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. 

Revision 26-1; Effective March 16, 2026

Interest List Management (ILM) unit staff must release individuals from the Medically Dependent Children Program (MDCP) interest list (IL) as program slots become available. ILM unit staff contact all released individuals by phone to notify them their names reached the top of the list and to confirm interest in applying for MDCP.

ILM unit staff create an interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART). They assign it to Program Support Unit (PSU) staff when the individual confirms their interest in pursuing MDCP. ILM unit staff update the HEART case record. They note the individual is being released because of the first position IL option, if applicable.

2100.1 MDCP ILR: Individuals Enrolled in STAR Kids 

Revision 26-1; Effective  March 16, 2026

An individual with Supplemental Security Income (SSI) or SSI-related Medicaid is already enrolled with a STAR Kids managed care organization (MCO) and:

• does not need to go through the process of selecting a STAR Kids MCO, unless requested for an individual who chose the first position interest list (IL) option;
• is financially eligible for the Medically Dependent Children Program (MDCP); and
• must have the STAR Kids Screening and Assessment Instrument (SK-SAI) completed to determine if they meet the medical necessity (MN) for MDCP.

Program Support Unit (PSU) staff must complete all the following activities. This must be done within ten business days of receipt of an MDCP interest list release (ILR) case record from Interest List Management (ILM) unit staff in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• reassign the HEART case record to the appropriate PSU staff; and
• document in the HEART case record the individual is enrolled in STAR Kids.

PSU staff must complete the following activities within five business days of receipt of the MDCP ILR case record in HEART:

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify both:
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.
  • STAR Kids managed care enrollment in the Managed Care screen.
• Ensure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2).
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16).
    • Home and Community-based Services (HCS) Program (SG 21).
    • Texas Home Living (TxHmL) Program (SG 22).
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Research the previous HEART case records for an individual who requested first position, to:
  • Ensure the individual has never pursued first position. Note: First position can only be pursued one time.
  • Determine if the individual or legally authorized representative (LAR) requested the following, if the individual qualifies for first position:
    • A new STAR Kids MCO or to remain with their current STAR Kids MCO upon ILR.
    • A different service coordinator with their current STAR Kids MCO to complete the new assessment, if applicable.
• Upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the current STAR Kids MCO in the MCOHub and: 
  • Include the following in the Comments section, if the individual qualifies for first position and chooses to remain with their current STAR Kids MCO:
    • The individual or LAR has requested:
      • First position and needs to be reassessed for MDCP.
      • A different service coordinator to conduct the new assessment, if applicable.
    • The program the individual is currently receiving such as STAR Kids.
• Mail the following enrollment packet to the individual or LAR, if the individual qualifies for first position and requests a new STAR Kids MCO:
  • Form 2600-C, MDCP Waiver Release Letter – Other Medicaid Types or Applicable First Position Requests
  • Form H2053-B, Health Plan Selection
  • STAR Kids Comparison Charts
  • STAR Kids Report Cards
  • Appendix IV, MDCP Frequently Asked Questions
  • Appendix XX, MDCP Program Description
  • A postage-paid envelope 
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

PSU staff do not have to complete a 14-day contact for individuals enrolled in STAR Kids who will stay with their current MCO. PSU staff must refer to 2220, MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

New STAR Kids MCO Requested for First Position Individuals

PSU staff must contact the individual or LAR within 14 days of the enrollment packet mail date, if the individual or LAR requested:

• first position; and 
• a new STAR Kids MCO. 

PSU staff must complete the following activities when contacting the individual or LAR:

• verify receipt of the enrollment packet;
• confirm interest in MDCP and give a general description of MDCP services;
• explain the need to select a new STAR Kids MCO as soon as possible or one will be defaulted to them, if applicable;
• inform the individual or LAR of the following, if applicable:
  • any delay in selecting a new STAR Kids MCO could result in a delay in the MDCP eligibility determination; and
  • the new STAR Kids MCO selection can be changed at any time but will not go into effect until after one full calendar month of MDCP service provision;
• document the individual or LAR’s new STAR Kids MCO choice in the HEART case record if obtained during the 14-day contact; and
• document all contact attempts and any delays in the HEART case record.

PSU staff must refer to 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

An individual must select or be defaulted to the new STAR Kids MCO so the SK-SAI can be performed. PSU staff must refer to 2010.2, MCO Selection or Default, within two business days after the 30^th day an enrollment packet is mailed, if a new STAR Kids MCO was not selected.

Receipt of a New STAR Kids MCO Selection

PSU staff must complete the following activities within two business days of receipt of the new STAR Kids MCO selection, if an enrollment packet is mailed to the individual:

• Upload Form H3676, Section A, to the new STAR Kids MCO in the MCOHub including the following in the Comments section:
  • Individual or LAR requested first position and needs to be reassessed for MDCP.
  • Program the individual is currently receiving such as STAR Kids.
  • Name of the previous STAR Kids MCO.
• Upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the losing STAR Kids MCO:
  • That the individual is transferring to a new STAR Kids MCO.
  • The name of the gaining STAR Kids MCO;
• Email the Enrollment Resolution Services (ERS) unit notice of the individual’s new STAR Kids MCO selection with:
  • This subject line: First Position XX [member’s first and last name initials].
  • The following items in the body of the email:
    • Individual’s name.
    • Individual requested first position.
    • Medicaid identification (ID) number.
    • New STAR Kids MCO selection.
    • New STAR Kids MCO effective date. Note: The member will become active with the new STAR Kids MCO based on the state Medicaid cut-off date found in Appendix XIV, State Cutoff Dates.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

PSU staff must refer to 2220 for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2100.2 MDCP ILR: Individuals Enrolled in STAR Health

Revision 26-1; Effective March 16, 2026

An individual enrolled in a STAR Health managed care organization (MCO):

• must stay enrolled with the STAR Health MCO and will not select a STAR Kids MCO;
• is financially eligible for the Medically Dependent Children Program (MDCP); and
• must have the STAR Kids Screening and Assessment Instrument (SK-SAI) completed to determine if they meet the medical necessity (MN) for MDCP.

Program Support Unit (PSU) staff must complete all the following activities. This must be done within ten business days of receipt of an MDCP interest list release (ILR) case record from Interest List Management (ILM) unit staff in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• reassign the HEART case record to the appropriate PSU staff; and
• document in the HEART case record the individual is enrolled in STAR Health and does not require an enrollment packet.

PSU staff must complete the following activities within five business days of receipt of the MDCP ILR case record in HEART:

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify:
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.
  • STAR Health managed care enrollment in the Managed Care screen.
• Ensure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2).
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16).
    • Home and Community-based Services (HCS) Program (SG 21).
    • Texas Home Living (TxHmL) Program (SG 22).
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Research the previous HEART case records for an individual who requested first position to:
  • Ensure the individual has never pursued first position. Note: First position can only be pursued one time.
  • Determine if the individual or legally authorized representative (LAR) requested that a different service coordinator complete the new assessment, if the individual qualifies for first position. 
• Upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the STAR Health MCO in the MCOHub, updating the Comments section to:
  • Request the STAR Health MCO:
    • Contact the primary medical consenter, or secondary if the primary medical consenter is unavailable, to complete the MDCP assessment.
    • Provide the name and mailing address of the primary or secondary medical consenter when communicating the outcome of the assessment to PSU staff. Note: PSU staff must not update Form H3676, Section A, with the primary or secondary medical consenter’s contact information unless it has been documented in the HEART case record.
  • Note the individual or LAR requested first position and a different service coordinator to conduct the new assessment, if applicable.
• Email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information:
  • This email subject line: Referral for MDCP Assessment for STAR Health Member XX [first letter of the individual’s first and last name].
  • The following items in the body of the email:
    • Individual’s name.
    • Medicaid identification (ID) number.
    • Date of birth (DOB).
    • Notice that a referral for an MDCP assessment was submitted to the STAR Health MCO on MM/DD/YYYY. PSU staff will send a follow up email when an MDCP eligibility determination is made. Note: The DFPS DDS Manager is not required to respond to PSU staff’s notification a referral for an MCDP assessment has been submitted.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

The PSU staff are not required to complete a 14-day contact for individuals enrolled in STAR Health. 

PSU staff must refer to 2220, MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2100.3 MDCP ILR: Individuals Enrolled in STAR and Individuals Receiving Other Types of Medicaid

Revision 26-1; Effective March 16, 2026

Individuals enrolled in a STAR managed care organization (MCO) and individuals who receive other types of Medicaid not related to Supplemental Security Income (SSI), must go through the process of:

• selecting or being defaulted to a STAR Kids MCO;
• a financial eligibility determination for the Medically Dependent Children Program (MDCP), if applicable; and
• completing the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if they meet the medical necessity (MN) for MDCP.

Program Support Unit (PSU) staff must complete all the following activities. This must be done within ten business days of receipt of an MDCP interest list release (ILR) case record from Interest List Management (ILM) unit staff in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• mail the following enrollment packet to the individual or legally authorized representative (LAR), if the individual receives Medicaid but is not enrolled in an MCO, or is enrolled in a STAR MCO without a STAR Kids companion plan:
  • Form 2600-C, MDCP Waiver Release Letter – Other Medicaid Types or Applicable First Position Requests;
  • Form H2053-B, Health Plan Selection;
  • STAR Kids Comparison Charts;
  • STAR Kids Report Cards;
  • Appendix IV, MDCP Frequently Asked Questions;
  • Appendix XX, MDCP Program Description; and
  • a postage-paid envelope;
• Note: a companion plan is defined as an MCO that is operated by the same parent organization as the individual’s current MCO;
• refer to Appendix XXXII, STAR Kids Companion Plans, for a list of STAR Kids companion plans; 
• reassign the HEART case record to the appropriate PSU staff; and
• document in the HEART case record:
  • when and where the enrollment packet was mailed; or
  • the individual is enrolled in a STAR MCO with a STAR Kids companion.

PSU staff must complete the following activities within five business days of receipt of the MDCP ILR case record in HEART:

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify:
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.
  • Managed care enrollment in the Managed Care screen.
• Ensure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2)
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16)
    • Home and Community-based Services (HCS) Program (SG 21)
    • Texas Home Living (TxHmL) Program (SG 22)
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Refer to Appendix XVI, Medicaid Program Actions, to determine if Form H1746-A, MEPD Referral Cover Sheet, must be faxed to the Medicaid for Elderly and People with Disabilities (MEPD) specialist for a financial eligibility determination.
• Fax Form H1746-A to the MEPD specialist, if applicable. Note: The MEPD specialist notifies PSU staff of the financial eligibility determination within 45 days, or up to 90 days if it is necessary to get a disability determination.
• Refer to 2010.2, MCO Selection or Default, for information on defaulting an individual to a STAR Kids companion plan, if the individual is enrolled in a STAR MCO.
• For an individual who has a STAR Kids companion plan and requested first position, research the previous HEART case records, to:
  • Ensure the individual has never pursued first position. Note: First position can only be pursued one time.
  • Determine if the individual or LAR requested the following, if the individual qualifies for first position:
    • A new STAR Kids MCO or to remain with their previous STAR Kids companion plan upon ILR.
    • A different service coordinator with their previous STAR Kids companion plan, if applicable.
• Upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the STAR Kids companion plan in the MCOHub, if applicable, and note:
  • All zeros for the Social Security Number (SSN), if the individual does not have an established SSN.
  • The following in the Comments section, if the individual requested first position and to remain with the previous STAR Kids companion plan: 
    • Individual or LAR requested first position and needs to be reassessed for MDCP.
    • A different service coordinator must conduct the new assessment, if applicable or:
• Mail the following enrollment packet to the individual or LAR, if the individual qualifies for first position and has a STAR Kids companion plan, but requested a new STAR Kids MCO:
  • Form 2600-C
  • Form H2053-B
  • STAR Kids Comparison Charts
  • STAR Kids Report Cards
  • Appendix IV
  • Appendix XX
  • A postage-paid envelope 
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

PSU staff do not complete a 14-day contact for individuals released from the MDCP interest list (IL) who were defaulted to a STAR Kids companion plan. PSU staff must refer to 2220, MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A, if the form was uploaded to the STAR Kids companion plan.

14th Day Contact

PSU staff must contact the individual or LAR within 14 days of the enrollment packet mail date, if the individual:

• receives Medicaid but is not enrolled in an MCO;
• is enrolled in a STAR MCO that does not operate a STAR Kids companion plan; or 
• has a STAR Kids companion plan but requested first position and a new STAR Kids MCO.

