF.
  • Notifying the MCO SC within one business day of an emergency room visit.
  • Notifying the MCO SC within 72 hours of a member's death.
  • Notifying the MCO SC of any other important circumstances such as the relocation of residents due to a natural disaster.
  • Providing the MCO SC access to the facility, members' medical information and records, and NF staff.

What is the role of the STAR+PLUS MCO service coordinator?  What should providers expect from them in assisting in the management of the patients/residents served? Do MCO service coordinators have a role in assessing patients in a facility for appropriate placement or possible discharge?

Service coordinators (SCs) are the MCO representatives with primary responsibility for providing service coordination and care management to STAR+PLUS program members. All STAR+PLUS members within a nursing facility will have the same assigned MCO SC, and will receive quarterly face-to-face MCO service coordination contacts. An MCO may have more than one SC assigned to a nursing facility if the number of residents warrants it. Contracted nursing facility providers will agree to work with the MCO's SC or other designated representative to coordinate all medically necessary nursing facility add-on services.

If a resident indicates in Section Q of the MDS, or otherwise indicates to the MCO they would like to be moved into the community, the MCO will work with the resident, the nursing facility, and other involved parties regarding the request.

The MCO is responsible for all of the following:

  • Partnering with the member, family, NF care coordinator/staff and others in the development of a service plan, including services provided through the NF, add-on services, acute medical services, behavioral health services, and primary or specialty care. The approval of additional services outside of the NF Unit Rate is based on medical necessity and benefit structure. 
  • Participating in NF care planning meetings telephonically or in person, provided the member does not object.
  • Comprehensively reviewing the member's service plan, including the NF plan of care, at least annually, or when there is a significant change in condition.
  • Visiting members living in NFs in person at least quarterly. Visits should include, at a minimum, a review of the member's service plan and when possible, a person-centered discussion with the member about the services and supports the member is receiving, any unmet needs or gaps in the person's service plan, and any other aspect of the member's life or situation that may need to be addressed.
  • Assisting with the collection of applied income when a NF has documented unsuccessful efforts, per the state-mandated NF requirements.
  • Cooperating with representatives of regulatory and investigating entities including DADS Regulatory Services, the LTC Ombudsman Program, DADS trust fund monitors, Adult Protective Services, the Office of the Inspector General, and law enforcement.
  • Fulfilling requirements of the Texas Promoting Independence Initiative (PII) as described in UMCC Section 8.3.9.2. The quarterly in-person visits required of MCO SCs can include assessments required under the PII, and the MCO SC can serve as the designated point of contact for an individual referred to return to the community under PII.
  • Coordinating with the NF discharge planning staff to plan discharge and transition from the NF.
  • Notifying the NF within ten days of a change to the MCO's assigned service coordinator.
  • Returning a call from a NF within 24 hours after the call is placed by the NF.

Will onsite review of every Medicaid resident by the MCO be required?

All STAR+PLUS members within a nursing facility must have the same assigned MCO service coordinator (SC), and they must receive quarterly face-to-face MCO service coordination contacts. An MCO may have more than one SC assigned to a nursing facility if the number of residents warrants it. Contracted nursing facility providers will agree to work with the MCO's SC or other designated representative to coordinate all Medically Necessary Nursing Facility Add-on Services.

Other Provider Access

What impact will the transition to managed care have on residents and their families regarding choice of providers (for example ancillary services, pharmacy, and physician)?

HHSC encourages the STAR+PLUS MCOs and nursing facilities to work together to ensure network adequacy and maintain continuity of care; however, the STAR+PLUS MCOs are not required to contract with existing ancillary, pharmacy, or other providers.

If a nursing facility signs contracts with MCOs not in their region, or nursing facilities engage in a single case agreement for a patient/resident, do each of the nursing facility's ancillary providers (physicians, pharmacy, lab, DME etc.) have to sign a contract or single case agreement with that MCO as well?

Ancillary providers are not required to contract with the STAR+PLUS MCOs, although they're encouraged to do so to allow them to be reimbursed for providing services to existing members.

Will MCOs be required to contract with existing ancillary providers for pharmacy, lab, and x-ray?

The MCOs are not required to contract with existing ancillary providers, although HHSC is encouraging nursing facilities and MCOs to work together to ensure network adequacy and maintain continuity of care.

Will the MCOs be required to contract with attending physicians?

MCOs are not required to contract with existing attending physicians, although HHSC is encouraging nursing facilities, physicians, and MCOs to work together to ensure network adequacy and maintain continuity of care.

