1100 Legal Basis and Values

Revision 25-1; Effective May 16, 2025

STAR Kids Medicaid Managed Care Program is required by:

• Texas Government Code Section 533.00253 Title 1; and
• Texas Administrative Code (TAC) Section 353:
  • Subchapter M, Home and Community Based Services in Managed Care; and
  • Subchapter N, STAR Kids, outline the delivery of STAR Kids services and Medically Dependent Children Program (MDCP) services.

Requirements about 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 used by managed care organizations (MCOs), contractors and service providers to deliver STAR Kids MDCP services to eligible members.

1110 Mission Statement

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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.

Revision 25-3; Effective Oct. 20, 2025

An individual can be assessed for services through the Medically Dependent Children Program (MDCP) when their name reaches the top of the MDCP interest list (IL). Title 1 Texas Administrative Code (TAC) Section 353.1155 (b)(1) states an individual’s name may be added to the MDCP IL by:

• calling the Texas Health and Human Services Commission (HHSC) Interest List Management (ILM) unit at 877-438-5658;
• submitting a written request to the ILM unit; or
• generating a referral through YourTexasBenefits.com using the Find Support Services screening and referral tool.

An individual becomes an applicant when they are released from the IL, confirm interest in MDCP and:

• have submitted Form H1200, Application for Assistance – Your Texas Benefits; or
• Program Support Unit (PSU) staff have submitted a referral for an assessment to the MCO.

A member is a person who is currently enrolled in and receiving services through MDCP.

An applicant or member must meet the following criteria stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 to be eligible for the Medically Dependent Children Program (MDCP):

• Be under 21 years old.
• Live in Texas.
• Meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care as determined by HHSC. Note: This requirement is verified through an approved STAR Kids Screening and Assessment Instrument (SK-SAI).
• Have an unmet need for support in the community that can be met through one or more MDCP services. Note: This requirement is verified through a STAR Kids individual service plan (SK-ISP) with services under the established cost limit.
• Choose MDCP as an alternative to NF services, described in 42 Code of Federal Regulations (CFR) Section 441.302(d).
• Not be enrolled in one of the following waiver programs:
  • the Community Living Assistance and Support Services (CLASS) Program;
  • the Deaf Blind with Multiple Disabilities (DBMD) Program;
  • the Home and Community-based Services (HCS) Program;
  • the Texas Home Living (TxHmL) Program; or
  • the Youth Empowerment Services (YES) waiver.
• Live in:
  • the person's home; or
  • an agency foster home defined in Texas Human Resource Code, Section 42.002, (relating to Definitions).
• Be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title relating to Medicaid Eligibility for the Elderly and People with Disabilities (MEPD).

An applicant receiving NF Medicaid is approved for MDCP if the applicant requests services while living in a NF and meets the eligibility criteria listed above.

PSU staff must refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an individual, applicant or member.

1210 Medical Necessity Determination

Revision 25-4; Effective Dec. 12, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(C) states to be eligible for the Medically Dependent Children Program (MDCP), an applicant or member must have an approved medical necessity (MN) determination for a nursing facility (NF) level of care (LOC). The MN determination comes from a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) conducts and submits the SK-SAI to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

The TMHP LTCOP automatically processes the SK-SAI, determines MN and calculates the Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level. The PDPM LTC level determines cost limits in MDCP. The MCO uses the SK-SAI to create and submit the applicant or member’s STAR Kids individual service plan (SK-ISP) to the TMHP LTCOP. The SK-ISP lists the applicant or member’s services and preferences for care and is valid for a 12-month period, if they remain eligible for the program.

The MCO must conduct and submit an initial SK-SAI for an applicant in the TMHP LTCOP within 60 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff. The MCO must conduct and submit the SK-SAI to the TMHP LTCOP for members annually, or when the member has a change in condition after initial enrollment. The MCO must not submit a reassessment SK-SAI in the TMHP LTCOP before 90 days of the expiration of the member’s current SK-ISP. The reassessment SK-SAI must be submitted at least 30 days before the member’s current SK-ISP expires.

The TMHP LTCOP automatically creates an MDCP Enrollment Form when the MCO submits a new SK-SAI for MDCP. This is if there is no existing MDCP Enrollment Forms or all other MDCP Enrollment Forms are in an invalid, denied or terminated status. PSU staff must verify data populated in the MDCP Enrollment Form is correct, update incorrect information, populate blank fields and save the form for all applicable MDCP cases. PSU staff must consult their supervisor before trying to manually create an MDCP Enrollment Form.

Refer to the STAR Kids Handbook (SKH) for more information on the MN determination.

