3110  Medicaid, Medicare and Dual-Eligibles

3111  Dual-Eligible Members

Managed care organizations (MCOs) are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member in developing an appropriate plan of care. MCOs are expected to provide innovative, cost-effective care from the outset in order to prevent or delay unnecessary institutionalization.

STAR+PLUS Medicaid-only members are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals receive all services, both acute care and long-term services and supports (LTSS), from the MCO.

Members who receive both Medicaid and Medicare (dual-eligibles) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare eligibility or services. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

3112  Medicaid Eligibility

At the time of the initial application for the HCBS STAR+PLUS Waiver (SPW), the STAR+PLUS Support Unit (SPSU) must obtain information on the applicant's Medicaid and/or financial status. SPSU must also obtain verification of the applicant's current eligibility for an appropriate type Medicaid program through the Texas Integrated Eligibility Redesign System (TIERS). If there is no existing acceptable coverage type, SPSU initiates the Medicaid financial eligibility determination process.

Refer to Section 3114, Applicants with Medicaid Eligibility, for Medicaid programs appropriate for SPW financial eligibility status.

Medicaid eligibility may have already been determined and must be used unless there have been changes in the applicant's financial situation. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Department of Aging and Disability Services (DADS) may not need to complete a new Form H1200. The SPSU coordinator must check with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding the need for a new Form H1200.

See Appendix V, Medicaid Program Actions, to determine if a program transfer by MEPD will be required. See also Section 3230, Financial Eligibility, for additional information regarding financial eligibility.

Note: The completion or signing of an application for an applicant/member does not automatically authorize a person to receive protected health information from SPSU or the managed care organization regarding that member/applicant. See Section 2119, Personal Representatives, for individuals who may receive or authorize the release of an applicant's/member's individually identifiable health information under Health Insurance Portability and Accountability Act privacy regulations.

3113  Transmittal of Form H1200 or Form H1200-EZ

When transmitting Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, to Medicaid for the Elderly and People with Disabilities (MEPD), the STAR+PLUS Support Unit faxes Form H1200 or Form H1200-EZ to MEPD. The Department of Aging and Disability Services (DADS) retains the original Form H1200 or Form H1200-EZ with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

If DADS staff are co-housed with MEPD, the original Form H1200 or Form H1200-EZ is hand-delivered to MEPD staff and DADS staff retain a copy of the form in the case record. If unusual circumstances exist in which the original must be mailed to MEPD after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 or Form H1200-EZ and sending by electronic mail is prohibited.

3114  Applicants with Medicaid Eligibility

At the time of the initial intake for the HCBS STAR+PLUS Waiver (SPW), the STAR+PLUS Support Unit (SPSU) coordinator must obtain information on the applicant's Medicaid and/or financial status. The SPSU coordinator must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from Medicaid for the Elderly and People with Disabilities (MEPD) staff or through inquiry in the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for SPW, the applicant must be on one of the following Medicaid programs:

Note: Individuals who are in Title XIX-approved nursing facilities are potentially eligible for SPW through Money Follows the Person.

Applicants who receive Supplemental Security Income are financially eligible for Medicaid and do not require a financial determination; the Social Security Administration has already made this determination.

Applicants receiving services through Community Attendant Services (TIERS TP14) are not automatically eligible for SPW. MEPD staff must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Department of Aging and Disability Services (DADS) may not need to complete a new Form H1200.

3115  Applicants Without Medicaid Eligibility

The Code of Federal Regulations, Section 42 CFR 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas State Plan designates the Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for Medical Assistance Only (MAO) cases.

Financial eligibility for non-Supplemental Security Income (SSI) HCBS STAR+PLUS Waiver (SPW) services is determined exclusively by Medicaid for the Elderly and People with Disabilities (MEPD) staff. STAR+PLUS Support Unit staff must not:

• screen applicants from referral to MEPD due to apparent financial ineligibility; or
• deny applications or recertifications based on financial eligibility criteria unless notified by MEPD of financial ineligibility.

If the applicant's individual income exceeds the SSI federal benefit rate (FBR) per month, the applicant applies for Medicaid through HHSC by completing Form H1200, Application for Assistance – Your Texas Benefits, for MAO. If the combined income of the applicant and the spouse exceeds the SSI FBR for a couple, the applicant may apply for MAO with HHSC. See Appendix VIII, Monthly Income/Resource Limits, for the current SSI FBR.

3116  Monthly Income Below the SSI Standard Payment

An applicant in the community (with no ineligible spouse) who has income less than the Supplemental Security Income (SSI) federal benefit rate must apply for SSI through the Social Security Administration. The Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except for cases in which the SSI application for disability has been pending for more than 90 days and a decision is made by HHSC Disability Determination Unit staff.

If there is a question whether the applicant should apply for SSI or for Medical Assistance Only, the STAR+PLUS Support Unit coordinator may consult regional Medicaid for the Elderly and People with Disabilities staff.

3117  Coordination with MEPD Staff

The STAR+PLUS Support Unit (SPSU) coordinator must inform the applicant/member without pre-existing Medicaid coverage and/or his/her representative that Medicaid for the Elderly and People with Disabilities (MEPD) staff will complete a financial eligibility (Medicaid) determination. The SPSU coordinator must encourage the applicant/member and/or representative to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by the SPSU coordinator must be shared with the MEPD specialist to prevent the applicant/member from having to provide the information twice.

The SPSU coordinator must inform MEPD staff of the request for HCBS STAR+PLUS Waiver (SPW) services according to regional procedures. For those applicants/members already on an appropriate type of Medicaid program, the SPSU coordinator must obtain a copy of the most recent:

• Form H1200, Application for Assistance – Your Texas Benefits;
• Form H1200-A, Medical Assistance Only (MAO) Recertification; or
• Form H1010, Texas Works Application for Assistance – Your Texas Benefits

An applicant for SPW who has MA coverage type Medicaid services may only receive SPW services after a program transfer to Medicaid waivers is completed by MEPD. When an applicant for SPW Waiver has MA coverage type as indicated in the Texas Integrated Eligibility Redesign System (TIERS), a completed Form H1200 must be sent to the applicant. The completed application must be forwarded to MEPD for processing.

The SPSU must also send an email to gay.smauley@hhsc.state.tx.us and aldonna.kroeker@hhsc.state.tx.us that includes the following information:

• the applicant’s name;
• applicant’s Medicaid number;
• individual has MA coverage-type Medicaid, which will require a program transfer; and
• name and phone number of the SPSU contact.

MEPD will make the necessary changes to allow the MA coverage-type Medicaid individual to receive SPW.

Identification of MA Coverage-Type Medicaid

SPSU staff can check TIERS to determine an individual’s coverage type. In TIERS, the coverage type on the Search/Summary Screen is displayed with the preface of MA.

An application form is not required for members receiving Supplemental Security Income (SSI).

If an SPW applicant's/member's application for SSI disability has been pending more than 90 days, the Health and Human Services Commission's Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDU staff to make a disability determination, DDU staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, MEPD staff are notified.

3117.1  Income and Resource Verifications for MEPD

Any information, including information on third-party insurance, obtained by the STAR+PLUS Support Unit (SPSU) coordinator must be shared with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to prevent the applicant/member from having to provide the information twice. Any information obtained by managed care organization staff must be immediately forwarded to the SPSU coordinator so it can be passed on to MEPD.

Inform Medical Assistance Only applicants of the importance of providing the most complete packet possible to MEPD. Explain that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

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

• Bank accounts – bank name, account number, balance and account verification (for example, a copy of the bank statement)
• Award letters showing the amount and frequency of income payments
• Life insurance policy – company name, policy number, face value or a copy of the policy
• A signed and dated Form 0003, Authorization to Furnish Information
• Confirmation that Medicaid Estate Recovery Program information was shared with the applicant by checking the appropriate box on Form H1746-A, MEPD Referral Cover Sheet
• Preneed funeral plans – name of the company, policy/plan number and a copy of the preneed agreement
• Correct and up-to-date phone numbers
• Power of Attorney or Guardianship – copy of the legal document

The SPSU coordinator must inform MEPD staff of the request for HCBS STAR+PLUS Waiver (SPW), according to regional procedures. The SPSU coordinator should obtain a copy of the most recent Form H1200, Application for Assistance – Your Texas Benefits, for those applicants/members already on an appropriate type of Medicaid program. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

If an SPW applicant's/member's application for SSI disability has been pending more than 90 days, the Health and Human Services Commission Disability Determination Services (DDS) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDS staff to make a disability determination, DDS staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, MEPD staff will be notified.

3117.2  MAO Applicants Not Previously Certified in TIERS

A new application is defined as an application for a Medicaid for the Elderly and People with Disabilities (MEPD) household not previously certified in either the Texas Integrated Eligibility Redesign System (TIERS).

Once staff determine applicants being referred to MEPD for a financial determination do not have any prior certifications in TIERS, Form H1746-A, MEPD Referral Cover Sheet, and Form H1746-B, Batch Cover Sheet, must be used to send Form H1200, Application for Assistance – Your Texas Benefits, Form H1200-EZ, Application for Assistance – Aged and Disabled, or Form H1010, Texas Works Application for Assistance – Your Texas Benefits, to the Midland Document Processing Center (DPC). Form H1746-B must be attached to the top of each batch containing more than one Form H1746-A being sent to DPC.

3117.3  Unsigned Applications

Unsigned applications received by Medicaid for the Elderly and People with Disabilities (MEPD) staff are returned to the sender. Department of Aging and Disability Services (DADS) staff must ensure applications are signed prior to referring to MEPD; if not, DADS staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

• Form H1200, Application for Assistance – Your Texas Benefits;
• Form H1200-EZ, Application for Assistance – Aged and Disabled (Large Print);
• Form H1200-A, Medical Assistance Only (MAO) Recertification; and
• Form H1010 – Texas Works Application for Assistance – Your Texas Benefits.

If MEPD receives an unsigned application from DADS with Form H1746-A, MEPD Referral Cover Sheet, MEPD returns the application to DADS with an annotation on the cover form (Form H1746-A) that the application is unsigned and must be signed before the agency (Health and Human Services Commission) can establish a file date. Once DADS staff receive an unsigned application from MEPD, it is the responsibility of DADS staff to coordinate with applicants/members in getting applications signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and DADS eligibility processes and could adversely affect service delivery to applicants/members.

3117.4  Medicaid Eligibility Decisions Pending Past the Program Due Date

For most Medicaid for the Elderly and People with Disabilities (MEPD) applications, eligibility decisions are due by the 45th day. However, applications for individuals under age 65 may require a 90-day time frame to allow the agency to obtain a disability determination. This applies when the person's age is less than 65 and the person does not receive Retirement, Survivors and Disability Insurance (RSDI), Supplemental Security Income (SSI) or Railroad Retirement (RR). A disability determination by the Health and Human Services Commission is required even if the person has received a medical necessity and level of care determination under the HCBS STAR+PLUS Waiver (SPW) eligibility component criteria.

For other case actions (for example, program transfers), MEPD staff may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income/resources. STAR+PLUS Support Unit (SPSU) staff may inquire about these cases once they have been pending more than 45 days.

A list of individuals to contact when the SPSU is attempting to determine the status of MEPD case actions that have passed MEPD program due dates can be found in Appendix III, Medicaid for the Elderly and People with Disabilities (MEPD) Management Team. SPSU staff must not contact MEPD until the MEPD due date has passed.

Once the deadline has passed, SPSU staff may contact the program manager's administrative assistant at the number provided in the right-hand column of the list. Do not contact the program manager directly.

3118  Address Changes for Supplemental Security Income (SSI) Recipients

The STAR+PLUS Support Unit (SPSU) must not send address change requests for SSI recipients to the Document Processing Center (DPC) in Midland. The SPSU must inform the individual or his responsible party to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System (TIERS) after SSA makes the change.

The SPSU must also send an email to the Health Plan Operations (HPO) mailbox to notify Managed Care Operations of the request for a change in address.

3120  Other Available Services

3121  Prescription Drugs

Prescription drugs are not part of the managed care organization's (MCO's) array of services. STAR+PLUS Medicaid-only members continue to have prescriptions filled by any pharmacist participating in the state's Vendor Drug Program. They will receive unlimited medically necessary prescriptions instead of the traditional three prescriptions per month limit. Drug coverage through Vendor Drug is limited to the state's formulary and may not cover all of the prescribed medications required for the individual.

Medicare prescription drug coverage (Medicare Part D) is insurance that covers both brand name and generic prescription drugs at participating pharmacies in the member's area. Medicare prescription drug coverage provides protection for people who have very high drug costs. Medicare members are eligible for this coverage, regardless of income and resources, health status or current prescription expenses. Members who are eligible for both Medicaid and Medicare (dual-eligible) receive the majority of their drugs through Medicare Part D.

The MCO must inform individuals requesting STAR+PLUS program services of prescription coverage available through the STAR+PLUS program and the Medicare Part D program. The following information regarding the impact of the Medicare Part D program on members must be explained to the applicant:

• If a member is considered dual-eligible (receiving both Medicare and Medicaid), the member obtains prescriptions first through Medicare Part D or, for certain prescribed drugs excluded from Medicare Part D, through the Vendor Drug Program.
• Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all of the prescribed medications required for the individual. Prescriptions not covered by Medicare Part D may be paid by the Medicaid Vendor Drug Program; however, the Medicaid Vendor Drug formulary does not cover certain prescription drugs and over-the-counter medications.
• Members who participate in Medicare Part D are responsible for purchasing any medications and copayments for medications not covered through Medicare Part D or the Medicaid Vendor Drug Program.
• Members not participating, or those choosing private insurance over Medicare Part D, are also responsible for purchasing medications and copayments for medications not covered by Medicare Part D or the Medicaid Vendor Drug Program.
• Members eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program. These members pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may not be authorized for prescriptions, copayments and costs if the member is eligible for Medicare Part D and chooses private insurance rather than participation in Medicare Part D. Non-covered medications cannot be billed through the STAR+PLUS program as medical supplies or adaptive aids.

Copayments for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through the STAR+PLUS program.

Members who contribute to the cost of their care may be eligible to count Medicare Part D costs as an incurred medical expense if they:

• reside in the community and have a Qualified Income Trust; or
• receive Assisted Living or Adult Foster Care services.

For a member whose current Medicaid identification card does not include the statement "can receive more than three prescriptions," pharmacists may verify the STAR+PLUS program eligibility for more than three prescriptions by calling Pharmacy Billing at 1-800-435-4165.

A list of the STAR+PLUS program enrollments is sent to the Medicaid Vendor Drug Program daily. Vendor Drug staff register the member on the system within two days after the member's enrollment record is registered for STAR+PLUS Program services.

Pharmacists must check the member's Your Texas Benefits Medicaid card monthly to ensure that the member remains eligible for Medicaid.

HCBS STAR+PLUS Waiver (SPW) members who contribute to the cost of their care may be eligible to count Medicare Part D costs as incurred medical expenses. Refer to Section 3123, Incurred Medical Expenses.

3122  Over-the-Counter Drugs

The HCBS STAR+PLUS Waiver (SPW) does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

Medications, including over-the-counter drugs not covered through the Medicaid Vendor Drug Program, Medicare Part D or other third-party resources, cannot be paid for by SPW. Refer to Section 3121, Prescription Drugs, for additional information.

3123  Incurred Medical Expenses

Incurred medical expenses (IMEs) are out-of-pocket expenses a Medical Assistance Only member can incur for necessary medical services. IMEs include the cost of medically necessary items not covered by Medicaid, such as Medicare Part D premiums.

HCBS STAR+PLUS Waiver (SPW) members who contribute to the cost of their care may be eligible to count Medicare Part D costs (such as premiums, enhanced premiums, prescription drug copayments/deductibles, drugs not covered by Medicare Part D, the Medicaid Vendor Drug Program and non-formulary drugs) as IMEs if they:

• reside in the community and have a Medicaid copayment as a result of a Qualified Income Trust; or
• reside in an Adult Foster Care home or Assisted Living facility.

Members who wish to use IMEs to pay for Medicare Part D costs should report these costs to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist so the costs can be included in the calculation of copayment for waiver services. The member's statement of Medicare Part D expenses is acceptable. No written documentation is required from the member to support the declaration. The arrangement for payment of the prescriptions is between the member and the pharmacist.

Some drugs are not covered by Medicare Part D, Medicaid or private drug coverage. In order for these non-formulary drugs to be considered as IMEs, a member must request an exception from the Medicare Part D plan for the drugs. The member is expected to use the procedure for requesting an exception, as required by his/her Medicare Part D plan. The member can submit the results of the requested exception directly to MEPD staff. If an exception is not requested, the non-formulary drugs are not allowable IMEs and the cost will be the responsibility of the member.

MEPD applies the IME policy during the certification process to all new members who meet the above criteria. MEPD also reviews Medicare costs and IMEs once every six months as part of the regular case monitoring, or whenever the member makes a request to update IME costs. The member or his/her representative may identify and request IMEs by contacting the MEPD specialist.

3124  Medical Transportation

HCBS STAR+PLUS Waiver (SPW) members, as recipients of Medicaid, are eligible to use the Medicaid medical transportation system for Medicaid-covered medical appointments. The Medicaid medical transportation system is accessed by calling the local agency whose number should be available from the Texas Health and Human Services Commission. Adult Foster Care (AFC) and Assisted Living (AL) providers are responsible for scheduling transportation for the residents.

The local medical transportation contractors have procedures regarding service area limitations, schedules for traveling to certain areas and requirements on the amount of notice required by SPW members. The AFC/AL provider must provide an escort for the participant, if necessary.

There may be questions about eligibility for participants who are living in AFC/AL facilities. In cases of difficulties in scheduling, or questions about eligibility for transportation, participants should contact the managed care organization to intercede on the participant's behalf with the local Medicaid medical transportation system.

3125  HCBS STAR+PLUS Waiver (SPW) Members Requesting Non-Managed Care Services

Requirements of the HCBS STAR+PLUS Waiver (SPW) provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, Community Care for Aged and Disabled services cannot be authorized for SPW members. SPW members requesting additional services must be referred to the managed care organization's service coordinator.

3126  STAR+PLUS Services Members Requesting Non-Managed Care Services

Individuals receiving STAR+PLUS services are potentially eligible to receive a variety of services from the Department of Aging and Disability Services. For specific information, see:

• Section 3126.1, Community Care for Aged and Disabled Services; and
• Section 3126.2, In-Home and Family Support Program Services.

3126.1  Community Care for Aged and Disabled Services

If members meet program requirements, STAR+PLUS Services members are eligible to receive the following Community Care for Aged and Disabled (CCAD) services:

• Adult Foster Care
• Residential Care
• Emergency Response Services
• Home-Delivered Meals
• Special Services to Persons with Disabilities

Members may also be eligible for Family Care if the managed care organization (MCO) has denied their request for personal attendant services due to the:

• lack of practitioner's statement of need for the services; or
• lack of personal care tasks.

STAR+PLUS Services members may never receive the following services from the Department of Aging and Disability Services (DADS):

• Day Activity and Health Services
• Community Attendant Services
• Primary Home Care
• Assisted Living

An individual requesting Community Care services should be added to any applicable interest lists at the time of the request, in order to protect the date and time of the request. Prior to processing an application, the CCAD case manager must verify the service array does not include a service equivalent of the Title XX service requested. They may view the STAR+PLUS Program Health Plan Comparison Charts and value-added services on the Health and Human Services (HHSC) website at:
http://www.hhsc.state.tx.us/starplus/ComparisonCharts.html.

Value-added services offered by an MCO are extra services approved by HHSC. Value-added services will vary by MCO. DADS staff are not required to wait for appeal decisions from MCOs to process requests for Title XX services if the service requested is not a value-added service on the member’s plan. Once released from the Title XX interest list, the CCAD case manager verifies the applicant’s MCO does not offer an equivalent service as a value-added service and proceeds with the eligibility determination for the requested Title XX service.

The member should be asked if he or she has requested the service from the MCO, if the requested service is not a value-added service but is part of the MCO's service array. If the answer to that question is:

• no, the community care case manager refers the individual to the MCO.
• yes, and services were approved, the community care case manager refers the individual to the MCO to initiate service delivery.
• yes, and services were not approved or the individual doesn't know if they were approved, the community care case manager contacts the STAR+PLUS Support Unit (SPSU). Once SPSU confirms services were not approved, the application can be processed.
• unsure, the community care case manager refers the individual to SPSU. SPSU will contact the MCO to inquire about the request.

Once released from the interest list, Community Care case managers may proceed to determine eligibility. Process applications for individuals who are enrolled in STAR+PLUS Services managed care only if they meet the criteria outlined above. Do not authorize Title XX services for anyone receiving HCBS STAR+PLUS Waiver (SPW).