PSU staff must complete the following activities when contacting the individual or LAR:

• verify receipt of the enrollment packet;
• confirm interest in MDCP and give a general description of MDCP services;
• explain the need to select a STAR Kids MCO as soon as possible or one will be defaulted to them, if applicable;
• inform the individual or LAR of the following, if applicable:
  • any delay in selecting a new STAR Kids MCO could result in a delay in the MDCP eligibility determination; and
  • the new STAR Kids MCO selection can be changed at any time but will not go into effect until after one full calendar month of MDCP service provision;
• document the individual or LAR’s STAR Kids MCO choice in the HEART case record if obtained during the 14-day contact; and
• document all contact attempts and any delays in the HEART case record.

PSU staff must refer to 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

The following individuals must select or be defaulted to a STAR Kids MCO so the MCO can perform the SK-SAI:

• an individual:
  • who receives Medicaid but is not enrolled in an MCO;
  • enrolled in a STAR MCO that does not operate a STAR Kids companion plan; or 
  • who has a STAR Kids companion plan but requested first position and a new STAR Kids MCO.

PSU staff must refer to:

• 2010.2, MCO Selection or Default, within two business days after the 30^th day an enrollment packet is mailed, if an MCO has not been selected; or
• 2210, Individuals Enrolled in STAR and Individuals Receiving Other Types of Medicaid, when PSU staff get a STAR Kids MCO selection for these individuals.

PSU staff must refer to 6300, Denials and Terminations, for information on MDCP case closure when:

• notification is received about the individual’s death; or
• the individual or LAR decline MDCP services..

2100.4 MDCP ILR: Individuals Not Receiving Medicaid or Individuals Enrolled in CHIP  

Revision 26-1; Effective March 16, 2026

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO), including those enrolled in the Children’s Health Insurance Program (CHIP), must go through the process of:

• selecting or being defaulted to a STAR Kids MCO;
• being tested to determine if they meet financial eligibility for the Medically Dependent Children Program (MDCP); and
• completing the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if they meet the medical necessity (MN) for MDCP.

Program Support Unit (PSU) staff must complete the following activities within ten business days of receipt of an MDCP interest list release (ILR) case record from Interest List Management (ILM) unit staff in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• mail the following enrollment packet to the individual or legally authorized representative (LAR);
  • Form 2600-A, MDCP Waiver Release Letter - Medical Assistance Only;
  • Form H2053-B, Health Plan Selection;
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Form H3034, Disability Determination Socio-Economic Report;
  • Form H3035, Medical Information Release and Disability Determination;
  • STAR Kids Comparison Charts;
  • STAR Kids Report Cards;
  • Appendix IV, MDCP Frequently Asked Questions;
  • Appendix XX, MDCP Program Description;
  • a postage-paid envelope;
• reassign the HEART case record to the appropriate PSU staff; and
• document in the HEART case record when and where the enrollment packet is mailed.

PSU staff must complete the following activities within five business days of receipt of the MDCP ILR case record in HEART:

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify:
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.
  • Managed care enrollment in the Managed Care screen.
• Ensure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2)
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16)
    • Home and Community-based Services (HCS) Program (SG 21) 
    • Texas Home Living (TxHmL) Program (SG 22)
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Research the previous HEART case records for an individual who requested first position, to: 
  • Ensure the individual has never pursued first position. Note: First position can only be pursued one time.
  • Determine if the individual or LAR requested the following, if the individual qualifies for first position:
    • A new STAR Kids MCO or to remain with their previous STAR Kids MCO upon ILR.
    • A different service coordinator with their previous STAR Kids MCO, if applicable. 
•  Upload all applicable documents to the HEART case record.
• Document the HEART case record.

14th Day Contact

PSU staff must contact the individual or LAR within 14 days of the enrollment packet mail date to:

• verify receipt of the enrollment packet;
• confirm interest in MDCP and give a general description of MDCP services;
• explain the following as applicable:
  • the Medicaid application process and the need to return Form H1200 within 30 days from of the enrollment packet mail date;
  • the need to select a STAR Kids MCO as soon as possible or one may be defaulted to them;
• inform the individual or LAR that:
  • any delay returning the Medicaid application could result in a delay in the MDCP eligibility determination, if applicable;
  • the STAR Kids MCO selection can be changed at any time, but the change will not go into effect until after one full calendar month of MDCP service provision;
• document the individual or LAR’s STAR Kids MCO choice in the HEART case record if obtained during the 14-day contact;
• document all contact attempts and any delays in the HEART case record.

PSU staff must refer to 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must check the HHS Benefits Portal to verify Form H1200 was received if the individual or LAR states Form H1200 was submitted during the 14-day contact.

An individual or LAR must select or be defaulted to a STAR Kids MCO so the MCO can perform the SK-SAI. PSU staff must refer to:

• 2010.2, MCO Selection or Default, if a STAR Kids MCO selection was not obtained upon:
  • locating Form H1200 in the HHS Benefits Portal; or
  • receipt of a signed Form H1200 from the applicant or LAR; or
• 2210.1, Individual not Receiving Medicaid or Individuals Enrolled in CHIP, upon receipt of Form H1200, if a STAR Kids MCO is selected.

PSU staff must refer to:

• 2010.1, Incomplete Enrollment Packet, within two business days of receipt of an enrollment packet with an unsigned Form H1200.
• 6300, Denials and Terminations, for information on MDCP case closure when:
  • notification is received about the individual’s death; or
  • the individual or LAR:
    • decline MDCP services; or
    • failed to return Form H1200 within 30 days from the date an enrollment packet is mailed.

2120 Inability to Contact the Individual

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff who cannot contact an individual or the legally authorized representative (LAR) within 14 days from the date the enrollment packet was mailed must make another attempt to contact the individual or LAR. PSU staff must complete the contact attempt by the 30th day from the date the enrollment packet was mailed if the individual or LAR has not returned:

• Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
• Form H2053-B, Health Plan Selection.

PSU staff must complete the actions in the following sections, if:

• the forms noted above were not returned; and 
• the individual or LAR was not contacted within 30 days of the enrollment packet mail date:
  • 2010.2, MCO Selection or Default, for Form H2053-B; or
  • 6300.6 Unable to Locate, for Form H1200.

PSU staff should not try to contact an individual if the Texas Health and Human Services Commission (HHSC) receives notification about the individual’s death. PSU staff must refer to 6300.1, Death, for more information on processing a Medically Dependent Children Program (MDCP) case closure due to an individual’s death.

PSU staff must refer to 2310, Contacting the Interest List Management Unit to Reopen a Closed Interest List Release, for more information about processing reopen requests.

2130 Declining Medically Dependent Children Program Services

Revision 25-1; Effective May 16, 2025

Program Support Unit (PSU) staff must refer to 6300.3, Voluntarily Declined Services, for information on processing the Medically Dependent Children Program (MDCP) case closure within two business days of notification the individual or legally authorized representative (LAR) decline MDCP services. 

Revision 25-1; Effective May 16, 2025

2210 Individuals Enrolled in STAR and Individuals Receiving Other Types of Medicaid 

Revision 26-1; Effective March 16, 2026

The following individuals must select a STAR Kids MCO to begin the enrollment process:

• individuals:
  • receiving Medicaid but not enrolled in a managed care organization (MCO); 
  • enrolled in a STAR MCO that does not operate a STAR Kids companion plan; or
  • who have a STAR Kids companion plan but requested first position and a new STAR Kids MCO.

Program Support Unit (PSU) staff must complete the following activities within two business days of getting a STAR Kids MCO selection for the individuals noted above:

• confirm the individual continues to receive Medicaid in the Texas Integrated Redesign System (TIERS);
• check the Texas Health and Human Services (HHS) Benefits Portal to verify Form H1746-A, MEPD Referral Cover Sheet, was received, if applicable;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the selected STAR Kids MCO in the MCOHub indicating:
  • all zeros in Item No. 3, Social Security Number (SSN), if the applicant does not have an established SSN for Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to 1; and 
  • the following in the Comments section, if the applicant qualifies for first position: 
    • applicant or legally authorized representative (LAR) requested first position, and the applicant needs to be reassessed for MDCP; and
    • a different service coordinator must conduct the new assessment, if applicable; 
• upload all applicable documents to the Texas HHS Enterprise Administrative Record Tracking System (HEART) case record; and
• document the HEART case record.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist will notify PSU staff of the financial eligibility determination, if applicable. PSU staff must upload the MEPD specialist’s notification to the HEART case record.

PSU staff must check TIERS to verify Medicaid financial eligibility if the MEPD specialist has not notified PSU staff by the 45^th day after Form H1746-A was faxed to the MEPD specialist.

PSU staff must refer to 2010.2, MCO Selection or Default, within two business days after the 30^th day an enrollment packet is mailed, if an individual did not select a STAR Kids MCO and the individual:

• receives Medicaid but is not enrolled in an MCO; 
• is enrolled in a STAR MCO that does not operate a STAR Kids companion plan; or
• has a STAR Kids companion plan but requested first position and a new STAR Kids MCO.

2210.1 Individuals Not Receiving Medicaid or Individuals Enrolled in CHIP 

Revision 26-1; Effective  March 16, 2026

Individuals must return Form H1200, Application for Assistance – Your Texas Benefits, to start the enrollment process if the are:

• not receiving Medicaid; or 
• enrolled in the Children’s Health Insurance Program (CHIP).

Program Support Unit (PSU) staff must complete the following activities. They must do this within two business days of locating Form H1200 in the Texas Health and Human Services (HHS) Benefits Portal or receiving the signed form from the applicant or legally authorized representative (LAR):

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid eligibility;
• upload a copy of Form H1200 to the Texas HHS Enterprise Administrative Report and Tracking System (HEART) case record;
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist:
  • if Form H1200 is found in the HHS Benefits Portal; or
  • with Form H1200 and any other verification documents provided by the applicant or LAR, if received from the applicant or LAR;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the selected STAR Kids MCO in the MCOHub including the following in the Comments section, if the applicant qualifies for first position: 
  • applicant or LAR requested first position and the applicant needs to be reassessed for MDCP;
  • a different service coordinator must conduct the new assessment, if applicable;
• upload all applicable documents to the HEART case record;
• document the HEART case record

The MEPD specialist notifies PSU staff of the financial eligibility determination. PSU staff must upload the MEPD specialist’s notification in the HEART case record.

PSU staff must check TIERS to verify Medicaid financial eligibility if the MEPD specialist has not notified PSU staff by the 45^th day after Form H1746-A was faxed to the MEPD specialist.

PSU staff must refer to 2010.2, MCO Selection or Default, if a STAR Kids managed care organization (MCO) selection was not obtained for an applicant not receiving Medicaid or enrolled in the Children’s Health Insurance Plan (CHIP) upon:

• locating Form H1200 in the HHS Benefits Portal; or
• receipt of a signed Form H1200 from the applicant or LAR.

2220 MCO Coordination 

Revision 25-3; Effective Oct. 20, 2025

The managed care organization (MCO) has 60 days from receipt of  Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A to complete all initial assessment activities for an applicant to the Medically Dependent Children Program (MDCP). This includes:

• verifying the individual meets all other eligibility criteria referenced in the STAR Kids Handbook (SKH), 1000, Overview and Eligibility;
• completing Form H3676, Section B, and uploading it to the MCOHub;
• conducting and submitting the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items, to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); and
• completing and submitting Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, to the TMHP LTCOP.

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received instead of Form H3676, Section B, in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable.

PSU staff must email the Program Support Operations Review Team (PSORT) within two business days of an MCO failing to submit initial assessment information within the 60-day time frame. The email to PSORT must include:

• this email subject line: MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
• attachments of any pertinent documents received from the MCO such as Form H2067-MC.

PSU staff must:

• continue to monitor the TMHP LTCOP and the MCOHub for receipt of the above information; and
• email any case information received from the MCO to the PSORT mailbox within two business days from its receipt.

The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues unrelated to late initial assessment information. PSU staff must include the following components when emailing MCCO Unit staff:

• this email subject line: MDCP MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • SSN or Medicaid ID number;
  • DOB;
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must ensure the medical necessity (MN) determination on the SK-SAI in the TMHP LTCOP is valid by verifying the approval date does not exceed 120 days. PSU staff must complete the following activities within two business days from the MN expiration of 120 days:

• upload Form H2067-MC to the MCOHub advising the MCO:
  • the approved MN determination is past 120 days; and
  • a new initial SK-SAI is required for PSU staff to determine MDCP eligibility;
• upload Form H2067-MC to the HEART case record; and
• document the HEART case record.