1210.1 Reserved for Future Use

Revision 25-4; Effective Dec. 12, 2025

1210.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 25-1; Effective May 16, 2025

A medical necessity (MN) approval is valid for 120 days from the Texas Medicaid & Healthcare Partnership (TMHP) MN approval date for an initial applicant. The managed care organization (MCO) must complete another initial STAR Kids Screening and Assessment Instrument (SK-SAI) if the applicant is not enrolled in the Medicaid for Dependent Children Program (MDCP) within 120 days from the MN approval date. 

1220 Individual Cost Limit

Revision 25-1; Effective May 16, 2025

A Medically Dependent Children Program (MDCP) applicant or member’s STAR Kids individual service plan (SK-ISP) must fall within the applicant or member’s cost limit. The managed care organization (MCO) conducts a STAR Kids Screening and Assessment Instrument (SK-SAI) to assess the applicant or member. The MCO submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP LTCOP automatically processes the SK-SAI and calculates the applicant or member’s Resource Utilization Group (RUG) value and determines if medical necessity (MN) is approved. The MCO uses the SK-SAI to create the applicant or member’s SK-ISP. The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the RUG value.

Program Support Unit (PSU) staff must not calculate the SK-ISP cost limit as it is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field. PSU staff must verify the applicant or member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than then Annual Cost Limit in the TMHP LTCOP SK-ISP.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

1230 Unmet Need for at Least One Medically Dependent Children Program Service

Revision 18-0; Effective September 4, 2018

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) Section 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

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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

Revision 25-1; Effective May 16, 2025

The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services. These services are outlined in Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(B), Medically Dependent Children Program.

If the applicant is under 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, outlined in Title 1 TAC Section 353.1155(b)(1)(G)(ii).

Managed care organization (MCO) service coordinators must confirm the applicant or member, if under 18, lives with a family member, such as a parent, guardian, grandparent or sibling, defined in the Glossary. The MCO service coordinator must review guardianship documentation or get a statement from the applicant, member, legally authorized representative (LAR) or family member about the relationship. The MCO service coordinator must maintain this documentation in the member’s case file.

1270 Financial Eligibility

Revision 25-4; Effective Dec. 12, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1155(a)(1)(H) states to be eligible for the Medically Dependent Children Program (MDCP), an applicant or member  must be determined by the Texas Health and Human Services Commission (HHSC) to be financially eligible.

Program Support Unit (PSU) staff review the Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

PSU staff do not have to get Form H1200, Application for Assistance – Your Texas Benefits, for an individual with an appropriate type of Medicaid assistance in TIERS. PSU staff must refer to Appendix XVI, MEPD Referral Crosswalk, to determine if the individual’s type of assistance (TOA) requires PSU staff to fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist to determine Medicaid financial eligibility for MDCP.

PSU staff must get the following completed forms, if an individual is not already Medicaid eligible:

• Form H1200;
• Form H3034, Disability Determination Socio-Economic Report; and
• Form H3035, Medical Information Release and Disability Determination.

PSU staff must fax the forms noted above, with Form H1746-A as a cover sheet, to the MEPD specialist within two business days of receipt. The MEPD specialist has 45 days, or up to 90 days if a disability determination is necessary, to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200, Form H3034 and Form H3035 within 30 days from the mail date of the application.

PSU staff must return an unsigned Form H1200 to the individual or legally authorized representative (LAR) within two business days of receipt. A completed Form 2606, Managed Care Enrollment Processing Delay, must be mailed with the original unsigned Form H1200. PSU staff must ensure that a copy of the unsigned Form H1200 and Form 2606 are uploaded to the Texas Health and Human Services HHS Enterprise Administrative Report and Tracking System (HEART) case record.

1270.1 Individual with a Qualified Income Trust

Revision 25-1; Effective May 16, 2025

An individual or applicant with a qualified income trust (QIT) may be determined financially eligible for the Medically Dependent Children Program (MDCP) even though their income is more than the special institutional income limit for the program.

PSU staff must refer questions about QIT to Access and Accessibility Services (AES). This is done by faxing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist.

1270.2 Copayment and Room and Board

Revision 26-2; Effective June 1, 2026

Members determined to be financially eligible based on the institutional income limit may have to share in the cost of Medically Dependent Children Program (MDCP) services. These shared costs are paid by the member through room and board (R&B) and copayment charges. The R&B amount is determined by the Social Security Administration (SSA). The copayment amount is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Medical assistance only (MAO) members who are eligible based on the institutional income limit must pay R&B and copayment. Supplemental Security Income (SSI) members are only required to pay R&B and will not have a copayment.