3126.2  In-Home and Family Support Program Services

Individuals receiving STAR+PLUS services may receive In-Home and Family Support Program services (IHFSP) if:

• they meet program requirements; and
• receiving IHFSP would not result in a duplication of services.

Individuals requesting IHFSP should be added to any applicable interest lists at the time of the request in order to protect the date and time of the request. At the time of release from the interest list, the IHFSP case manager must contact the STAR+PLUS Support Unit (SPSU). The SPSU coordinator will contact the managed care organization (MCO) to ensure IHFSP does not deliver any services already being supplied by the MCO.

Do not authorize IHFSP services for anyone receiving HCBS STAR+PLUS Waiver (SPW).

3127  Health Insurance Premium Payment Program

The Health Insurance Premium Payment (HIPP) program is a Medicaid program that reimburses eligible individuals for their share of an employer-based health insurance premium payment. In order to qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The reimbursement may pay for individuals and their family members to receive employer-sponsored health insurance benefits when it is determined the cost of insurance premiums and administration are less than the cost of projected Medicaid expenditures.

Individuals who participate in the HIPP program may not participate in any Medicaid managed care program, including STAR+PLUS. HIPP program participation requires individuals to access their benefits through traditional fee-for-service Medicaid.

There is no HIPP indicator in any DADS automated system; therefore, staff will only be aware of HIPP coverage if reported by the individual. HIPP recipients who contact STAR+PLUS Support Unit staff requesting managed care services must be informed they must choose between HIPP and managed care. If an individual wishes to withdraw from HIPP in order to enroll in STAR+PLUS, he must first contact a HIPP specialist at 1-800-440-0493 to request disenrollment.

3210  Service Delivery Areas

STAR+PLUS services are currently available in the following areas:

3220  Eligible Groups

3221  Mandatory Groups

The following groups of individuals, unless under age 21, must receive services through STAR+PLUS. Individuals under age 21 may be served by STAR+PLUS, but their participation is not mandatory. The program designations are used in the following list.

• Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) TA 01, TA 02 and TA 22 — Individuals who qualify for this needs-tested program administered by the Social Security Administration (full Medicaid recipients).
• Pickle Amendment Group, TIERS TP 03 — Individuals who would continue to be eligible for SSI benefits if cost of living increases (COLAs) were deducted from their countable income.
• Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), aged 60-65 and with a disability, who:
  • were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
  • are ineligible for Medicare; and
  • would continue to be eligible for SSI benefits in the absence of those early aged widow's/widower's benefits and any increases in those benefits.
• Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), aged 50-60 and with a disability, who:
  • are ineligible for Medicare and were denied SSI due to an increase in widow's/widower's benefits as a result of the relaxing of disability criteria; and
  • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
• Disabled Adult Children, TIERS TP 18 — Adults with a disability that began before age 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
• Medicaid Buy-In, TIERS TP 87 (designated in TIERS as "ME — Medicaid Buy In") — Disabled working adults who receive full Medicaid benefits as a result of buying into the Medicaid program.
• Community Based Alternatives Program, TIERS TA 10 — Aged or disabled individuals who receive a wide variety of home and community-based services as cost-effective alternatives to institutional care in nursing facilities.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact the STAR+PLUS Support Unit and provide the details for disenrollment from STAR+PLUS.

3222  Excluded Groups

§353.603 — Client Participation

(a)

All supplemental security income (SSI) and SSI-related clients and clients who qualify for Medicaid benefits as medical assistance only (MAO) clients must receive their Medicaid services through the STAR+PLUS pilot. Clients will have a choice among at least two Health Maintenance Organizations.

(b)

SSI or SSI-related clients who are receiving services from the following programs are excluded from participation in STAR+PLUS:

(1)

Frail Elderly waiver;

(2)

Community Living Assistance and Support Services (CLASS) waiver;

(3)

Deaf Blind Multiple Disabled waiver;

(4)

Mental Health/Mental Retardation (MHMR) Home and Community-based Services (HCS) waiver and Home and Community based Services-OBRA (HCS-OBRA) waiver;

(5)

Medically Dependent Children Program (MDCP) waiver;

(6)

clients receiving services in residential MHMR facilities;

(7)

clients who qualify for Medicaid based on residency in a nursing facility (Medical Assistance Only);

(8)

members of a managed care organization after four months of residency in a nursing home; and

(9)

clients who are in a nursing facility prior to managed care enrollment.

(c)

SSI clients under 21 years of age, SSI clients receiving ongoing rehabilitative services through the local mental health authority, and SSI clients on the waiting list to receive MHMR HCS waiver services will have the option of STAR+PLUS participation or choosing the Primary Care Case Management Program for their acute care services and remaining fee-for-service for their long term care services.

The following groups are always excluded from participation in the HCBS STAR+PLUS Waiver (SPW):

• individuals receiving services from any 1915(c) waiver except Community Based Alternatives;
• residents of intermediate care facilities for persons with intellectual disability;
• individuals not eligible for full Medicaid benefits outside an institution (for example, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Community Attendant Services individuals);
• nursing facility residents;
• individuals with no Medicaid benefits; and
• children in state foster care.

The following individuals may be able to participate in SPW under certain circumstances:

• individuals not covered by Medicaid who are able to obtain Medical Assistance Only Medicaid eligibility; and
• nursing facility residents who are able to transition to the community under Money Follows the Person procedures.

3223  Hospice Services in STAR+PLUS

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of Hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, Hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF Hospice services can be identified in the Service Authorization System (SAS) as Service Group (SG) 8, Service Code (SC) 31. SG8/SC31 authorizations do not start the NF counter for disenrollment. The NF counter is activated by non-Hospice NF authorizations, which appear in SAS as SG1/SC1 or SG1/SC3. Do not contact Managed Care Operations to request disenrollment based on SG8/SC31 enrollments.

3230  Financial Eligibility

HCBS STAR+PLUS Waiver (SPW) applicants who are not already Medicaid eligible are required to complete Form H1200, Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed application form must be sent to Medicaid for the Elderly and People with Disabilities (MEPD) staff by close of business of the second business day from receipt. MEPD has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Applicants have 30 days from the mail date of the application to complete, sign and return Form H1200. After 30 days, the application must be denied for failure to return the information needed to determine financial eligibility. Before denying the application, STAR+PLUS Support Unit staff must check first to make sure the application form was not mailed directly to MEPD.

If denial is necessary, document "Your application is being denied because you failed to return the application form mailed to you on [date]" in the comments section of Form 2065-D, Notification of STAR+PLUS Program Services.

See Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for SPW.

3231  Income Diversion Trust

An applicant who has a Qualified Income Trust (QIT) may be determined eligible for HCBS STAR+PLUS Waiver (SPW) services even though his or her income is greater than the special institutional income limit, if the applicant also meets all other eligibility criteria. Income converted to the trust does not count for purposes of determining financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD); however, the total income (including income diverted to the trust) is considered for the calculation of copayment for SPW services. An applicant may be eligible for services if all other eligibility criteria are met, even if the amount he or she has available for copayment equals or exceeds the total cost of his/her individual service plan (ISP).

Financial eligibility for an applicant with a QIT is determined by MEPD staff. He or she is informed that any funds deposited into the trust must be used as copayment for the cost of services delivered. The MEPD specialist calculates the amount of income available from the trust for copayment and provides the amount to the STAR+PLUS Support Unit (SPSU). SPSU notifies the managed care organization (MCO) via Form 2067, Case Information.

For an applicant who is financially eligible based on a QIT, the eligibility based on the ISP cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase waiver services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of waiver eligibility. A member with a QIT copayment that covers all waiver costs receives the benefit of contracted rates as opposed to private pay rates.

First, a plan of care is developed by the MCO without consideration of the trust. Then, if the individual is eligible for the waiver based on the cost limit, the excess funds from the trust (the monthly income in excess of the institutional income limit and allowable deductions for a spouse's needs and medical expenses) are allocated to pay for services identified on Form H1700-1, Individual Service Plan – SPW (Pg.1), as waiver services. The ISP total, and therefore the amount of the authorizations to providers, is reduced by the amount of excess funds. The member must pay the provider directly for the amount of services equivalent to the amount of excess funds. Use of the trust fund is documented on Form 8598, Non-Waiver Services. Continuing Medicaid eligibility through the waiver is contingent upon payment of the QIT copayment to the provider(s).

Refer to Section 3236, Copayment and Room and Board, and Section 3232, Payments from the Qualified Income Trust, for specific SPSU and MCO procedures related to QIT copayments.

3232  Payments from the Qualified Income Trust

Applicants/members with a Qualified Income Trust (QIT) are responsible for a copayment in Adult Foster Care (AFC), Assisted Living (AL) or the at-home setting. The managed care organization (MCO) must clearly explain to the applicant/member the funds from the QIT determined to be available for copayment must be used to purchase waiver services. Payments are made directly to the AFC, AL or other provider.

For applicants/members residing in AFC or AL settings, the copayment amount is usually applied to the cost of AFC or AL first. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other STAR+PLUS Waiver services, such as nursing, personal assistance services (PAS) or medical supplies. For applicants/members at home, the copayment is first used to purchase PAS, nursing or medical supplies. The MCO calculates the type and amount of payment the applicant/member will make directly to the service provider using the following steps:

• The MCO develops the individual service plan (ISP) showing the total requested services and total cost of the ISP without consideration of the amount of services the QIT copayment will purchase.
• Once the ISP has been developed, the MCO uses the QIT copayment amount provided by Medicaid for the Elderly and People with Disabilities staff to determine the units of service to be purchased from the trust. The units of service are determined by dividing the monthly copayment amount by the unit rate for the service and rounding the result to the next lower half unit. The MCO documents the amount of services the member must pay directly to the provider(s) and obtains the applicant's/member's agreement. Refer to Section 3234, Qualified Income Trust Copayment Agreement, for specific details about documenting the agreement.
• The MCO develops a second Form H1700-1, Individual Service Plan – SPW (Pg.1), to reflect the amount of services reduced by the QIT copayment amount. The second Form H1700-1 is annotated in the top margin as "Adjusted ISP for QIT Copayment." For the service category where the QIT payment will be applied, the monthly units to be purchased through the copayment are multiplied by 12 to determine an annual amount of services to be purchased. This amount is subtracted from the total authorized amount to determine the new service units to be authorized and the new ISP total. Form 8598, Non-Waiver Services, is used to document the specific services provided through the QIT.
• The amounts on the adjusted ISP are entered into the Service Authorization System (SAS). The total available QIT copayment amount is not entered on Form H1700-1 and is not reflected in SAS copayment screens for QIT members living at home. If the member lives in an AFC or AL setting, the calculated QIT copayment amount will be reflected in the Copayment screens in SAS. Refer to the information in Section 3233, Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL, if the available QIT copayment amount is sufficient to fully pay for AFC or AL. The copayment amount for services other than AFC or AL is documented on Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and Form 2065-D, Notification of STAR+PLUS Program Services.
• The adjusted ISP and Form 1578 are sent to the service provider(s). The provider will review the adjusted ISP and attachments to determine the acceptance of a referral.
• Form 2065-D is used to notify the member and provider(s) of the amount of copayment to be made directly to the provider(s). QIT copayment amounts to the MCO contracted provider are shown on Form 2065-D in the comments section.

3233  Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL

If the available Qualified Income Trust (QIT) copayment amount exceeds the daily rate for Adult Foster Care (AFC) or Assisted Living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment amount remains after the monthly copayment amount is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to Section 3235, Refusal to Pay Qualified Income Trust Copayment.

3234  Qualified Income Trust Copayment Agreement

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

• service purchased;
• amount available for copayment;
• unit rate;
• units purchased; and
• monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in Adult Foster Care (AFC) or Assisted Living (AL) settings, the copayment amount is usually applied to the cost of AFC or AL. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase PAS, nursing or medical supplies.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-MC, 1915(c) STAR+PLUS Waiver Addendum to Form 2060, or other individual service plan attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

3234.1  Calculation Example and Completion of Form 1578

There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) it equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Next, calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan — SPW (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to enter on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization discusses the copayment with the applicant/member and the trustee of the trust. After explaining the requirements, the applicant/member, his responsible party and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant/member and/or his responsible party and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant's/member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant/member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.

3235  Refusal to Pay Qualified Income Trust Copayment

The trustee of the Qualified Income Trust (QIT) must pay the QIT copayment directly to the provider by the 10th day of the month, or not later than 10 calendar days after STAR+PLUS Waiver services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form 2067, Case Information, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

• write a letter to the member and the trustee explaining the consequences of continued failure to pay; and
• notify Medicaid for the Elderly and People with Disabilities (MEPD) staff that the trustee has refused to make the copayment.

If the copayment is not fully paid within 30 calendar days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form 2067.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify MEPD staff of the refund.

Refer to Section 7100, Adult Foster Care, for procedures related to failure to pay copayment.

3236  Copayment and Room and Board

Members who are determined to be financially eligible based on the special Medical Assistance Only institutional income limit may be required to share in the cost of waiver services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for HCBS STAR+PLUS Waiver (SPW).

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the HCBS STAR+PLUS Waiver (SPW) and specified on the member's individual service plan. The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized waiver services.

To determine the room and board amounts for members residing in Adult Foster Care or Assisted Living settings, apply the following post-eligibility calculations:

• for individuals, the room and board amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance;
• for SSI couples, the room and board amount is the SSI FBR [for a couple] minus the personal needs allowance for an individual multiplied by two; or
• for couples with incomes that exceed the SSI FBR for couples, the room and board amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the room and board amount for an individual.

Some individuals will be responsible for contributing toward the cost of SPW services. This is referred to as copayment and/or room and board charges. The copayment amount is not a factor in determining the individual's eligibility for services.

MEPD staff calculate copayment and deduct allowable incurred medical expenses for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a Qualified Income Trust (QIT). Refer to Section 3123, Incurred Medical Expenses, and Appendix XXII, §1915(c) Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance, are not required to make a copayment and no copayment calculation is necessary for them. SPW members who reside in Adult Foster Care (AFC) or Assisted Living (AL) settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the applicant, if it is determined the applicant must pay a monthly copayment, that the copayment amount must be paid directly to the AL or AFC provider. All SPW members, including SSI recipients, are required to pay room and board in AL and AFC settings.

The MCO must also explain to the member that the member is required to pay the AFC or AL provider a room and board charge. If the member fails to pay the agreed-upon room and board charge and/or copayment, the member could be terminated from the SPW program.

Refer to Appendix VI, Calculation of Copayment and Room and Board for SPW Members, for examples of how to calculate the monthly room and board and monthly amounts available for copayment.

STAR+PLUS Support Unit coordinators notify the member and the provider of new copayment amounts to be collected on Form 2065-D, Notification of STAR+PLUS Program Services.

Refer to Section 3232, Payments from the Qualified Income Trust, and Section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

3237  Determining Room and Board Charges

All HCBS STAR+PLUS Waiver (SPW) individuals must pay the room and board charges to be eligible for Assisted Living (AL). Room and board cannot be waived, but an AL facility may choose to accept an individual for a lower amount. SPW policy does not direct the facility to accept or reject the individual.

The room and board charge for an individual is fixed at the amount remaining after subtracting $85 from the Supplemental Security Income (SSI) federal benefit rate (FBR). FBR current amounts are found in Appendix VIII, Monthly Income/Resource Limits, which is updated when the FBR changes.

For couples where both partners are residing in AL or Adult Foster Care (AFC) settings, $170 is subtracted from the couple's income so each member of the couple keeps $85 a month for personal needs and the remainder is the room and board charge for the couple. Due to the difference in income between couples and individuals, the amount of room and board charge for a couple depends on income.

• For SSI couples, the room and board charge is the FBR for a couple minus the $170 personal needs allowance.
• For couples who are not SSI recipients, but whose income is less than the current FBR for an individual doubled, the room and board charge is their monthly income minus the $170 for personal needs.
• For couples whose income exceeds twice the SSI FBR for an individual, the full room and board charge for two individuals is required.

The AL/AFC participant will keep $85 a month for personal needs.

Refer to Appendix VI, Calculation of Copayment and Room and Board for SPW Members, for instructions about how to calculate room and board for a partial month.

3238  Determining Copayment Amounts

After determining financial eligibility for Medicaid, Medicaid for the Elderly and People with Disabilities (MEPD) staff determine the amount of money available for copayment. MEPD staff send Form 2067, Case Information, or Form H1746-A, MEPD Referral Cover Sheet, and a copy of the completed MEPD Waiver Program Copayment Worksheet to the STAR+PLUS Support Unit (SPSU) indicating the amount available for the monthly ongoing copayment. SPSU forwards this information to the managed care organization (MCO) by posting Form 2065-D, Notification of STAR+PLUS Program Services, to TxMedCentral.

3239  Copayment Changes

A member's copayment may change during the time he is receiving HCBS STAR+PLUS Waiver (SPW) services, typically due to a change in income or medical expenses. Copayment changes must always be effective on the first day of the month. If the copayment is increasing, the STAR+PLUS Support Unit (SPSU) must send the member and managed care organization (MCO) notification on Form 2065-D, Notification of STAR+PLUS Program Services, and the increase is effective the first day of the month after the expiration of the adverse action period. The MCO is responsible for notifying the provider.

If the first day of the month occurs before the end of the adverse action period, the copayment increase is effective the first day of the subsequent month. Decreases in copayment require Form 2065-D notification, but can be effective the first day of the month after the notification is sent.

Copayments may also change due to other circumstances. Medicaid for the Elderly and People with Disabilities (MEPD) staff are responsible for calculating and handling fraud referrals. Notices and letters on these issues are prepared by MEPD staff with copies to SPSU staff. MEPD staff inform SPSU of fraud referrals and determine whether any corrections are necessary to the member's copayment based on a change in the amount available for copayment. SPSU posts Form 2067, Case Information, to inform the MCO of any change in the copayment amount.

Underpayments by the member that are not part of a fraud referral, such as those based on reconciliation of variable income, result in MEPD staff sending a letter to the member requesting that the member pay the MCO the amount of copayment that was underpaid. SPSU is not responsible for determining if the underpayment is made to the MCO. The underpayment is not retroactively considered in the copayment calculation. The MEPD specialist notifies SPSU if the ongoing copayment amount increases. If the amount does increase, SPSU staff must post Form 2065-D notifying the MCO of the increase in the monthly copayment amount. The increase in copayment is effective the first day of the month after the expiration of the adverse action period indicated on Form 2065-D.

Refunds due to the member require a new copayment calculation be completed. The copayment may be calculated to allow the refund to be deducted from the member's next copayment amount due to the provider or the member may be given a reimbursement by the Adult Foster Care/Assisted Living (AFC/AL) provider if there are no future copayments. The MCO determines if the AFC/AL provider should submit a negative billing. The effective date of the decrease in copayment is the first of the month after Form 2065-D is sent.

Example: The member's ongoing copayment is $100 per month. MEPD determines a copayment amount of $75 should have been effective February 1. A refund of $25 per month for the months of February, March, April and May total $100. SPSU finds out about the new amount on May 20 and immediately posts Form 2065-D notifying the MCO. The MCO contacts the provider of the member's new copayment amounts: June – $0, July – $50, August – $75, ongoing.

Additional information on copayment and room and board payments is included in Appendix VI, Calculation of Copayment and Room and Board for SPW Members.

3240  Waiver Requirements

The HCBS STAR+PLUS Waiver (SPW) is provided by virtue of authority granted to the state of Texas to allow delivery of long-term services and supports that assist members to live in the community in lieu of a nursing facility. To be eligible for services under SPW, the following criteria must be met:

• medical necessity (see Section 3241, Medical Necessity Determination);
• services under the established cost limits (see Section 3242.1, Maximum Limit);
• the member's unmet need for at least one waiver service (see Section 3242.2, Unmet Need for at Least One Waiver Service); and
• full Medicaid coverage.

3241  Medical Necessity Determination

An HCBS STAR+PLUS Waiver (SPW) applicant/member must have a valid medical necessity (MN) determination before admission into the SPW program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant's/member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for SPW applicants/members. TMHP processes MN/LOC Assessments for applicants/members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of NF staffing intensity and is used in waiver programs to:

• categorize needs for applicants/members; and
• establish the service plan cost limit.

When TMHP processes an MN/LOC Assessment, a three-alphanumeric digit RUG appears in the Level of Service record in the Service Authorization System (SAS) and in the TMHP Long Term Care (LTC) online portal. An MN/LOC Assessment with incomplete information will result with a BC1 code instead of a RUG value. An MN/LOC Assessment resulting with a BC1 code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. Code BC1 is not a valid RUG to determine SPW eligibility.

The MCO nurse must correct the information on the MN/LOC Assessment within 14 calendar days of submitting the assessment that resulted in a BC1 code. After 14 calendar days, the MCO nurse must inactivate the MN/LOC Assessment and resubmit the assessment with correct information to TMHP.