The MCO must submit a new initial SK-SAI to the TMHP LTCOP before PSU staff can determine MDCP eligibility. 

2230 MDCP ILR: PSU Staff Coordination 

Revision 25-4; Effective Dec. 12, 2025

Program Support Unit (PSU) staff must determine if the applicant meets the eligibility criteria for the Medically Dependent Children Program (MDCP) within two business days of receiving the following documentation from the managed care organization (MCO):

• Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, in the MCOHub; and
• the STAR Kids Individual Service Plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received in lieu of Form H3676, Section B, in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable.

The start of care (SOC) date for MDCP services is the first day of the month after the applicant meets all the eligibility criteria.

Example: If an MCO submits all eligibility criteria on March 1 and PSU staff verify the applicant meets all eligibility criteria on March 3, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month after the applicant meets all eligibility criteria. The eligibility date on Form H2065-D, Notification of Managed Care Program Services, will be April 1.

Example: If an MCO submits all eligibility criteria on March 31 and PSU staff verify the applicant meets all eligibility criteria on April 2, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month after the applicant meets all eligibility criteria. The eligibility date on Form H2065-D is April 1. The individual met the eligibility criteria on March 31. Delay in services must not occur due to PSU staff processing times.

Applicant with Approved Financial Eligibility

PSU staff must complete the following activities on the same day they confirm all eligibility criteria for MDCP are met, if the applicant has approved financial eligibility for MDCP:

• in the TMHP LTCOP:
  • review and adjust the SK-ISP record SOC and end dates, as needed;
  • update the MDCP Enrollment Form and save the form;
  • generate Form H2065-D;
• mail Form H2065-D to the member or legally authorized representative (LAR);
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the member has been approved for MDCP;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the member is enrolled in STAR Health:
  • this email subject line: MDCP Determination for STAR Health Member XX [first letter of the member’s first and last name];
  • the following items in the body of the email:
    • member’s name;
    • Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • notice of the MDCP approval with the member’s SK-ISP dates;
  • Form H2065-D as an attachment.
• Note: The DFPS DDS Manager does not have to respond to PSU staff’s notice MCDP services were approved.
• email the Enrollment Resolution Services (ERS) unit the following information:
  • this email subject line: MDCP ILR Enrollment Request for XX [first letter of the member’s first and last name]
  • the following items in the body of the email:
    • member’s name;
    • Medicaid ID number;
    • type of request: interest list release enrollment;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO selection;
    • effective date of MDCP enrollment; and
  • Form H2065-D as an attachment;
• close the interest list release (ILR) case record in the Community Services Interest List (CSIL) database documenting the closure reason and date;
• upload all applicable documents to the HEART case record; and
• close the HEART case record.

Applicant Pending Financial Eligibility

PSU staff must complete the following activity on the same day they confirm all other eligibility criteria for MDCP are met, if the applicant requires a financial eligibility determination:

• fax Form H1746-A to the Medicaid for Elderly and People with Disabilities (MEPD) specialist noting:
  • the applicant has approved medical necessity (MN) and a SK-ISP for MDCP;
  • the proposed SOC date; and
  • the case requires a Medicaid financial eligibility decision.

The MEPD specialist will notify PSU staff of the financial eligibility determination. PSU staff must upload the MEPD specialist’s determination in the HEART case record once received.

PSU staff must complete the following activities within two business days from receipt of the MEPD specialist’s notification the applicant meets Medicaid financial eligibility, if the applicant continues to meet all other MDCP eligibility criteria:

• in the TMHP LTCOP:
  • review and adjust the SK-ISP record SOC and end dates, as needed;
  • update the MDCP Enrollment Form and save the form;
  • generate Form H2065-D;
• mail Form H2065-D to the member or LAR;
• email the ERS unit the following information:
  • this email subject line: MDCP ILR Enrollment Request for XX [first letter of the member’s first and last name]
  • the following items in the body of the email:
    • the member’s name;
    • Medicaid ID number;
    • type of request: interest list release enrollment;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO selection;
    • effective date of MDCP enrollment; and
  • Form H2065-D as an attachment;
• close the ILR case record in the CSIL database documenting the closure reason and date;
• upload all applicable documents to the HEART case record; and
• close the HEART case record.

The MCO must monitor the TMHP LTCOP for the status of the member’s SK-ISP and to retrieve Form H2065-D.

PSU staff must refer to 6300, Denials and Terminations, for information on processing MDCP applicant denials.

2240 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

Revision 25-1; Effective May 16, 2025

An individual can be placed on multiple interest lists (ILs) but may only enroll in one Medicaid waiver program at a time.

Program Support Unit (PSU) staff must refer the individual to the Interest List Management (ILM) Unit at 877-438-5658 to add an individual to the Medically Dependent Children Program (MDCP) IL for the first time.

An individual may choose to:

• pursue eligibility for another program and decline MDCP at the time of interest list release (ILR); or
• decline MDCP at the time of the ILR but choose to remain on the MDCP IL.

Individuals who decline MDCP at the time of the ILR but choose to remain on the MDCP IL will move to the bottom of the IL.

PSU staff must email the ILM unit to add an individual who was previously on the MDCP IL back to the bottom of the list on the same day PSU staff deny or terminate MDCP eligibility. The email must include:

• an email subject line that reads New IL Request for XX [first letter of the individual’s first and last name];
• the following items in the body of the email:
  • the individual’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • phone number;
  • contact person such as the individual or legally authorized representative (LAR); and
  • waiver type: MDCP.

PSU staff must refer to 6300.3, Voluntarily Declined Services, within two business days of notification the individual declines MDCP or wants to continue receiving or pursue eligibility for another program.

2310 Contacting the ILM Unit to Reopen a Closed Interest List Release

Revision 25-1; Effective May 16, 2025

Program Support Unit (PSU) staff must email the Interest List Management (ILM) unit within two business days of receipt of a request to reopen a closed interest list release record in the Community Services Interest List (CSIL) database. The email must include the following:

• an email subject line that reads: MDCP Reopen Request for XX [individual’s first and last initials];
• the following items in the body of the email:
  • individual’s name;
  • interest list identification (ID) number;
  • individual’s Medicaid ID number or Social Security number (SSN);
  • the individual or legally authorized representative’s (LAR’s) contact name and phone number; and
  • reason for the request to reopen such as the application for an alternate 1915(c) Medicaid waiver program was denied and the individual now wishes to reapply for MDCP.

The ILM unit responds to the request within five business days.

PSU staff must complete the following activities if the exception is granted:

• contact the individual to begin the application process;
• document the reopen request in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
• upload the ILM unit’s decision email to the HEART case record; and
• keep the HEART case record open until MDCP eligibility is approved or denied.

PSU staff must complete the following activities if the exception is not granted:

• upload the ILM unit’s decision email to the HEART case record; and
• close the HEART case record. 

2320 Earliest Date for Adding an Individual Back to the Interest List After Denial or Termination

Revision 18-0; Effective September 4, 2018

The earliest date an individual may be added back to the Community Services Interest List (CSIL) database, for the same program the individual is denied, is the date the individual is determined to be ineligible for the program.

Example: The individual is released from the Medically Dependent Children Program (MDCP) interest list on August 2. The individual is denied eligibility for MDCP on August 28, and a notification is sent to the individual of ineligibility. The first date the denied individual can be added back to the MDCP interest list is August 28.

Example: The individual’s MDCP services are terminated July 31 due to denial of medical necessity (MN). The first date the individual can be added back to the MDCP interest list is August 1. The earliest date an individual may be added back to the CSIL database for the same program the individual is terminated from is the first date the individual is no longer eligible for the terminated program, which in this example is August 1.

2410 Traditional Money Follows the Person

Revision 24-4; Effective Dec. 1, 2024

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). The managed care organization (MCO) performs the functional assessment and service planning for residents who need the Medically Dependent Children Program (MDCP) services upon discharge from the NF.

Individuals in a NF are assigned permanency planners. The permanency planner coordinates permanency planning through the traditional MFP process into MDCP. The state-contracted permanency planner is EveryChild Inc.

Permanency planning is:

• the placement process for a child in a NF; and
• A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship. (Title 4 Texas Government Code Section 531.151).

An individual receiving NF Medicaid must request MDCP while living in a NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

An individual without Medicaid must:

• request MDCP while living in a NF;
• live in a NF for no less than 30 days or until Medicaid eligibility is approved; and
• remain in the NF until PSU staff make a final eligibility determination for MDCP.

An individual is denied if the individual discharges from the NF before being determined eligible for MDCP.

PSU staff must refer to Section 1200, Medically Dependent Children Program Eligibility, for more information about MDCP eligibility requirements.

Individuals who meet the medically fragile criteria and are not able to live in a NF for a minimum of 30 days or until Medicaid is approved may be able to enter MDCP through the MFP Limited NF stay process.

PSU staff must refer to Section 2420, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual, for more information about the MFP limited NF stay process.

2411 Reserved for Future Use

Revision 24-4; Effective Dec. 1, 2024

2412 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents 

Revision 26-2; Effective June 1, 2026

The individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) unit. This is done within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

• notify the Texas Health and Human Services Commission (HHSC) that the individual selected MDCP through the traditional Money Follows the Person (MFP) process; and
• update the individual’s address on file, if needed.

Note: Other entities may contact the ILM unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include the:

• legally authorized representative (LAR);
• individual; or 
• nursing facility (NF).  

2412.1 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Interest List Management Responsibilities 

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a non-STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

• create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
• verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
• add the individual to the interest list if they are not on the interest list;
• immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
• assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2412.2 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

2412.2.1 Enrollment Following Interest List Release Bypass 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type;
• determine if Form H1200, Application for Assistance – Your Texas Benefits, is required in the enrollment packet;
  • refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200 to determine Medicaid financial eligibility;
• contact or attempt to contact the individual or legally authorized representative (LAR) by phone to explain the:
  • Medicaid application process, if applicable;
  • importance of selecting a STAR Kids managed care organization (MCO); and
  • the importance of promptly returning the enrollment packet, if applicable;
• mail the following enrollment packet to the individual or LAR:
  • Form H2053-B, Health Plan Selection;
  • Form H1200, if applicable;
  • STAR Kids Comparison Charts;
  • STAR Kids Report Cards;
  • Appendix IV, MDCP Frequently Asked Questions; and
  • Appendix XX, MDCP Program Description; and
  • a postage-paid envelope; and
• •upload the applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to:

• verify receipt of the enrollment packet;
• explain the Medicaid application process, if applicable;
• give a general description of MDCP services;
• explain the need to select a STAR Kids MCO within 30 days from the mail date of the above enrollment packet;
• inform the individual or LAR that a delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
• encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual:
  • has not selected a STAR Kids MCO; or
  • has not provided Form H1200, if applicable; and
• advise the individual, LAR or nursing facility (NF) to immediately submit Form H1200 if:
  • the individual requires Form H1200 to determine Medicaid financial eligibility; and
  • TIERS does not have a record of submission; and
• document all contact attempts and any delays in the HEART case record. 

PSU staff must check TIERS to verify Form H1200 has been submitted if the applicant, LAR or NF states Form H1200 has already been submitted during the 14-day follow-up contact.

PSU staff must fax Form 1746-A, MEPD Referral Cover Sheet, and Form H1200 to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist within two business days from locating Form H1200 in TIERS without Form H1746-A, if applicable. PSU staff must notate the following on Form H1746-A:

• Form H1200 is in TIERS; and
• the applicant is requesting to pursue the MFP process.

PSU staff must review the enrollment packet upon receipt to ensure all documents are completed. PSU staff must complete the following activities within two business days from the date Form H1200 is received:

• fax Form H1746-A and Form H1200 to the MEPD specialist;
• notate the applicant is requesting to pursue the MFP process on From H1746-A;
• record the date Form H1200 was received from the applicant and the date PSU staff faxed Form H1200 to the MEPD specialist in the HEART case record;
• maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in TIERS;
• check TIERS to determine if Form H1200 is received;
• maintain a copy of page one of Form H1200 in the applicant’s HEART case record;
• upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
• document the HEART case record.

PSU staff must ensure Form H1200 is signed prior to faxing Form H1200 to the MEPD specialist, if applicable. The MEPD specialist will return the unsigned Form H1200 to PSU staff requesting the applicant or LAR’s signature before processing the application. 

PSU staff must complete the following activities within two business days from notification by the MEPD specialist that Form H1200 is unsigned:

• contact the applicant or LAR;
• advise that the application cannot be processed unless Form H1200 is signed; and
• document the HEART case record.