Program Support Unit (PSU) staff use Form H2065 -D, Notification of Managed Care Program Services, to notify the member and managed care organization (MCO) of R&B and copayment amounts. The begin date entered on Form H2065-D for the initial R&B and copayment charges will match the:

• MDCP eligibility effective date for:
  • interest list release (ILR) cases; and 
  • transfers from another Medicaid waiver program; and 
• first day of the month that the applicant discharged from the nursing facility (NF) for traditional Money Follows the Person (MFP) and MFP limited NF stay cases. 

The MCO must explain to the member that they must pay the copayment and R&B amounts directly to the provider contracted to deliver MDCP services. 

1270.3 Copayment Changes

Revision 26-2; Effective June 1, 2026

A member's copayment may change during the time they are enrolled in the Medically Dependent Children Program (MDCP). Copayment changes are typically due to a change in income, medical expenses or other circumstances.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist is responsible for calculating copayment amounts. The MEPD specialist notifies Program Support Unit (PSU) staff through the MEPD Communication Tool of copayment amounts. PSU staff may also determine the copayment amount has changed in Texas Integrated Eligibility Redesign System (TIERS) at reassessment. The MEPD specialist informs PSU staff if corrections to the member's copayment are necessary based on a change in the income amount available for copayment.

PSU staff must complete the following activities within five business days from getting the copayment amounts:

• mail Form H2065-D, Notification of Managed Care Program Services, to the member or legally authorized representative (LAR);
• upload Form H2065-D to the MCOHub;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

Copayment changes are always effective on the first day of the month. Adverse action is required if the copayment amount is increasing. The copayment increase is effective the first day of the month after the adverse action period has expired.

Adverse action is not required when:

• the initial Form H2065-D is generated advising the member of the copayment amounts for the first time;
• no changes are happening to ongoing copayment amounts; or
• copayment amounts are decreasing.

The copayment amount is effective the first day of the month after the copayment amount is determined when adverse action is not required.

The MEPD specialist and the managed care organization (MCO) handle issues for underpayments, refunds and copayment amount appeals. 

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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:

• ambulance services;
• audiology services, including hearing aids;
• behavioral health services, including:
  • in-patient mental health services;
  • out-patient mental health services;
  • out-patient chemical dependency services for children;
  • detoxification services; and
  • psychiatry services;
• birthing services provided by a certified nurse midwife in a birthing center;
• chiropractic services;
• dialysis;
• durable medical equipment (DME) and supplies;
• emergency services;
• family planning services;
• home health care services;
• inpatient hospital services;
• outpatient hospital services;
• laboratory;
• 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;
• optometry, glasses and contact lenses, if medically necessary;
• podiatry;
• prenatal care;
• primary care services;
• radiology, imaging and X-rays;
• specialty physician services;
• therapies, including physical, occupational and speech;
• transplantation of organs and tissues; and
• vision services.

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

Revision 18-0; Effective September 4, 2018

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

Revision 24-4; Effective Dec. 1, 2024

STAR Kids provides members with a range of services 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
• Personal Care Services (PCS).

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:

• employment assistance (EA);
• Flexible Family Support Services (FFSS);
• respite; and
• 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.

The member, LAR or AR work with assistance from a financial management services agency (FMSA) in the CDS option model. 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. The MCO coordinates delivery of non-member directed services if the member chooses to self-direct certain services.

An agency is the attendant’s employer and handles the business details, such as paying taxes and doing the payroll, in the SRO model. The agency also orients attendants to agency policies and standards before mailing them to the member’s home. The member or LAR 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.

PSU staff must refer to the STAR Kids Handbook (SKH) for more information about these service delivery options. 

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

1430 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

1440 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

1441 Program Point of Contact

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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.

1510 Community Services Interest List

Revision 26-2; Effective June 1, 2026

Community Services Interest List (CSIL) is an online database used by Interest List Management (ILM) unit and Program Support Unit (PSU) staff. CSIL maintains an interest list and tracks individuals waiting to receive services for Long Term Services and Supports (LTSS) waiver programs including:

• Community Living Assistance and Support Services (CLASS);
• Home and Community-based Services (HCS);
• Medically Dependent Children Program (MDCP);
• STAR+PLUS Home and Community Based Services (HCBS) program; and
• Texas Home Living (TxHmL).

PSU staff use CSIL to verify an individual’s status on the interest list. CSIL is also used to prevent dual enrollment in another Medicaid waiver program when an individual is entering MDCP. PSU staff must select the appropriate closure reasons and close the CSIL record when an individual is enrolled in MDCP.

1520 Health and Human Services Commission Benefits Portal

Revision 26-2; Effective June 1, 2026 

The Texas Health and Human Services Commission (HHSC) Benefits Portal is an online database used by:

• Program Support Unit (PSU);
• Access and Eligibility Services (AES); and 
• Fair and Fraud Hearings (FFH) staff. 

