Source: https://hhs.texas.gov/laws-regulations/handbooks/skoph/section-1000-star-kids-overview-eligibility
Timestamp: 2020-08-03 21:12:29
Document Index: 665067221

Matched Legal Cases: ['§533', '§353', '§1915', '§353', '§1915', '§1915', '§1915', '§1915', '§441', '§353', '§353', '§441', '§1915', '§1915', '§353', '§1915', '§353']

Section 1000, STAR Kids Overview and Eligibility | Texas Health and Human Services
Revision 19-10; Effective June 14, 2019
Senate Bill 7 from the 83rd Legislature, Regular Session, in 2013, required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).
STAR Kids does not change or impact an individual’s Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, age birth through 20, enrolled with a STAR Kids MCO, are called members of the MCO. All STAR Kids members have access to service coordination provided by an MCO employee or through a member’s primary care provider, authorized by the MCO.
Service coordination is specialized care management performed by an MCO service coordinator and includes, but is not limited to:
identification of needs, including physical health, behavioral health services and LTSS development of an individual service plan (ISP) to address those identified needs;
assistance to ensure timely and coordinated access to an array of providers and services;
attention to addressing unique needs of members; and
coordination of Medicaid benefits with non-Medicaid services and supports, as necessary and appropriate.
All STAR Kids members receive an annual comprehensive assessment of their physical and functional needs by an MCO service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI). Within the time frame listed in the STAR Kids Contract, Section 8.1.39, STAR Kids Initial Screening and Assessment Process, if a member has a change in their physical or behavioral health, a change in functional ability or caregiver supports, the MCO must reassess the member and update their ISP, as applicable, and authorize necessary services upon request from the member, legally authorized representative (LAR), authorized representative (AR) or health home.
In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, Flexible Family Support Services (FFSS), adaptive aids, minor home modifications, employment services and Transition Assistance Services (TAS) to children and young adults who meet the level of care (LOC) provided in a nursing facility (NF) so he or she can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list of MDCP applicants. A child, young adult, LAR or AR may ask their MCO about how to be placed on the MDCP interest list at any time or call the HHSC Interest List Management (ILM) Unit staff’s toll-free number at 1-877-438-5658.
1100 Legal Basis and Values
STAR Kids Medicaid Managed Care Program is required by Texas Government Code §533.00253. Title 1 Texas Administrative Code (TAC) §353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of STAR Kids services, as well as Medically Dependent Children Program (MDCP) services. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract.
The STAR Kids Program Support Unit Operational Procedures Handbook includes operational procedures for the Texas Health and Human Services Commission (HHSC) Program Support Unit (PSU) staff.
The STAR Kids Handbook includes policies and procedures to be used by managed care organizations (MCOs), contractors and service providers in the delivery of STAR Kids MDCP services to eligible members.
1110 Mission Statement
The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:
coordinate care across service arrays;
improve quality, continuity and customization of care;
improve access to care and provide person-centered health homes;
improve ease of program participation for members, managed care organizations (MCOs) and providers;
improve provider collaboration and integration of different services;
improve member outcomes to the greatest extent achievable;
prepare young adults for the transition to adulthood;
foster program innovation; and
achieve cost efficiency and cost containment.
1120 Medically Dependent Children Program
The Medically Dependent Children Program (MDCP) is a home and community based services program authorized under §1915(c) of the Social Security Act. MDCP provides respite, Flexible Family Support Services (FFSS), minor home modifications, adaptive aids, Transition Assistance Services (TAS), employment assistance (EA), supported employment (SE) and financial management services (FMS) through a STAR Kids managed care organization (MCO). This section provides an overview of MDCP, including its eligibility requirements.
1130 Medically Dependent Children Program Goal
The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults age 20 and younger who are medically dependent, and to encourage de-institutionalization of children and young adults who reside in nursing facilities (NFs).
MDCP accomplishes this goal by:
enabling children and young adults who are medically dependent to remain safely in their homes;
offering cost-effective alternatives to placement in NFs and hospitals; and
supporting families in the role as the primary caregiver for their children and young adults who are medically dependent.