PSU staff may complete the following activities within two business days from the date PSU staff received an unsigned Form H1200: 

• generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
• mail Form 2606 with the original unsigned Form H1200 to the applicant; and
• document the HEART case record.
• PSU staff must complete the following activities if Form 2606 was mailed:
• upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
• document the HEART case record.

PSU staff must check TIERS to verify if Form H1200 and Form H1746-A is received, as applicable. 

PSU staff must document all contact attempts and any delays in the HEART case record. 

The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.  

2412.2.2 Managed Care Organization Selection or Default

Revision 25-1; Effective May 16, 2025

Non-STAR Kids nursing facility (NF) residents pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process must select a STAR Kids managed care organization (MCO). Program Support Unit (PSU) staff may accept an individual, applicant or legally authorized representative’s (LAR’s) verbal or written STAR Kids MCO selection. The individual, applicant or LAR may provide their written STAR Kids MCO selection on Form H2053-B, Health Plan Selection.

PSU staff must refer to 2010.2, MCO Selection or Default, for more information on the MCO selection and default processes.   

2412.2.3 Receipt of Enrollment Packet 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days from:

• receiving the completed enrollment packet from a non-STAR Kids nursing facility (NF) resident pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process; or
• a STAR Kids managed care organization (MCO) selection or default:
  • complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating the individual or applicant requests the traditional Money Follows the Person (MFP) option;
  • upload Form H3676, Section A, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must contact the individual or legally authorized representative (LAR) within two business days from the receipt of an enrollment packet that is incomplete, incorrect, or missing information to:

• obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
• obtain missing or corrected information required to process the case if information is missing or incorrect;
• encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
  • has not selected a STAR Kids MCO; or
  • has not provided Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
• advise the individual or LAR to immediately submit Form H1200 if:
  • the individual requires Form H1200 to determine Medicaid financial eligibility; and
  • PSU staff do not see Form H1200 in the Texas Integrated Redesign System (TIERS).

PSU must document all contact attempts in the HEART case record.

PSU staff may complete the following activities within two business days from the 30th day of the enrollment packet mail date if the applicant has not returned Form H1200:

• generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
• mail Form 2606 with the original unsigned Form H1200 to the applicant; and
• document the HEART case record.
• PSU staff must complete the following activities if Form 2606 was mailed:
• upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
• document the HEART case record. 

2412.3 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Managed Care Organization Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

• complete Form H3676, Section B and upload it to TxMedCentral;
• complete the SK-SAI in the TMHP LTCOP;
• obtain the applicant’s physician's signature on Form 2601;
• complete the SK-ISP; and
• submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

• Form H3676, Section B;
• SK-ISP; and
• SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and Persons with Disabilities (MEPD) specialist to notify the MEPD specialist within two business days of the receipt of:

• a valid SK-ISP; and
• the SK-SAI if Medicaid is still pending. 

PSU staff must notate the following on Form H1746-A:

• The applicant has an approved MN; and
• The applicant has a valid SK-ISP.

PSU staff must check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid eligibility, if applicable.

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

• an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
• the following items in the body of the email:
  • individual or applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
• attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication).

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received from the MCO to the PSORT mailbox within two business days from its receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information. PSU staff must include the following components when emailing MCCO Unit staff:

• an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
• the following items in the body of the email:
  • applicant or member’s name;
  • SSN or Medicaid ID number;
  • DOB;
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.
• PSU staff must:
• collaborate, as needed, with all involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document delays;
• track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
• upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record. 

2412.4 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination 

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities in one business day following the receipt of all documentation required for the Medically Dependent Children Program (MDCP) eligibility, as well as the Medicaid financial eligibility determination, as applicable:

• confirm MDCP eligibility by verifying the applicant:
  • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
  • is a Texas resident in TIERS;
  • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
  • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • has a STAR Kids individual service plan (SK-ISP):
    • with a least one MDCP service; and
    • within the applicant's cost limit;
• manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
• PSU staff must refer to Form H2065-D instructions for more information on field entries;
• mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
• upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO will provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day after the NF discharge notification date:

• approve the SK-ISP in the TMHP LTCOP;
• electronically generate the final Form H2065-D following the instructions in Appendix II;
  • PSU staff must refer to Form H2065-D instructions for more information on field entries.
  • The start of care (SOC) date is the first of the month in which the discharge occurred.
• mail the final Form H2065-D to the member or LAR;
• upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
• fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
• email Enrollment Resolution Services (ERS) requesting MDCP enrollment. The email must include the following information:
  • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;”
  • the member's name;
  • Medicaid identification (ID) number;
  • the type of request (i.e., MFP NF discharge);
  • SK-ISP receipt date;
  • SK-ISP begin date;
  • SK-ISP end date;
  • effective date of enrollment;
  • MN approval date;
  • MCO selection; and
  • Form H2065-D;
• close the Community Services Interest List (CSIL)
• database record using the appropriate closure code;
• upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record.

2412.5 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials 

Revision 23-3; Effective May 22, 2023

An individual without Medicaid must:

• request the Medically Dependent Children Program (MDCP) while living in a nursing facility (NF);
• live in an NF for no less than 30 days or until Medicaid eligibility is approved; and
• remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre-Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

• met MDCP eligibility; or
• completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

• an email subject line that reads: "MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name]." For example, the email subject line for an MFP denial for Ann Smith would be "MDCP MFP Denial for AS;"
• the individual or applicant’s name;
• Medicaid identification (ID) number or Social Security number (SSN);
• contact name and phone number;
• the reason for the denial; and
• the request to return the individual or applicant to the MDCP interest using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

• deny MDCP for an MDCP MFP individual;
• close the CSIL record for an MDCP MFP individual; or
• generate and mail Form 2442, Notification of Interest List Release Closure for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2413 Traditional Money Follows the Person STAR Kids Nursing Facility Residents

Revision 22-3; Effective Sept. 9, 2022

An individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) Unit within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

• notify the Texas Health and Human Services Commission (HHSC) that the individual has selected MDCP under the traditional Money Follows the Person (MFP) process; and
• update the individual’s address on file, if needed.

Note: Other entities may contact the ILM Unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include:

• legally authorized representative (LAR);
• individual; or
• nursing facility (NF). 

2413.1 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Interest List Management Responsibilities

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

• create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
• verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
• add the individual to the interest list if they are not on the interest list;
• immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
• assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2413.2 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

2413.2.1 Enrollment Following Interest List Release Bypass

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type;
• mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Appendix IV, MDCP Frequently Asked Questions; and
  • Appendix XX, MDCP Program Description;
• complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating:
  • the individual or applicant is enrolled in STAR Kids; and
  • requests the traditional Money Follows the Person (MFP) option;
• upload Form H3676, Section A, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
• upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to: 

• verify receipt of the enrollment packet; and
• provide a general description of MDCP services.

2413.3 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Managed Care Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services Commission (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

• Form H3676, Section B and upload it to TxMedCentral;
• the SK-SAI in the TMHP LTCOP;
• the SK-ISP;
• obtain the applicant’s physician's signature on Form 2601; and
• submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

• Form H3676, Section B;
• SK-ISP; and
• SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

• an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
• the following items in the body of the email:
  • individual’s or applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
  • attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication)

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received to the PSORT mailbox within two business days of receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information.

PSU staff must include the following components when emailing MCCO Unit staff:

• an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
• the following items in the body of the email:
  • applicant or member’s name;
  • SSN or Medicaid ID number;
  • DOB;
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must: 

• collaborate, as needed, with all involved parties throughout the Medically Dependent Children Program (MDCP) eligibility determination process to assist with problem resolution and to document delays;
• track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
• upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record. 

2413.4 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities within one business day following the receipt of all documentation required for Medically Dependent Children Program (MDCP) eligibility:

• confirm MDCP eligibility by verifying the applicant:
  • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
  • is a Texas resident in TIERS;
  • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
  • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • has a STAR Kids individual service plan (SK-ISP):
    • with a least one MDCP service; and
    • within the applicant’s cost limit;
  • manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
    • PSU staff must refer to Form H2065-D instructions for more information on field entries;
  • mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • upload all applicable documents to the (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral, following the instructions in Appendix IX, within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO must provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day following the NF discharge notification date: 

• approve the SK-ISP in the TMHP LTCOP;
• electronically generate the final Form H2065-D; following the instructions in Appendix II;
  • PSU staff must refer to Form H2065-D instructions for more information on field entries.
  • The start of care (SOC) date is the first of the month in which the discharge occurred.
• mail the final Form H2065-D to the member or LAR;
• upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
• email Enrollment Resolution Services (ERS), requesting MDCP enrollment. The email must include the following information:
  • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;”
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request (i.e., MFP NF discharge);
  • SK-ISP receipt date;
  • SK-ISP begin date;
  • SK-ISP end date;
  • effective date of enrollment;
  • MN approval date;
  • MCO; and
  • Form H2065-D;
• close the Community Services Interest List (CSIL) database record using the appropriate closure code;
• upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
• document and close the HEART case record.

2413.5 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials

Revision 23-3; Effective May 22, 2023

An individual receiving nursing facility (NF) Medicaid must request the Medically Dependent Children Program (MDCP) while residing in an NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre- Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

• met MDCP eligibility; or
• completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

• an email subject line reads: “MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for an MFP denial for Ann Smith would be “MDCP MFP Denial for AS;”
• the individual or applicant's name;
• Medicaid identification (ID) number or Social Security number (SSN);
• contact name and phone number;
• the reason for the denial; and
• the request to return the individual or applicant to the MDCP interest list using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

• deny MDCP for an MDCP MFP individual;
• close the CSIL record for an MDCP MFP individual; or
• generate and mail Form 2442, Notification of Interest List Release Closure, for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2414 MDCP Money Follows the Person Delays in NF Discharge

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff and the managed care organization (MCO) must use their judgment and work with a Medically Dependent Children Program (MDCP) traditional Money Follows the Person (MFP) applicant who has community living arrangements pending but not finalized. 

PSU staff must keep the request for services open if the applicant has an estimated discharge date beyond a four-calendar month period.

PSU staff must refer traditional MFP cases pending beyond four calendar months to the PSU supervisor when an applicant: 

• has not established living arrangements to return to the community;
• cannot decide when to return to the community; or
• has no viable plan or support system in the community.

2415 Money Follows the Person Demonstration (MFPD) References in STAR Kids

Revision 22-3; Effective Sept. 9, 2022 

Money Follows the Person Demonstration (MFPD) does not apply to the Medically Dependent Children Program (MDCP). Children transition to the least restrictive setting under the traditional Money Follows the Person (MFP) program. For this reason, managed care organizations (MCOs) are not required to track an individual or applicant’s enrollment period or seek informed consent from an individual, applicant, or legally authorized representative (LAR). Program Support Unit (PSU) staff must disregard the "MFPD" check box on Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

2420 Money Follows the Person Limited NF Stay Option for a Medically Fragile Individual

Revision 18-0; Effective September 4, 2018

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

• ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
• renal dialysis;
• 24 hour/day supplemental oxygen dependence;
• total nutrition through enteral tube feeding;
• total parenteral nutrition (TPN);
• seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
• documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
• congestive heart failure requiring hospitalization and routine medication within the past six months; or
• in hospice care.

An individual determined to be medically fragile and is approved for a limited NF stay, must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress to the individual, legally authorized representative (LAR) or authorized representative (AR), in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from an NF on a Friday, Saturday, Sunday, or any day preceding a state holiday as services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy. 

2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-0; Effective September 4, 2018

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual’s name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in bypassing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to bypass the MDCP interest list:

• STAR Kids program, if not enrolled;
• an overview of MDCP services;
• the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
• the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
• Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
• required medical documentation from the individual’s clinical record at the physician’s office, hospital or clinic (not from a patient portal) must be within 12 months of the date the documentation is submitted to ILM Unit staff; and
• admission and discharge documentation from the NF will be required.

ILM Unit staff will mail Form 2406 to the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian, LAR or AR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian, LAR or AR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2422 Money Follows the Person Limited Nursing Facility Stay Procedures

Revision 18-0; Effective September 4, 2018 

2422.1 Processing Form 2406 and Medical Documents

Revision 18-0; Effective September 4, 2018

Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed by the individual’s physician, licensed to practice in the state of Texas through the Texas Medical Board, and signed by the physician within 90 days of receipt by Interest List Management (ILM) Unit staff, to be considered for the Money Follows the Person (MFP) limited nursing facility (NF) stay option. The Texas physician must attach to Form 2406 documentation (such as a visit note or hospital discharge summary) of chronic conditions. The medical documentation provided must include:

• documentation of the individual’s chronic conditions and the current health status of the individual  that will substantiate the boxes checked on Form 2406; and
• medical records from within 12 months of the date the documentation is being submitted. Medical records must be physician-originated (not from a patient portal).