For applicants/members needing a Medicaid eligibility financial decision, the STAR+PLUS Support Unit (SPSU) must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the applicant/member meets MN. This notification can be by telephone or may be documented on Form H1746-A, MEPD Referral Cover Sheet, which the SPSU sends to the MEPD specialist. The MEPD specialist may view the SAS or LTC online portal to confirm that the applicant/member has met the MN criteria.

3241.1  Medical Necessity Determination for Applicants Residing in Nursing Facilities

During the initial contact with the applicant/member, the STAR+PLUS Support Unit (SPSU) must explore the applicant's/member's status in the nursing facility (NF) and determine whether the applicant/member has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. Communication with the NF regarding plans for submittal of the MN/LOC Assessment may be necessary. SPSU must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary and to avoid duplication of submittal to Texas Medicaid & Healthcare and Partnership (TMHP) for an MN determination.

Approved MNs for individuals residing in NFs may be verified through the Service Authorization System (SAS). In this situation, the MCO must not complete a new MN/LOC Assessment. The MN on record will be accepted as a valid MN. The MCO should ask the NF for a courtesy copy of the MN/LOC Assessment completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.

If an applicant/member is applying for Medicaid as a resident in the NF and is concurrently applying for HCBS STAR+PLUS Waiver (SPW), the NF should complete the MN/LOC Assessment. The MCO is instructed not to complete a new MN/LOC Assessment with the pre-enrollment assessment. SPSU must notify the MCO that MN exists by entering the RUG Group and expiration date in Section A, Item 7, of Form 3676- MC, Managed Care Pre-Enrollment Home Health Assessment Authorization. If the NF refuses to complete the MN/LOC Assessment in a timely manner, SPSU must authorize the MCO to complete the MN/LOC Assessment on the applicant/member by entering N/A in Section A, Item 7, of Form 3676-MC and posting to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

A different situation exists when an SPW applicant/member enters the NF on Medicare. The NF is under no obligation to complete the MN process during the time the NF member is on Medicare, even if the member plans to stay and become a full Medicaid member. SPSU must authorize the MCO to complete the MN/LOC Assessment, as described above, to expedite receiving an MN and avoid a delay for the applicant/member returning to the community.

A denied MN decision resulting from an Admission Assessment submitted by the MCO for an NF applicant is not used to deny an SPW applicant who has a current valid NF MN. The NF MN and Resource Utilization Group are used in the SPW eligibility determination.

An MN record must be located in the SAS so the individual service plan (ISP) registration does not suspend because of a lack of MN information. The SAS MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.

3241.2  Medical Necessity Determination for Applicants Not Residing in Nursing Facilities

For HCBS STAR+PLUS Waiver (SPW) applicants not living in nursing facilities, the medical necessity determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) doing the pre-enrollment home health assessment.

The MCO must electronically submit the MN/LOC Assessment to TMHP after it has been signed by the physician. A copy of the MN/LOC Assessment is filed in the member's case folder.

3242  Individual Cost Limit Requirement

3242.1  Maximum Limit

The cost of HCBS STAR+PLUS Waiver (SPW) cannot exceed 200% of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the SPW applicant must have an individual service plan (ISP) developed that is at or below 200% of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.

3242.2  Unmet Need for at Least One Waiver Service

The Code of Federal Regulations specifies individuals are not eligible to receive HCSB STAR+PLUS Waiver (SPW) unless they have a need for at least one waiver service. Therefore, the Department of Aging and Disability Services cannot approve any individual service plan (ISP) which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan — SPW (Pg. 1). When the STAR+PLUS Support Unit (SPSU) receives a service plan from the managed care organization (MCO) with a $0.00 waiver cost, the following activities occur.

Within two business days:

SPSU posts Form 2067, Case Information, to the appropriate XXXSPW folder in TxMedCentral, using the appropriate naming convention. This will inform the MCO to verify if the ISP, which has no services, is accurate.

• If the ISP was submitted incorrectly:
  • the MCO must resubmit a corrected ISP within two business days (for example, the ISP posted correctly but is missing services); and
  • SPSU must honor the original post date if the MCO posts the corrected ISP within two business days of notification by SPSU; or
• If the ISP was submitted correctly:
  • the MCO must post Form 2067 informing SPSU the ISP reflects the member's needs; and
  • SPSU:
    • begins denial procedures for these cases by completing Form 2065-D, Notification of STAR+PLUS Program Services;
    • mails the original form to the member;
    • posts it on TxMedCentral in the XXXSPW folder, using the appropriate naming convention;
    • faxes or mails a copy to Medicaid for the Elderly and People with Disabilities staff, if applicable; and
    • emails a copy to Health and Human Services Commission – Managed Care Operations with Form 2067, explaining that the form was signed, dated and sent to the applicant.

3310  Intake and Enrollment

When the Department of Aging and Disability Services (DADS) receives a request for HCBS STAR+PLUS Waiver (SPW) in a STAR+PLUS county, intake staff must assess whether the request for services should be forwarded for processing to the:

• appropriate DADS unit;
• STAR+PLUS Support Unit (SPSU); or
• appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS service delivery areas. Note: A caller may request Community Based Alternatives (CBA) services. It is important to explain that in a managed care area, the STAR+PLUS Waiver is the CBA equivalent.

Because of member choice issues, MCOs are prohibited from contacting non-members without the authorization from SPSU to complete required waiver assessments. For MDCP members aging out, individuals on the STAR+PLUS Waiver interest list, or MFP and MFP Demonstration initiative individuals, SPSU:

• completes Section A of Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization; and
• posts the form in the XXXSPW folder on TxMedCentral, following the naming convention instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance.

Note: When SPSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

3311  Interim Services for Individuals Awaiting Managed Care Enrollment

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care for Aged and Disabled (CCAD) program. Referrals to CCAD must be made for all full Medicaid recipients. Case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

3311.1  Interest List Procedures

Separate interest lists for Community Based Alternatives (CBA) services and HCBS STAR+PLUS Waiver (SPW) are maintained in regions with STAR+PLUS counties:

• one for CBA services, which contains information on interested individuals who do not reside in STAR+PLUS areas; and
• one for SPW services, which contains interested individuals in the STAR+PLUS service area who are not mandatory STAR+PLUS members.

Requests from Supplemental Security Income or other full Medicaid program recipients must be assigned immediately. Regions must use the Community Services Interest List (CSIL) as a tracking system for Money Follows the Person applications from individuals living in STAR+PLUS counties who are not yet members of a managed care organization (MCO). The individual is released from the interest list immediately after being entered into CSIL.

The Department of Aging and Disability Services (DADS) is responsible for managing both of these lists. The STAR+PLUS Support Unit (SPSU) manages activities related to the SPW interest list, including:

• placing individuals on the interest list;
• releasing individuals from the interest list;
• tracking SPW slots allocated for use by individuals who are not mandatory participants; and
• confirming that individuals on the interest list are viable STAR+PLUS candidates before release by:
  • verifying all contact information is correct,
  • checking the Service Authorization System and System for Applications, Verifications, Eligibility Reports and Referral or the Texas Integrated Eligibility Redesign System to determine the Medicaid eligibility status, and
  • verifying the individual still wants SPW services.

The SPSU coordinator sends Form 2053-A, STAR+PLUS Release Letter, to inform the individual that his name has come to the top of the SPW interest list. Along with Form 2053-A, send:

• Form 3675-MC, Application Acknowledgement;
• Form 2053-B, Health Plan Selection;
• Form H1200, Application for Assistance – Your Texas Benefits;
• STAR+PLUS information; and
• a postage-paid envelope.

Form 3675-MC is sent to applicants upon release from the SPW interest list. Actions related to the form depend on whether the individual released from the interest list does or does not wish to proceed with the eligibility determination process.

• If the individual does want to proceed to the eligibility determination process:
  • Do not return Form 3675-MC if the individual provides a verbal statement of desire to apply for services.
  • Document in the case record the date the individual’s wishes were relayed to DADS staff.
• If the individual does not want to proceed with the eligibility determination process:
  • Return Form 3675-MC (if the form is not readily available, make a diligent effort to obtain the form from the individual).
  • If Form 3675-MC is not returned, DADS staff must record the date the individual relayed his wishes to not pursue the eligibility determination process in the case record.
  • Document any efforts made to secure return of the form in the case record.

Within 14 days of release from the interest list, SPSU contacts the applicant regarding selection of an MCO as quickly as possible so the selected MCO can conduct the assessment and develop the initial individual service plan. Any delay in selecting an MCO will result in a delay in eligibility determination for SPW services.

If the applicant has not selected an MCO within 30 days of contact by SPSU, an MCO is assigned on a rotational basis from the list of available MCOs in the service area. The applicant is contacted within three business days and informed that:

• an MCO has been assigned to the individual; and
• the MCO in which the individual is enrolled can be changed at any time after the first day of the month of service.

See Section 3312, Enrollment, for steps to be taken after an individual is released from the SPW interest list.

3311.2  Interest List Slot Allocations

Individuals receiving Medicaid services under any of the programs listed in the chart below must receive those services through managed care if they live in designated STAR+PLUS service delivery areas. This does not impact the STAR+PLUS Services member's right to access non-Medicaid services through the Department of Aging and Disability Services. HCBS STAR+PLUS Waiver (SPW) members must receive all services through the waiver, excluding hospice care.

The number of full mandatory recipients receiving waiver services under managed care does not impact the number of Community Based Alternatives (CBA) or Medical Assistance Only (MAO) CBA managed care slots allocated to the region. Only Medicaid Waivers cases count against regional slot allocations, as the following table illustrates:

3311.3  Earliest Date for Adding an Individual Back to the Interest List

The earliest date an applicant/member may be added back to the Community Services Interest List (CSIL) for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program (for applicants) or (for HCBS STAR+PLUS Waiver (SPW) recipients), the first date the applicant/member is no longer eligible for the program denied.

Example 1: The applicant is released from the SPW CSIL on March 2, 2011. The case manager determines the applicant is not eligible for SPW on March 28, 2011, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the SPW interest list is March 28, 2011.

Example 2: An SPW recipient is determined not eligible on March 28, 2011, and the SPSU sends notification to the SPW recipient of termination of benefits. Termination is effective April 30. The first date the denied member can be added back to the SPW interest list is May 1, 2011.

If the applicant's/SPW recipient's name is added back to the interest list prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System will cause the name to be removed from the interest list for that program.

Example 3: A member's SPW services are denied due to medical necessity and end on March 30, 2011. The first date the member can be added back to the SPW interest list is April 1, 2011.

Example 4: A member's SPW services are denied and will end March 13, 2011. The first date the member can be added back to the SPW interest list is March 14, 2011. If the member is already on another interest list, the denial date for SPW services would not impact the member's original date on the other interest list.

3312  Enrollment

The enrollment broker mails enrollment packets to all Medicaid recipients who are candidates for STAR+PLUS. This packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the recipient can choose. Recipients can return enrollment forms via mail, complete an enrollment form at an enrollment event or presentation, or call the enrollment broker and enroll via telephone.

Recipients have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the recipient will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Recipient assignments to an MCO or PCP are automatic, using a default process. Recipients assigned through the default process may still make a choice about their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, they must receive Medicaid services through the assigned MCO and PCP until they contact the MCO or the enrollment broker at 1-800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity determination is required.

3312.1  Enrollment Procedures Following Release from the Interest List

Within 14 days of release from the interest list (see Section 3311.1, Interest List Procedures), the STAR+PLUS Support Unit (SPSU) takes the following steps to ensure candidates are successfully enrolled in the HCBS STAR+PLUS Waiver (SPW).

SPSU staff contact the applicant or responsible party to:

• give a general description of SPW services;
• provide a list of managed care organizations (MCOs) and encourage the member to contact one for service information;
• discuss the importance of choosing an MCO so assessments and initial individual service plans (ISPs) can be completed timely in order to avoid a delay in eligibility determination for SPW services; and
• inform the individual the MCO in which he/she enrolls can be changed at any time after the first month of service.

If the Service Authorization System (SAS) and Texas Integrated Eligibility Redesign System (TIERS) inquiry conducted before release from the interest list indicates an individual does not have pre-existing Medicaid coverage, SPSU sends an application for assistance (Form H1200, Application for Assistance – Your Texas Benefits) to the individual released from the interest list to begin the Medicaid eligibility determination process. Once the form is returned, SPSU sends the signed and completed application form, identifying the action to be taken, within two business days of receipt to Medicaid for the Elderly and People with Disabilities (MEPD) staff, along with Form H1746-A, MEPD Referral Cover Sheet.

The applicant chooses an MCO and notifies SPSU verbally or in writing.

Within two business days of the MCO selection, SPSU completes Section A of Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, and posts it on TxMedCentral in the MCO's SPW folder, following the naming convention instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance.

The MCO completes:

• a nursing facility risk criteria assessment;
• Section B of Form 3676-MC, indicating whether or not risk criteria are met;
• a Medical Necessity and Level of Care (MN/LOC) Assessment; and
• the ISP.

*Note: The Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with the applicant to begin the assessment process within 14 days of receipt of Form 3676-MC. The MCO has 45 days per UMCC requirement to complete all assessments and submit the results via Form 3676-MC, Part B, to SPSU.

The MCO posts the SPW ISP to TxMedCentral in the MCO's ISP folder, following the naming instructions in Section 5110. The MCO posts Form 3676-MC to TxMedCentral in the SPW folder, following instructions in Section 5110.

If the ISP from the MCO is not posted within 45 days after the Form 3676-MC, Part A was posted, the SPSU notifies Managed Care Operations (HMCO) that the time frame was not met by sending an email to the HMCO mailbox at HPO_STAR_PLUS@hhsc.state.tx.us.

Within two business days of receipt of the ISP, SPSU completes Section C of Form 3676-MC and sends it to MEPD staff to complete. MEPD determines financial eligibility and completes Section D of Form 3676-MC and returns it to SPSU.

Within five business days of receipt of all required waiver eligibility documentation, SPSU verifies eligibility based on Medicaid eligibility, medical necessity and level of care (MN/LOC), risk criteria met on Form 3676-MC, Section B, and an ISP cost within the individual's assessed cost limit based on the established Resource Utilization Group value.

The start of care (SOC) date for SPW is the first day of the month following receipt of the latter of:

• MN/LOC;
• ISP; and
• Medicaid eligibility.

Example: MN/LOC is received at Texas Medicaid & Healthcare Partnership on May 15, the ISP is posted to TxMedCentral on June 2, and Medicaid eligibility is effective May 1. The SOC date is July 1.

The SOC date is the same as the ISP begin date, and will always be the first day of the month. Because individuals are not eligible for any SPW benefits between the notification form signature date and the ISP begin date, SPSU coordinators must take care in recording the correct date on the notification to the member.

For Money Follows the Person Demonstration effective dates, see Section 3500, Money Follows the Person, and the instructions for Form 2065-D, Notification of STAR+PLUS Program Services.

If eligibility is approved, SPSU completes Form 2065-D, and:

• mails the original to the applicant;
• posts the form on TxMedCentral in the MCO's SPW folder, following the instructions in Section 5110;
• faxes or mails a copy to MEPD staff; and
• emails a copy to HMCO.

If eligibility is denied, SPSU completes Form 2065-D and:

• mails the original to the applicant;
• posts it on TxMedCentral in the MCO's SPW folder, following the instructions in Section 5110; and
• faxes or mails a copy to MEPD staff.

SPSU makes Service Authorization System (SAS) entries following procedures in the SAS Help File within five business days of receipt of all required eligibility verification.

After the individual has been determined eligible for SPW, HMCO updates the member's TIERS record to indicate managed care enrollment.

Note: HMCO periodically makes SAS changes outside the normal routine based on additional information from third-party entities, such as MCOs, providers, etc. HMCO is not required to consult SPSU. These changes are necessary and must not be changed by SPSU staff.

If staff believe changes made by HMCO may be in error, forward those via email to the state office STAR+PLUS policy specialist, who will contact HMCO so they can confirm whether the entries are correct.

3313  Termination of CCAD Services Upon STAR+PLUS Waiver Enrollment

Code of Federal Regulations §431.213 Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a)

The agency has factual information confirming the death of a recipient;

(b)

The agency receives a clear written statement signed by a recipient that —

(1)

He no longer wishes services; or

(2)

Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c)

The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d)

The recipient's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e)

The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f)

A change in the level of medical care is prescribed by the recipient's physician….

The STAR+PLUS Support Unit must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the CCAD case manager so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service. The HCBS STAR+PLUS Waiver (SPW) individual must be encouraged to contact the managed care organization to request any services being denied that are not included in the SPW individual service plan.

The 10-day adverse action prior notice requirement does not apply to individuals transferring from CCAD or other waiver programs to SPW services.

3313.1  Procedure for SPW Applicants

For individuals just entering the HCBS STAR+PLUS Waiver (SPW) program, the STAR+PLUS Support Unit must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the waiver or CCAD case manager. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

In-Home and Family Support Program (IHFSP) services are terminated by the IHFSP case manager no later than the day prior to SPW enrollment, if prior notice is received by the IHFSP case manager. If prior notice is not received, the case manager must initiate denial within three business days of awareness of the transfer to STAR+PLUS.

The case manager must send Form 2065-E, Notification of In-Home Family Support Program Benefits, to initiate denial. It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System.

CCAD services are terminated by the CCAD case manager no later than the day prior to HCBS STAR+PLUS Waiver (SPW) enrollment. This is crucial since no SPW individual may receive CCAD and SPW services on the same day. The CCAD case manager must send:

• Form 2065-A, Notification of Community Care Services, denying ongoing DADS services; and
• Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring to SPW.

Community Based Alternatives (CBA) services are terminated by the CBA case manager no later than the day prior to SPW enrollment. The CBA case manager must send Form 2065-D, Notification of STAR+PLUS Program Services, including a notation to the provider in the comments section that the individual is transferring to SPW.

3313.2  Procedure for SPW Individuals

If it is determined that an existing HCBS STAR+PLUS Waiver (SPW) individual is receiving any Service Group (SG) 3 Community Based Alternatives (CBA) or SG 7 Community Care for the Aged and Disabled (CCAD) services, the STAR+PLUS Support Unit must begin denial procedures for the SG 3/7 service immediately.

If In-Home and Family Support Program (IHFSP) services are authorized in the Service Authorization System (SAS), the IHFSP case manager must send Form 2065-E, Notification of In-Home and Family Support Program Benefits, within three business days to initiate denial. It is not necessary to provide an adverse action period prior to closing the authorization in SAS.

If CCAD services are authorized in SAS, the CCAD case manager must immediately send:

• Form 2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to SPW; and
• Form 2101, Authorization for Community Care Services.

If CBA services are authorized in SAS, the CBA case manager must send Form 2065-D, Notification of STAR+PLUS Program Services, including a notation to the provider in the comments section that the individual is transferring to SPW.

3314  MCO Changes

Members may change managed care organization (MCO) plans as often as monthly by contacting the enrollment broker at 1-800-964-2777. The enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of the month. Depending on which day of the month (before or after the enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834 daily enrollment file notifying the MCO of the new member. The STAR+PLUS Support Unit, when notified by the member, state or an MCO that a member has elected to change MCOs, will update the Service Authorization System to change the previous MCO to the new MCO.

3315  STAR+PLUS Waiver Individuals Requesting Non-Managed Care Services

Requirements of the HCBS STAR+PLUS Waiver (SPW) provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for SPW recipients. SPW recipients requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or HCBS STAR+PLUS (SPW).

3315.1  Requests from Individuals Awaiting Managed Care Enrollment

Individuals awaiting managed care enrollment may be assessed for interim Community Care for the Aged and Disabled (CCAD) services. Department of Aging and Disability Services case managers may assess all individuals whose managed care enrollment is pending if it appears CCAD services can be approved and delivered prior to enrollment in managed care.

3315.2  Requests from HCBS STAR+PLUS Waiver (SPW) Members

Requirements of the federal 1115 waiver dictate that the HCBS STAR+PLUS Waiver (SPW) provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for SPW members. SPW members requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or HCBS STAR+PLUS Waiver (SPW).

3315.3  Requests from STAR+PLUS Services Members

When a STAR+PLUS services managed care member requests non-Medicaid services, Department of Aging and Disability Services (DADS) staff must first determine if there is a slot available for the requested service. If not, the individual's name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.

When a slot is available, or before release from the interest list, DADS staff consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is a STAR+PLUS member (see Section 5130, Managed Care Data in TIERS). If it is determined that the individual is a STAR+PLUS member, intake staff must contact the STAR+PLUS Support Unit (SPSU) before assignment to a case manager to determine if the managed care organization (MCO) is already delivering the managed care version of the requested service.