1200 Medically Dependent Children Program Eligibility
An individual becomes eligible to be assessed for Medically Dependent Children Program (MDCP) services when their name reaches to the top of the MDCP interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if he or she is already enrolled in STAR Kids. Once an individual’s name reaches the top of the interest list, the individual selects an MCO who beings the determination of eligibility as the individual applies for services. An individual going through the application and eligibility process for STAR Kids is referred to as an applicant. An individual enrolled in STAR Kids is referred to as a member.
MDCP is provided by virtue of 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 (NF). To be eligible for services under MDCP, the applicant or member must meet the following criteria:
have an approved medical necessity (MN) for an NF level of care (LOC);
have an individual service plan (ISP) with services under the established cost limit;
have an unmet need for at least one MDCP service;
be birth through age 20;
be a U.S. citizen and resident of Texas;
live in an appropriate living situation; and
have full Medicaid eligibility.
Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F), states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.
1210 Medical Necessity Determination
A Medically Dependent Children Program (MDCP) applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before admission into the MDCP. The determination of MN is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant’s or member’s individual service plan (ISP) cost limit is calculated based on information gathered through the SK-SAI MDCP module.
The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care (LTC) Online Portal for MDCP applicants or members. TMHP processes the SK-SAI for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in §1915(c) Medicaid waiver programs to categorize needs for applicants or members and establish the ISP cost limit.
When TMHP processes an SK-SAI, a three-alphanumeric digit RUG is generated and appears in the TMHP LTC Online Portal, as well as the MCO response file. An SK-SAI with incomplete RUG information results in a "BC1" code instead of a RUG value. An SK-SAI resulting in a “BC1” code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. A “BC1” code is not a valid RUG to determine MDCP eligibility.
The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a “BC1” code. The MCO nurse must also submit any corrections to SK-SAI items used to determine MN within 14 days. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. See the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for detailed instructions pertaining to the MCO communicating inactivation and corrections to the SK-SAI to TMHP.
Applicants without Medicaid require a Medicaid eligibility financial determination. For these individuals, the HHSC Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when the applicant meets MN. This notification is documented on Form H1746-A, MEPD Referral Cover Sheet, which PSU staff fax to the MEPD specialist. This process is outlined in more detail in Section 2210, Income and Resource Verifications for Medicaid Eligibility.
1211 Medical Necessity Determination for an Applicant or Member Residing in a Nursing Facility
During initial contact with the applicant or member, the managed care organization (MCO) service coordinator must explore the applicant’s or member’s status in the nursing facility (NF) and desire to transition to the community. The MCO service coordinator completes the STAR Kids Screening and Assessment Instrument (SK-SAI) and submits the assessment to Texas Medicaid & Healthcare Partnership (TMHP) indicating a request for a determination of medical necessity (MN). This process is described in more detail in the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP.
1212 Medical Necessity Determination for an Applicant or Member Not Residing in a Nursing Facility
For applicants or members not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the STAR Kids Screening and Assessment Instrument (SK-SAI) completed by the managed care organization (MCO) selected by the applicant or member.
The MCO must electronically submit the SK-SAI to TMHP through the TMHP Long Term Care (LTC) Online Portal indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO’s records.
1220 Individual Cost Limit
The cost of Medically Dependent Children Program (MDCP) services on the STAR Kids individual service plan (ISP) cannot exceed 50 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the managed care organization (MCO) service coordinator must develop an ISP consisting of MDCP services requested by the applicant and the cost of those services. The cost must be developed at or below 50 percent of the cost to provide services to the applicant, based on the Resource Utilization Group (RUG) in an NF.
Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if the Medicaid state plan services and the MDCP services would pose a risk to the individual’s health, safety or welfare.
1230 Unmet Need for at Least One Medically Dependent Children Program Service
The §1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.
Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a §1915(c) Medicaid waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.
1240 Age
To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.
1250 Citizenship and Identity Verification
As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long term services and supports (LTSS) members whose financial eligibility is based on a determination from the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD specialists, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry of those programs.
1260 Living Arrangement and Texas Residency
The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services as outlined in Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(B), Medically Dependent Children Program.