Upon receipt of Form 2406 and medical documentation, ILM Unit staff will identify the physician’s recommendation.

If the individual’s physician attests the individual does meet the medically fragile criteria and is too medically fragile to reside in an NF setting for an extended period of time on Form 2406, ILM Unit staff will verify the following within two business days:

• the individual’s name and date of birth are present and legible on Form 2406;
• the individual is under age 21;
• the physician’s name, address, license number, signature and date are on Form 2406;
• physician that signed Form 2406 is licensed in the state of Texas by conducting a license search on the Texas Medical Board’s website; and
• physician signature on Form 2406 is within 90 days of receipt.

If Form 2406 contains all required information and medical documentation appears to be from an appropriate source and dated within the allowable date range, ILM Unit staff will email all documents to the Texas Health and Human Services Commission (HHSC) nurse to determine if the individual meets the medically fragile criteria. ILM Unit staff must submit each request in a separate email to the HHSC nurse. The email’s subject line must read: Medically Dependent Children Program Form 2406 for XX. The “XX” in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "Medically Dependent Children Program Form 2406 for AS."

ILM Unit staff must place the individual in a “Release” status in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will also create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload Form 2406. ILM Unit staff must not upload medical records to the HEART case record.

If the individual’s physician attests the individual does not meet the medically fragile criteria for a limited NF stay, ILM Unit staff must contact the individual within two business days, to inform him or her of the physician’s recommendation. The individual can remain on the interest list until his or her name reaches the top, or follow the traditional MFP option as described in Section 2410, Traditional Money Follows the Person.

If Form 2406 does not contain the required information, ILM Unit staff must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within two business days of receipt to discuss the elements of the form that are incomplete, and that Form 2406 and associated documents will be returned.

This includes medical documentation that is over 12 months old or not from an appropriate source (such as a patient portal). The individual, parent, guardian, LAR or AR, may submit additional records to satisfy the medical record requirement. If additional records are not submitted before the physician signature on Form 2406 expires (90 days from the physician signature date), the Medically Dependent Children Program (MDCP) MFP limited NF stay interest list request will remain in an “Open” status until the individual reaches the top of the interest list and no additional action is taken. 

2423 HHSC Nurse or Physician Review of Medical Fragility

Revision 18-0; Effective September 4, 2018

A Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and medical documentation within two business days to determine if an individual meets the limited nursing facility (NF) stay criteria.

If the individual’s physician attests the individual meets the medically fragile criteria and the physician’s documentation clearly substantiates the individual meets two or more criteria on Form 2406, the HHSC nurse may approve the limited NF stay request. Within two business days of the decision, the HHSC nurse will document his or her decision that the individual “meets criteria” in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

If the documentation does not substantiate the individual meets two or more criteria on Form 2406, the HHSC nurse will forward Form 2406 and associated medical records to the HHSC physician for a decision. ILM Unit staff are also included in the email. 

2424 Physician Determination of Medical Fragility

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the ILM Unit staff and reply all to notify ILM Unit staff of the decision. 

2425 Individual Not Meeting the Medically Fragile Criteria

Revision 18-0; Effective September 4, 2018

If the Texas Health and Human Services Commission (HHSC) physician determines the individual does not meet the medically fragile criteria, Interest List Management (ILM) Unit staff will contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) by telephone within two business days of receipt of the HHSC physician’s decision email. If the HHSC physician has a comment regarding the information submitted, this will be noted in the HHSC physician response to ILM Unit staff. ILM Unit staff must include this comment when advising the individual of the outcome of the limited nursing facility (NF) stay request. ILM Unit staff will inform the individual that a limited NF stay is not approved and the individual has the option to transition from an NF stay, as described in 2410, Traditional Money Follows the Person, to access Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) traditional option.

If the individual does not choose to complete an NF stay as described in 2410, his or her name will return to an “Open” status in the Community Services Interest List (CSIL) database and the “Residing in a Nursing Facility” bypass code removed. The individual will remain on the interest list until his or her name comes to the top of the list. If the individual, parent, guardian, LAR or AR requests to reapply for the limited NF stay process, ILM Unit staff must inform the individual, parent, guardian, LAR or AR that a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2426 Individual Approved for an MFP Limited NF Stay: ILM Unit Procedures

Revision 25-4; Effective Dec. 12, 2025

Interest List Management (ILM) unit staff complete the following activities for individuals who request to pursue the Money Follows the Person (MFP) limited nursing facility (NF) stay process:

• check if the individual is on the Medically Dependent Children Program (MDCP) interest list (IL) in the Community Services Interest List (CSIL) database;
• add the individual to the MDCP IL, if applicable;
• immediately release the individual from the MDCP IL using the bypass code Residing in a Nursing Facility; and
• create an MFP limited stay case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

ILM unit staff must assign the MFP limited stay HEART case record to the appropriate Program Support Unit (PSU) staff within two business days of an individual being approved for an MFP limited NF stay.

No more action is required for ILM unit staff.

2427 MFP Limited NF Stay: Individuals Enrolled in STAR Kids

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must complete the following activities for individuals enrolled in STAR Kids. This is done within five business days from receiving the Money Follows the Person (MFP) limited stay case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify: 
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen; and
  • STAR Kids managed care enrollment in the Managed Care screen;
• make sure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2);
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16);
    • Home and Community-based Services (HCS) Program (SG 21); or
    • Texas Home Living (TxHmL) Program (SG 22); and
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the current STAR Kids managed care organization (MCO) in the MCOHub and note the applicant:
  • lives at home; and 
  • is enrolled in STAR Kids and was approved for an MFP limited nursing facility (NF) stay;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff are not required to complete a 14-day contact for individuals enrolled in STAR Kids. PSU staff must refer to 2428, MFP Limited NF Stay: MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2427.1 MFP Limited NF Stay: Individuals Enrolled in STAR Health

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must complete the following activities for individuals enrolled in STAR Health. This is done within five business days from receiving the Money Follows the Person (MFP) limited stay case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify both: 
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.  
  • STAR Health managed care enrollment in the Managed Care screen.
• Make sure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2).
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16).
    • Home and Community-based Services (HCS) Program (SG 21). 
    • Texas Home Living (TxHmL) Program (SG 22).
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the STAR Health managed care organization (MCO) in the MCOHub. Note: PSU staff must not update Form H3676 with the primary or secondary medical consenter’s contact information unless it has been documented in the HEART case record. Form H3676 should:
  • Note the applicant lives at home.
  • State the applicant is enrolled in STAR Health and was approved for an MFP limited nursing facility (NF) stay.
  • Request the STAR Health MCO complete the following:
    • Contact the primary medical consenter, or secondary if the primary medical consenter is unavailable, to complete the Medically Dependent Children Program (MDCP) assessment. 
    • Provide the name and mailing address of the primary or secondary medical consenter when communicating the outcome of the assessment to PSU staff.
• Email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information:
  • This email subject line: Referral for MDCP Assessment for STAR Health Member XX [first letter of the applicant’s first and last name].
  • The following items in the body of the email:
    • Applicant’s name
    • Medicaid identification (ID) number
    • Date of birth (DOB)
    • Notice a referral for an MDCP assessment was submitted to the STAR Health MCO on MM/DD/YYYY, and PSU staff will send a follow up email when an MDCP eligibility determination is made.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

Note: The DFPS DDS Manager is not required to respond to PSU staff’s notification that a referral for an MCDP MFP limited NF stay assessment was submitted.

PSU staff are not required to complete a 14-day contact for individuals enrolled in STAR Health. PSU staff must refer to 2428, MFP Limited NF Stay: MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2427.2 MFP Limited NF Stay: Individuals Enrolled in STAR or Individuals Receiving Other Types of Medicaid

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must complete the following activities for individuals:

• enrolled in a STAR managed care organization (MCO); or
• receiving other types of Medicaid not related to Supplemental Security Income (SSI).

This is done within five business days from receiving the Money Follows the Person (MFP) limited stay case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• Check the Texas Integrated Eligibility Redesign System (TIERS) to verify both: 
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen.  
  • Managed care enrollment in the Managed Care screen.
• Make sure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2).
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16).
    • Home and Community-based Services (HCS) Program (SG 21). 
    • Texas Home Living (TxHmL) Program (SG 22). 
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record.
• Refer to Appendix XVI, MEPD Referral Crosswalk, to determine if Form H1746-A, MEPD Referral Cover Sheet, must be faxed to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for a financial eligibility determination.
• Fax Form H1746-A to the MEPD specialist, if applicable. Note the request is for an MFP limited nursing facility (NF) stay applicant and eligibility must be expedited and assigned immediately. Note: the MEPD specialist notifies PSU staff of the financial eligibility determination within 45 days. Can be up to 90 days if it is necessary to get a disability determination.
• Email HHSC OES MEPD IC. Cc: HHSC OES CCC IC, if Form H1746-A was faxed to the MEPD specialist. The email must include:
  • This email subject line: MDCP Request for Expedited Processing for XX [first letter of the applicant’s first and last name].
  • The following items in the body of the email:
    • Applicant’s name.
    • Social Security number (SSN) or Medicaid identification (ID) number.
    • Type of service: Medically Dependent Children Program (MDCP) MFP limited NF stay.
    • Form 1746-A was faxed to MEPD on MM/DD/YYYY requesting MEPD expedite the program transfer since this case is an MFP limited NF stay case. Note: These assignments will be special assigned by an MEPD complaint resolution specialist.
• For individuals enrolled in a STAR MCO:
  • Refer to Appendix XXXII, STAR Kids Companion Plans, to check if the individual’s STAR MCO operates a STAR Kids companion plan. Note: A companion plan is defined as an MCO that is operated by the same parent organization as the individual’s current MCO.
  • Upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the STAR Kids companion plan in the MCOHub, if applicable. Note the applicant lives at home and:
    • All zeros for the SSN, if the applicant does not have an established SSN.
    • The applicant is approved for an MFP limited NF stay.
• Mail the following enrollment packet to the individual or legally authorized representative (LAR), if the individual either:
  • Receives Medicaid but is not enrolled in an MCO. 
  • Is enrolled in a STAR MCO without a STAR Kids companion plan:
    • Form H2053-B, Health Plan Selection
    • STAR Kids Comparison Charts
    • STAR Kids Report Cards
    • Appendix IV, MDCP Frequently Asked Questions
    • Appendix XX, MDCP Program Description 
    • A postage-paid envelope.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

PSU staff do not complete a 14-day contact for individuals approved for an MFP limited NF stay who were defaulted to a STAR Kids companion plan. PSU staff must refer to 2428, MFP Limited NF Stay: MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A, if the form was uploaded to the STAR Kids companion plan.

14th Day Contact

PSU staff must contact the individual or LAR within 14 days of the enrollment packet mail date, if the individual:

• receives Medicaid but is not enrolled in an MCO; or
• is enrolled in a STAR MCO that does not operate a STAR Kids companion plan.

PSU staff must complete the following activities when contacting the individual or LAR:

• verify receipt of the enrollment packet;
• confirm interest in MDCP and give a general description of MDCP services;
• explain the need to select a STAR Kids MCO as quickly as possible or one will be defaulted to them, if applicable;
• inform the individual or LAR of the following, if applicable:
  • any delay in selecting a STAR Kids MCO could result in a delay in the MDCP eligibility determination;
  • the STAR Kids MCO selection can be changed at any time but will not go into effect until after one full calendar month of MDCP service provision;
• document the individual or LAR’s STAR Kids MCO choice in the HEART case record if obtained during the 14-day contact;
• make sure the individual or LAR understands the MFP limited NF stay process by advising the individual that the MFP limited NF stay:
  • must be coordinated with the MCO service coordinator;
  • cannot be completed until notified by the MCO service coordinator;
  • must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
  • process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge; and
• document all contact attempts and any delays in the HEART case record.

PSU staff must refer to 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

The following individuals must select or be defaulted to a STAR Kids MCO so the MCO can perform the STAR Kids Screening and Assessment Instrument (SK-SAI):

• an individual:
  • who receives Medicaid but is not enrolled in an MCO; or
  • enrolled in a STAR MCO that does not operate a STAR Kids companion plan. 