The HHSC Benefits portal provides access to applications, case documents and other case and client information. The HHSC Benefits Portal also provides access to the Texas Integrated Eligibility Redesign System (TIERS) and important details about AES tasks.

1530 Health and Human Services (HHS) Enterprise Administrative Report and Tracking System

Revision 26-2; Effective June 1, 2026 

The Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is an online database used by Program Support Unit (PSU) staff. HEART is a repository of current and historic case records for individuals, applicants and members.

PSU staff use HEART to:

• review an individual, applicant or member’s case history;
• open new case records;
• update existing case records;
• upload forms, documents and screenshots;
• add narratives of case actions;
• set due date reminders for case actions;
• track progress on cases;
• create relationships between case records; and
• close case records.

PSU staff document every case action, including phone calls, mail dates, fax dates, form receipt dates and any other relevant information in the HEART narrative. Complete the HEART documentation so that someone without knowledge of the case can follow along in HEART and come to the same case action decision. 

PSU staff must refer to Appendix XXXI, HEART Case Record Assignment Procedures, for more information on processing information or data received from, or relating to, an individual, applicant or member.

1540 Service Authorization System Online

Revision 26-2; Effective June 1, 2026 

Service Authorization System Online (SASO) is an online database used by Program Support Unit (PSU) staff. It helps prevent dual enrollment in the Medically Dependent Children Program (MDCP) and another Medicaid waiver program. 

PSU staff must ensure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the SASO Enrollment and Service Authorization records. PSU staff review these records for the following Medicaid waiver programs, which maintain individual service plans (ISPs) in SASO:

• Community Living Assistance & Support Services (CLASS) (Service Group (SG) 2);
• Deaf Blind with Multiple Disabilities (DBMD) (SG 16);
• Home and Community-based Services (HCS) (SG 21); and
• Texas Home Living (TxHmL) (SG 22).

Note: SASO was the primary system of record for MDCP before Nov. 1, 2016. Beginning Nov. 1, 2016, the TMHP LTCOP became the primary system of record for MDCP members. 

1550 Texas Integrated Eligibility Redesign System

Revision 26-2; Effective June 1, 2026

Texas Integrated Eligibility Redesign System (TIERS) is an online database used by Program Support Unit (PSU) staff. PSU staff use TIERS to verify an individual, applicant or member’s:

• age; 
• case mailing address and county of residence; 
• Medicaid eligibility; 
• managed care enrollment; and 
• enrollment in the Youth Empowerment Services (YES) waiver.

Searching TIERS for Verification Information

PSU staff can find the information noted above in TIERS by:

• selecting Inquiry under the My TIERS Functions;
• choosing the option Individual; and 
• entering the following information for the individual, applicant or member on the Individual-Search page:
  • first and last name;
  • Social Security number (SSN);
  • Medicaid identification (ID) number noted in TIERS as the Individual #;
  • date of birth (DOB); or 
  • case number.

Information for the individual, applicant or member will populate in the Search Results field at the bottom of the Individual-Search page. PSU staff can find the specific information they need to verify using the information in the Search Results field. 

Age

The DOB can be found in the Search Results field at the bottom of the Individual-Search page.

Case Mailing Address and County of Residence

PSU staff can find the case mailing address and county of residence by selecting the link for the individual, applicant or member’s Case # in the Search Results field at the bottom of the Individual-Search page. This will open the Case/Application – Search/Summary page which contains the current county of residence and case mailing and residence addresses.

The case mailing address and case residence address for an individual, applicant, or member may be different. All correspondence must be mailed to the case mailing address.

An individual, applicant, member, legally authorized representative (LAR) or managed care organization (MCO) may provide PSU staff with a different mailing address than the TIERS case mailing address. PSU staff must complete the following activities within two business days of receiving a different mailing address than the TIERS case mailing address:

• verify an individual, applicant, member, AR or LAR’s knowledge of two of the following about the individual, applicant or member:
  • SSN;
  • DOB; or
  • Medicaid ID number;
• verify that the person who self-identifies as a LAR is listed as the AR in:
  • TIERS;
  • the most recent signed Form H1200, Application for Assistance – Your Texas Benefits; or 
  • Form H1826, Case Information Release, completed and signed by the individual, applicant or member;  
• advise the:
  • person to contact the following entities to update their address in TIERS:
    • the Social Security Administration (SSA) if the individual, applicant or member receives Supplemental Security Income (SSI); or
    • 2-1-1, or 877-541-7905, if the individual, applicant or member is medical assistance only (MAO); and
  • MCO to help the applicant or member contact the SSA or 2-1-1, or 877-541-7905, to update their address; and
• make sure the person or MCO understands the importance of immediately updating the individual, applicant or member’s address as any future correspondence will be mailed to the case mailing address noted in TIERS.