If the applicant is under age 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, as outlined in Title 1 TAC §353.1155(b)(1)(G)(ii).
Managed care organization (MCO) service coordinators must confirm the applicant or member, if under age 18, lives with a family member, such as a parent, guardian, grandparent or sibling, as defined in the Glossary. The MCO service coordinator must review guardianship documentation or obtain a statement from the applicant, member, legally authorized representative (LAR), authorized representative (AR) or family member regarding relation. The MCO service coordinator must maintain this documentation in the member’s case file.
1270 Financial Eligibility
Applicants or members who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. Program Support Unit (PSU) staff must determine if an applicant or member is currently on Medicaid and check the Texas Integrated Eligibility Redesign System (TIERS) to confirm the current status of an applicant or member. A Medicaid for the Elderly and People with Disabilities (MEPD) determination may have already been completed for an applicant or member and must be used unless there have been changes in the applicant’s or member’s financial situation.
If the applicant does not have a Medicaid eligibility determination, it is PSU staff’s responsibility to assist the applicant with completing the application and obtaining the necessary verifications to establish eligibility from MEPD specialists. These processes are described in Section 2100, Enrollment Following Release from the Interest List.
1300 STAR Kids Services and Service Delivery Options
STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service (FSS) Medicaid, described in the Texas Medicaid state plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).
1310 Acute Care Services
STAR Kids members may receive medically necessary services through their managed care organization (MCO), and as required under Title 42 Code of Federal Regulations (CFR) §441, Subpart B, Early and Periodic Screening, Diagnostics and Treatment (EPSDT) of Individuals Under Age 21. This includes, but is not limited to:
audiology services, including hearing aids;
in-patient mental health services;
out-patient mental health services;
out-patient chemical dependency services for children;
detoxification services; and
psychiatry services;
durable medical equipment (DME) and supplies;
medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps Program (THSteps);
oral evaluation and fluoride varnish in conjunction with THSteps medical checkup for children six months through 35 months of age;
STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members will receive dental care through their primary insurer, their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service (FSS) model.
1320 Long Term Services and Supports
STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):
Day Activity and Health Services (DAHS) for members age 18 through 20. DAHS includes nursing and Personal Care Services (PCS), therapy extension services, nutrition services, transportation services and other supportive services.
PCS will provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.
Prescribed pediatric extended care center (PPECC), which is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic, and developmental services to medically dependent or technologically dependent members under the age of 21 up to 12 hours per day.
Private duty nursing (PDN) is nursing services for members who meet medical necessity (MN) criteria outlined in the SK-SAI and who require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services.
STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following services through their STAR Kids MCO:
Community First Choice (CFC), which is available to all STAR Kids members who meet an institutional LOC for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease. Members enrolled in a §1915(c) Medicaid waiver program for individuals with an intellectual disability or related condition (IID) receive CFC through their waiver provider. CFC services include:
Habilitation, also called CFC-HAB, which provides acquisition, maintenance and enhancement of skills necessary for the member to accomplish ADLs, IADLs and health-related tasks.
CFC personal assistance services (PAS), also called CFC-PAS, which provide assistance with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.
Note: CFC-PAS is the same service as PCS. The key difference is CFC-PAS is part of the CFC benefit and must be reported differently. Members may choose to receive CFC-PAS only if he or she does not need or want CFC habilitation.
Emergency Response Services (ERS), which is back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports.
Support management, which is training provided to members, legally authorized representatives (LARs) or authorized representative (ARs) on how to manage and dismiss their attendants.
STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in an NF. Receipt of MDCP services does not impact a member’s eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP include:
Adaptive aids, which are needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the ADL or control the environment in which he or she lives. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources (TPR).
Employment assistance (EA), which is assistance provided to a member to help the member locate paid, competitive employment in the community.
Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS provides assistance to members with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.
Flexible Family Support Services (FFSS) are direct care services needed because of a member’s disability that help a member participate in child care, post-secondary education, employment, independent living or support a member’s move to an independent living situation.
Minor home modifications are physical changes to a member’s residence that are needed to prevent institutionalization or to support the most integrated setting for a member to remain in the community.