PSU staff cannot process the MFP limited NF stay without an SK-SAI with an approved MN determination. PSU staff must complete the activities in 2010.2, MCO Selection or Default, within two business days after the 30th day an enrollment packet is mailed, if an MCO has not been selected.

PSU staff must complete the activities in 6300, Denials and Terminations, when:

• notification is received about the individual’s death; or
• the individual or LAR decline MDCP services.

Receipt of STAR Kids MCO Selection

PSU staff must complete the following activities within two business days from obtaining a STAR Kids MCO selection:

• confirm the individual continues to receive Medicaid in TIERS;
• check the HHS Benefits Portal to verify Form H1746-A, was received, if applicable;
• upload Form H3676, Section A, to the selected STAR Kids MCO in the MCOHub noting the applicant lives at home and:
  • all zeros for the Social Security Number (SSN), if the applicant does not have an established SSN; and
  • the applicant is approved for an MFP limited NF stay, in the Comments section;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must refer to 2428 for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2427.3 MFP Limited NF Stay: Individuals Not Receiving Medicaid or Individuals Enrolled in CHIP

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must complete the following activities for individuals:

• not receiving Medicaid; or
• enrolled in the Children’s Health Insurance Program (CHIP).

This is done within five business days of receiving the Money Follows the Person (MFP) limited stay case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify: 
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen; and 
  • managed care enrollment in the Managed Care screen;
• make sure the individual does not have an open enrollment with another Medicaid waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for one of the following:
    • Community Living Assistance and Support Services (CLASS) Program (Service Group (SG) 2);
    • Deaf Blind with Multiple Disabilities (DBMD) Program (SG 16);
    • Home and Community-based Services (HCS) Program (SG 21); or
    • Texas Home Living (TxHmL) Program (SG 22); and
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the Youth Empowerment Services (YES) waiver record;
• mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Form H2053-B, Health Plan Selection;
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Form H3034, Disability Determination Socio-Economic Report;
  • Form H3035, Medical Information Release and Disability Determination;
  • STAR Kids Comparison Charts;
  • STAR Kids Report Cards;
  • Appendix IV, MDCP Frequently Asked Questions;
  • Appendix XX, MDCP Program Description; and
  • a postage-paid envelope;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

14th Day Contact

PSU staff must contact the individual or LAR within 14 days of the enrollment packet mail date to:

• verify receipt of the enrollment packet;
• confirm interest in Medically Dependent Children Program (MDCP) and give a general description of MDCP services;
• explain the following as applicable:
  • the Medicaid application process and the need to return Form H1200 within 30 days from the enrollment packet mail date;
  • the need to select a STAR Kids MCO as quickly as possible or one may be defaulted to them;
• inform the individual or LAR that:
  • any delay in returning the Medicaid application could result in a delay in an eligibility determination for MDCP, if applicable;
  • the STAR Kids MCO selection can be changed at any time, but the change will not go into effect until after one full calendar month of MDCP service provision;
• document the individual or LAR’s STAR Kids MCO choice in the HEART case record if obtained during the 14-day contact;
• make sure the individual or LAR understands the MFP limited nursing facility (NF) stay process by advising the individual that the MFP limited NF stay:
  • must be coordinated with the MCO service coordinator;
  • cannot be completed until notified by the MCO service coordinator;
  • must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
  • process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge; and
• document all contact attempts and any delays in the HEART case record.

PSU staff must refer to 2120, Inability to Contact the Individual, when they cannot contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must check the HHS Benefits Portal to verify Form H1200 was received. This is if the individual or LAR states Form H1200 was submitted during the 14-day contact.

An individual or LAR must select or be defaulted to a STAR Kids MCO so the MCO can perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited NF stay without an SK-SAI with an approved MN determination. PSU staff must complete the activities in 2010.2, MCO Selection or Default, if a MCO selection has not been obtained upon:

• locating Form H1200 in the HHS Benefits Portal;
• receipt of a signed Form H1200 from the applicant or LAR.

PSU staff must complete the activities in:

• 2010.1, Incomplete Enrollment Packet, upon receipt of an enrollment packet with an unsigned Form H1200.
• 6300, Denials and Terminations, when:
  • notification is received about the individual’s death; or
  • the individual or LAR:
    • decline MDCP services; or
    • failed to return Form H1200 within 30 days from the date an enrollment packet is mailed.

Receipt of Form H1200

PSU staff must complete the following activities within two business days of locating Form H1200 in the HHS Benefits Portal or receiving the signed form from the applicant or LAR:

• check TIERS to verify Medicaid eligibility;
• upload a copy of Form H1200 to the HEART case record;
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist identifying the application is for an MFP limited NF stay applicant and eligibility must be expedited and assigned immediately:
  • if Form H1200 was in the HHS Benefits Portal; or
  • with Form H1200 and any other verification documents received from the applicant or LAR, if applicable;  
• email HHSC OES MEPD IC and Cc: HHSC OES CCC IC an email that includes:
  • this subject line: MDCP Request for Expedited Processing for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • type of service: MDCP MFP limited NF stay; and
    • notice that Form H1200 and Form H1746-A were faxed to MEPD on MM/DD/YYYY and requesting MEPD expedite the applicant’s eligibility process since this case is an MFP limited NF stay case;
    • Note: These assignments are special assigned by an MEPD complaint resolution specialist;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the STAR Kids MCO in the MCOHub noting the applicant lives at home and is approved for the MFP limited NF stay option, in the Comments section;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must refer to 2428, MFP Limited NF Stay: MCO Coordination, for information on the MCO’s responsibilities after receipt of Form H3676, Section A.

2428 MFP Limited NF Stay: MCO Coordination

Revision 25-4; Effective Dec. 12, 2025

The managed care organization (MCO) service coordinator must contact an applicant or legally authorized representative (LAR) to begin the assessment process for the Money Follows the Person (MFP) limited nursing facility (NF) stay within 14 days from receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO informs the applicant or LAR of the Medically Dependent Children Program (MDCP) eligibility process and explains the MFP limited NF stay during the contact. The MCO must explain that the:

• applicant must not proceed with the limited NF stay until authorized to do so by the MCO; and
• NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO.

The MCO has 60 days after receipt of Form H3676, Section A, to complete all initial assessment activities and submit required forms to Program Support Unit (PSU) staff. The MCO must:

• complete Form H3676, Section B, and upload it to the MCOHub;
• conduct and submit the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items, to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); and
• complete and submit the electronic Form 2604, Individual Service Plan - Service Tracking Tool, to the TMHP LTCOP.

Note: The MCO must use + in the Medicaid identification (ID) number field when uploading Form 2604 to the TMHP LTCOP. This is if the applicant is medical assistance only (MAO) and does not have a Medicaid ID number. A Medicaid ID number is assigned to the individual in the Texas Integrated Eligibility Redesign System (TIERS) and TIERS will interface with the TMHP LTCOP to update the applicant’s Medicaid ID number, once the applicant has been authorized for MDCP services for 30 days.

PSU staff must email the Program Support Operations Review Team (PSORT) within two business days of an MCO failing to submit initial assessment information within the 60-day time frame. The email to PSORT must include:

• this email subject line: MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • Social Security number (SSN) or Medicaid ID number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
• attachments of any pertinent documents received from the MCO such as Form H2067-MC.

PSU staff must continue to monitor the TMHP LTCOP and the MCOHub for receipt of the above information. PSU staff must email any case information received from the MCO to the PSORT mailbox within two business days from its receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email Managed Care Contracts and Oversight (MCCO) unit staff for MCO non-compliance issues unrelated to late initial assessment information. PSU staff must include the following when emailing MCCO unit staff:

• this email subject line: MDCP MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • SSN or Medicaid ID number;
  • DOB;
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must ensure the medical necessity (MN) determination on the SK-SAI in the TMHP LTCOP is valid by verifying the approval date does not exceed 120 days. The MCO must submit a new initial SK-SAI to the TMHP LTCOP before PSU staff can determine MDCP eligibility if the SK-SAI has expired.

2428.1 MFP Limited NF Stay: PSU Staff Coordination

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must determine if the applicant meets the eligibility criteria for the Medically Dependent Children Program (MDCP) within two business days of receiving the following from the managed care organization (MCO):

• Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, in the MCOHub; and
• the STAR Kids Individual Service Plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received instead of Form H3676, Section B. This is done in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable.

PSU staff must upload Form H2067-MC to the MCOHub notifying the MCO to proceed with the Money Follows the Person (MFP) limited nursing facility (NF) stay on the same day they confirm all MDCP eligibility criteria is met except for the NF stay, if the:

• applicant is financially eligible for MDCP; or
• Medicaid for Elderly and People with Disabilities (MEPD) specialist has confirmed the individual is eligible for Medicaid except for the limited NF stay and 30 days of MDCP authorization.

The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by uploading Form H2067-MC to the MCOHub.

The MDCP start of care (SOC) date will be the first of the month that the MFP individual discharged from the NF. Example: A member leaves the NF Dec. 12, 2025, and begins MDCP services Dec. 12, 2025. The eligibility date on Form H2065-D is Dec. 1, 2025.

The following activities must occur within 24 hours after the limited NF stay discharge:

• the MCO must notify PSU staff that the limited NF stay was completed by uploading Form H2067-MC to the MCOHub.  Form H2067-MC must:
  • document the admission and discharge dates of the limited NF stay; and
  • request PSU staff approve MDCP services;
• PSU staff must:
  • confirm the applicant continues to meet the eligibility criteria for MDCP; 
  • complete the following in the TMHP LTCOP, if the applicant meets the eligibility criteria for MDCP:
    • review and adjust the SK-ISP record SOC and end dates, as needed;
    • update the MDCP Enrollment Form and save the form;
    • generate Form H2065-D, Notification of Managed Care Program Services;
  • mail Form H2065-D to the member or legally authorized representative (LAR);
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities. This is done within two business days from receiving notification from the MCO that the applicant is authorized to receive MDCP services:

• fax Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist noting the member has transferred from a NF to MDCP, if applicable;
• email the: 
  • Interest List Management (ILM) unit the following information for the Community Services Interest List (CSIL) database record closure:
    • this email subject line: MFP Limited NF Stay Closure Request for XX [first letter of the member’s first and last name];
    • the following items in the body of the email:
      • member's name;
      • Medicaid ID number; and
      • CSIL closure reason: Certified to Enter Program;
  • Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the member is enrolled in STAR Health:
    • this email subject line: MDCP Determination for STAR Health Member XX [first letter of the member’s first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid identification (ID) number;
      • date of birth (DOB);
      • name of the MCO and plan code;
      • notice of the MDCP approval with the member’s SK-ISP dates; and
    • Form H2065-D as an attachment; 
    • Note: The DFPS DDS Manager does not have to respond to PSU staff’s notice that MCDP services were approved;
  • Enrollment Resolution Services (ERS) unit the following information:
    • this email subject line: MDCP MFP Limit NF Stay Enrollment Request for XX [first letter of the member’s first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid ID number;
      • type of request: MFP limited NF stay;
      • date of MFP limited NF stay;
      • MN approval date;
      • ISP receipt date;
      • ISP begin date;
      • ISP end date;
      • MCO selection; 
      • effective date of MDCP enrollment; and
    • Form H2065-D as an attachment; 
• upload all applicable documents in HEART case record; and
• close the HEART case record.

Note: ERS updates the member’s Texas Integrated Eligibility Redesign System (TIERS) record to show managed care enrollment after the member was determined eligible for MDCP, if applicable.

MCOs must monitor the TMHP LTCOP and the MCOHub for: 

• the status of their member’s ISP; and 
• to retrieve Form H2065-D.

PSU staff must complete activities in 6300, Denials and Terminations, upon notification an applicant:

• fails to meet any of the eligibility criteria for MDCP; or
• Medicaid is denied by the MEPD specialist for financial eligibility.

2429 Delays in Limited NF

Revision 25-3; Effective Oct. 20, 2025

The managed care organization (MCO) must notify Program Support Unit (PSU) staff of any delays with completion of the Money Follows the Person (MFP) limited nursing facility (NF) stay by the applicant. They do this by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

Applicants Pending Medicaid

PSU staff must request the Medicaid for the Elderly and People with Disabilities (MEPD) specialist delay Medicaid certification, if the applicant:

• cannot complete the limited NF stay within 40 days after the MEPD specialist communicated that the applicant is eligible for Medicaid except for:
  • completing the limited NF stay; and
  • 30 days of Medically Dependent Children Program (MDCP) authorization.