Medicaid Eligibility and Managed Care Enrollment 

PSU staff can check for Medicaid eligibility and managed care enrollment by selecting the hyperlink of the individual’s name in the Search Results field at the bottom of the Individual-Search page. The Individual-Summary screen will appear. 

In the Individual-Summary screen, PSU staff can find the individual, applicant or member’s:

• Medicaid eligibility by:
  • hovering over the Individual # field and selecting Medicaid/CHIP/CHIP perinatal History. The Medicaid/CHIP/CHIP perinatal History screen:
    • shows current and previous types of assistance the individual, applicant or member has received; or
    • will be empty if the individual or applicant has never received Medicaid; 
• Managed care enrollment by:
  • hovering over the Individual # field and selecting Managed Care. The managed care information will appear in the Individual Managed Care History field. The data elements in the Individual Managed Care History field include the:
    • Provider — The name of the provider contracted by the MCO to deliver services to members.
    • Plan — The name and plan code of the MCO providing Medicaid services to the member.
    • Program — For STAR Health managed care members, FOSTER CARE MANAGED CARE will appear in this field. For all other managed care members, STAR KIDS will appear in this field. 
    • County — Individual’s County of Residence.
    • Begin Date — The date enrollment began under this plan.
    • End Date — The date enrollment ended under this plan.
    • Status — Describes the type of action.
    • Eligibility — Choices are CANDIDATE (applicant), ENROLLED (active) and SUSPENDED (closed).
    • Candidature — Describes the individual’s status.

Enrollment in the YES Waiver

PSU staff can check for enrollment in the YES waiver by selecting the hyperlink of the individual’s name in the Search Results field at the bottom of the Individual-Search page. The Individual-Summary screen will appear. In the Individual-Summary screen, PSU staff can determine if the individual, applicant or member is enrolled in the YES waiver by:

• hovering over the Individual # field and selecting LTSS Eligibility Periods. The LTSS Eligibility Periods Details screen:
  • shows if the individual, applicant or member has received or is currently receiving the YES waiver or any long-term services and supports (LTSS); and
    • the dates of enrollment in YES or any LTSS.

Note: The individual, applicant, or member is considered enrolled in the YES waiver or another LTSS if there is no end date. 

1560 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision 26-2; Effective June 1, 2026

The Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) is an online database used by:

• Program Support Unit (PSU); 
• managed care organizations (MCOs);
• Office of the Medical Director (OMD) staff; and
• TMHP staff. 

The TMHP LTCOP maintains the STAR Kids Screening and Assessment Instrument (SK-SAI) and STAR Kids individual service plan (SK-ISP) that contains the services and cost limits for members.

The MCO must submit the SK-SAI through the TMHP LTCOP to process a determination of medical necessity (MN) and cost limit. MCOs submit the SK-SAI as an:

• initial SK-SAI for an applicant being assessed for the Medically Dependent Children Program (MDCP);
• annual SK-SAI for a member’s ongoing eligibility for MDCP program; or
• a significant change in status SK-SAI Assessment for an MDCP member requesting a change to their cost limit.

The MCO must generate an amended SK-ISP when a significant change occurs in a member’s condition. The MCO must keep amended SK-ISPs in the MCO’s member case file. The MCO does not provide the amended SK-ISP to PSU staff and does not enter the amended SK-ISP in the TMHP LTCOP. PSU staff must advise the MCO that PSU staff do not process SK-ISPs resulting from a significant change if the MCO uploads an amended SK-ISP to the MCOHub.

The MCO uses the TMHP LTCOP to:

• check and verify MN status and cost limit;
• review workflow actions that result from the submittal of the SK-SAI or the SK-ISP;
• manage and act in response to workflow messages; 
• submit Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool; and
• monitor for Form H2065-D, Notification of Managed Care Program Services.

PSU staff use the TMHP LTCOP to:

• review an applicant’s or member’s case history;
• verify the MCO has submitted the SK-SAI and SK-ISP timely;
• verify the SK-SAI has an approved MN and a Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level under the cost limit;
• verify the SK-ISP has the correct date range and identifies at least one unmet need;
• adjust SK-ISP date ranges, if applicable;
• update the MDCP Enrollment Form and save the form;
• approve, invalidate and terminate ISPs;
• monitor the status of MN denials;
• add case notes to the narrative history;
• generate Form H2065-D, for approvals and MN denials; and
• generate reports.