Within two business days of contact by intake staff, the SPSU:

• contacts the appropriate MCO by posting Form 2067, Case Information, to TxMedCentral in the MCO XXXSPW folder using the appropriate naming convention. Form 2067 must contain:
• the individual's name;
• Medicaid number; and
• a request to determine if service is already being delivered; and
• follows up by phone every five business days until a response is received from the MCO.

Within five business days of receiving posted Form 2067, the MCO must respond to SPSU by posting Form 2067 to the XXXSPW folder in TxMedCentral using the appropriate naming convention.

Within two business days of receipt of the MCO's response, the SPSU must notify the referring DADS staff by email or with Form 2067.

If the SPSU determines the requested service is not being delivered by the MCO, the intake must be assigned to a case manager. The case manager processes the application and authorizes services if all eligibility criteria are met.

The SPSU's response must be included in materials forwarded to the case manager at the time of case assignment. How the case manager proceeds with the eligibility determination process depends on the SPSU's documented response.

If the SPSU determines the requested service is already being delivered by the MCO, the SPSU informs the member of the MCO's response. The member is urged to consult the MCO if he/she disagrees or feels the services are not sufficient to meet his/her needs.

See Section 3310, Intake and Enrollment, for additional information on intake and referral procedures.

3316  Requests for STAR+PLUS Waiver Services from Participants in Other 1915(c) Medicaid Waivers

Participants in other 1915(c) Medicaid waivers who reside in managed care service areas may request an assessment for HCBS STAR+PLUS Waiver (SPW) services at any time if they:

• have Supplemental Security Income (SSI) Medicaid or another full Medicaid program; or
• are Medical Assistance Only.

When a 1915(c) Waiver recipient in a STAR+PLUS service area requests SPW services through the Department of Aging and Disability Services, a referral is made to the STAR+PLUS Support Unit (SPSU).

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

• moves the individual to the top of the SPW interest list with an "assessment requested" notation;
• contacts the HCBS STAR+PLUS Waiver (SPW) recipient and explains SPW services; and
• sends a copy of the regional STAR+PLUS managed care organization (MCO) provider directories and comparison chart to the 1915(c) Waiver recipient.

Within two business days of notification of the MCO selection by the waiver individual, SPSU completes Section A of Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, and posts it in the XXXSPW folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
• medical necessity and level of care (MC/LOC);
• Section B of Form 3676-MC; and
• Form H1700-1, Individual Service Plan — SPW (Pg. 1), and Form H1700-2, Individual Service Plan — SPW (Pg. 2), and attachments.

The MCO posts both Form H1701-1 and Form 3676-MC in the XXXSPW folder on TxMedCentral using the appropriate naming convention. If the packet from the MCO is not received within 45 days after the assessment is authorized, SPSU contacts Managed Care Operations (HMCO) as notification the time frame for completing the individual service plan (ISP) was not met.

Health and Human Services Commission
Managed Care Operations — STAR+PLUS
P.O. Box 13247, Mail Code H-320
Austin, TX 78711

Within two business days of receipt of all required waiver eligibility documentation, SPSU determines waiver eligibility based upon medical necessity, and an ISP cost within the Resource Utilization Group cost limit.

If eligibility for SPW is denied or the waiver individual decides not to accept SPW services, SPSU completes Form 2065-D, Notification of STAR+PLUS Program Services, and:

• mails the original to the 1915(c) Waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving;
• posts a copy on TxMedCentral; and
• emails a copy to MCO with Form 2067, Case Information, explaining the form was signed, dated and sent to the applicant.

If eligibility is approved and the individual chooses to accept SPW services, the individual is enrolled in SPW the first day of the next month.

Within two days of determining the start of care date for SPW services, SPSU completes Form 2065-D and:

• mails the original to the 1915(c) Waiver recipient;
• posts a copy on TxMedCentral; and
• emails a copy to HMCO with Form 2067, explaining the form was signed, dated and sent to the member.

SPSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) Waiver services end the day before enrollment in SPW.

3320  Coordination with MEPD

3321  General Eligibility Issues

At the initial contact, the STAR+PLUS Support Unit (SPSU) coordinator must inform the Medical Assistance Only applicant/member and/or his/her representative that Medicaid for the Elderly and People with Disabilities (MEPD) staff will complete a financial eligibility (Medicaid) determination. The SPSU coordinator should encourage the applicant/member and/or representative to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by the SPSU coordinator must be shared with the MEPD specialist to prevent the applicant/member from having to provide the information twice.

The SPSU coordinator must inform MEPD staff of the request for HCBS STAR+PLUS Waiver (SPW) services by sending a completed Form H1200, Application for Assistance – Your Texas Benefits, within two business days of receipt, according to regional procedures. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

3321.1  Disability Determinations

The following information is provided for informational purposes only regarding the disability determination process. STAR+PLUS Support Unit (SPSU) staff have absolutely no role in this process.

If an SPW applicant's/member's application for Supplemental Security Income (SSI) disability has been pending for over 90 days, the Health and Human Services Commission Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration determination. SPSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, MEPD staff must obtain the following:

• Form H3034, Disability Determination Socio-Economic Report;
• Form H3035, Medical Information Release/Disability Determination; and
• a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment.

3322  Actions Pending Past the MEPD Due Date

Because STAR+PLUS Support Unit (SPSU) staff depend on Medicaid for the Elderly and People with Disabilities (MEPD) staff to determine eligibility for Medical Assistance Only applicants, there are times when SPSU staff must check with MEPD staff regarding the status of an application or program change.

Before contacting MEPD, SPSU staff must ensure the following:

• Make sure the MEPD time frame has expired.  MEPD staff have 45 days to complete applications for individuals over age 65. For individuals under age 65 whose disability has not yet been determined by the Social Security Administration, MEPD staff have 90 days.
• Contact the administrative assistant (AA), as indicated below, for the appropriate Management Team leader. Do not communicate with anyone other than the AA.

3330  STAR+PLUS Members Requesting an Upgrade to the Home and Community-based Services STAR+PLUS Waiver

The managed care organization (MCO) service coordinator must, within 45 calendar days of a STAR+PLUS member's request for Home and Community-based Services STAR+PLUS Waiver (SPW) services:

• complete an assessment in order to prepare the individual service plan;
• complete the Medical Necessity/Level of Care Assessment and submit it to Texas Medicaid & Healthcare Partnership to request medical necessity; and
• post Form H1700-1, Individual Service Plan — SPW (Pg. 1) in TxMedCentral.

Within five business days of receipt of Form H1700-1 from the MCO, SPSU staff review the form to determine if the member meets eligibility criteria for SPW services.

If not eligible, SPSU staff:

• follow actions in Section 3632, DADS-Initiated Denials/Terminations, to deny the request;
• send Form 2065-D, Notification of STAR+PLUS Program Services, within three business days to the member; and
• post Form 2065-D to TxMedCentral to the MCO's SPWXXX folder.

If the member is eligible, SPSU staff:

• complete Form 2065-D and send it to the member and (if applicable) the Medicaid for the Elderly and People with Disabilities specialist;
• post Form 2065-D in TxMedCentral to the MCO's SPWXXX folder; and
• complete Service Authorization System entries to authorize eligibility for SPW.

3410  Transfer Scenarios

3411  CBA Individuals Transferring to SPW

Notification of a Community Based Alternatives (CBA) case transfer to the Home and Community-based Services STAR+PLUS Waiver (SPW) may be received in a variety of ways, but typically the referral will come from an individual, responsible party or a provider contacting the Department of Aging and Disability Services.

As described in Section 3411.1, Notice is Received Prior to Relocation, and Section 3411.2, Notice is Received After Relocation, notification of the move may be received before or after relocating to a STAR+PLUS service area.

3411.1  Notice is Received Prior to Relocation

Within three business days of the move notification, the Community Based Alternatives (CBA) case manager contacts:

• the CBA individual to determine when and where the individual plans to move; and
• STAR+PLUS Support Unit (SPSU) in the appropriate managed care area to:
  • inform SPSU of the individual's intent to move;
  • inform SPSU if the individual is utilizing general revenue funds, as described in Section 3400, Transferring In and Out of STAR+PLUS;
  • provide the anticipated move date;
  • provide the CBA member's:
    • name;
    • Social Security number;
    • Medicaid number;
    • current and future contact information; and
  • provide contact information for the losing Medicaid for the Elderly and People with Disabilities (MEPD) case specialist (if the individual is a Medical Assistance Only (MAO) individual) to include:
    • name;
    • telephone number; and
    • email address.

Within two business days of receiving notification of a CBA individual's planned move, SPSU:

• contacts the individual by telephone to:
  • explain how services are provided in managed care through the Home and Community-based Services STAR+PLUS Waiver (SPW);
  • reinforce an address change must be made with the Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients or MEPD staff for MAO individuals;
  • remind MAO individuals an address change, including an update to residence county code in the Texas Integrated Eligibility Redesign System (TIERS), must be made by MEPD staff;
  • provide a list of STAR+PLUS managed care organizations (MCOs) and encourage the individual to choose an MCO during this telephone call, if possible;
  • explain if the individual does not choose an MCO before the move, services will be delayed;
  • inform the individual he/she can change the MCO in which he/she is enrolled after one month of enrollment in managed care; and
• sends the individual a managed care enrollment packet (if the MCO is not selected during the initial contact), which consists of:
  • a copy of the appropriate managed care service area MCO provider lists (including provider names, telephone and fax numbers); and
  • comparison charts.

SPSU contacts the individual by telephone five days prior to the anticipated move if the individual has not selected an MCO. If the individual does not select an MCO, SPSU explains that:

• an MCO will be selected for the individual; and
• he/she can change the MCO after 30 days of enrollment.

Within five business days of notifying SPSU, the CBA case manager:

• sends SPSU Form 3671-1, Individual Service Plan (Page 1), and Form 3671-2, Individual Service Plan (Page 2), and all attachments;
• alerts MEPD staff in the gaining service area of the MAO individual's impending move on Form H1746-A, MEPD Referral Cover Sheet; and
• reminds the SSI individual an address change must be made with SSA; or
• reminds the MAO individual an address change, including an update to the residence county code in TIERS, must be made by MEPD staff.

SPSU remains in contact with the CBA individual to determine when the move actually occurs.

Within two business days of MCO selection, SPSU:

• notifies the MCO by email:
  • of the pending transfer;
  • if the individual is utilizing general revenue funds, as described in Section 3400; and
  • that information is posted to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention without identifying the individual in any way;
• faxes Form 3671-1 and all attachments to the MCO; and
• posts Form 2067, Case Information, to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention, and includes in the Comments section the:
  • expiration date of the individual service plan (ISP) and medical necessity (MN)/level of care (LOC); and
  • Resource Utilization Group (RUG) value.

The MCO is responsible for completing subsequent reassessments in a timely manner, as indicated in Section 8.3.3 of the Uniform Managed Care Contract.

Within two business days of receipt of all required waiver eligibility documentation from the losing CBA case manager, SPSU:

• verifies waiver eligibility based upon:
  • Medicaid eligibility;
  • MN; and
  • an ISP cost within the RUG cost limit;
• completes Form 2065-D, Notification of STAR+PLUS Program Services, if eligibility is verified; and:
  • mails the original to the individual;
  • posts the form on TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention;
  • faxes or emails a copy to MEPD staff; and
• in the rare event that eligibility is not continued, completes Form 2065-D and:
  • mails the original to the individual;
  • posts it on TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention;
  • faxes or mails a copy to MEPD staff, if this is an MAO individual; and
  • emails a copy to Managed Care Operations (HMCO) with Form 2067, explaining that the form was signed, dated and sent to the applicant.

Within two business days of receipt of Form 2065-D, the MCO:

• contacts the individual to:
  • determine which services will be needed when the individual makes the actual move to the service area;
  • confirm the date of the expected move; and
• sets up services with contracted providers to start on the move date.

The losing CBA case manager coordinates with the losing provider, as appropriate, and closes authorized services in the Service Authorization System (SAS).

Within five business days of verifying eligibility, SPSU makes SAS entries following the procedures in the SAS Help File. Once SAS entries have been completed, SPSU emails a copy of Form 2065-D to HMCO.

Within three business days of receiving Form 2065-D, HMCO:

• verifies that SAS has been updated appropriately;
• verifies Medicaid eligibility;
• enrolls the member if SAS and Medicaid eligibility indicate the member meets waiver criteria; and
• sends an email to the appropriate SPSU if HMCO determines the SAS record and/or Medicaid eligibility indicate the individual does not meet waiver criteria.

Within two business days of receiving the email from HMCO, SPSU:

• contacts MEPD (for MAO recipients) informing MEPD of the individual's ineligibility for waiver services;
• sends Form 2065-D to the individual;
• corrects SAS; and
• notifies HMCO via the Health Plan Operations (HPO) mailbox that corrections have been made.

SPSU monitors TIERS to confirm the necessary changes have been made to indicate residence in a managed care service area.

Within two business days of SPSU notifying HMCO that changes have been made, HMCO:

• verifies changes were made; and
• enrolls the individual into managed care.

SPSU coordinates all appropriate activities between the losing case manager, MCO, the individual and other key parties to help ensure a successful transition to SPW. This includes tracking each step of the process through the start of SPW services. When existing time frames are not met, SPSU contacts the appropriate entity to assist with resolution of the problem while documenting any delays. If the losing case manager does not meet the above time frames, the supervising program manager or regional director is notified.

Within 14 days of the move, the MCO meets with the individual to:

• confirm the services are initiated;
• determine if additional services are needed; and
• revises Form 3671-1, if appropriate.

Note: Providers follow procedures described in Section 5400, Administrative Payment Process, for services rendered between the date the individual moved and the end of the month in which the move occurred. If the move occurred on the first day of the month, the provider follows the MCO claims adjudication payment process.

3411.2  Notice is Received After Relocation

Use the following procedure when the Community Based Alternatives (CBA) individual contacts a local Department of Aging and Disability Services (DADS) office after moving into a STAR+PLUS service area.

One business day after notification the move has occurred, DADS intake or other staff must:

• notify the STAR+PLUS Support Unit (SPSU) of the move (follow up with an email within two days);
• provide the CBA individual's:
  • name;
  • Social Security number;
  • Medicaid number;
  • contact information; and
• provide contact information for the losing Medicaid for the Elderly and People with Disabilities (MEPD) case specialist (if the individual is a Medical Assistance Only (MAO) recipient), to include:
  • name;
  • telephone number; and
  • email address.

Within two business days of being notified the CBA individual has already moved into the managed care service area, SPSU:

• contacts the losing CBA case manager by telephone, along with sending a follow-up Form 2067, Case Information, requesting:
  • a copy of Form 3671-1, Individual Service Plan (Page 1), and Form 3671-2, Individual Service Plan (Page 2), and all attachments;
  • notification of whether the individual is utilizing general revenue funds, as described in Section 3400, Transferring In and Out of STAR+PLUS;
  • coordination with the losing provider(s); and
  • the losing CBA case manager notify the losing MEPD staff of the MAO individual's move on Form H1746-A, MEPD Referral Cover Sheet;
• contacts the gaining MEPD specialist if the individual is MAO, alerting MEPD of the individual's move and the necessity to change the residence address and county code;
• contacts the individual by telephone to:
  • explain how services are provided in managed care through the Home and Community-based Services STAR+PLUS Waiver (SPW);
  • reinforce an address change must be made with the Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients;
  • instruct MAO individuals an address change, including an update to residence county code in the Texas Integrated Eligibility Redesign System (TIERS), must be made by MEPD staff;
  • provide a list of STAR+PLUS managed care organizations (MCOs) and encourage the individual to choose an MCO during this telephone call, if possible;
  • explain that if the individual does not choose an MCO during the telephone call, one will be chosen for the individual to avoid further delay in service delivery;
  • inform the individual he/she can change the MCO in which the individual is enrolled after one month of managed care enrollment; and
• sends the individual a managed care enrollment packet that consists of:
  • a copy of the appropriate managed care service area MCO provider list (including provider names, telephone and fax numbers); and
  • comparison charts.

Within two business days of being notified of the transfer by the SPSU, the losing CBA case manager:

• sends the individual's Form 3671-1, Form 3671-2 and all attachments to SPSU;
• alerts local MEPD staff of the individual's move on Form H1746-A, if the individual is MAO eligible;
• reminds the individual to contact SSA to report an address change, if the individual is SSI eligible; and
• reminds the MAO individual an address change, including an update to the residence county code in TIERS, must be made by MEPD staff.

Within one business day of receipt of notification from the CBA case manager, SPSU:

• faxes Form 3671-1 and all attachments to the MCO;
• posts Form 2067 to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention and including in the "Comments" section the:
  • expiration date of the individual service plan (ISP) and medical necessity (MN)/level of care (LOC); and
  • Resource Utilization Group (RUG) value; and
• sends an urgent email to let the MCO know:
  • a transferred individual needs services;
  • if the individual is utilizing general revenue funds, as described in Section 3400; and
  • information is posted to TxMedCentral in the MCO's XXXSPW folder without identifying the individual in any way.

Note: Emails should be sent secured. The word "URGENT" must appear in the subject line.

Within 24 hours of receipt of the urgent email, the MCO:

• contacts the individual to determine which services are needed; and
• sets up services with contracted providers.

Within two business days of the receipt of all required eligibility documentation, SPSU:

• completes Form 2065-D, Notification of STAR+PLUS Program Services, if eligibility is verified, and:
  • mails the original to the individual;
  • posts the form on TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention;
  • faxes or emails a copy to MEPD staff; and
• in the rare event that eligibility is not continued, completes Form 2065-D and:
  • mails the original to the applicant;
  • posts it on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • faxes or mails a copy to MEPD staff, if this is an MAO individual; and
  • emails a copy to Managed Care Operations (HMCO) with Form 2067, explaining that the form was signed, dated and sent to the applicant.

The losing CBA case manager coordinates with the losing provider, as appropriate, and closes authorized services in the Service Authorization System (SAS). SPSU monitors TIERS to confirm the necessary changes in residence are made to indicate residence in a managed care service area.

Within five business days of receipt of all required eligibility documentation, SPSU makes SAS entries following the procedures in the SAS Help File. Once SAS entries have been completed, SPSU emails a copy of Form 2065-D to HMCO.

Within three business days of receiving Form 2065-D, HMCO:

• verifies SAS has been updated appropriately;
• verifies Medicaid eligibility;
• enrolls the individual if SAS and Medicaid eligibility indicate the individual meets waiver criteria; and
• sends an email to the appropriate SPSU if HMCO determines the SAS record and/or Medicaid eligibility indicate the individual does not meet waiver criteria.

Within two business days of receiving HMCO's notification, SPSU:

• contacts MEPD (for MAO recipients) informing MEPD of the individual's ineligibility for waiver services;
• sends Form 2065-D to the individual;
• corrects SAS; and
• notifies HMCO via the Health Plan Operations (HPO) mailbox that corrections have been made.

Within two business days of SPSU notifying HMCO that transfer activities have been completed, HMCO:

• verifies changes were made; and
• enrolls the individual into managed care.

SPSU coordinates all appropriate activities between the losing CBA case manager, MCO, individual and other key parties to help ensure a successful transition to SPW. This includes tracking each step of the process through the start of SPW services. When existing time frames are not met, SPSU contacts the appropriate entity to assist with resolution of the problem while documenting any delays. If the losing CBA case manager does not meet the above time frames, the supervising program manager or regional director is notified.

Note: Providers need to follow procedures described in Section 5400, Administrative Payment Process, for services rendered between the date the individual moved and the end of the month in which the move occurred. If the move occurred on the first day of the month, the provider follows the MCO claims adjudication payment process.

3412  SPW Members Transferring to CBA

When the STAR+PLUS Support Unit (SPSU) is notified of the transfer out of a STAR+PLUS service area, SPSU contacts the program manager in the gaining region to determine the Community Based Alternatives (CBA) case manager assignment. Within five business days of notification (or two business days, if the member is already in the CBA service delivery area), SPSU also:

• notifies the member of the:
  • CBA case manager assignment; and
  • contact information;
• provides the CBA case manager the member's:
  • name;
  • Social Security number;
  • Medicaid number;
  • current and future contact information; and
  • date of the move or anticipated move;
• sends Form H1700-1, Individual Service Plan — SPW (Pg. 1), to the assigned CBA case manager;
• notifies Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, if appropriate; and
• posts Form 2067, Case Information, to TxMedCentral in the XXXSPW folder, using the appropriate naming convention, requesting that the managed care organization (MCO) send the following forms, as applicable:
  • Form H1700-2, Individual Service Plan — SPW (Pg. 2);
  • Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-A1, Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-B, Non-HCBS STAR+PLUS Waiver Services;
  • Form 8598, Non-Waiver Services;
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization; and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Within two business days of requesting the forms, the MCO mails or faxes the above-mentioned forms to SPSU and posts Form 2067 to the appropriate XXXSPW folder, using the appropriate naming convention, indicating the attachments have been mailed or faxed.