PSU staff must complete the following activities within two business days after the 40th day, if the limited NF stay was not completed:

• fax Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist requesting a delay to Medicaid certification;
• include the statement “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending” in the comments section;
• upload Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

The MEPD specialist may extend the financial eligibility time frame to the following, if the request for delay in certification is approved:

• 135 days from the original file date; or
• 180 days from the original file date if a disability determination is required

The MEPD specialist will deny the application if there is a continued delay in completion of the limited NF stay beyond:

• 135 days from the file date; or
• 180 days from the file date for an applicant requiring a disability determination.

PSU staff must refer to 6300.4, Financial Eligibility, to process the MDCP eligibility denial on the same day they confirm the Medicaid denial.

MCOs must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the MCOHub for:

• the status of the applicant or member’s individual service plan (ISP); and
• to retrieve Form H2065-D, Notification of Managed Care Program Services.

The MFP limited NF stay application process must start over if the individual, parent, guardian or legally authorized representative (LAR) continues to pursue the MFP limited NF stay option after MDCP eligibility was denied. The individual, parent, guardian or LAR must contact the Interest List Management (ILM) unit, described in 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, to restart the process.

The MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI) if the applicant’s medical necessity (MN) expired due to the delay in the limited NF stay.

PSU staff must request the MEPD specialist reopen the Medicaid application within two business days from receipt of the new SK-SAI, if the new SK-SAI is received within 90 days of the MEPD specialist’s denial. PSU staff must complete the following for the Medicaid application reopen request:

• fax Form H1746-A to the MEPD specialist:
  • selecting Application as the Action Type;
  • noting:
    • the previously submitted Medicaid application needs to be reopened and re-evaluated for an MDCP MFP limited NF stay applicant; and
    • eligibility must be expedited and assigned immediately;
• email OESMEPDIC@hhsc.state.tx.us and cc: OESCCCIC@hhsc.state.tx.us an email that includes:
  • this subject line: MDCP Request for Expedited Processing for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • type of service: MDCP MFP limited NF stay;
    • notating that Form H1746-A was faxed to MEPD on MM/DD/YYYY and requesting the last MEPD application be reopened, re-evaluated, and the eligibility process expedited since this case is an MFP limited NF stay case.

Note: These assignments are special assigned by an MEPD complaint resolution specialist.

The MEPD specialist’s time frame for certification starts over once the Medicaid application is reopened. PSU staff must request the MEPD specialist delay certification, as noted above, if the NF stay cannot be completed within 40 days after the date the request to reopen the Medicaid application was submitted to the MEPD specialist. However, the MEPD specialist may not approve more requests for delay in certification based on the amount of time that passed since the original application file date.

PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures. They do this by posting Form H2067-MC to the MCOHub, if the MEPD specialist approves the request for delay in certification. PSU staff must inform the individual, parent, guardian or LAR that a new Form H1200, Application for Assistance – Your Texas Benefits, must be completed if the MEPD specialist denies the request to delay certification due to the age of the application.

Limited NF Stay More than One Year

PSU staff must request the ILM unit decide if an MFP limited NF stay case can be transitioned to an interest list release (ILR) if the limited NF stay was not completed within one year of receiving the HEART assignment.

The ILM unit reviews the MFP limited NF stay case to check if the case can be processed as an ILR if the MDCP request date in the Community Services Interest List (CSIL) is on or before the current MDCP release through date.

PSU staff must email their supervisor within two business days from the 365^th day of the HEART assignment, to notify an MFP limited NF stay case was pending for a year. The email must include:

• this email subject line: MFP Limited NF Stay Pending Over One Year for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • the applicant’s name;
  • Medicaid ID number;
  • the date the MFP limited NF stay case was assigned in HEART; and
  • request for the case to be processed as an ILR.

The PSU supervisor forwards the email request to the ILM unit manager to decide if the MFP limited NF stay applicant can be processed as an ILR, within two business days from the PSU staff request to transition the case. The ILM unit manager responds to the PSU supervisor within two business days with an approval or denial of the request.

PSU staff must complete the following activities within two business days of receiving approval to transition the MFP limited NF stay case to an ILR: 

• upload Form H2067-MC to the MCO noting the following:
  • case is pending since MM/DD/YYYY [date of the HEART case record assignment];
  • case can be processed as an ILR instead of an MFP limited NF stay case; and
  • applicant is not required to complete the NF stay.
• refer to 2100, Activities Following an MDCP Interest List Release, to process the case as an ILR;
• upload the applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must continue to process the case following MFP limited NF stay policy within two business days of receiving notice the request to transition the MFP limited NF stay case to an ILR was denied.

Revision 18-0; Effective September 4, 2018

All children and young adults enrolled with a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and Community First Choice (CFC), Personal Care Services (PCS) and/or Medically Dependent Children Program (MDCP) services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member, legally authorized representative (LAR) or authorized representative (AR) should notify the MCO of the intended provider of services and the MCO will reach out to the provider.

Revision 25-4; Effective Dec. 12, 2025

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed timely. The MCO must initiate a reassessment to determine and validate continued need for services for each member before the end date of the annual SK-SAI.

The MCO uses the SK-SAI to create and submit a Medically Dependent Children Program (MDCP) member’s STAR Kids individual service plan (SK-ISP) to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The SK-ISP lists the member’s services and preferences for care and is valid for one year. The MCO does not submit an SK-ISP in the TMHP LTCOP for a service change or a change in condition. The MCO maintains amended SK-ISPs resulting from a service change or a change in condition SK-SAI in the member file.

The MCO must:

• Complete all member reassessment activities within 30 days before the SK-ISP expiration date.
• Not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the previous SK-SAI.
• Submit the SK-SAI in the TMHP LTCOP no earlier than 90 days before or no later than 30 days before the expiration of the member’s current SK-ISP on file.
• Upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub documenting any reason for a delay.

Program Support Unit (PSU) staff must:

• Ensure the member’s SK-ISP is authorized annually.
• Verify the member continues to meet the eligibility criteria for MDCP stated in 1200, MDCP Eligibility.
• Issue Form H2065-D, Notification of Managed Care Program Services, as notification MDCP services were approved or terminated at reassessment.

Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility.

The assigned PSU staff must notify the Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the Individual Service Plan (ISP) Expiring Report to the PSORT mailbox monthly. The ISP Expiring Report details members with SK-ISPs that expire within the next 90 days. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs reported as an MCO non-compliance. The subject line for the email must read: MDCP Reassessment Delinquencies for [Month].

PSU staff do not have to send a follow-up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

• Form H2067-MC;
• the SK-SAI; or
• the SK-ISP.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and document the HEART case record.

PSU staff must refer to 3327, Individual Service Plan Expiring Report, for more information about the ISP Expiring Report.

3210 Reassessment of Medical Necessity Determination

Revision 25-4; Effective Dec. 12, 2025

A Medically Dependent Children Program (MDCP) member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before Program Support Unit (PSU) staff recertifies the member for MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

PSU staff must refer to 1200, MDCP Eligibility, for more information on the eligibility criteria for MDCP including an MN determination.

The MCO completes and submits a reassessment SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) annually. The TMHP LTCOP automatically processes the SK-SAI and redetermines the member’s Patient-Driven Payment Model (PDPM) Long-Term Care (LTC) level and MN. The TMHP LTCOP sends the SK-SAI to the Office of the Medical Director (OMD) staff for manual review if the SK-SAI fails automatic MN approval.

PSU staff must monitor the TMHP LTCOP every five business days from the MN denial date in the TMHP LTCOP, until the MN status updates to one of the final statuses below:

• MN Approved: The status may change to MN Approved if the OMD physician overturns the denial because more information is received; or
• Overturn Doctor Review Expired: The status may change to Overturn Doctor Review Expired when the 14-business day period for the OMD physician to overturn the denied MN has expired, and no more or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the member or legally authorized representative (LAR) requests a state fair hearing.

The MCO must notify PSU staff of a member’s MN denial and request Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must complete actions in the following sections when notified a member is denied MN or requests an appeal of an MN denial:

• 6300, Denials and Terminations.
• 7200, State Fair Hearing Procedures for Medically Dependent Children Program.

Revision 25-1; Effective May 16, 2025

The managed care organization (MCO) must collaborate with the member and legally authorized representative (LAR) to create and update Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool (SK-ISP). The MCO develops the SK-ISP using a person-centered process with the support of a group of people chosen by the member or LAR.

The SK-ISP articulates assessment findings from the STAR Kids Screening and Assessment Instrument (SK-SAI). It includes short and long-term goals, service needs and member preferences.

The MCO uses the SK-ISP to:

• document findings from the SK-SAI;
• develop a plan for services received through the MCO;
• document services received through third-party sources;
• identify a member's strengths, preferences, support needs and desired outcomes;
• identify what is important to the member;
• identify natural supports available to the member and needed service system supports;
• document the member's preferences for when and how to receive services;
• identify special needs, requests, or considerations the MCO or providers should know when supporting the member; and
• document the member's unmet needs.

The MCO must:

• write the SK-ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language;
• submit the electronic SK-ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable;
• create and update the SK-ISP at least annually, as applicable;
• ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility;
• provide a printed or electronic copy of the SK-ISP to the member or LAR following any significant update;
• provide the Texas Health and Human Services Commission (HHSC) staff with the SK-ISP upon request;
• keep any amended SK-ISP in an MCO member's case file;
• not provide significant change SK-ISPs to Program Support Unit (PSU) staff;
• not submit any significant change SK-ISPs to the TMHP LTCOP; and
• authorize all services identified on the SK-ISP.

The SK-ISP must be within the member's cost limit. PSU staff do not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP SK-ISP Annual Cost Limit field.

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.

3310 Service Planning

Revision 23-3; Effective May 22, 2023

Form 2603, STAR Kids Individual Service Plan (SK-ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and to develop the SK-ISP. The managed care organization (MCO) is responsible for completing Form 2603. The MCO maintains Form 2603 in the MCO's case file.

At a minimum, Form 2603 must account for the following information:

• a summary document describing the recommended service needs identified through the SK-SAI;
• covered services currently received;
• covered services not currently received but the member may benefit from;
• a description of non-covered services that could benefit the member;
• member and family goals and service preferences;
• natural strengths and supports of the member, including helpful family members, community supports or special capabilities;
• a description of roles and responsibilities for the member, legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the MCO and the member's school with respect to maintaining and maximizing the health and well-being of the member;
• a plan for coordinating and integrating care between providers and covered and non-covered services;
• short and long-term goals for the member's health and well-being;
• services provided to the member through other third-party resources (TPR) and the sources or providers of those services;
• plans specifically related to transitioning to adulthood for members 15 and older;
• a list of Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable;
• a brief rationale for the services; and
• any other information to describe strategies to meet service objectives and member goals.

The MCO must include the items listed above in the SK-ISP.

3320 Service Planning for Medically Dependent Children Program Services

Revision 24-4; Effective Dec. 1, 2024

The STAR Kids individual service plan (SK-ISP) contains a list of all the member's services including Medically Dependent Children Program (MDCP) services. The managed care organization (MCO) lists MDCP services on Form 2603, STAR Kids Individual Service Plan Narrative. The list of MDCP services on Form 2603 must match the services listed on the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool.

The MCO must submit Form 2604 to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) before the start date of the member's SK-ISP.

The MCO must collaborate with the member or legally authorized representative (LAR) to create the SK-ISP to ensure MDCP services do not exceed the member's cost limit. Only MDCP services count toward the cost limit. Program Support Unit (PSU) staff will not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field.

The MCO must initiate a reassessment for MDCP to determine and validate the need for continued services listed on the SK-ISP for each member before the end date of the annual STAR Kids Screening and Assessment Instrument (SK-SAI). The MCO must ensure all member reassessment activities, including submitting the SK-ISP to the TMHP LTCOP, are completed no earlier than 90 days and by 30 days before the expiration of the member's current SK-ISP on file. Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility.

Program Support Unit (PSU) staff must refer to Section 3327, Individual Service Plan Expiring Report, for information on reporting delinquent MCO reassessments.

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 24-4; Effective Dec. 1, 2024

It may be necessary for the managed care organization (MCO) to revise the STAR Kids individual service plan (SK-ISP) within the SK-ISP period due to situations outlined in the STAR Kids Contract, Section 8.1.39.1 (PDF).

The MCO must retain the amended SK-ISP in the MCO's member case file.

The MCO must not submit the revised SK-ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to the MCOHub.

