Revision 12-3; Effective October 1, 2012
Acute care — Medical care designed to treat or cure disease or injury, usually within a limited time period. Acute care usually refers to physician and/or hospital services of less than three months' duration. All the covered services in the State Medicaid Plan for adults that are considered acute in nature are available to members of the STAR+PLUS members that are Medicaid only. Exception: Some services for children are considered chronic and are covered under the State Medicaid Plan.
Agency Option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.
Consumer Directed Services (CDS) — A service delivery option in which a member or legally authorized representative employs and retains service providers and directs the delivery of HCBS STAR+PLUS Waiver (SPW) personal assistance services and respite services. A member participating in the CDS option is required to use a CDS agency chosen by the member or legally authorized representative (LAR) to provide financial management services.
Denial — Closure of an application with a finding of ineligibility.
Eligibility date — The first date all waiver eligibility criteria are met, as described in Section 3240, Waiver Requirements.
Enrollment broker — A contracted entity that assists individuals in selecting and enrolling with a managed care organization (MCO). If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP). Members of STAR+PLUS may request to change MCOs at any time after the first month of enrollment by contacting the enrollment broker. The change is effective the first day of the subsequent month if the request is made prior to state cut-off or the first of the following month if the request is made after the cut-off date.
Health and Human Services Commission (HHSC) — The state agency responsible for Medicaid. Certain functions related to SPW eligibility and coordination between trading partners are delegated to the Department of Aging and Disability Services (DADS).
Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) — Authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility. This is also known as the SPW.
Individual service plan (ISP) — A plan of care developed for the HCBS STAR+PLUS Waiver (SPW) member by the MCO.
Interdisciplinary team (IDT) — All individuals/entities involved in planning the SPW memberís plan of care. This typically includes the member, the memberís legal/authorized representative, the service coordinator, the primary care physician, etc.
Long-term Services and Supports (LTSS) — Services, including Primary Home Care, Day Activity and Health Services, and the HCBS STAR+PLUS Waiver (SPW), that assist members in living in the community.
Managed Care Operations (HMCO) — A unit within the Medicaid/Children's Health Insurance Program Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.
Managed Care Organization (MCO) — An insurer licensed by the Texas Department of Insurance as an MCO in accordance with Chapter 843 of the Texas Insurance Code. The MCO provides Medicaid benefits to individuals who are enrolled in STAR+PLUS.
Medicaid Estate Recovery Program (MERP) — A program that requires HHSC, as the State Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients. For further information, see the MERP website at http://dadsview.dads.state.tx.us/merp/index.html.
Member — An individual who is enrolled in and receiving services through a STAR+PLUS MCO.
Money Follows the Person (MFP) — A process whereby the funds used for payment of institutional care follows the person when transitioning to the community under the SPW.
Money Follows the Person Demonstration (MFPD) — A federal grant program that provides additional services to members who utilize the MFP process.
Mutually exclusive services — Two or more services that may not be authorized for the same individual during the same time period.
Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and long-term services and supports. The POC is not the same as the individual service plan for SPW services.
Responsible party — An individual who:
- assists and/or represents an applicant or member in the application or eligibility redetermination process; and/or
- is familiar with the applicant/member and his/her financial affairs and functional condition.
Service coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR+PLUS members.
Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services. The member decides how services are provided. It leaves the business details to a provider of the member's choosing.
STAR+PLUS Program — The umbrella designation that includes both the STAR+PLUS services and HCBS STAR+PLUS Waiver (SPW).
STAR+PLUS program specialist — The DADS staff person responsible, along with Managed Care Operations, for STAR+PLUS policy development.
STAR+PLUS Services — Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute care, Primary Home Care, and Day Activity and Health Services through a managed care delivery system in specific service delivery areas.
STAR+PLUS specialist — The Managed Care Operations staff person working with policy and operational issues.
STAR+PLUS Support Unit (SPSU) — A DADS unit of coordinators who support and handle certain aspects of the STAR+PLUS program, as described in Section 3300, Administrative Procedures.
STAR+PLUS Support Unit (SPSU) coordinator — A DADS employee who works in SPSU.
Termination – Closure of an ongoing case due to a finding of ineligibility.
Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid claims processing and the Medicaid primary care case management services program. TMHP is responsible for processing medical necessity/level of care assessments for the waivers.
TxMedCentral — A secure Internet bulletin board the state and MCOs use to share information, as described in Section 5110, TxMedCentral Naming Convention and File Maintenance.
Upgrade — An existing STAR+PLUS member enrolled in the STAR+PLUS services who requests and is granted SPW services after meeting waiver eligibility criteria.