1570 MCOHub

Revision 26-2; Effective June 1, 2026 

The MCOHub is a secure online bulletin board used by Program Support Unit (PSU) and managed care organizations (MCOs). The MCOHub contains forms and documents uploaded by PSU staff and MCOs. PSU staff and MCOs use the MCOHub for all communications sent between the two parties.

PSU staff and the MCO are:

• Only required to upload the English versions of forms to the MCOHub.
• Not required to upload the Spanish versions of forms to the MCOHub.

PSU staff must electronically back up documents from the MCO’s ISP and SPW folder daily to prevent loss of form history. PSU staff must not back up documents directly in the MCOHub. Instead, PSU staff must move files daily to a secure location.

The MCOHub automatically purges documents every 14 days due to the volume of documents uploaded. 

1610 Confidential Nature of Medical Information - Health Insurance Portability and Accountability Act

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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.

Reasonable diligence for employees responsible for records includes keeping records:

• in a locked office when the building is closed;
• properly filed during office hours; and
• in the office at all times, except when authorized to remove or transfer them.

1613 Responsible Party to Authorize Disclosure

Revision 18-0; Effective September 4, 2018

1613.1 Legally Authorized Representatives and Authorized Representatives

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

A parent is the legally authorized representative (LAR) for a minor child except when:

• the minor child can consent to medical treatment. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment when the:
  • minor is on active duty with the U.S. military;
  • minor is age 16 years or older, lives separately from the parents and manages his or her own financial affairs;
  • consent involves diagnosis and treatment of disease that must be reported to the local health officer or the Texas Department of State Health Services (DSHS);
  • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
  • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
  • 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;
  • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
  • consent involves suicide prevention or sexual, physical or emotional abuse.
• a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about health care decisions not made by the parent.

1613.3 Adults and Emancipated Minors

Revision 18-0; Effective September 4, 2018

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:

• person the member has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
• 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

Revision 18-0; Effective September 4, 2018

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:

• an executor, including an independent executor;
• an administrator, including a temporary administrator;
• a surviving spouse;
• a child;
• a parent; and
• an heir.

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 Establishing Identity 

Revision 23-4; Effective Aug. 21, 2023

1614.1 Phone Communication

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must establish the identity of a person who self-identifies as an individual, applicant, member, legally authorized representative (LAR) or medical consenter over the phone. PSU staff must verify the person’s knowledge of two of the following about the individual, applicant or member:

• Social Security number (SSN);
• date of birth (DOB); or
• Medicaid identification (ID) number.

PSU staff must verify that the person who self-identifies as a LAR or medical consenter over the phone is listed as the LAR or medical consenter in:

• the Texas Integrated Eligibility Redesign System (TIERS); or
  • Note: The medical consenter is known as the ‘Alternate Payee’ in TIERS when the individual, applicant, or member has STAR Health or Medicaid as a result of Department of Family and Protective Services (DFPS) involvement.
• the most recent signed Form H1200, Application for Assistance – Your Texas Benefits; or
• Form H1826, Case Information Release, completed and signed by the individual, applicant or member.

PSU staff must not release case information to a person who is not able to be verified as the individual, applicant, member, LAR or medical consenter.

Refer to Section 1615, Information That May Be Disclosed, for more information about scenarios when: 

• PSU staff is not able to verify the person calling;
• the person calling PSU staff is not the individual, applicant, member, LAR or medical consenter; or
• PSU staff must obtain Form H1826.

PSU staff must direct all case-related information requests from a lawyer to the PSU supervisor. 

1614.2 In-Person Communication

Revision 18-0; Effective September 4, 2018

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):

• valid U.S. passport;
• Texas Department of Public Safety (DPS) ID card;
• DPS driver license;
• DPS Texas Election Identification Certificate;
• DPS handgun license;
• U.S. military identification card containing the person’s photograph;
• U.S. citizenship certificate containing the person’s photograph;
• state agency employee badge;
• Social Security number (SSN) card;
• Medicaid ID card;
• birth certificate or birth record;
• hospital record;
• work or school ID card;
• voter registration card; and/or
• wage stub.

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers or contractors by examining at least one source such as:

• employee badge; or
• government-issued identification card with a photograph.

Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access confidential information through one of the following:

• official correspondence or a telephone call from a state or regional office; or
• 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

Revision 18-0; Effective September 4, 2018

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:

• is sent to a verified email address;
• is sent as an encrypted message;
• does not contain PHI in the email’s subject line; and
• 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."

Password-protected documents sent by email and electronic fax (e-fax) documents are not considered a secure method for transmitting PHI.