Within two business days of receiving the forms, SPSU forwards the forms to the gaining CBA case manager.

Once the gaining CBA case manager receives Form H1700-1 and the additional forms, the case manager follows the usual intake procedures specified in Section 3310, Intake and Enrollment. The process will be abbreviated since the member already has a:

• medical necessity/level of care;
• Form H1700-1;
• Resource Utilization Group; and
• financial eligibility determination by MEPD, if applicable.

SPSU coordinates all appropriate activities between the CBA case manager, MCO, member, Managed Care Operations (HMCO) and other key parties to help ensure a successful transition to CBA. For SPSU, this includes tracking each step of the process through the start of CBA services.

SPSU maintains contact with the member until the move is complete. Within five business days after the move, SPSU:

• sends an email to the Health Plan Operations (HPO) mailbox notifying HMCO the member has moved;
• manually closes all service authorization records effective the end of the month the member moves; and
• notifies the CBA case manager of Service Authorization System (SAS) closure.

Within three business days of notification of the move, HMCO disenrolls the member effective the end of the month in which the member moved.

The MCO is contractually obligated to pay for services to the member in the gaining area until the end of the month in which the move occurred. If the member reports he/she is not currently receiving services in the non-STAR+PLUS service area, SPSU contacts the CBA case manager.

In order to avoid a gap in services between disenrollment and CBA certification, it is recommended that the gaining CBA case manager and Home and Community Support Services provider honor the ISP forwarded by SPSU.

The gaining CBA case manager:

• enters the CBA authorization using SAS wizards, which is created as an initial authorization; and
• sends Form 2065-B, Notification of Waiver Services, to the individual, provider(s), SPSU and (if applicable) MEPD.

3413  Nursing Facility Applicant in a Non-STAR+PLUS Service Area Transferring to a STAR+PLUS Service Area

If the applicant is residing in a nursing facility (NF) in a non-STAR+PLUS service area and wishes to relocate to a STAR+PLUS service area, the applicant is first processed for Community Based Alternatives (CBA) enrollment. Once the applicant is determined eligible for CBA, the CBA case manager contacts the STAR+PLUS Support Unit (SPSU) to:

• inform SPSU of the individual's intent to move; and
• provide the individual's:
  • name;
  • Social Security number;
  • Medicaid number; and
  • current and future contact information.

Within five business days of contacting SPSU, the case manager sends SPSU a copy of Form 3671-1, Individual Service Plan (Page 1), Form 3671-2, Individual Service Plan (Page 2), and all other attachments. For Medical Assistance Only individuals, the case manager alerts the local Medicaid for the Elderly and People with Disabilities staff about the transfer, using Form H1746-A, MEPD Referral Cover Sheet.

Within two business days of receipt of this information, SPSU contacts the individual to:

• explain how services are provided in managed care through the HCBS STAR+PLUS Waiver (SPW);
• assist the individual in selecting the managed care organization (MCO) the individual will use in the STAR+PLUS service area; and
• inform the individual SPSU will select an MCO if one is not selected during this contact.

Within two business days of the MCO selection, SPSU posts:

• Form 2067 to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention; and
• Form 3671-1 and Form 3671-2 to TxMedCentral in the MCO's XXXISP folder, using the appropriate naming convention.

The MCO is responsible for coordinating services to be implemented once the individual discharges from the nursing facility. When all services are coordinated, the MCO will notify SPSU of the requested start of care date. Prior to discharge, SPSU will send Form 2065-D, Notification of STAR+PLUS Program Services, to the MCO as notification of approval for discharge.

At discharge from the NF, the individual relocates to the desired STAR+PLUS service area. Within two business days of relocation, SPSU:

• remains in contact with the member to ensure services begin immediately upon the move to the service area;
• monitors the Texas Integrated Eligibility Redesign System (TIERS) to confirm the necessary changes in residence are made for the STAR+PLUS service area;
• updates the Service Authorization System with the individual service plan; and
• requests a manual enrollment via email with an attached electronic copy of Form 2065-D to Managed Care Operations (HMCO).

For more detailed information, consult the following:

• Section 3510, Money Follows the Person and Managed Care;
• Section 3411, CBA Individuals Transferring to SPW; and
• Section 3412, SPW Members Transferring to CBA.

Within two business days of receipt of Form 2065-D, HMCO manually enrolls the member.

3414  Nursing Facility Applicant in a STAR+PLUS Service Area Transferring to a Non-STAR+PLUS Service Area

If the applicant is residing in a nursing facility (NF) in a STAR+PLUS service area and wishes to relocate to a non-STAR+PLUS service area, the applicant is first processed for Home and Community-based Services STAR+PLUS Waiver (SPW) enrollment. Once the applicant is determined eligible for SPW, the STAR+PLUS Support Unit (SPSU) contacts the program manager in the gaining area to:

• determine case manager assignment; and
• inform the Community Based Alternatives (CBA) case manager of the applicant's intent to move, providing the:
  • applicant's name;
  • Social Security number;
  • Medicaid number; and
  • current and future contact information.

Within five business days of notifying the gaining region, SPSU obtains copies of Form H1700-1, Individual Service Plan — SPW (Pg. 1), Form H1700-2, Individual Service Plan — SPW (Pg. 2), and all other attachments from the managed care organization and sends the information to the case manager. SPSU, in coordination with the gaining case manager, must also assist the member in selecting a provider who will deliver services in the non-STAR+PLUS service area. For Medical Assistance Only individuals, the case manager alerts the local Medicaid for the Elderly and People with Disabilities staff about the transfer, using Form H1746-A, MEPD Referral Cover Sheet.

At discharge from the NF, the member relocates to the desired non-STAR+PLUS service area. The SPSU coordinator:

• sends Form 2065-D, Notification of STAR+PLUS Program Services, to the member as notification of the transfer to CBA;
• remains in contact with the member to ensure services begin immediately upon the move to the area; and
• monitors the Texas Integrated Eligibility Redesign System (TIERS) to confirm the necessary changes in residence are made to indicate residence in a non-STAR+PLUS area.

For more detailed information, consult the following:

• Section 3510, Money Follows the Person and Managed Care;
• Section 3411, CBA Individuals Transferring to SPW;
• Section 3412, SPW Members Transferring to CBA; and
• Section 3413, Nursing Facility Applicant in a Non-STAR+PLUS Service Area Transferring to a STAR+PLUS Service Area.

3415  SPW Member Transferring to Another SPW Service Delivery Area with Prior Knowledge

When the STAR+PLUS Support Unit (SPSU) is notified of a transfer from one STAR+PLUS service area to another STAR+PLUS area, within two business days, the losing SPSU:

• notifies the gaining SPSU a member is transferring to its service area and provides the member's:
  • name;
  • Social Security number;
  • Medicaid number;
  • current and future contact information; and
  • date of the move or anticipated move;
• sends Form H1700-1, Individual Service Plan — SPW (Pg. 1), to the gaining SPSU;
• notifies Medicaid for the Elderly and People with Disabilities (MEPD) using Form 2067, Case Information, on Medical Assistance Only individuals;
• reminds Supplemental Security Income members to contact the Social Security Administration to change the address; and
• posts Form 2067, Case Information, to the managed care organization (MCO) XXXSPW folder in TxMedCentral using the appropriate naming convention, and requests Form H1700-1 and all forms listed below from the losing MCO:
  • Form H1700-2, Individual Service Plan — SPW (Pg. 2);
  • Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-A1, Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-B, Non-HCBS STAR+PLUS Waiver Services;
  • Form 8598, Non-Waiver Services;
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
  • the medical necessity/level of care (MN/LOC); and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Once the gaining SPSU receives Form H1700-1, SPSU follows the usual intake procedures. The process is abbreviated since the member already has a:

• medical necessity;
• Resource Utilization Group; and
• financial eligibility determination by MEPD, if applicable.

The gaining SPSU coordinates all appropriate activities between the losing SPSU, MCOs, member, Managed Care Operations (HMCO) and other key parties to help ensure a successful transition. For the SPSU, this includes tracking each step of the process through the start of the new SPW services in the gaining area.

The gaining SPSU maintains contact with the member until the move is complete. Within five business days after the move, SPSU:

• sends an email to the HMCO mailbox notifying HMCO the member has moved;
• manually closes all Service Authorization System (SAS) records for the losing MCO effective the end of the month the member moves;
• updates SAS with the gaining MCO's information;
• sends Form 2065-D, Notification of STAR+PLUS Program Services, to the member and includes the begin and end dates in the Comments section; and
• posts a copy of Form 2065-D to the appropriate MCO's XXXSPW folder in TxMedCentral, using the appropriate naming convention.

Within three business days of notification of the move, HMCO disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

3416  SPW Member Transferring to Another SPW Service Delivery Area Without Prior Knowledge

When the STAR+PLUS Support Unit (SPSU) is notified a transfer from one STAR+PLUS service area to another STAR+PLUS area has already occurred, within one business day the losing SPSU:

• notifies the gaining SPSU a member has transferred to its service area and provides the member's:
  • name;
  • Social Security number;
  • Medicaid number;
  • current and future contact information; and
  • date of the move or anticipated move;
• posts Form 2067, Case Information, to the managed care organization (MCO) XXXSPW folder in TxMedCentral, using the appropriate naming convention, and requests Form H1700-1, Individual Service Plan — SPW (Pg. 1), and all the forms listed below from the losing MCO:
  • Form H1700-2, Individual Service Plan — SPW (Pg. 2)
  • Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-A1, Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services;
  • Form H1700-B, Non-HCBS STAR+PLUS Waiver Services;
  • Form 8598, Non-Waiver Services;
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
  • the medical necessity/level of care (MN/LOC); and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.
• notifies Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, for Medical Assistance Only individuals; and
• reminds Supplemental Security Income members to contact the Social Security Administration to change the address.

Within two business days of notification from the losing SPSU, the gaining SPSU:

• contacts the member to select an MCO from the gaining area;
• sends the packet containing the MCO comparison chart; and
• posts Form 2067 to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention, requesting the MCO to inform the gaining health plan of the move.

Upon receipt of Form 2067, the gaining MCO must contact the member within one business day and begin services within two business days.

Once the gaining SPSU receives Form H1700-1, staff follow the usual intake procedures. The process is abbreviated since the member already has a:

• MN/LOC;
• Resource Utilization Group; and
• financial eligibility determination by MEPD, if applicable.

The gaining SPSU coordinates all appropriate activities between the losing SPSU, MCOs, the member, Managed Care Operations (HMCO) and other key parties to help ensure a successful transition. For SPSU, this includes tracking each step of the process through the start of the new SPW services in the gaining area.

Within two business days after completing the steps above, the gaining SPSU:

• sends an email to the HMCO mailbox notifying HMCO the member has moved;
• manually closes all service authorization records effective the end of the month the member moves;
• updates the Service Authorization System with the gaining MCO's information;
• sends Form 2065-D, Notification of STAR+PLUS Program Services, to the member (with the begin and end date in the Comments section); and
• posts a copy of Form 2065-D to the appropriate XXXSPW folder in TxMedCentral, using the appropriate naming convention.

Within two business days of notification of the move, HMCO manually updates the plan code to reflect the current MCO.

3417  SPW Member Transferring from One MCO to Another Within the Same SPW Service Delivery Area

Once the initial enrollment period of one calendar month is passed, a member is eligible to change managed care organization (MCO) plans. When a member 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 call to 1-800-964-2777, or via written correspondence.

The enrollment broker will ask if the member is in a hospital or residing in a nursing facility. If so, the member cannot change plans until the member has been discharged. The member can change MCOs as many times as the member wants, but not 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.

For more details, see the Uniform Managed Care Manual, Chapter 3.4, Attachment C to the Medicaid Managed Care Member Handbook Required Critical Elements.

Monthly Plan Changes Report

Health and Human Services Commission – Managed Care Operations prepares and sends the Monthly Plan Changes report to the STAR+PLUS Support Unit (SPSU) and the gaining MCOs. SPSU receives a full list; the MCO receives a member-specific report. The report gives a list of HCBS STAR+PLUS Waiver (SPW) members who have changed MCOs from the previous month. SPSU must correct the contract number in the Service Authorization System to reflect all MCO changes. See Appendix I-E, Monthly Plan Changes.

Within five business days of receiving the list, the gaining MCO must request Form H1700-1, Individual Service Plan — SPW (Pg. 1), and Medical Necessity and Level of Care from the losing MCO. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 14 calendar days of notification of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 30 calendar days of notification of the new member, the gaining MCO must conduct a home visit to assess the member's needs.

3418  Case Transfers Between CCAD and STAR+PLUS Services

3418.1  Individuals Moving Into a STAR+PLUS Area

For individuals receiving Community Care for Aged and Disabled (CCAD) services in the losing area, the individual is transferred in the usual manner as described in the Case Manager CCAD Handbook, Section 2722, Consumer Moves and Case Transfers.

Once in the new area, the gaining region identifies potential STAR+PLUS cases. Once identified, the gaining CCAD case manager must check these cases weekly for managed care enrollment. Confirmation of STAR+PLUS enrollment is obtained by checking the Texas Integrated Eligibility Redesign System (TIERS) managed care screen. TIERS must be checked for enrollment dates.

When the enrollment date is posted in TIERS, the losing CCAD case manager in the STAR+PLUS area closes non-managed care services effective the day before managed care organization (MCO) enrollment. The case manager faxes to the STAR+PLUS Support Unit (SPSU) Form 2101, Authorization for Community Care Services.

Within two business days of receiving Form 2101, the SPSU faxes Form 2101 to the MCO and notifies the MCO via email the information was faxed. The following applies during the transition period:

• Individuals receiving Primary Home Care (PHC) or Title XIX Day Activity and Health Services (DAHS) continue receiving these services through traditional (non-managed care) Department of Aging and Disability Services (DADS) contractors and are assigned to a DADS case manager until the individual is enrolled with an MCO.
  
  It may take one to four months to complete the enrollment process into an MCO, depending on when the individual selects an MCO or if the individual fails to make a choice and is defaulted into an MCO. The case manager must flag the case and check weekly for managed care enrollment in TIERS. At the time the member is enrolled with an MCO, the DADS case manager closes the PHC or DAHS case in the Service Authorization System (SAS) effective the day before managed care enrollment. Other DADS services, such as Emergency Response Services or Home-Delivered Meals, can remain open pending verification of whether the MCO is delivering the particular service.
• The MCO must review Form 2101 and develop a transition plan within 30 days of receiving the member's enrollment. Services authorized on Form 2101 remain in place until the MCO contacts the member and coordinates modifications to the member's current treatment/long-term care services plan.
  
  The MCO must ensure the existing services continue and there are no breaks in services. The MCO may either contact the DADS contracted provider listed on Form 2101 or the MCO's contracted provider on the first day of enrollment to deliver authorized services. The MCO must pay the member's current DADS contracted provider, even if the provider is not in the MCO's network, until the MCO has made an assessment visit and developed a new plan of care. The SPSU must inform the non-contracted provider to call the MCO for coordination and authorization. At the time of the MCO's assessment, the individual may need to switch providers if the provider currently being used is not within the MCO's network.

Under certain conditions, Medicaid recipients receiving only STAR+PLUS services can continue receiving services through DADS, even after enrollment with a STAR+PLUS MCO. See Section 3315, STAR+PLUS Waiver Individuals Requesting Non-Managed Care Services, for additional information. These cases are managed by DADS case managers.

3418.2  STAR+PLUS Members Moving Out of a STAR+PLUS Area

When a member moves out of a STAR+PLUS area, the managed care organization (MCO) must continue to pay for services (in accordance with the MCO's out-of-network payment procedures) through the end of the month in which the move occurred.

The following transfer processes must be followed to avoid gaps in service delivery:

• The MCO posts Form 2067, Case Information, to TxMedCentral in the XXXSPW folder, using the appropriate naming convention, notifying the STAR+PLUS Support Unit (SPSU) of the move.
• The SPSU:
  • contacts the program manager in the gaining Department of Aging and Disability Services (DADS) service area, either verbally or by email, within two business days of notification of the move to obtain a case manager assignment;
  • contacts the member to inform him/her of the case manager assignment, including complete contact information; and
  • obtains a copy of the member's service plan from the MCO and forwards it to the gaining case manager, along with the name and contact information of the member's MCO.
• The SPSU coordinator and the DADS case manager follow the usual policies regarding individual transfers, as described in Section 3400, Transferring In and Out of STAR+PLUS, and in the Case Manager Community Care for Aged and Disabled Handbook Section 2722, Consumer Moves and Case Transfers.

In situations where the member moves out of a STAR+PLUS area and then calls the local DADS office requesting services, DADS staff inform the SPSU of the move within two business days. After receiving the notification, SPSU staff follow applicable procedures outlined above.

The SPSU is the main contact point for transfers in and out of a STAR+PLUS service area. The SPSU:

• contacts the MCO for assistance with transfers of Primary Home Care (PHC), Title XIX Day Activity and Health Services (DAHS), or other community care services;
• checks the Service Authorization System (SAS) to see if the member is receiving any non-managed care long-term services and supports;
• coordinates with the appropriate DADS case manager or Medicaid for the Elderly and People with Disabilities (MEPD) unit regarding the transfer of non-managed care cases; and
• emails the Health Plan Operations (HPO) mailbox at hpo_star_plus@hhsc.state.tx.us informing HPO of the date of the move.

The MEPD specialist in the STAR+PLUS area must enter the address change for Medical Assistance Only cases when it is reported. The Supplemental Security Income (SSI) member is responsible for reporting the address change to the Social Security Administration (SSA).

Within two business days of receiving SPSU email, HPO must force disenrollment and, if the address change has not occurred in the Texas Integrated Eligibility Redesign System (TIERS), force a never-not.

Staff can check managed care status by using either the TIERS application by clicking on the Managed Care hyperlink on the Individual – Summary page in TIERS. This takes the user to the Managed Care page, which shows the individual's managed care history, including the provider and plan codes. See Section 5131, Identifying Managed Care Members in TIERS, for additional information.

While receipt of the Home and Community-based Services STAR+PLUS Waiver can be verified in SAS, receipt of the STAR+PLUS Program and the associated managed care PHC and DAHS services are not registered in SAS. Therefore, STAR+PLUS Program status is confirmed by the indication of managed care enrollment in TIERS in conjunction with the absence of a STAR+PLUS waiver authorization in SAS.

3419  Payment for Delivered Services During a Period of Extended Delay in Notification of a Move into a STAR+PLUS Service Area

When an individual moves from a non-managed care service area to a managed care area, the managed care organization (MCO) is not responsible for payment of any services delivered until the date the individual is enrolled in managed care. Therefore, providers who deliver services without notifying the Department of Aging and Disability Services (DADS) or the MCO in the gaining service area, are at risk of not being paid for services delivered.

If notification is received after moving into the managed care service area, the enrollment date is the first day of the month following the date of notification. If notification is the first day of the month, the enrollment date is the same day.

The provider may contact the DADS regional Claims Management System coordinator to determine if the provider is eligible for payment of any of the services delivered between the actual date of the move and the day before the enrollment date. The MCO is responsible for authorizing services effective on the enrollment date.

3420  Individuals Aging Out of Children's Programs

A variety of Medicaid programs are available to children under 21 years of age that are no longer available when children are aging out (turning 21). Three of these programs are the:

• Medically Dependent Children Program (MDCP);
• Texas Health Steps Comprehensive Care Program (THS-CCP) Private Duty Nursing (PDN); and
• Texas Health Steps Comprehensive Care Program (THS-CCP) Personal Care Services (PCS).

An individual who is aging out of any of these programs may apply for services through the STAR+PLUS program to continue to receive community services and avoid institutionalization after his/her 21st birthday.

3421  Aging Out of the Medically Dependent Children Program, Texas Health Steps Comprehensive Care Program or Texas Health Steps Private Duty Nursing

3421.1  12 Months Prior to the Individual's 21st Birthday

Twelve months prior to the Medically Dependent Children Program (MDCP)/Texas Health Steps Comprehensive Care Program (CCP)/Texas Health Steps Private Duty Nursing (PDN) individual's 21st birthday, the following process will commence.

The Department of Aging and Disability Services (DADS) Access and Intake unit furnishes a list of individuals turning age 21 in the next 18 months to regional directors, who distribute the list to regional staff.

The Department of State Health Services (DSHS) Case Management Unit furnishes a list of individuals turning age 21 in the next 12 months to DSHS regional case managers.