Respite services are direct care services needed because of a member’s disability that provides a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
Supported employment (SE) provides assistance to sustain paid, competitive employment to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which members without disabilities are employed.
Transition Assistance Services (TAS) are a one-time service provided to a Medicaid-eligible resident of an NF located in Texas to assist the resident in moving from the NF into the community to receive MDCP services.
1330 Service Delivery Options for Certain Long Term Services and Supports
STAR Kids provides members with an array of services, as identified on each member’s individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.
STAR Kids members may choose from three service delivery options for the delivery of certain long term services and supports (LTSS). The options available are the Agency Option (AO), Service Responsibility Option (SRO) and Consumer Directed Services (CDS) option. State plan LTSS which can be delivered through these service delivery options are:
Community First Choice habilitation (CFC-HAB);
Community First Choice personal assistance services (CFC-PAS); and
STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:
Flexible Family Support Services (FFSS);
supported employment (SE).
STAR Kids members, legally authorized representatives (LARs) or authorized representatives (ARs) may choose to participate in the AO, CDS option or SRO delivery models.
Members who choose the AO model select an MCO-contracted agency to coordinate service delivery for the services on their ISP.
In the CDS option model, the member, LAR or AR work with assistance from a financial management services agency (FMSA). FMSA personnel may be employed directly by or through personal service agreements or subcontracts with the providers. Members who choose the CDS option model are given the authority to self-direct certain services. If the member chooses to self-direct certain services, the MCO coordinates delivery of non-member directed services.
In the SRO model, an agency is the attendant’s employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before mailing them to the member’s home. The member, LAR, or AR is responsible for most of the day-to-day management of the attendant’s activities, beginning with interviewing and selecting the person who will be the attendant.
More information about these service delivery options is available in Section 5000, Service Delivery Options.
1400 Service Coordination through the Managed Care Organization
All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member’s health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the MCO service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing facility (NF) or other long-term care facility, the MCO service coordinator must inform the member, LAR or AR about options available through home and community based services programs, in addition to facility-based options.
MCO service coordinators are responsible for assessing a member’s needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the MCO service coordinator must:
review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
acknowledge and document goals and objectives that may need to be adjusted;
develop new goals and objectives with input from the member, family, LAR, AR and providers;
update the member’s ISP;
assist with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
inform members receiving long term services and supports (LTSS) about the Consumer Directed Services (CDS) and Service Responsibility Option (SRO);
educate the member, LAR or AR about their rights regarding acts that constitute abuse or neglect (Child Protective Services) and abuse, neglect or exploitation (Adult Protective Services (APS)); and
review member rights and MCO processes for service authorization, appeals and complaints.
1410 Service Coordination Requirements
Managed care organizations (MCOs) provide a different level of service coordination, depending on a member’s needs. Members with more complex needs receive more service coordination than members whose needs are less complex.
Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits from a named MCO service coordinator annually, in addition to monthly telephone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 MCO service coordinators must be a registered nurse (RN), nurse practitioner (NP), physician’s assistant (PA), social worker (MSW, LCSW or LBSW), or licensed professional counselor (LPC) if the member’s service needs are primarily behavioral. Level 1 members include those who:
are enrolled in the Medically Dependent Children Program (MDCP) or Youth Empowerment Services (YES) waiver program;
have complex needs or a history of developmental or behavioral health issues (multiple outpatient visits, hospitalization or institutionalization within the past year);
are diagnosed with severe emotional disturbance (SED) or serious and persistent mental illness (SPMI); or
are at risk for institutionalization.
Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named MCO service coordinator, unless otherwise requested by the member, LAR or AR. Level 2 MCO service coordinators must be either an RN, NP, PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who:
do not meet the requirements for Level 1 but receive long term services and supports (LTSS);
the MCO believes would benefit from a higher level of service coordination based on results from the STAR Kids Screening and Assessment Instrument (SK-SAI) and additional MCO findings;
have a history of substance abuse (multiple outpatient visits, hospitalization or institutionalization within the past year); or
are without SED or SPMI, but who have another behavioral health condition that significantly impairs function.
Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 MCO service coordinators must have a minimum of a high school diploma or a general education diploma (GED) and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years.
Members receiving Level 1 or Level 2 service coordination must have a single named person as their assigned MCO service coordinator. Level 3 members, LARs or ARs may request a single named MCO service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who qualify for Level 3 who reside in a nursing facility (NF) or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following non-capitated §1915(c) Medicaid waiver programs: Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL). The MCO must notify members within five business days of the name and telephone number of the new MCO service coordinator, if the service coordinator changes.
MCOs must notify all members in writing of the:
name of the service coordinator;
telephone number of the service coordinator;
minimum number of contacts he or she will receive every year; and
types of contacts he or she will receive.
1420 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities
Members who have intellectual and developmental disabilities (IDD) living in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or who receive services through one of the following IDD waivers, receive their acute care services and some long term services supports (LTSS) (e.g., private duty nursing (PDN)) through STAR Kids and continue to receive most of their LTSS through the following programs:
Texas Home Living (TxHmL); or
ICF/IIDs.
A member with IDD that meets the above criteria has a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member, legally authorized representative (LAR) or authorized representative’s (AR’s) personal preference.
These members also have a person(s) outside of the MCO who develops and implements a service plan and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member’s IDD waiver case manager or service coordinator. The member’s IDD waiver case manager or service coordinator should invite MCO service coordinators to their care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in-person or telephonically. The MCO service coordinator is responsible for the coordination of these members’ acute care services and capitated LTSS.
Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.
1430 Service Coordination and the Youth Empowerment Services Waiver Program
A member who receives services through the Youth Empowerment Services (YES) waiver program receive their acute care services and some long term services and supports (LTSS) (e.g., Day Activity and Health Services (DAHS), private duty nurse (PDN), and Community First Choice (CFC)) only through STAR Kids and continues to receive their waiver services through the YES waiver program. A member served by the YES waiver program will have a named managed care organization (MCO) service coordinator and is considered a Level 1 member.
YES waiver program members also have a case manager outside of the MCO who develops and implements the YES waiver service plan and monitors YES waiver service delivery. This case management is provided through the capitated Mental Health Targeted Case Management (MHTCM) benefit, which the MCO must authorize for any member receiving YES waiver program services. The MCO service coordinator must respond to requests from the member’s YES waiver case manager. The member’s YES waiver case manager should invite the MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be either in-person or telephonically. The MCO service coordinator is responsible for the coordination of these member’s acute care services and capitated LTSS.
1440 Service Coordinators and Home and Community Based Services - Adult Mental Health
The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves members who have serious and persistent mental illness (SPMI) and:
a history of extended (three cumulative or consecutive years of the past five) institutional stays in psychiatric facilities;
severe mental illness (SMI) and frequent visits to the emergency department; and
SMI and frequent arrests and stays in a correctional facility.
HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program’s population. HCBS-AMH is operated on a fee-for-service (FFS) basis for members age 18 and up. Each participant is assigned a recovery manager (RM) who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with the Texas Department of State Health Services (DSHS). Additional information about HCBS-AMH can be found at https://www.dshs.state.tx.us/mhsa/hcbs-amh/.
1441 Program Point of Contact
Each managed care organization (MCO) must have a designated program point of contact (PPOC) for the Home and Community Based Services - Adult Mental Health (HCBS-AMH) program. The PPOC is responsible for:
ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
responding within three business days to concerns from the Texas Health and Human Services Commission (HHSC) or recovery managers (RMs) to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the HCBS-AMH program.
1442 Managed Care Organization Service Coordination Responsibility
Managed care organization (MCO) service coordinators must participate in telephonic recovery plan meetings, as scheduled by Texas Health and Human Services (HHSC) or recovery managers (RMs), and provide any requested member-specific information prior to the meeting. MCO service coordinators must:
Send requested information to the RM or HHSC three business days prior to the scheduled recovery plan meeting. This information includes:
updating the member’s condition;
sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
relevant member treatment documents as requested by the RM or HHSC.
Respond to ad-hoc requests from the RM or HHSC with "Urgent" in the subject line within one business day.