1615 Information That May Be Disclosed

Revision 23-4; Effective Aug. 21, 2023

The Texas Health and Human Services Commission (HHSC) follows Title 20 Code of Federal Regulations (CFR) Sections 401-403 concerning the disclosure of information about: 

• a person, both with and without the person's consent; 
• the maintenance of records; and
• the general guidelines in deciding whether to make a disclosure.

Program Support Unit (PSU) staff must make reasonable efforts to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to:

• determine eligibility;
• operate the program; and
• accomplish the request for disclosure.

PSU staff must only disclose case-related information with a person verified by the methods described in Section 1614.1, Phone Communication, Section 1614.2, In-Person Communication, and Section 1614.3, Electronic Mail Communication, when:

• the Texas Integrated Eligibility Redesign System (TIERS) indicates that the person requesting the information is the legally authorized representative (LAR);
• the person is the medical consenter as indicated in TIERS; 
  • The medical consenter is known as the ‘Alternate Payee’ in TIERS when the individual, applicant, or member has STAR Health or Medicaid as a result of Department of Family and Protective Services (DFPS) involvement.
• a signed Form H1200, Application for Assistance – Your Texas Benefits, indicates the person requesting the information is the LAR or medical consenter;
• a valid Form H1826, Case Information Release, is on file or received;
• the person is HHSC staff including the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; or
• the person is an HHSC contractor such as the managed care organization (MCO) or the Texas Medicaid & Healthcare Partnership (TMHP) staff.

PSU staff must refer requests to disclose information from federal agency staff, research staff or lawyer to the PSU supervisor.

PSU staff must complete the following activities when a person requesting the information does not fit in the categories noted in the previous paragraphs:

• research the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record for Form H1826;
• verify the individual, applicant, member, LAR or medical consenter signed Form H1826;
• ensure the person only receives the information approved for release on Form H1826; and 
• ensure Form H1826 is not expired.

PSU staff may use the following: 

• an existing and valid Form H1826 found in the HEART case record; or 
• a newly submitted Form H1826 received from the individual, applicant, member, LAR or medical consenter.

A valid Form H1826 is:

• signed by the individual, applicant, member, LAR or medical consenter; and
• within the information release authorization time frame.

PSU staff must ask the person requesting the information to provide a new Form H1826 if an existing Form H1826:

• is not signed;
• is expired; or 
• does not authorize the release of the information requested.

PSU staff must complete the following activities within two business days of receiving a valid Form H1826:

• create a HEART case record, if applicable;
• upload Form H1826 to the HEART case record;
• contact the person approved by the individual, applicant, member, LAR or medical consenter, as applicable, to receive case information;
• provide only the specific case information noted on Form H1826 during the approved time frame specified on Form H1826; and
• document the HEART case record.

The Office of the Chief Counsel at HHSC manages questions and concerns about releasing information. PSU staff must refer an individual, applicant, member, LAR or medical consenter to the Office of the Chief Counsel if there are questions and problems concerning releasing information.

PSU staff must notify the PSU supervisor if a person requests copies of an individual, applicant, or member’s records maintained by the HHSC.

PSU staff may refer to Title 20 CFR Sections 401-403, for more information regarding the disclosure of PHI.

PSU staff may refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements regarding STAR Health individuals, applicants, members or medical consenters.
 

1616 Verification and Documentation of Disclosure

Revision 18-0; Effective September 4, 2018

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):

• Valid U.S. passport;
• Texas Department of Public Safety (DPS) ID card;
• DPS driver license;
• DPS Texas Election Identification Certificate;
• DPS handgun license;
• U.S. military identification card containing the person’s photograph;
• U.S. citizenship certificate containing the person’s photograph;
• work or school identification card;
• state agency employee badge;
• Social Security number (SSN) card;
• Medicaid ID card;
• birth certificate or birth record;
• hospital record;
• work or school ID card;
• voter registration card; and/or
• wage stub.

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

Revision 18-0; Effective September 4, 2018

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

Revision 18-0; Effective September 4, 2018

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.

Examples:

• 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

Revision 24-4; Effective Dec.1, 2024

It is imperative to only share an applicant or member’s protected health information (PHI) with the selected managed care organization (MCO) to comply with the Health Insurance Portability and Accountability Act (HIPAA). It is crucial that when documents containing member information are posted in the incorrect MCO folder in the MCOHub, they are removed immediately once an error is realized.

Program Support Unit (PSU) staff must send an email of all MCOHub posting errors to the designated PSU staff. The email must include the:

• document identifying information; 
• name of the folder where it was erroneously uploaded; 
• time it was posted in the incorrect folder;
• name of the folder where it should have been posted; and 
• time the correction was made.

Example: Posted XX_2067_123456789_ABCD_1S_MFP.doc in SUPSK at 8:54 a.m. on December 20. Should have been posted to UHCSK. Corrected at 9:22 a.m. on Dec. 20.