The MDCP case manager:

• identifies MDCP individuals (may be MDCP-only or MDCP/CCP/PDN);
• schedules a transition visit with the DADS regional nurse and the individual/family to explain that:
  • MDCP/CCP/PDN services will terminate the day before the individual's 21st birthday;
  • STAR+PLUS Waiver (SPW) services are an option available to the individual at age 21;
  • a list of STAR+PLUS managed care organizations (MCOs) and a comparison chart is available in the service delivery area (SDA);
  • it is important to choose an MCO and primary care physician (PCP) six months before the 21st birthday in order to avoid assignment of an MCO or a gap in services; and
  • the individual/family can change MCOs anytime after the first month of enrollment;
• monitors service planning with the MDCP individual/family every 90 days during the year before the individual turns 21;
• contacts the STAR+PLUS Support Unit (SPSU) to discuss any problems or concerns; and
• advises the regional Complex Needs coordinator and SPSU that this may be a high needs individual, if the individual appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the HCBS STAR+PLUS Waiver (SPW).

The DSHS regional case manager:

• identifies individuals receiving CCP/PDN services only;
• schedules a transition visit with the individual/family to discuss that:
  • nursing services from CCP will terminate the day before the individual's 21st birthday;
  • SPW services are an option available to the individual at age 21;
  • a list of STAR+PLUS MCOs and a comparison chart is available by contacting SPSU in the appropriate SDA;
  • it is important to choose an MCO and PCP six months before the 21st birthday in order to avoid assignment of an MCO and/or a gap in services; and
  • the individual/family can change MCOs anytime after the first month of enrollment.

SPSU furnishes packets (containing the MCO lists and comparison chart) to the:

• MDCP case manager; and
• DSHS regional case manager.

3421.2  Six Months Prior to the MDCP/CCP/PDN Individual's 21st Birthday

Six months prior to the Medically Dependent Children Program (MDCP)/Texas Health Steps Comprehensive Care Program (CCP)/Texas Health Steps Private Duty Nursing (PDN) individual's 21st birthday:

The MDCP case manager:

• reviews the list of individuals (MDCP-only or MDCP/CCP/PDN) who are aging out (turning age 21);
• continues to identify individuals who may require designation as high needs;
• makes a referral to the STAR+PLUS Support Unit (SPSU) using Form 2067, Case Information; and
• informs the regional Complex Needs coordinator (CNC) and SPSU of the possible high needs situation if the individual appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the HCBS STAR+PLUS Waiver (SPW).

SPSU:

• identifies all MDCP or CCP/PDN individuals aging out in six months;
• contacts the individual/family by telephone to:
  • review the packet discussed at the 12-month MDCP or Department of State Health Services case manager's transition visit;
  • inform the individual/family they have 30 days to choose a managed care organization (MCO) and a primary care physician;
  • explain that if the individual/family does not choose an MCO, an MCO will be selected for the individual by the state on a rotating basis; and
  • explain that the individual/family can change MCOs anytime after the first month of enrollment.
• notifies the following regarding all possible high needs situations:
  • STAR+PLUS specialist at the Health and Human Services Commission – Managed Care Operations;
  • Department of Aging and Disability Services Access and Intake Unit; and
  • regional CNC.

3421.3  Five Months Prior to the MDCP/CCP/PDN Individual's 21st Birthday

Five months prior to the Medically Dependent Children Program (MDCP)/Texas Health Steps Comprehensive Care Program (CCP)/Texas Health Steps Private Duty Nursing (PDN) individual's 21st birthday, and within 30 calendar days of the previous contact, the STAR+PLUS Support Unit (SPSU) contacts the individual/family by telephone.

If the MDCP/CCP/PDN individual/family has made a managed care organization (MCO) and primary physician (PCP) choice:

• the MDCP/CCP/PDN individual/family member informs SPSU of the choice for an MCO; and
• SPSU informs the:
  • individual that he/she must remain with this MCO through the first month of HCBS STAR+PLUS Waiver (SPW) services to assure a smooth transition and service continuity; and
  • MCO of the individual's choice by posting Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder, using the appropriate naming convention. If applicable, include an email that Form 3676-MC has been posted to the XXXSPW folder in TxMedCentral. The email should also contain notice of possible high needs individuals and a recommendation to expedite the assessment and individual service plan (ISP) process.

If the MDCP/CCP/PDN individual/family member has not made an MCO and PCP choice:

• SPSU informs the individual/family that if an MCO is not selected within seven calendar days, one will be assigned; and
• if the selection is not made within seven calendar days, SPSU:
  • selects an MCO for the individual on a rotating basis;
  • informs the individual that:
    • the state has selected an MCO; and
    • he/she must remain with this MCO through the first month of SPW services to assure a smooth transition and service continuity; and
  • informs the MCO of the choice by posting Form 3676-MC to TxMedCentral in the XXXSPW folder, using the appropriate naming convention.

Note: Within 14 days of posting Form 3676-MC, the MCO must schedule the initial home visit with the MDCP/CCP/PDN individual/family member.

3421.4  Within 45 Days of Receiving Notification of a Form 3676-MC Referral

Within 45 calendar days of receiving email notification of Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, Section A, the managed care organization (MCO):

• completes Form 2333, Nursing Facility Risk Criteria Scoring Form;
• completes Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
• completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the form to the Long Term Care Portal (Note: The initial MN/LOC may be submitted up to 120 days prior to the individual's 21st birthday or 180 days if the individual has been designated as having high needs status, as described in Appendix XIV, Determination of High Needs Status for the HCBS STAR+PLUS Waiver (SPW));
• completes Form H1700-1, Individual Service Plan — SPW (Pg. 1), and Form H1700-2, Individual Service Plan — SPW (Pg. 2);
• posts Form H1700-1 to TxMedCentral in the MCO's XXXISP folder, using the appropriate naming convention. An approved MN/LOC must be received before posting Form H1700-1;
• completes Section B of Form 3676-MC; and
• posts Section B of Form 3676-MC to TxMedCentral in the appropriate MCO XXXSPW folder, using the appropriate naming convention.

3421.5  Confirm STAR+PLUS Waiver Eligibility

The STAR+PLUS Support Unit (SPSU) confirms eligibility within five business days of receipt of all required eligibility documentation from the managed care organization (MCO) and Texas Medicaid & Healthcare Partnership, based on:

• approved medical necessity (MN); and
• an initial individual service plan (ISP) cost within 200% of the Resource Utilization Group (RUG) cost limit. Note: If the ISP exceeds 200% of the RUG, refer to Section 3421.6, ISP Cost Exceeds 200% of the RUG Cost Limit.

If eligibility is approved, within two business days, SPSU:

• establishes the ISP effective date, which is the Medically Dependent Children Program (MDCP)/Texas Health Steps Comprehensive Care Program (CCP)/Texas Health Steps Private Duty Nursing (PDN) individual's 21st birthday;
  
  Example:
  
  MDCP/CCP/PDN individual's 21st birthday is Aug. 4, 2010:
  • STAR+PLUS Waiver (SPW) registration is effective Aug. 4, 2010;
  • ISP will then be entered for the SPW ISP period;
  • SPW registration is Aug. 4, 2010, to Aug. 31, 2011;
• follows the ISP registration process outlined in the Service Authorization System Help File, applying the appropriate effective date rule above; and
• completes Form 2065-D, Notification of STAR+PLUS Program Services, and:
  • sends the original to the member;
  • posts Form 2065-D to TxMedCentral in the appropriate MCO's XXXSPW folder, using the appropriate naming convention; and
  • sends an email with Form 2065-D attached to Managed Care Operations (HMCO), which includes the Medicaid number and primary care physician (PCP), if the individual does not have Medicare (Medicaid only).

Within three business days of receipt of Form 2065-D from SPSU, HMCO:

• forces enrollment of the member into STAR+PLUS managed care in the Texas Integrated Eligibility Redesign System (TIERS); and
• establishes managed care enrollment as of the first day of the following month of the MDCP/CCP/PDN individual's 21st birthday. Note: If the member's birthday is the first day of the month, enrollment is effective the same day and month.

Examples:

MDCP/CCP/PDN individual's 21st birthday is Aug. 4, 2011.
Managed care enrollment is effective Sept. 1, 2011.

MDCP/CCP/PDN individual's 21st birthday is Sept. 1, 2011.
Managed care enrollment is effective Sept. 1, 2011.

The administrative payment process (see Section 5400, Administrative Payment Process) must be followed for services provided between the 21st birthday and the managed care enrollment effective date.

If eligibility is denied, SPSU:

• completes Form 2065-D, Notification of STAR+PLUS Program Services;
• mails the original to the individual;
• posts Form 2065-D on TxMedCentral in the appropriate MCO's XXXSPW folder, using the appropriate naming convention; and
• emails a copy of Form 2065-D to the HMCO mail box.

3421.6  ISP Cost Exceeds 200% of the RUG Cost Limit

If the individual service plan (ISP) cost exceeds 200% of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) (if efforts to secure alternatives to ensure health and safety within the cost limit are unsuccessful) sends an email to the Health and Human Services Commission (HHSC) STAR+PLUS specialist to request a staffing, and includes a copy of the ISP. The staffing may result in a recommendation to the MCO to bring the plan within the cost limit. The General Revenue (GR) process begins when a formal request is received from HHSC Managed Care Operations for a clinical assessment for GR.

3422  Procedures for Individuals Aging Out of Personal Care Services

Early Enrollment in STAR+PLUS for Individuals Aging Out of Personal Care Services (PCS)

Services to PCS recipients end as of 12:01 a.m. on their 21st birthday. Because managed care enrollment always occurs on the first day of the month, there will always be at least a partial-month gap in services unless the birthday falls on the first day of the month. By opting to enroll in STAR+PLUS no later than the first day of the month of the 21st birthday, individuals can ensure there is no gap in services. SPSU coordinators must ensure individuals aging out of PCS understand the option of early enrollment and must document in the case record if an individual declines early enrollment.

SPSU coordinators can assist individuals who desire early enrollment by:

• coordinating the PCS end date with PCS staff; and
• sending an email to the HPO mailbox (HPO_STAR_PLUS@hhsc.state.tx.us) that contains the:
  • name of the individual;
  • individual’s Medicaid number;
  • date the individual is to be enrolled in managed care; and
  • name of the individual’s primary care physician, if the individual is Medicaid only (not applicable to individuals with Medicare).

Individuals must be offered early enrollment in managed care at both the six-month and three-month contacts. When determining the date of managed care enrollment, ensure a minimum of 14 days to enable the MCO to assess the member for service needs prior to enrollment.

3422.1  Six to 12 Months Prior to the PCS Individual's 21st Birthday

Six to 12 months prior to the Personal Care Services (PCS) individual's 21st birthday, the Department of State Health Services (DSHS) regional case manager schedules a transition visit with the individual/family to explain:

• PCS services will terminate the day before the individual's 21st birthday;
• HCBS STAR+PLUS Waiver (SPW) services are an option available to the individual at age 21;
• STAR+PLUS services (not SPW) may be available prior to age 21, depending on the individual's eligibility and service needs:
  • enrollment in STAR+PLUS is voluntary for children under age 21 receiving Supplemental Security Income and not enrolled in an excluded program (see exclusions below);
  • voluntary enrollment is through the enrollment broker; and
  • at age 21, an enrollee in STAR+PLUS may request an upgrade to SPW;
• a list of STAR+PLUS managed care organizations (MCOs) and a comparison chart, which DSHS can obtain from the STAR+PLUS Support Unit in the STAR+PLUS service delivery area;
• the importance of choosing an MCO at least three months before the individual's 21st birthday in order to avoid assignment of an MCO and/or a gap in services;
• the individual/family can change MCOs anytime after the first month of enrollment; and
• how to choose an MCO.

The following people cannot participate in the STAR+PLUS program:

• individuals admitted to a hospital or a nursing facility;
• STAR+PLUS members who have been in a nursing facility for more than four months;
• individuals of Medicaid waiver services, except Community Based Alternative services;
• residents of intermediate care facilities for persons with intellectual disability;
• individuals not eligible for full Medicaid benefits, such as recipients of Community Attendant Services, Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries and Qualified Disabled Working Individuals;
• undocumented aliens;
• people not eligible for Medicaid; and
• children in state foster care.

3422.2  Three Months Prior to the PCS Individual's 21st Birthday

Three months prior to the Personal Care Services (PCS) individual's 21st birthday, the Department of State Health Services (DSHS) regional case manager makes a referral to the STAR+PLUS Support Unit (SPSU) using the referral form, DSHS-PCS, including selection of a managed care organization (MCO).

If the choice of MCO or primary care provider (PCP) is not indicated on the referral form, DSHS-PCS, SPSU contacts the PCS individual/family member to identify the choice for an MCO.

If the PCS individual/family has made an MCO choice, SPSU:

• informs the individual that he/she must remain with this MCO through the first month of STAR+PLUS services to assure a smooth transition and service continuity;
• posts Form 2067, Case Information, to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention, and sends the referral form, DSHS-PCS, to the MCO, notifying the MCO:
  • a PCS individual will be enrolled;
  • the enrollment date;
  • the need to complete Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • services must be in place by the enrollment date; and
• sends a copy of Form 2067 to DSHS notifying it the:
  • PCS individual will be enrolled into STAR+PLUS;
  • name of the MCO; and
  • enrollment date.

If the PCS individual/family has not made an MCO choice, SPSU informs the individual within seven calendar days of receiving the referral:

• that the individual must choose an MCO or is at risk of losing services for up to three months following the individual's 21st birthday;
• the deadline to ensure continued coverage and cutoff dates;
• the option to immediately select an MCO and PCP while on the telephone. If the family does not choose while on the telephone, provide the 1-800-964-2777 contact number for the enrollment broker; and
• that the PCS individual must remain with this MCO through the first month of STAR+PLUS services to assure a smooth transition and service continuity.

Once an MCO is selected, SPSU sends an email to Managed Care Operations (HMCO) at HPO_Star_Plus@hhsc.state.tx.us, including:

• a notice that a PCS individual needs enrollment;
• the individual's packet control number or Medicaid number; and
• name of the PCP for individuals with Medicaid only.

SPSU:

• posts Form 2067 to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention, and sends the referral form, DSHS-PCS, to the MCO, notifying the MCO:
  • a PCS individual will be enrolled;
  • the enrollment date;
  • the need to complete an assessment;
  • services must be in place by the enrollment date; and
• sends a copy of Form 2067 to DSHS notifying it the:
  • PCS individual will be enrolled into STAR+PLUS;
  • name of the MCO; and
  • enrollment date.

HMCO completes the process for STAR+PLUS services enrollment.

3510  Money Follows the Person and Managed Care

The Department of Aging and Disability Services Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports. For residents in a STAR+PLUS service area who need HCBS STAR+PLUS Waiver (SPW) services, the managed care organization (MCO) will perform the functional assessment and service planning.

Note: MCOs can use an NF's Medical Necessity/Level of Care (MN/LOC), and STAR+PLUS Support Units can accept an NF’s MN/LOC for MFP applicants as long as the MN/LOCs are approved and have not yet expired. The NF’s MN/LOC may not be used for upgrades. For more information about upgrades, see Section 3330, STAR+PLUS Members Requesting an Upgrade to the Home and Community-based Services STAR+PLUS Waiver.

One of the eligibility requirements for MFP is that the individual be approved for waiver services prior to leaving the NF. Individuals must reside in the NF until a final determination is made indicating approval of SPW services. Individuals leaving before receiving an approval notification form are denied using Denial Code 39 (Other).

Once the assessment process has been completed and the resident is determined eligible for SPW, the MCO must be prepared to initiate the individual service plan (ISP) upon notification of eligibility. Individuals are enrolled in managed care on the first day of the month in which discharge from the NF is planned. This flexible enrollment process only applies to MFP.

See Section 3310, Intake and Enrollment, for more information about MFP.

The MCO participates in community planning groups (for example, the Community Transition Team) and other activities related to the state's Promoting Independence Initiative.

3511  Money Follows the Person Procedure

A referral is made through the Department of Aging and Disability Services (DADS) Access and Intake when a nursing facility resident in a STAR+PLUS service area wishes to receive services in the community through HCBS STAR+PLUS Waiver (SPW). Intake staff must refer all Money Follows the Person requests to the STAR+PLUS Support Unit. Referrals can be made by anyone, including family members, nursing facility staff, relocation specialists and DADS case managers.

3512  Money Follows the Person Applications Pending Due to Delay in Nursing Facility Discharge

In keeping with the Promoting Independence Initiative, the STAR+PLUS Support Unit (SPSU) and managed care organizations are obligated to assist the nursing facility (NF) applicant/member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, SPSU has the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four calendar month time frame is the guideline used in determining pending or denying requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the individual is ready to discharge from the NF.

Examples:

• A STAR+PLUS Waiver (SPW) applicant has a definite date of discharge within four calendar months from the date services were requested. Allow the referral to remain open until the member is ready to discharge and coordinate the transfer to the community.
• An SPW applicant is in the process of making living arrangements that will allow him to leave the NF within four calendar months from the date services were requested. Allow the application to remain open.

If the applicant has an estimated date of discharge that may or may not go beyond the four calendar month period, SPSU should keep the request for services open. See Section 3513 below for information about applications pending more than four calendar months.

3513  Applications Pending More than Four Calendar Months Due to Delay in Nursing Facility Discharge

STAR+PLUS Support Unit (SPSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but are not finalized. If the applicant has an estimated date of discharge that goes beyond the four-calendar-month period, SPSU should keep the request for services open.

Applicants who have not made any living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community should be denied. Deny the request for services by sending Form 2065-D, Notification of STAR+PLUS Program Services, within two business days after the end of the four-calendar-month pending period.

If an Assisted Living (AL) applicant meets eligibility criteria but is on an interest list for a contracted SPW AL facility, SPSU verifies through the MCO that the applicant is on the list and may leave the service request pending until the slot opens.

3514  Individuals Residing in a Facility in a Non-Managed Care Area

If the individual is residing in a nursing facility (NF) in a non-managed care service area and wishes to relocate to a managed care service area, he/she is first processed for Community Based Alternatives enrollment. At discharge from the NF, he/she is transferred to the desired managed care service area using policy outlined in Section 3413, Nursing Facility Applicant in a Non-STAR+PLUS Service Area Transferring to a STAR+PLUS Service Area.

3515  Individuals Residing in a Managed Care Area

When a nursing facility (NF) resident in a managed care service area first requests a transition to the community using Money Follows the Person provisions, it is not necessary for him/her to have pre-existing Medicaid coverage at that time. STAR+PLUS Support Unit (SPSU) staff must check the automation system to determine the individual's Medicaid status. If the individual does not have the appropriate type of Medicaid coverage, SPSU must immediately send a referral to Medicaid for the Elderly and People with Disabilities (MEPD). Referral to the managed care organization (MCO) must be made at the same time as the referral to MEPD.

SPSU is responsible for completing the following activities within 14 days of the initial request for services. All attempted contacts with the NF resident or encountered delays must be documented. SPSU:

• releases the NF resident from the HCBS STAR+PLUS Waiver (SPW) interest list;
• makes a referral to MEPD if a referral has not already been made or the individual does not already have the appropriate type of Medicaid coverage for SPW;
• contacts the NF resident/responsible party to explain SPW services;
• refers the individual for relocation assistance by completing Form 1579, Referral for Relocation Services;
• sends a copy of the appropriate STAR+PLUS MCO contact list to the NF resident/responsible party;
• discusses with the NF resident the importance of choosing an MCO to conduct the assessment and develop the initial individual service plan (ISP) to avoid a delay in eligibility determination for SPW services; and
• informs the NF resident that the MCO in which he or she is enrolled can be changed at any time after the first month of service.

Prior to determination of Waiver eligibility, SPSU staff must confirm that Medicaid has made a payment, or portion of a payment, to the NF for care of the resident. (Any type of Medicaid, even one usually connected to community-based services, is acceptable. This could include a 20% copayment for an individual with Medicare cost-sharing coverage.) Lack of Medicaid coverage at the time of the initial request must not be allowed to delay the MFP determination process. The financial eligibility determination by MEPD must be made in parallel with the SPSU and MCO process in order to avoid a delay in service delivery.

SPSU coordinates the necessary Money Follows the Person process to ensure a successful transition to the community. For SPSU, this includes tracking each step of the process through the start of SPW services. If appropriate time frames are not met, SPSU contacts the appropriate entity to assist with problem resolution while documenting any delays. Coordination with local service providers regarding barriers to transition to the community are handled through the Community Transition Team. Problems encountered with services provided by relocation or Transition to Life in the Community (TLC) providers are handled through regional contract managers. If appropriate time frames are not met, SPSU contacts the appropriate entity to assist with resolution of the problem while documenting any delays.