Respond to non-urgent ad-hoc requests in a timely manner.
Coordinate with HHSC and the RM when a member transitions into or out of HCBS-AMH.
HCBS-AMH may provide transitional planning for members who reside in an institution and also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, telephonically or in-person, during the member’s stay. Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.
1600 Disclosure of Information
1610 Confidential Nature of Medical Information - Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to secure the confidentiality of protected health information (PHI). PHI is information that identifies or could be used to identify an applicant or member and that relates to the:
past, present or future physical, mental or behavioral health or condition of the applicant or member;
provision of health care to the applicant or member; or
past, present or future payment for the provision of health care to the applicant or member.
PHI includes an applicant or member’s date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number, and demographic data.
1611 Confidential Nature of a Case Record
Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify an applicant or member. An applicant, member, legally authorized representative (LAR) or authorized representative (AR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.
1612 Custody of Records
Texas Health and Human Services Commission (HHSC) staff must use reasonable diligence to safeguard, protect and preserve records and prevent disclosure of the protected health information (PHI) he or she contain, except as provided by the HHSC regulations.
1613 Responsible Party to Authorize Disclosure
1613.1 Legally Authorized Representatives and Authorized Representatives
Only the member’s legally authorized representative (LAR) or authorized representative (AR) can exercise the applicant’s or member’s rights with respect to protected health information (PHI). Therefore, only an applicant, member, LAR or AR may authorize the use or disclosure of PHI or obtain PHI on behalf of an applicant or member. Exception: Texas Health and Human Services Commission (HHSC) is not required to disclose the information to the LAR or AR if the applicant or member is subjected to domestic violence, abuse or neglect by the LAR or AR. Consult HHSC Privacy Office, as described in Section 1615, Information That May Be Disclosed, if it is believed that health information should not be released to the LAR or AR.
Note: A responsible party is not automatically an LAR or AR.
1613.2 Unemancipated Minors
A parent is the legally authorized representative (LAR) for a minor child except when:
minor is age 16 years or older, lives separately from the parents and manages his or her own financial affairs;
consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by the state of Texas;
1613.3 Adults and Emancipated Minors
If the applicant or member is an adult or emancipated minor, including married minors, the applicant’s or member’s legally authorized representative (LAR) or authorized representative (AR) is a person who has the authority to make health care decisions about the member and includes a:
court-appointed guardian for the applicant or member; or
person designated by law to make health care decisions when the applicant or member is in a hospital or nursing facility (NF) and is incapacitated or mentally or physically incapable of communication.
Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, for approval.
1613.4 Deceased Applicant or Member
The legally authorized representative (LAR) or authorized representative (AR) for a deceased applicant or member is an executor, administrator or other person with authority to act on behalf of the applicant, member or the member’s estate. These include:
Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, about whether a particular person is the LAR or AR of an applicant or member.
1614 Verifying the Identity of an Applicant, Member, LAR, AR or Third Party Individual
1614.1 Telephone Communication
Program Support Unit (PSU) staff must establish the identity of an individual who identifies himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) by verifying the individual’s knowledge of two of the following:
applicant’s or member’s Social Security number (SSN);
applicant’s or member’s date of birth (DOB); or
applicant’s or member’s Medicaid identification (ID) number.
Establish the identity of an attorney, LAR or AR by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the applicant or member.
1614.2 In-Person Communication
Program Support Unit (PSU) staff must establish the identity of the individual who presents himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) office by examining two forms of identification with at least one form of identification being a government-issued photo identification (ID):
Texas Department of Public Safety (DPS) ID card;
DPS driver license;
U.S. citizenship certificate containing the person’s photograph;
state agency employee badge;
voter registration card; and/or
wage stub.
Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access confidential information through one of the following:
contact the HHSC Office of Chief Counsel.
Contact the HHSC Office of Chief Counsel when federal agency staff, contractors, researchers or other HHSC or MCO staff come to the office without prior notification or adequate identification and request permission to access records.