1640 Applicant or Member Correction of Information

Revision 18-0; Effective September 4, 2018

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.

A request for correction must be in writing and:

• identify the applicant or member asking for the correction;
• identify the disputed information about the applicant or member;
• state why the information is wrong;
• include any proof that shows the information is wrong;
• state what correction is requested; and
• 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:

• fair hearing;
• civil rights hearing; or
• other appeal process.

The decision in the above review processes is the decision on the request to correct information.

1650 Disposal of Records

Revision 18-0; Effective September 4, 2018

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.

Revision 25-1; Effective May 16, 2025

Member rights and responsibilities are in the member handbook. Find the required critical elements here at the Texas Medicaid and CHIP - Uniform Managed Care Manual.

The member handbook must be provided to the applicant, member or legally authorized representative (LAR) at application. Share this document in the language preference expressed by the applicant or member.

In addition, an applicant, member, or LAR may refer to the Title 1 Texas Administrative Code (TAC) Section 353 Subchapter C, Member Bill of Rights and Responsibilities, for the full list of member rights and responsibilities.

1810 Program Support Unit Staff Notification Requirements

Revision 23-4; Effective Aug. 21, 2023

Form H2065-D, Notification of Managed Care Program Services, is the legal notice Program Support Unit (PSU) staff must mail to the applicant, member, legally authorized representative (LAR) or medical consenter indicating:

• the Medically Dependent Children Program (MDCP) eligibility for approvals, denials and terminations for MDCP;
• the right to a state fair hearing, as applicable;
• annual cost-of-living adjustments (COLA) for room and board (R&B) charges; and
• a fair hearing officer’s ruling to reverse an MDCP denial or termination.

PSU staff must mail the English and Spanish versions of Form H2065-D to the applicant, member, LAR or medical consenter.

PSU staff generate Form H2065-D manually or electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) as applicable. PSU staff must follow the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, when completing Form H2065-D.

PSU staff must notify the applicant, member, LAR or medical consenter of MDCP approval using Form H2065-D upon verification that the applicant or member meets all eligibility criteria. PSU staff time frames for mailing Form H2065-D vary depending on the approval type. For example, PSU staff must mail Form H2065-D for an approval within: 

• 24 hours of the nursing facility (NF) discharge for the Money Follows the Person (MFP) limited NF stay process;
  • Note: The applicant must meet all MDCP, and MFP limited NF stay eligibility criteria before admission to the NF for the limited NF stay.
• One business day from the date the applicant meets all MDCP eligibility criteria for the first Form H2065-D used in the Traditional MFP process;
• five business days from the date of NF discharge for the second Form H2065-D used in the Traditional MFP process;
  • Note: The applicant must meet all MDCP and MFP eligibility criteria before discharging from the NF.
• two business days from the date the member meets all MDCP eligibility criteria for interest list releases (ILRs); and
• five business days from the date the member is determined to continue to meet all MDCP eligibility criteria for reassessments.

PSU staff must notify the applicant, member, LAR or medical consenter of a program eligibility denial or termination using Form H2065-D upon notification that eligibility criteria is not being met within two business days.

PSU staff must provide the English version of Form H2065-D to the managed care organization (MCO) either: 

• electronically through the TMHP LTCOP; or
• manually by uploading to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, as applicable. 
   

1820 Managed Care Organization Notification Requirements for PSU Staff

Revision 24-4; Effective Dec. 1, 2024

The managed care organization (MCO) must use Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), Section B, and Form H2067-MC, Managed Care Programs Communication (PDF), for all communications sent to Program Support Unit (PSU) staff, as applicable. The MCO must upload Form H3676, Section B, or Form H2067-MC to the MCOHub. PSU staff will retrieve all MCO postings daily from the MCOHub.

The MCO has 60 days from the date PSU staff uploaded Form H3676, Section A, to the MCOHub, to upload Form H3676, Section B. The MCO has between one business day and 14 days to upload Form H2067-MC, depending on the situation for an individual, applicant or member. Specific MCO time frames for Form H2067-MC are defined throughout this handbook.

1830 Notifications with MEPD Involvement 

Revision Notice 25-2; Effective July 11, 2025

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.

PSU staff communications with MEPD specialists must include Form H1746-A, MEPD Referral Cover Sheet, as applicable. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.

PSU staff are required to mail the MDCP applicant, member or legally authorized representative (LAR) notification of the denial of MDCP services. They must do this on Form H2065-D, Notification of Managed Care Program Services, even though the MEPD specialist is required to notify the applicant, member or LAR of all Medicaid eligibility decisions.