The NF resident chooses an MCO and notifies SPSU verbally or in writing. Within two business days of the MCO selection, SPSU completes Section A of Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, and posts it to the MCO's XXXSPW folder on TxMedCentral using the appropriate naming convention. Form 3676-MC is faxed to the relocation contractor. If the NF resident requires assistance transitioning to the community because of lack of supports, lack of housing or other barriers, ensure that the appropriate items on Form 3676-MC are completed. The MCO is notified by email that information is posted in a specific folder.

The MCO completes:

• Section B of Form 3676-MC; and
• the ISP.

If relocation assistance is not indicated in Section A of Form 3676-MC, the MCO requests a referral:

• in the appropriate item in Section B of Form 3676-MC;
• using Form 2067, Case Information; or
• via telephone contact with SPSU.

The MCO coordinates with relocation contractors to ensure that everything needed for community living is in place at discharge from the NF. If needed, the MCO coordinates Transition Assistance Services as part of the SPW. The MCO is not responsible for obtaining independent housing for the resident, but is responsible for identifying assisted living or adult foster care alternatives available in the network. TLC services must be coordinated through SPSU.

The MCO posts the SPW packet to TxMedCentral.

If the packet from the MCO is not received within 45 days after the assessment is authorized, SPSU contacts Managed Care Operations (HMCO) to let it know the time frame for packet completion was not met.

Texas Health and Human Services Commission
Managed Care Operations – STAR+PLUS
Mail Code H-320
P. O. Box 13247
Austin, TX 78711

Within two business days of receipt of the packet, SPSU completes Section C of Form 3676-MC and sends it with Form H1746-A, MEPD Referral Cover Sheet, to MEPD staff to complete and return.

MEPD determines financial eligibility, completes Section D of Form 3676-MC and returns it to SPSU.

Within five business days of the receipt of all required eligibility documentation, SPSU determines eligibility based upon Medicaid eligibility, medical necessity, risk assessment and an ISP cost within the individual's assessed cost limit based on information submitted on the Medical Necessity and Level of Care (MN/LOC) Assessment.

If eligibility is denied, SPSU completes Form 2065-D, Notification of STAR+PLUS Program Services, and:

• mails the original to the applicant;
• posts it on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
• faxes or mails a copy to MEPD staff; and
• emails a copy to HMCO with Form 2067, explaining that the form was signed, dated and sent to the applicant.

If eligibility is approved, SPSU works with the relocation contractor, NF, resident and MCO to identify a firm discharge date. The MCO is the responsible party for notifying SPSU of the discharge date. Should any other entity contact SPSU with a discharge date, SPSU must notify the MCO to determine if the date is acceptable. Before discharge, the NF resident must have Form 2065-D with eligibility noted in order to transition to SPW services. (A secondary Form 2065-D containing the service effective date will be sent once everything is complete.)

When the discharge date is determined, SPSU completes Form 2065-D and:

• mails the original to the applicant;
• posts it on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
• faxes or mails a copy to MEPD staff; and
• emails a copy to HMCO.

When discharge from the NF is verified, SPSU makes Service Authorization System (SAS) entries following the procedures in the SAS Help File, and updates the Community Services Interest List.

3520  Money Follows the Person Demonstration Initiative

3521  MFPD Initiative

The Money Follows the Person Demonstration (MFPD) Initiative was implemented in order to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities and receive necessary long-term services and supports (LTSS) in the setting of the individual's choice. Participation in MFPD does not affect the type or amount of services received, or the manner in which they are delivered. Managed care Medicaid waiver services received by the member participating in MFPD are the same as services delivered to other HCBS STAR+PLUS Waiver (SPW) members.

In addition to HCBS STAR+PLUS Waiver (SPW), MFPD participants receive more extensive relocation assistance and follow up. They are also eligible to access Behavioral Health Services (BHS) in the following counties in the Bexar and Travis STAR+PLUS service areas: Travis County, Atascosa County, Bexar County, Guadalupe County and Wilson County.

BHS is designed to assist adults with mental health and substance abuse diagnoses who wish to transition to the community from nursing facilities. Services include Cognitive Adaptation Training (CAT) and adult substance abuse treatment.

CAT provides community-based and in-home assistance to help individuals organize their environment and function independently. The training engages the member in performing self-care and using environmental modifications to facilitate independence. Both substance abuse services and CAT may be provided for participants for up to six months before discharge from the nursing facility as "pre-transition services" and also for one year when participants leave the nursing facility and live in the community.

Substance abuse treatment is provided by STAR+PLUS managed care organizations (MCOs). Individuals will access these services through the MCO.

The state benefits from member participation in MFPD by receiving enhanced funding and more information about LTSS through the participant survey.

3522  Screening Criteria for MFPD Eligibility

To be eligible for Money Follows the Person Demonstration (MFPD), the applicant must meet current waiver and MFP policy, and:

• reside in a STAR+PLUS area;
• reside continuously in an institutional setting for at least 90 days prior to the eligibility date and be enrolled from a Medicaid certified nursing facility;
• be Medicaid eligible under Title XIX of the Social Security Act, including transition into a qualified residence that includes:
  • a home owned or leased by the individual or individual's family member;
  • an apartment with an individual lease that includes living, sleeping, bathing and cooking areas in which the individual/family member has domain;
  • Assisted Living apartment (Service Code 19);
  • Residential Care apartment (Service Code 19A); and
  • Adult Foster Care home (no more than four unrelated individuals living in the home);
• Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, signed by the individual or signed by a guardian/legally authorized representative (LAR) and managed care organization staff after explanation of MFPD and prior to delivery of services; and
• include the guardian/LAR in the actual transition planning, if applicable.

For MFPD, an institutional setting is defined as a nursing facility, intermediate care facility for persons with intellectual disability, hospital or state hospital. The 90-day residency rule may be met by a continuous stay in a combination of the settings.

Example: An MFP applicant may have resided continuously in a nursing facility for 30 days, in a hospital for 60 days and then re-entered the nursing facility for another month. This would meet the 90-day institutional residency rule for MFPD.

3523  STAR+PLUS Support Unit Responsibilities

Apply the screening criteria, as discussed above, to determine if the individual is potentially eligible to participate in the Money Follows the Person Demonstration (MFPD) Initiative. The requirement that the individual reside continuously in an institutional setting for 90 days need not be met until the actual MFPD eligibility date. The individual does not have to have been in the facility 90 days at the time of referral. The individual meets the screening criteria if it appears likely he/she will have been in the facility at least 90 days by the eligibility date.

To verify MFPD, nursing facility or other institutional residency requirements, staff may:

• use Minimum Data Set (MDS) information, available on the Texas Medicaid & Healthcare Partnership (TMHP) website;
• view Service Authorization System (SAS) nursing facility records (Service Code 1);
• contact the nursing facility for admission dates; or
• as a last resort, obtain confirmation from the applicant.

Communicate to managed care organization (MCO) staff that the individual is potentially eligible for MFPD by completing the MFPD qualifying begin and end dates in Item 20 on Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization. MCO staff are responsible for presenting the initiative to the member and obtaining his/her signature on the informed consent form.

3524  Enrollment in MFPD

Individuals who choose to enroll in and meet the eligibility requirements for Money Follows the Person Demonstration (MFPD) must be designated in the Service Authorization System using the following procedures:

• Enrollment Record — Enrolled From Field: Choose "12-Rider 37/28 (FAC to COMM)."
• Service Authorizations:
  • Force Box — Check the Force box for each service authorization.
  • Fund Type — Choose "19MFP-Money Follows the Person." This code applies only to MFPD recipients.
  • Force Comment — Enter "MFP Demonstration Member" and select "Force."

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD period is over or if the member withdraws from MFPD. If a member enters a nursing facility and then re-enters the community setting before the MFPD ISP period is over, the MFPD entitlement period resumes until the end of the ISP or the month of a new ISP period if the 365-day period extends beyond the current ISP period.

The STAR+PLUS Support Unit (SPSU) must maintain a list of MFPD participants. This list must contain the participant's:

• name;
• Medicaid number; and
• ISP start date.

The member may withdraw from MFPD at any time by completing Form 3632, Withdrawal Confirmation, and sending it to SPSU. Although MFPD eligibility may end, the member continues to receive waiver services if all eligibility criteria are met.

3525  MFPD Entitlement Period Tracking

Time spent in an institutional setting does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) members receive the full 365-day entitlement period. The entitlement period begins the date the member who agrees to participate in the demonstration is enrolled in STAR+PLUS Waiver (SPW).

In order to assure that the member has been put on the Service Authorization System as an MFPD applicant, the STAR+PLUS Support Unit must notify the managed care organization (MCO) via Form 2067, Case Information, in the MCO's XXXSPW folder using the most appropriate naming convention, that Fund Code 19MFP has been entered.

Example: The applicant chooses to participate in MFPD and is enrolled in SPW effective June 1. If there are no institutional stays during the initial individual service plan (ISP) period, the MFPD period ends on May 31. If the MFPD member is institutionalized for 10 days in April, the MFPD period is extended to June 10, following the ISP end date of May. If the MFPD member is authorized for a new MFPD service during the initial ISP period, the 365-day period would still end on May 31, if there were no institutional stays.

Tracking is required to ensure MFPD members receive the full 365-day entitlement period unless the member withdraws from MFPD. The MCO is responsible for tracking the MFPD entitlement period because DADS staff have no way of knowing when SPW members are admitted and released from nursing facilities. Once the 365-day period has passed, the MCO is responsible for posting Form 2067, Case Information, to TxMedCentral to inform the STAR+PLUS Support Unit of the date the member's entitlement period ended. Once received, this information must be forwarded to the regional MFPD reporting coordinator within two business days.

It is essential that complete and accurate records are maintained because MFPD tracking is subject to audit by the Centers for Medicare and Medicaid Services. Staff must follow policy in Section 6412, Maintenance Requirements for Member Information and Forms, which requires a daily backup of TxMedCentral files to compact disk.

3526  Documentation of the 90-Day Qualifying Institutional Stay Required for MFPD Eligibility in SPW

To be eligible for the Money Follows the Person Demonstration (MFPD) Initiative, individuals must have resided continuously in an institutional setting for at least 90 days prior to the eligibility date, and be enrolled from a Medicaid-certified facility. The individual's date of entry and date of discharge from a hospital, nursing facility or other institutional setting are included in the number of days the individual is considered to be institutionalized. Check the Service Authorization System (SAS) for verification of residence in qualified institutional settings. This may include stays in a combination of applicable settings, which include:

• Service Group (SG) 1, Service Code (SC) 1, Nursing Facility — Daily care;
• SG5, SC1, State Operated Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
• SG6, SC1, Non-State Operated ICF/IID; and
• SG4, SC1, State Supported Living Centers.

Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization, must include documentation of the qualifying stays in Item 20, MFPD Qualifying Dates. Institutional stays for the 90 days prior to the eligibility date must be documented even if it appears the individual does not meet the criteria. If the applicant is currently residing in a qualified institutional setting at the time Form 3676-MC is sent to the managed care organization, enter the begin date of coverage and use "ongoing" as the end date. For example, Form 3676-MC for an individual transitioning to the community on November 1 may include the following:

The example below shows the individual has been in the nursing facility less than 90 days. However, SAS records do not include any possible hospitalizations (which also count toward the 90-day requirement). The managed care organization will determine if the individual was in a hospital either directly before or after the period indicated on Form 3676-MC.

The same is true if the individual has a gap in institutional coverage, as illustrated below. Again, the individual may have been in the hospital during that time.

3530  High/Complex Needs Members

3531  Designation of High Needs Members

The Uniform Managed Care Contract, Attachments A and B-1, Section 8.1.12, specifies the managed care organization (MCO) must develop and maintain a system and procedures for identifying members with special health care needs (MSHCN), including people with disabilities or chronic or complex medical and behavioral health conditions and children with special health care needs (CSHCN).

The MCO must contact members pre-screened by the Health and Human Services Commission (HHSC) Administrative Services contractor as MSHCN to determine whether they meet the MCO's MSHCN assessment criteria, and to determine whether the member requires special services. The MCO must provide information to the HHSC Administrative Services contractor identifying members who the MCO has assessed to be MSHCN, including any members pre-screened by the HHSC Administrative Services contractor and confirmed by the MCO as a MSHCN. The information must be provided in a format and on a time line to be specified by HHSC in the Uniform Managed Care Manual, and updated with newly identified MSHCN by the 10th day of each month. In the event that an MSHCN changes MCOs, the MCO must provide the receiving contractor information concerning the results of the MCO's identification and assessment of that member's needs to prevent duplication of those activities.

CSHCN means a child (or children) who:

• ranges in age from birth up to age 19;
• has a serious ongoing illness, a complex chronic condition or a disability that has lasted or is anticipated to last at least 12 continuous months or more;
• has an illness, condition or disability that results (or without treatment would be expected to result) in limitation of function, activities or social roles in comparison with accepted pediatric age-related milestones in the general areas of physical, cognitive, emotional, and/or social growth and/or development;
• requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel; and
• has a need for health and/or health-related services at a level significantly above the usual for the child's age.

MSHCN includes a CSHCN and any adult member who:

• has a serious ongoing illness, a chronic or complex condition, or a disability that has lasted or is anticipated to last for a significant period of time; and
• requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel.

3532  Determination of High Needs Status for Ongoing Members

If during the individual service plan (ISP) period the managed care organization (MCO) determines the member's subsequent ISP may have the potential to exceed the cost limit, that member is considered to have high needs status. Once designated as having a high needs status, the MCO must initiate in the ninth month of the ISP period plans to bring the ISP at/or under the cost limit.

If it appears the subsequent ISP will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the MCO initiates a request for a staffing with the Health and Human Services Commission to determine whether a request for the use of General Revenue funds is appropriate.

3533  Complex Needs Coordinators

Each Department of Aging and Disability Services region has a designated complex needs coordinator (CNC). The primary responsibilities are in the coordination of high needs members transitioning from children's programs to adult programs. Due to the complexity of some of these situations, the skills of the CNC are necessary.

Outlined below are the duties of the CNC. The CNC is the point of contact for issues and questions.

3533.1  Quarterly Comprehensive Care Program Transition Report

The designated complex needs coordinator (CNC) is responsible for:

• completing the quarterly Comprehensive Care Program (CCP) Transition Report for the region and submitting it to the Department of Aging and Disabilities Services state office Special Initiatives coordinator by the designated due date;
• being the point of contact for any questions on the quarterly CCP Transition Report;
• ensuring the 12-month visit and contacts are made by the Medically Dependent Children Program case managers and reporting to Health and Human Services Commission – Managed Care Operations any members who may potentially be over the cost limit based on current services; and
• ensuring all HCBS STAR+PLUS Waiver (SPW) aging out referrals (Form 3676-MC, Managed Care Pre-Enrollment Assessment Authorization) are sent on time.

See Appendix XIII, Reporting Requirements for the CCP Transition Report, for assistance in completing the report.

3533.2  Identifying and Tracking High Needs Aging-Out Members

The complex needs coordinator is responsible for coordinating with the:

• STAR+PLUS Support Unit supervisor to:
  • identify the aging out members who may be close to the cost limit or have other issues that may complicate the development of an acceptable individual service plan and reporting this information to Managed Care Operations (HMCO) and Department of Aging and Disabilities state office (SO) staff;
  • serve as the regional contact person for SO and HMCO staff for questions on pending applications or ongoing members with high needs;
  • assist with collecting and submitting the required medical and service documentation for an interdisciplinary team or when a physician's clinical visit is required for the Rider 36 General Revenue process; and
  • work with HMCO and SO staff if the Rider 36 process is initiated;
• assigned staff on all high needs assessments for aging out applicants; and
• managed care organization to ensure a cost effective individual service plan is developed that assures health and safety and is ready to be implemented on the aging out date.

3534  Services for Individuals Disenrolled from STAR+PLUS

In some situations, a STAR+PLUS member or his managed care organization (MCO) may request, and be granted, disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive services available from the Department of Aging and Disability Services (both Medicaid and Title XX) if determined eligible, with the exception of Community Based Alternatives (CBA). There are no CBA contracts in managed care areas.

3610  Revising the Individual Service Plan

It may be necessary to revise the individual service plan (ISP) within the ISP period due to changes in the needs of the member or changes in the services offered or emergency situations. The managed care organization documents revision to the ISP on Form H1700-1, Individual Service Plan — SPW (Pg. 1). A revised ISP is not submitted to the STAR+PLUS Support Unit via TxMedCentral, but is kept in the member's case record.

3611  MCO Required Notifications from the Provider

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

• the member leaves the service area for more than 30 days;
• the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
• the member is not financially eligible for Medicaid benefits;
• providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
• the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
• the member fails to pay his/her qualified income trust copayment;
• the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
• the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
• the member requests that services end.

3611.1  Immediate Suspension or Reduction of Services

If the member or someone in the member's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the managed care organization (MCO) and MCO-contracted provider are required to make an immediate referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services and/or the police and suspend services. The MCO must immediately provide written notice of temporary suspension of service to the member, and the right of appeal to a fair hearing must be explained to the member. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference and the right of appeal.

The provider must verbally inform the MCO by the following business day of the reason for the immediate suspension, and follow up with written notification to the MCO within two business days of verbal notification. The MCO must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the STAR+PLUS Waiver provider may continue providing services to assist in the resolution of the crisis. If the crisis is not satisfactorily resolved, the MCO follows the established denial procedures. Services do not continue during the appeal process.

3611.2  Required Notification of Service Denial from the MCO

If the managed care organization (MCO) determines that documentation supports initiation of denial, the MCO provides written notification of denial to the member within five business days. The MCO, within five business days, sends Form 2065-D, Notification of STAR+PLUS Program Services, to the member.

Form 2065-D must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal. The MCO forwards a copy of the notification to the provider within two business days.

If the member appeals the notification of denial within the 10-day adverse action period, the MCO must continue SPW services until notification of the decision by the state fair hearings officer. The MCO must not reduce waiver services until the outcome of the appeal is known.

3620  Reassessment

3621  Reassessment Procedures

The STAR+PLUS Support Unit (SPSU) must ensure the member's individual service plan (ISP) is entered into the Service Authorization System (SAS) annually. The SPSU:

• checks TxMedCentral to determine if the managed care organization has submitted Form H1700-1, Individual Service Plan — SPW (Pg. 1), before the ISP end date;
• verifies the case has an approved medical necessity and level of service (both must have the same end date as the ISP being registered; if not, extend the medical necessity and level of service record through the end of the ISP being registered);
• confirms ongoing Medicaid eligibility;
• verifies continuing enrollment in SAS reflects any plan change;
• verifies the ISP is within the cost limit;
• determines if the ISP was submitted on time and if:
  • on time, enters service group (SG) 19 service code (SC) 12;
  • not on time, enters SG 19 SC 13 for the month(s) for which the ISP was late and SG 19 SC 12 for the remaining ISP period; and
• enters the ongoing ISP in SAS within five business days of receipt, not to exceed the ISP end date.

If the reassessment ISP is being submitted due to the participant's timely appeal of a STAR+PLUS Waiver denial, staff enter the information from the old ISP, extending the end date an additional four calendar months. Services continue using this ISP until a decision is received from the hearing officer. At that time, changes are made, if necessary, to comply with the hearing officer's decision.

3622  Notification Requirements

If the member continues to meet waiver requirements, it is not necessary to send Form 2065-D, Notification of STAR+PLUS Program Services, at the reassessment as notification of continuing services. If the member does not meet waiver requirements, the STAR+PLUS Support Unit (SPSU) must, within two business days of notification:

• send Form 2065-D to the member indicating why the case is being terminated;
• post a copy of Form 2065-D in TxMedCentral to the XXXSPW folder using the appropriate naming convention; and
• after the 10-day adverse action period, send a copy of Form 2065-D to HPO_STAR_PLUS@hhsc.state.tx.us.

If no appeal is filed, Managed Care Operations (HMCO) disenrolls the member from STAR+PLUS effective the latter of:

• the individual service plan (ISP) end date; or
• the last day of the month during which the 10-day adverse action period expires.

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

• sends Form H1746-A, MEPD Referral Cover Sheet, for cases in the Centralized Representation Unit, which forwards the information to the appropriate MEPD specialist;
• posts a copy of Form H1746-A in TxMedCentral to the XXXSPW 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);
• extends the end date of the current ISP an additional four calendar months; and
• sends an email to HMCO on Medical Assistance Only cases as notification that a timely appeal was submitted and enrollment should remain open.

HMCO, within 10 calendar days of receiving the fair hearings officer's decision, carries out the decision. See Section 4234, Hearing Decision.