1614.3 Electronic Mail Communication
If Program Support Unit (PSU) staff receive electronic mail, also known as email, from an applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party that contains protected health information (PHI), PSU staff must respond using the following procedures:
if PSU staff can answer the inquiry without supplying PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission for PHI, and respond to the sender appropriately; or
if the answer to the inquiry requires the inclusion of PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission of PHI, and respond to the sender that he or she must submit their request in writing via mail or facsimile.
PSU staff must not send PHI by email to non-government entity individuals, including applicants, members, LARs, ARs or third-party individuals. Refer to Section 1616, Verification and Documentation of Disclosure, for approved methods of transmitting PHI to applicants, members, LARs, ARs, and third party individuals to whom the applicant, member, LAR or AR have provided written consent for the release of PHI.
PSU staff may share PHI by email with Medicaid for the Elderly and People with Disabilities (MEPD), Texas Medicaid & Healthcare Partnership (TMHP), managed care organization (MCO) the applicant or member is enrolled with, and other Texas Health and Human Services Commission (HHSC) staff for work-related purposes, but only if the email:
contains this disclaimer: "Confidential: This transmission is confidential and intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient, you are notified that any review, retention, disclosure, copying, distribution, or the taking of any other action relevant to the contents of this transmission are strictly prohibited. If you received this transmission in error please return to sender."
1615 Information That May Be Disclosed
Reasonable effort must be made to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to determine eligibility and operate the program. The disclosure of the applicant or member’s PHI from the Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant or member.
PHI may only be disclosed to a person who has written permission from the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to obtain the information. The applicant, member, LAR or AR authorizes the release of information by completing and signing:
the applicant or member’s:
full name (including middle initial) and Medicaid identification (ID) number; or
full name (including middle initial) and either date of birth (DOB) or Social Security number (SSN);
a description of the information to be released. Note: If a general release is authorized, provide the information that can be disclosed to the applicant, member, LAR or AR. Withhold confidential information from the case record, such as names of persons who disclosed information about the household without the household’s knowledge, and the nature of pending criminal prosecution;
a statement describing the applicant or member’s right to revoke the authorization to release information;
the signature of the applicant, member, LAR or AR.
Note: If the case information to be released includes PHI, the document must also tell the applicant, member, LAR or AR that information released under the document may no longer be private, and may be released further by the person receiving the information.
Occasionally, requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and their survivors.
The HHSC Privacy Office handles questions about the release of information. All questions and problems encountered by individuals concerning release of information should be referred to this office. MCO staff should contact HHSC Managed Care Compliance & Operations (MCCO) staff.
1616 Verification and Documentation of Disclosure
It is only acceptable for Program Support Unit (PSU) staff to disclose protected health information (PHI) to the applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party individual to whom the applicant, member, LAR or AR has provided written consent for the release of PHI.
PSU staff verify the identity of the person who requests disclosure of PHI by examining two forms of identification, with at least one form of identification being a government-issued photo identification (ID):
When disclosing PHI, PSU staff must document transactions and maintain documentation in the member’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record pertaining to how the identity of the person was verified and the method of how the information was released to the individual. Approved methods of releasing PHI include providing the requestor copies of documentation in person, by facsimile or by regular mail.
1620 Alternate Means of Communication with the Applicant or Member
The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant, member, legally authorized representative (LAR) or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.
The applicant, member, LAR or AR must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the applicant or member.
1630 Confidential Information on Notifications
The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member, legally authorized representative (LAR) or authorized representative (AR) during the eligibility determination process. This includes inclusion of PHI by HHSC staff to third parties who receive a copy of a notification of eligibility form.
HHSC staff must not include PHI on the eligibility notice shared with the service provider or another third party.
Notification is received from Medicaid for the Elderly and People with Disabilities (MEPD) that the member has lost Medicaid because his income of $2,892 exceeds the eligibility limit of $2,022. It is a violation of confidentiality to record on Form H2065-D, Notification of Managed Care Program Services, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "You are no longer eligible for Medicaid."
Another applicant is being denied Medically Dependent Children Program (MDCP) services because the presence of weapons in his or her home presents a hazard to service providers. It is a violation of confidentiality to record on Form H2065-D, "The presence of weapons in your home presents a hazard to service providers." The comment should simply state, "Your services are being denied due to hazardous conditions in your home."