If physicians do not contract with the MCOs, then will the MCO have the ability to assign a physician?

The MCO may assign a network provider if an existing provider chooses not to contract with the MCO for acute care or Nursing Facility Add-on Services.  The MCO will not be obligated to provide a member with access to out-of-network services if such services become available from a network provider.

The MCO must ensure that the care of newly enrolled members is not disrupted or interrupted. The MCO must take special care to provide continuity in the care of newly enrolled members whose health or behavioral health condition has been treated by specialty care providers or whose health could be placed in jeopardy if Medically Necessary Covered Services are disrupted or interrupted. The MCO must ensure members receiving services through a prior authorization receive continued authorization of those services for the shortest period of one of the following: (1) 90 calendar days after the transition to a new MCO, (2) until the expiration date of the prior authorization, or (3) until the MCO has evaluated and assessed the member and issued or denied a new authorization.

MCO Enrollment

How will residents (current and potential) and families receive information about their choices in selecting a STAR+PLUS MCO as well as selecting a provider (i.e. nursing facility, physician)?

Residents or their designated representatives are encouraged to choose a STAR+PLUS MCO and primary care provider; if they don't make a choice, HHSC will assign them to a primary care provider and an MCO. Nursing facilities may inform residents with which MCO they are contracted; however, nursing facilities may not choose an MCO on behalf of the resident.

  • Nursing facility residents eligible for STAR+PLUS managed care will receive an introduction letter in November 2014 to announce the change.
  • Later in November 2014, HHSC will send enrollment packets to residents that will include a welcome letter, provider directory, MCO comparison chart, enrollment form, and frequently asked questions.
  • By mid-February 2015, residents must choose an MCO or HHSC will assign the resident to an MCO.

Can nursing facility residents change MCOs? What is the process for changing MCOs?

A resident may change his/her MCO by contacting MAXIMUS, the State's enrollment broker, at any time.  Residents may enroll by:

  • Mail: P.O. Box 14400, Midland, TX 79711-4400
  • Phone: 1-800-964-2777
  • Fax: 1-855-671-6038
  • In person at presentation sites and enrollment events: www.txmedicaidevents.com/  

Value-Added Services

What is a value-added service (VAS)?

Value-added services are additional services MCOs provide outside of traditional Medicaid services. VAS may be actual health care services, benefits, or positive incentives that HHSC determines will promote healthy lifestyles and improve health outcomes among members.  Each MCO offers a different set of VAS.

What types of value-added services will the MCOs provide to nursing facilities members?  How can a resident differentiate between MCOs?

Examples of value-added services that may be offered to nursing facility members include: dental, vision, podiatry, health and wellness services (for example smoking cessation), nursing facility welcome kits, Alzheimer's care, and gift cards. Because Medicaid benefits are identical across all STAR+PLUS MCOs, the MCOs use VAS to help distinguish themselves from one another, and nursing facility members may use VAS to help choose with which MCO they will enroll.

Planning/Next Steps

What recommendations does HHSC have for nursing facilities in anticipation of managed care roll out? What can the nursing facilities do to prepare?

  • Become familiar with the STAR+PLUS MCOs operating in counties where you serve residents.
  • Share your list of ancillary providers with the STAR+PLUS MCOs (PDF).
  • Let your ancillary providers know about the changes to nursing facilities and encourage them to reach out to the MCOs.
  • Ensure your rehabilitation therapists understand the distinction between billing practices currently and after March 1, 2015.
  • Ensure your medical director and attending physician(s) understand the distinction between billing practices currently and after March 1, 2015.
  • Provide each MCO with a list of the physicians currently serving as primary care physicians, specialists, and subspecialists for all your Medicaid-eligible residents.
  • Ensure your staff understands how to seek authorizations for add-on services from each MCO.
  • Make sure your social workers and other admissions staff understands the enrollment process so they may assist in explaining it to residents and families.
  • Be ready to answer questions about the changes to nursing facilities when residents and family members begin receiving letters in November 2014.
    • Make sure the mailing address and resident address (if different) are updated.
      • Find information to update your Medicare address here
      • Find information to update your Medicaid Address here, or
        • Call 1-800-252-8263 or dial 2-1-1
        • Go to www.YourTexasBenefits.com and follow these steps:
          • From the home page click “View my case.”
          • Follow the steps for setting up an account or logging in.
          • Click on the “Case facts” link near the top of the page.
          • Click on “Report a change to this case.