3623  HCBS STAR+PLUS Waiver (SPW) Eligibility Date on Form 2065-D

Staff must adhere to the following policy when establishing the eligibility date for HCBS STAR+PLUS Waiver (SPW) cases on Form 2065-D, Notification of STAR+PLUS Program Services. The effective date varies. The possible scenarios include:

• upgrades and interest list releases;
• Community Based Alternatives transfers from non-managed care service areas;
• individuals aging out of children's programs; and
• transfers from a nursing facility using the Money Follows the Person (MFP) or MFP Demonstration (MFPD) initiative.

3623.1  Upgrades and Interest List Releases

The start of care (SOC) date for an HCBS STAR+PLUS Waiver (SPW) applicant being released from the interest list or a member requesting/being processed for an upgrade is based on the:

• Medicaid eligibility effective date (MED);
• date the approved Medical Necessity/Level of Care (MN/LOC) was submitted through the Long-term Care portal; and
• date the member's individual service plan (ISP) was posted to TxMedCentral.

STAR+PLUS Support Unit (SPSU) staff determine the effective date based on the later of the above dates. If the date falls on the first day of the month, the effective date on Form 2065-D, Notification of STAR+PLUS Program Services, is the first day of that month. If the date falls between the second and the last day of the month, the effective date is the first date of the following month.

Examples:

Upgrades

• An individual has an MED of 07-01-11, an approved MN/LOC submittal date of 10-15-11, and an ISP posted 11-01-11. The eligibility effective date on Form 2065-D is 11-01-11.
• An individual has an MED of 07-01-11, an approved MN/LOC submittal date of 10-15-11, and an ISP posted 10-20-11. The eligibility effective date on Form 2065-D is 11-01-11.

Interest List

• An individual has an MED of 07-01-11, an approved MN/LOC submittal date of 6-15-11, and an ISP posted 7-01-11. The eligibility effective date on Form 2065-D is 7-01-11.
• An individual has an MED of 07-01-11, an approved MN/LOC submittal date of 6-15-11, and an ISP posted 7-20-11. The eligibility effective date on Form 2065-D is 8-01-11.

3623.2  CBA Transfers from Non-Managed Care Service Areas

The effective date on Form 2065-D, Notification of STAR+PLUS Program Services, for individuals transferring from Community Based Alternatives (CBA) to the HCBS STAR+PLUS Waiver (SPW) is the first day of the month following the date of the move. Exception: If the move occurs on the first day of the month, the effective date is the first day of that month.

Service Authorization System (SAS) registration for CBA transfers occur as follows:

• CBA Service Group 3 SAS registrations must be closed the day of the move.
• SPW Service Group 19 SAS registrations must be the first day of the month following the move. If the move occurs on the first day of the month, SPW Service Group 19 registration is the first day of that month.

3623.3  Individuals Aging Out of Children's Programs

The effective date on Form 2065-D, Notification of STAR+PLUS Program Services, for individuals aging out of the Medically Dependent Children Program, Comprehensive Care Program and Personal Care Services is the first day of the month following the 21st birthday, unless the birthday is on the first day of the month. If the birthday is on the first, the effective date is the 21st birthday.

Examples:

• Individual's birthday is October 15; the effective date is November 1.
• Individual's birthday is November 1; the effective date is November 1.

Service Authorization System registration for age outs must occur as follows:

• HCBS STAR+PLUS Waiver (SPW) Service Group 19 Service Authorization System registrations must be the first day of the month following the birthday.
• If the birthday occurs on the first day of the month, SPW Service Group 19 registration is the first day of that month.

3623.4  MFP/MFPD Nursing Facility Releases

The effective date on Form 2065-D, Notification of STAR+PLUS Program Services, for individuals transferring from nursing facilities (NFs) to the HCBS STAR+PLUS Waiver (SPW) via the Money Follows the Person (MFP)/MFP Demonstration (MFPD) process is the date of discharge. Service Authorization System (SAS) registration for MFP/MFPD releases from NFs must occur as follows:

• NF Service Group 1 SAS registrations must be closed the day before the discharge.
• SPW Service Group 19 SAS registrations begin with a one-day registration to set the managed care organization capitation payment, which must be the first day of the month of the discharge. The ongoing registration covers the entire individual service plan period. The effective date on Form 2065-D is the date of discharge. Exception: If the discharge occurs on the first day of the month, SPW Service Group 19 registration is the first day of that month and the one-day registration is not needed.

3630  Denial/Termination Procedures

This section provides information, procedures and references pertaining to denial or termination of HCBS STAR+PLUS Waiver (SPW) services for active individuals, along with adequate notice of individuals' rights and opportunities to due process.

The following citation from the Code of Federal Regulations (CFR) specifies situations in which an adverse action period is not required:

CFR §431.213 Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a)

The agency has factual information confirming the death of a recipient;

(b)

The agency receives a clear written statement signed by a recipient that —

(1)

He no longer wishes services; or

(2)

Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c)

The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d)

The recipient's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e)

The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f)

A change in the level of medical care is prescribed by the recipient's physician….

The citation for the following rule, which appears in Texas Administrative Code, Title I, Part 15, Chapter 353, Subchapter G, §353.607, appears on Form 2065-D, Notification of STAR+PLUS Program Services. It is the basis for all STAR+PLUS case action.

"The Star+PLUS Handbook includes policies and procedures to be used by all health and human services agencies and their contractors and providers in the delivery of STAR+PLUS services and/or HCBS STAR+PLUS Waiver (SPW) to eligible members. The STAR+PLUS Handbook can be found on the Texas Health and Human Services Commission website."

3631  10-Day Adverse Action Notification

The Code of Federal Regulations (CFR) requires that the Department of Aging and Disability Services (DADS) provide a notice to the individual at least 10 calendar days before the action effective date. The member must be given the full 10-day adverse action period to give him/her time to file an appeal.

CFR, Subpart E, Sec. 431.230, Maintaining services.

(a)

If the agency mails the 10-day or 5-day notice as required under Sec. 431.211 or Sec. 431.214 of this subpart, and the recipient requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless—

(1)

It is determined at the hearing that the sole issue is one of federal or State law or policy; and

(2)

The agency promptly informs the recipient in writing that services are to be terminated or reduced pending the hearing decision.

(b)

If the agency's action is sustained by the hearing decision, the agency may institute recovery procedures against the applicant or recipient to recoup the cost of any services furnished the recipient, to the extent they were furnished solely by reason of this section.

Instructions on how to calculate time periods is provided in §311.014 of the Code Construction Act. It specifies that:

• in computing a period of days, the first day is excluded and the last day is included; and
• if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 10-day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when DADS offices are officially open, even with limited workforce.

The following examples demonstrate how to apply this requirement for any adverse action taken.

Example 1: This example assumes that the 10th day does not fall on a weekend or holiday.

Nov. 26: The STAR+PLUS Support Unit coordinator sends denial notification to the individual. This is day zero.

Dec. 6: This is day 10. The individual has through the end of the business day to file an appeal and have services continue.

Dec. 7: Day 10 passed without an appeal from the individual. This is the first day the individual will not receive services (if the case is being denied) or receive services at the lower level (in cases of service reductions).

Example 2: The example assumes that the 10th day falls on a Sunday.

Jan. 26: The STAR+PLUS Support Unit coordinator sends denial notification to the individual. This is day zero.

Feb. 5: This is day 10, which falls on a Sunday.

Feb. 6: The individual has through the end of this business day to file an appeal and have services continue.

Feb. 7: The extended 10-day period passed without an appeal from the individual. This is the first day the individual will not receive services (if the case is being denied) or receive services at the lower level (in cases of service reductions).

The full adverse action period may be waived if the individual signs a statement to waive the adverse action period.

3631.1  Denial of Medical Necessity/Level of Care/Individual Service Plan (MN/LOC/ISP)

3631.2  Denial of Medicaid Eligibility

Notes:

• If eligibility for Medicaid is reestablished with a gap of over four calendar months, this must be treated as an interest list release. The managed care organization (MCO) processes initial assessments.
• If eligibility for Medicaid is reestablished with a gap of four calendar months or less, the existing ISP and MN/LOC are still valid. If the ISP and MN/LOC have expired, the MCO is allowed to do a reassessment without penalty.

3631.3  Individuals No Longer in the Service Delivery Area

*The 10-day adverse action period expires after the end of the month.

3631.4  Unable to Locate

*The 10-day adverse action period expires after the end of the month.

3632  DADS-Initiated Denials/Terminations

The following sections contain policy citations that must be included on Form 2065-D, Notification of STAR+PLUS Program Services, when the denial or termination action is initiated by Department of Aging and Disability Services staff.

3632.1  Denial/Termination Due to Lack of Residence in a STAR+PLUS Service Area

In order to participate in STAR+PLUS managed care, the individual must reside in one of the designated STAR+PLUS service areas. If the individual's county of residence is not listed on the chart in Section 3210, Service Delivery Areas, he does not reside in a STAR+PLUS service delivery area.

Managed care organizations are required to notify the STAR+PLUS Support Unit within five business days when it becomes aware an applicant or member does not reside in a STAR+PLUS service delivery area.

STAR+PLUS Support Unit staff are required to initiate denial/termination by sending Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification or awareness that an applicant or member does not reside in a STAR+PLUS service delivery area.

3632.2  Denial/Termination Due to Death

Upon learning of the death of a member, the STAR+PLUS Support Unit (SPSU) must send to the managed care organization (MCO) within two business days of verification:

• Form 2067, Case Information; or
• Form H1746-A, MEPD Referral Cover Sheet.

Form H1746-A must be sent to the Medicaid for the Elderly and People with Disabilities specialist, if appropriate. Do not send a notice to the member's address or family. The effective date is the date of death.

If the member was receiving Supplemental Security Income (SSI) and the eligibility records reflect that SSI has been denied, SPSU must use the same effective date of denial as the SSI denial date. If the eligibility records reflect SSI is still active, SPSU must contact the Social Security Administration to notify it of the date of the member's death.

If a member's Medicaid eligibility has been denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries must be made to end enrollment in the Service Authorization System.

Services must be denied/terminated once death of the member has been confirmed by SPSU via:

• TIERS;
• obituaries in the local newspaper;
• contact with family or friends;
• notification from the MCO; or
• other reliable sources.

A 10-day adverse action period is not required for death denials.

3632.3  Denial/Termination Due to Residence in a Nursing Facility

STAR+PLUS enrollment is closed once a member has resided in a nursing facility for longer than four months, which need not be consecutive. Services must be terminated when the member is disenrolled; STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, as termination within three business days of notification.

Notification can come from:

• the monthly disenrollment report;
• Managed Care Operations;
• the managed care organization; or
• other reliable sources.

3632.4  Denial/Termination Due to Member Request

When the STAR+PLUS Support Unit (SPSU) has been notified by the Health and Human Services Commission (HHSC) that the individual does not want waiver services or no longer wishes to receive waiver services, SPSU staff must send Form 2065-D, Notification of STAR+PLUS Program Services. Notification must be sent within two business days of notification. SPSU must not initiate denial/termination until notified by HHSC.

3632.5  Denial/Termination of Financial Eligibility

An individual's continued receipt of STAR+PLUS services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or Medical Assistance Only (MAO) program requirements.

The individual is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or Medicaid for the Elderly and People with Disabilities (MEPD) staff for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate. STAR+PLUS Support Unit (SPSU) staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification. Notification can come from:

• monthly reports;
• Managed Care Operations;
• a managed care organization; or
• other reliable sources.

The chart below describes how to proceed if financial eligibility is denied.

For SSI members, the termination date must match the SSA termination date.

For MAO members, the termination date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past when the SPSU becomes aware of the denial.

3632.6  Denial/Termination of MN/LOC

STAR+PLUS Waiver services must be denied/terminated when the member's Medical Necessity/Level of Care (MN/LOC) Assessment is denied. STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification. Notification can come from:

• the Monthly ISP Expiring Report;
• Managed Care Operations;
• a managed care organization; or
• other reliable sources.

The MN/LOC Assessment status of "MN Denied" in the Long-term Care (LTC) Portal is the period when the SPW applicant's/member's physician has 14 calendar days to submit additional information. Once an MN/LOC Assessment status is in "MN Denied" status, several actions may occur:

• MN Approved: The status changes to "MN Approved" if the Texas Medicaid & Healthcare Partnership (TMHP) doctor overturns the denial because additional information is received;
• Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14 calendar day period for the TMHP doctor to overturn the denied MN has expired. No additional information was submitted for the doctor review. The denied MN remains in this status unless a fair hearing is requested; or
• Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

The SPSU coordinator must not mail Form 2065-D to deny the SPW case until after 14 calendar days from the date the "MN Denied" status appears in the LTC Portal. The SPSU coordinator must meet initial certification and annual assessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented.

3632.7  Denial/Termination Due to Inability to Locate the Member

HCBS STAR+PLUS Waiver (SPW) must be denied/terminated when the STAR+PLUS Support Unit (SPSU) coordinator is notified that a member cannot be found. The SPSU coordinator must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification. Notification can come from:

• monthly reports;
• Managed Care Operations;
• a managed care organization; or
• other reliable sources.

3632.8  Denial/Termination Due to Failure to Meet Other Waiver Requirement

Use this denial citation if the individual does not meet a waiver requirement mentioned in Section 3632.1 through Section 3632.7. For example, this citation would be used if the individual applying for services does not require at least one waiver service. STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification. Notification can come from:

• monthly reports;
• Managed Care Operations;
• a managed care organization; or
• other reliable sources.

3632.9  Denial/Termination for Other Reasons

Use this citation if initiating denial/termination for a reason not covered in Section 3632.1 through Section 3632.8. STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification. Notification can come from:

• monthly reports;
• Managed Care Operations;
• a managed care organization; or
• other reliable sources.

3633  Denial/Termination Initiated by the Managed Care Organization

Section 3633.1 through Section 3633.7 contains policy citations that must be included in denial notifications when the action is initiated by managed care organization (MCO) staff. After notification by the MCO, STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification from HHSC.

3633.1  Denial/Termination Due to Threats to Health and Safety

The managed care organization (MCO) and provider staff must take special precautions when an applicant's or member's comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant/member, an MCO-contracted provider or an MCO employee. If an applicant exhibits such behavior, the staff member must immediately notify his/her manager.

The Health and Human Services Commission (HHSC) reviews these situations on a case-by-case basis and determines the most appropriate action to be taken. If the applicant's/member's safety may be at risk, the MCO must follow current policy regarding notification to the Department of Family and Protective Services. If the staff member believes there is a potential threat to others, HHSC management should determine the best method for notifying the MCO and/or the contracted provider and for addressing the applicant's/member's needs without placing an MCO/provider staff member at risk.

After notification by the MCO, STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification from HHSC. The 10-day adverse action notification period does not apply in this situation.

3633.2  Denial/Termination Due to Hazardous Conditions or Reckless Behavior

When there is no immediate threat to the health or safety of the service provider, but the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, appropriate documentation of denial is essential. For example, a situation where the member has a large dog that may bite if let loose could be resolved if the member or a neighbor or family member will agree to restrain the dog during times of service delivery.

However, if the provider shows up on numerous occasions at the designated time and the dog is loose and the provider has documented a substantial pattern of being unable to deliver services due to this, services could be terminated.

Similarly, if there are illegal drugs in the member's home used by the member or others, the service provider may not be in immediate danger, yet the situation still poses a threat. It is imperative that all available interventions are presented and the opportunity offered for the member to get rid of the illegal drugs and/or users, and agree to refrain and not allow the illegal drug use to resume. A staffing should be held if the illegal drug usage occurs again, and the member must be warned in writing of the potential loss of services for allowing this activity to continue.

After notification by the managed care organization, STAR+PLUS Support Unit staff must send Form 2065-D, Notification of Ineligibility or Suspension of Waiver Services, within two business days of notification from the Health and Human Services Commission. The 10-day adverse action notification period does not apply in this situation.

3633.3  Denial/Termination Due to Harassment, Abuse or Discrimination

A substantial demonstrated pattern of verbal abuse or discrimination must be clearly established and documented by the managed care organization (MCO) before services can be denied for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the member and/or his/her family or legal representative, explaining that the MCO does not condone discrimination, harassment and/or verbal abuse.

Appropriate interventions must be sought. This may include counseling, referral to other case management agencies and possibly changes to the individual service plan, such as attending Day Activity and Health Services for nursing.

There must be meetings of the Health and Human Services Commission (HHSC) staff that include outside agencies, when appropriate, such as the Department of Family and Protective Services' Adult Protective Services. The results must be documented in letters sent to the member that offer an opportunity to stop the behavior, with clear indication that failure may result in loss of service. Copies of written warnings must be sent to all who attend the meetings and a copy must be retained in the case file.

If the situation persists and results in an inability to deliver services, the MCO may request disenrollment from HHSC, as described in the Uniform Managed Care Manual Chapter 11.5. After HHSC approves the disenrollment, HHSC notifies the STAR+PLUS Support Unit (SPSU) supervisor via email. SPSU sends Form H1746-A, MEPD Referral Cover Sheet, to Medicaid for the Elderly and People with Disabilities (MEPD).

SPSU staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification from HHSC. The 10-day adverse action notification period does not apply in this situation.

If the denial/termination is being considered due to verbal abuse or harassment of the service provider, HHSC must determine if this behavior is directly related to the individual's disability. If the member produces a letter from his physician indicating the behavior stems from the member's disability, services cannot be denied for this reason. Appropriate interventions to ensure service delivery as noted above should still be pursued.

3633.4  Denial as a Result of Exceeding the Cost Limit

The managed care organization (MCO) must consider all available support systems in determining if the waiver is a feasible alternative that ensures the needs of the applicant are adequately met. If the waiver is not a feasible alternative, the MCO must notify the STAR+PLUS Support Unit (SPSU) of the denial and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial is based on the inadequacy of the plan of care, including both waiver and non-waiver services, to meet the needs of the individual within the cost limit.

If Form H1700-1, Individual Service Plan — SPW (Pg. 1), is over the cost limit, SPSU staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of receipt of Form H1700-1 via TxMedCentral.

3633.5  Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions

If the member repeatedly and directly, or knowingly and passively, condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, services may be denied/terminated. Refusal to comply with service delivery provisions includes actions by the member or someone in the member's home that prevent determining eligibility, carrying out the service plan or monitoring services. The Health and Human Services Commission will notify the STAR+PLUS Support Unit to send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification.

3633.6  Denial/Termination Due to Failure to Pay R&B/Copay/QIT

If the member refuses to pay a required copayment, room and board (R&B) payment or Qualified Income Trust (QIT) payment, HCBS STAR+PLUS Waiver (SPW) must be denied. After notification by the managed care organization, STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification and must provide a 10-day adverse action period.

3633.7  Denial/Termination Due to Other Reasons

Use this denial/termination citation if initiating denial for a reason not covered above. After notification by the managed care organization, STAR+PLUS Support Unit staff must send Form 2065-D, Notification of STAR+PLUS Program Services, within two business days of notification.

3640  Disenrollment Request Policy

Mandatory STAR+PLUS members may request a case review for disenrollment from STAR+PLUS. Disenrollment of a mandatory member is only approved if a determination is made that a member would be better served under fee-for-service than participating in managed care.

Members who request to disenroll from STAR+PLUS must submit a written request with supporting documentation of medical condition and extenuating circumstances. This written request must be submitted to the Texas Health and Human Services Commission (HHSC) at the following address:

Texas Health and Human Services Commission
Managed Care, Mail Code W-516
P.O. Box 149030
Austin, TX 78714-9030

HHSC conducts a case review and makes a final determination. The member and the STAR+PLUS Support Unit will be notified in writing of the decision and any available alternatives. If the individual is disenrolled, HHSC will make the necessary system adjustments and notify the respective managed care organization and enrollment broker.

Although nursing facility (NF) care is beyond the scope of STAR+PLUS, individuals are not automatically disenrolled upon admittance to an NF. Individuals are disenrolled from STAR+PLUS the fourth time they are residing in a facility on the first day of the month. The months in which NF residence occurs on the first need not be consecutive.

The automated NF counter actually triggers disenrollment upon the first day of the month after completion of the fourth month of NF care. (A partial month counts as a full month.) Because auto-disenrollment does not occur until cut off of the fifth month, do not send requests for disenrollment until that time. See also Appendix XIX, Nursing Facility Counter Logic.

The individual can only re-enter the STAR+PLUS system and the HCBS STAR+PLUS Waiver using Money Follows the Person (MFP) procedures. See Section 3510, Money Follows the Person and Managed Care, for additional information.

3641  Services for Individuals Disenrolled from STAR+PLUS

In some situations, a STAR+PLUS member or his/her managed care organization may request, and be granted, disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available services from the Department of Aging and Disability Services (both Medicaid and Title XX) if determined eligible, with the exception of Community Based Alternatives (CBA). There are no CBA contracts in managed care areas. For additional information, see Section 3640, Disenrollment Request Policy.