In the examples above, revealing specifics of the applicant or member’s income or the condition of his home environment is a violation of his or her right to confidentiality. In all cases, HHSC staff must assess any information provided by the applicant or member to determine if its release would be a confidentiality violation.
1631 Program Support Unit Communications with Managed Care Organizations
In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member’s protected health information (PHI) to be shared only with his or her selected managed care organization (MCO). This makes it crucial that when documents containing member information are posted in the incorrect MCO folder in TxMedCentral, it be corrected immediately upon realization an error was made.
Program Support Unit (PSU) staff must send notification of all TxMedCentral posting errors to PSU Operations staff, including the document identifying information, the name of the folder in which it was erroneously posted, the name of the folder into which it should have been posted, and the time the correction was made.
Example: Posted XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been posted to MOLSKW. Corrected at 9:22 a.m. December 20.
1640 Applicant or Member Correction of Information
An applicant, member, legally authorized representative (LAR) or authorized representative (AR) has a right to correct any information that the Texas Health and Human Services Commission (HHSC) has about the applicant or member and any other individual on the applicant or member’s case.
include a return address, telephone number or email address at which HHSC can contact the applicant or member.
If HHSC agrees to change protected health information (PHI), the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the member’s request.
Notify the member, LAR or AR in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or the MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.
If HHSC or the MCO makes a correction to PHI, HHSC or the MCO must ask the member for permission before sharing with third parties. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if those persons may have relied or could rely on it to the disadvantage of the member. HHSC staff must follow regional procedures to contact the HHSC Office of Chief Counsel for a record of disclosures. MCOs must follow HHSC procedures as stated in the STAR Kids Managed Care Contract.
Note: Do not follow above procedures when the accuracy of information provided by a member, LAR or AR is determined by another review process, such as a:
1650 Disposal of Records
To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data, as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.
1700 Member Rights and Responsibilities
Member rights and responsibilities are included in the Member Handbook. The required critical elements can be found at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.
The Member Handbook must be provided to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.
In addition, an applicant, member, LAR or AR may refer to the Title 1 Texas Administrative Code (TAC) §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.
1800 Notifications
1810 Program Support Unit Staff Notification Requirements
Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member, LAR or AR of the actions taken regarding Medically Dependent Children Program (MDCP) services. Form H2065-D must be completed in plain language that can be understood by the applicant, member, LAR or AR. The language preference of the applicant, member, LAR or AR must be considered.
The applicant, member, LAR or AR must be notified on Form H2065-D within two business days of the date a case is certified for MDCP. Form H2065-D also includes information on the individual’s room and board charges and copayment, if applicable.
Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is terminated. PSU staff must notify the applicant, member, LAR or AR using Form H2065-D of the denial of application within two business days of the decision. Refer to Section 6000, Denials and Terminations.
Depending on when the notification is generated, Form H2065-D will either be posted to the MCO STAR Kids folder in TxMedCentral or generated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal on the case action date.
1820 Managed Care Organization Notification Requirements
The managed care organization (MCO) is responsible for notifying the member, legally authorized representative (LAR) or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member, LAR or AR has a right to appeal. Appeal rights of STAR Kids members are in the STAR Kids Managed Care Contract.
1830 Notifications with Medicaid for the Elderly and People with Disabilities or Texas Works Involvement
Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Program Support Unit (PSU) staff must coordinate changes, approvals, and denials of Medically Dependent Children Program (MDCP) services with the MEPD specialist.
Although the MEPD specialist is required to notify the applicant, member, legally authorized representative (LAR) or authorized representative (AR) of all Medicaid eligibility decisions, PSU staff are required to mail the MDCP applicant, member, LAR or AR the notification of denial of MDCP services on Form H2065-D, Notification of Managed Care Program Services. PSU staff also fax the MEPD specialist a copy of Form H2065-D at initial certification and denial for case actions that involve Medicaid eligibility. PSU staff communications with MEPD that do not include Form H2065-D must include Form H1746-A, MEPD Referral Cover Sheet. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.
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