STAR+PLUS Handbook

Section 3000

Waiver Eligibility and Services
Table of Contents

Ancillary Member Resources

3210: Service Delivery Areas

Eligible Groups

3221: Mandatory Groups

3222: Excluded Groups

3223: Hospice Services in STAR+PLUS

Waiver Requirements

Medical Necessity Determination

3241.1: Medical Necessity Determination for Applicants Residing in Nursing Facilities

3241.2: Medical Necessity Determination for Applicants Not Residing in Nursing Facilities

Individual Cost Limit Requirement

3242.1: Maximum Limit

3242.2: Unmet Need for at Least One Waiver Service

Administrative Procedures

Intake and Enrollment

Interim Services for Individuals Awaiting Managed Care Enrollment

3311.1: Interest List Procedures

3311.2: Interest List Slot Allocations

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

3312.1: Enrollment Procedures Following Release from the Interest List

Termination of CCAD Services Upon STAR+PLUS Waiver Enrollment

3313.1: Procedure for SPW Applicants

3313.2: Procedure for SPW Individuals

3314: MCO Changes

STAR+PLUS Waiver Individuals Requesting Non-Managed Care Services

3315.1: Requests from Individuals Awaiting Managed Care Enrollment

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

3315.3: Requests from STAR+PLUS Services Members

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

Coordination with MEPD

General Eligibility Issues

3321.1: Disability Determinations

3322: Actions Pending Past the MEPD Due Date

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

Transferring In and Out of STAR+PLUS

Transfer Scenarios

CBA Individuals Transferring to SPW

3411.1: Notice is Received Prior to Relocation

3411.2: Notice is Received After Relocation

3412: SPW Members Transferring to CBA

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

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

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

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

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

Case Transfers Between CCAD and STAR+PLUS Services

3418.1: Individuals Moving Into a STAR+PLUS Area

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

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

Money Follows the Person

Money Follows the Person and Managed Care

3511: Money Follows the Person Procedure

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

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

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

3515: Individuals Residing in a Managed Care Area

Money Follows the Person Demonstration Initiative

3521: MFPD Initiative

3522: Screening Criteria for MFPD Eligibility

3523: STAR+PLUS Support Unit Responsibilities

3524: Enrollment in MFPD

3525: MFPD Entitlement Period Tracking

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

High/Complex Needs Members

3531: Designation of High Needs Members

3532: Determination of High Needs Status for Ongoing Members

Complex Needs Coordinators

3533.1: Quarterly Comprehensive Care Program Transition Report

3533.2: Identifying and Tracking High Needs Aging-Out Members

3534: Services for Individuals Disenrolled from STAR+PLUS

Ongoing Service Coordination

Revising the Individual Service Plan

MCO Required Notifications from the Provider

3611.1: Immediate Suspension or Reduction of Services

3611.2: Required Notification of Service Denial from the MCO

3621: Reassessment Procedures

3622: Notification Requirements

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

3623.1: Upgrades and Interest List Releases

3623.2: CBA Transfers from Non-Managed Care Service Areas

3623.3: Individuals Aging Out of Children's Programs

3623.4: MFP/MFPD Nursing Facility Releases

Denial/Termination Procedures

10-Day Adverse Action Notification

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

3631.2: Denial of Medicaid Eligibility

3631.3: Individuals No Longer in the Service Delivery Area

3631.4: Unable to Locate

Denial/Termination Initiated by the Managed Care Organization

3633.1: Denial/Termination Due to Threats to Health and Safety

3633.2: Denial/Termination Due to Hazardous Conditions or Reckless Behavior

3633.3: Denial/Termination Due to Harassment, Abuse or Discrimination

3633.4: Denial as a Result of Exceeding the Cost Limit

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

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

3633.7: Denial/Termination Due to Other Reasons

Disenrollment Request Policy

3641: Services for Individuals Disenrolled from STAR+PLUS