3322 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

3323 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

3324 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

3325 Reserved For Future Use

Revision 23-4; Effective Aug. 21, 2023

3326 Suspension of Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018

To remain eligible for Medically Dependent Children Program (MDCP) services, a member must receive one MDCP service monthly. In the event that the member travels out of state, is admitted to a hospital or nursing facility (NF), or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. The MCO must document the:

• dates during which services are suspended; and
• reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

3327 Individual Service Plan Expiring Report

Revision 25-3; Effective Oct. 20, 2025

The assigned Program Support Unit (PSU) staff review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) monthly to ensure reassessments are done on time. The ISP Expiring Report details members with STAR Kids individual service plan (SK-ISPs) that expire in the next 90 days.

The MCOs must provide a status update for all members with SK-ISPs expiring in the next 45 days. Only SK-ISPs expiring in 45 days require a status update from the MCO.

The process to manage the ISP Expiring Report follows:

• The MCO must:
  • research and provide a written status for each member whose SK-ISP expires in 45 days; and
  • return a completed report to PSU staff within two business days of the monthly call.
• PSU staff review the MCO responses to determine if the MCO needs to provide clarification about any member’s SK-ISP status. Only SK-ISP statuses that PSU staff have questions on are reviewed during the monthly call. There is no need to review each member for the status of the SK-ISP if the MCO response is sufficient.

Note: The monthly call may also be held if PSU staff or the MCO need to discuss items unrelated to the ISP Expiring Report.

The assigned PSU staff must check the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to determine if the MCO has submitted the member’s SK-ISP before the SK-ISP end date. The assigned PSU staff must email PSORT the ISP Expiring Report each month as notification of late MCO reassessment activity. The ISP Expiring Report must be in an Excel spreadsheet format and edited so that it only identifies SK-ISPs being reported as delinquent. The subject line for the email must read: MDCP Reassessment Delinquencies for [Month].

The assigned PSU staff is not required to send a follow up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

• Form H2067-MC, Managed Care Programs Communication;
• the STAR Kids Screening and Assessment Instrument (SK-SAI); or
• the SK-ISP. 

3327.1 Reassessment Procedures

Revision 24-4; Effective Dec. 1, 2024

The managed care organization (MCO) must complete annual assessment activities within 45 days of the individual service plan (ISP) expiration date. Assessment activities include:

• conducting an annual STAR Kids Screening and Assessment Instrument (SK-SAI) assessment;
• developing the STAR Kids individual service plan (SK-ISP); and
• submitting the SK-SAI and SK-ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

Designated Program Support Unit (PSU) staff must:

• search the TMHP LTCOP for SK-ISPs submitted daily; and
• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and assign it to a designated PSU staff person.

PSU staff must complete the following activities within five business days of receipt of the reassessment HEART case record:

• ensure the member’s SK-ISP is authorized annually;
• check the Texas Integrated Eligibility Redesign System (TIERS) to verify the member:
  • is under 21;
  • has ongoing Medicaid financial eligibility and is actively enrolled in managed care;
• check the TMHP LTCOP to verify the member has:
  • an approved medical necessity (MN) and SK-SAI;
  • a SK-ISP that is within the cost limit that contains at least one Medically Dependent Children Program (MDCP) service;
• electronically generate Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTCOP if the member continues to meet all MDCP requirements;
• mail Form H2065-D to the member or legally authorized representative (LAR);
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must refer to:

• Section 6300, Denials and Terminations, if the member does not meet MDCP requirements at reassessment.
• Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, if the member or LAR files a state fair hearing within the adverse action notification period.

3410 Transfer from One MCO to Another

Revision 24-3; Effective Aug. 26, 2024

A member or legally authorized representative (LAR) can request to change managed care organizations (MCOs) at any time. However, a member can only be enrolled with one MCO for a given month. 

A member or LAR who wants to change from one MCO to another MCO must contact the state-contracted enrollment broker by:

• phone: 800-964-2777;
• fax: 855-671-6038; or
• mail: 
  HHSC 
  P.O. Box 149023 
  Austin TX 78714-9023

Note: Adoption Assistance or Permanency Care Assistance (AAPCA) members must contact the state’s enrollment broker to request transfer.

MCO enrollment changes become effective based on the date the MCO change is requested and processed in relation to state cutoff. The MCO selected before the state cutoff date will be the MCO of record on the first day of the next month. Any MCO change made after the state cutoff date is reflected in the following month.

Examples:

State cutoff date – Nov. 14

• A member requests an MCO change on Nov. 1, 2024. The enrollment effective date for the receiving MCO is Dec. 1, 2024.
• A member requests an MCO change on Nov. 18, 2024. The enrollment effective date for the receiving MCO is Jan. 1, 2025.

Program Support Unit (PSU) staff must refer to Appendix XIV, State Cutoff Charts, for more information on current cutoff dates.

Monthly Plan Changes Report

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes report to PSU staff. The report gives a full list of all Medically Dependent Children Program (MDCP) members who have changed MCOs from the previous month. PSU staff are not required to provide the Plan Change Report to the MCOs. MCOs receive the plan change report for their members only through an automated process in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP).

The losing MCO and the gaining MCO must coordinate and share applicable member information to prevent a gap in services during the transfer. The gaining MCO must notify the Managed Care Contracts and Oversight (MCCO) Unit staff if they encounter issues getting the transfer packet from the losing MCO. MCCO Unit staff may contact PSU staff for help transferring member information to the gaining MCO.

The gaining MCO will have access to current and historical STAR Kids Screening and Assessment Instruments (SK-SAIs) and STAR Kids - Individual Service Plans (SK-ISPs) in the TMHP LTCOP once the member is enrolled with them.

The gaining MCO is responsible for service delivery from the first day of enrollment. The gaining MCO must provide services and honor authorizations included in the prior SK-ISP until the member receives a new SK-SAI. 

3420 Transfer from Another Medicaid Waiver Program to MDCP

Revision Notice 25-2; Effective July 11, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1155(a)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one Medicaid waiver program at the same time. Program Support Unit (PSU) staff must refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received at the same time by a member.

Individuals in the following Intellectual and Developmental Disabilities (IDD) waiver programs may be on the interest list for MDCP:

• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS);
• Texas Home Living (TxHmL); or
• Youth Empowerment Services (YES) waiver program.

Individuals enrolled in the IDD waiver programs noted above are enrolled with a STAR Kids or STAR Health managed care organization (MCO).

PSU staff receive an MDCP interest list release (ILR) case record from the Interest List Management (ILM) unit in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART). The case record is assigned when an individual in another IDD waiver program comes to the top of the MDCP interest list (IL) and requests MDCP.

PSU staff must complete the following activities within ten business days of receiving the MDCP ILR case record in HEART:

• assign the HEART case record to the appropriate PSU staff; and
• document in the HEART case record the individual is enrolled in STAR Kids or STAR Health and does not require an enrollment packet.

PSU staff must complete the following activities within five business days of receiving the MDCP ILR case record in HEART:

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify:
  • Medicaid financial eligibility in the Medicaid/CHIP/CHIP perinatal History screen;
  • STAR Kids or STAR Health managed care enrollment in the Managed Care screen;
• confirm the individual’s enrollment with another IDD waiver program by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for:
    • CLASS (Service Group (SG) 2);
    • DBMD (SG 16);
    • HCS (SG 21);
    • TxHmL (SG 22); or
  • TIERS Long Term Services and Supports (LTSS) Eligibility Periods Details screen for the YES waiver;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, to the existing STAR Kids or STAR Health MCO in the MCOHub;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff do not have to complete a 14-day contact for individuals enrolled in STAR Kids or STAR Health.

MCO Coordination

The MCO must submit the following required documents within 60 days from the date PSU staff uploaded Form H3676, Section A, to the MCOHub:

• the STAR Kids Screening and Assessment Instrument (SK-SAI) and STAR Kids Individual Service Plan (SK-ISP) to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); and
• Form H3676, Section B, to the MCOHub.

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received in lieu of Form H3676, Section B, in the HEART case record, if applicable.

PSU staff must email the Program Support Operations Review Team (PSORT) within two business days of an MCO failing to submit initial assessment information within the 60-day time frame. The email to PSORT must include:

• an email subject line that reads: MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
• attachments of any pertinent documents received from the MCO such as Form H2067-MC.

PSU staff must continue to monitor the TMHP LTCOP and the MCOHub for receipt of the above information. PSU staff must email any case information received from the MCO to the PSORT mailbox within two business days from its receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Managed Care Contracts and Oversight (MCCO) unit for MCO non-compliance issues unrelated to late initial assessment information. The email to MCCO must include:

• an email subject line that reads: MDCP MCO Non-Compliance for XX [first letter of the applicant’s first and last name];
• the following items in the body of the email:
  • applicant’s name;
  • SSN or Medicaid ID number;
  • DOB;
  • name of the MCO and plan code;
  • date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must ensure the medical necessity (MN) determination on the SK-SAI in the TMHP LTCOP is valid by verifying the approval date does not exceed 120 days. PSU staff must complete the following activities within two business days from the MN expiration of 120 days:

• upload Form H2067-MC to the MCOHub advising the MCO:
  • the approved MN determination is past 120 days; and
  • a new initial SK-SAI is required for PSU staff to determine MDCP eligibility;
• upload Form H2067-MC to the HEART case record; and
• document the HEART case record.

The MCO must submit a new initial SK-SAI to the TMHP LTCOP before PSU staff can determine MDCP eligibility if the most recent assessment exceeds 120 days.

PSU Staff Coordination

PSU staff must contact and coordinate with IDD waiver program staff, the applicant, legally authorized representative (LAR) and MCO, as appropriate, to ensure the applicant’s current IDD waiver program services end one day before enrollment in MDCP.

PSU staff must determine if the applicant meets the eligibility criteria for MDCP within two business days of receiving all required documentation from the MCO.

PSU staff must complete the following activities on the same day they confirm all eligibility criteria for MDCP are met:

• in the TMHP LTCOP:
  • review and adjust the SK-ISP record start of care (SOC) and end dates, as needed;
  • update the MDCP Enrollment Form and save the form;
  • generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the member or LAR;
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the:
  • MDCP program SOC date; and
  • termination date for the other IDD waiver program;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the member is enrolled in STAR Health:
  • an email subject line that reads: MDCP Determination for STAR Health Member XX [first letter of the member’s first and last name];
  • the following items in the body of the email:
    • member’s name;
    • Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • notice of the MDCP approval with the member’s SK-ISP dates;
  • Form H2065-D as an attachment.

Note: The DFPS DDS Manager does not have to respond to PSU staff’s notice MCDP services were approved. 

• email the Enrollment Resolution Services (ERS) unit the following information:
  • an email subject line that reads: Waiver Transfer for XX [first letter of the member’s first and last name];
  • the following items in the body of the email:
    • member’s name;
    • Medicaid ID number;
    • type of request: waiver transfer;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO selection;
    • effective date of MDCP enrollment; and
  • Form H2065-D as an attachment;
• close the MDCP ILR case record in the Community Services Interest List (CSIL) database documenting the closure reason and date, if applicable;
• upload all applicable documents to the HEART case record;
• document all contacts with the IDD waiver program staff, member, LAR or MCO and any delays; and
• close the HEART record.

PSU staff must refer to 6300, Denials and Terminations, for more information on processing MDCP applicant denials.

3430 Transfer from MDCP to Another Medicaid Waiver Program

Revision 25-3; Effective Oct. 20, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(F) states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one Medicaid waiver program at the same time. Program Support Unit (PSU) staff must refer to Appendix XIX, Mutually Exclusive Services, to determine if a member may receive two services simultaneously.

MDCP members may be on an interest list for an Intellectual and Developmental Disabilities (IDD) waiver program, such as:

• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS);
• Texas Home Living (TxHmL); or
• Youth Empowerment Services (YES) waiver program.

PSU staff may receive notification from IDD waiver program staff or the MDCP member’s managed care organization (MCO) that the MDCP member:

• has come to the top of an IDD waiver program interest list;
• chooses to transfer to the IDD wavier program; or
• is already enrolled with an IDD waiver program.

PSU staff must complete the following activities within two business days from notification:

• create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART), if applicable;
• contact and coordinate with IDD waiver program staff by email to determine the:
  • MDCP termination date; and
  • start of care (SOC) date for the IDD waiver program with the MDCP termination date being the last day of the month before the IDD waiver SOC date;
• terminate the STAR Kids Individual Service Plan (SK-ISP) record and the MCDP Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) the last day of the month before the IDD waiver SOC date;
• manually generate Form H2065-D, Notification of Managed Care Program Services;
• upload Form H2065-D to the MCOHub;
• mail Form H2065-D to the member or legally authorized representative (LAR);
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the MDCP termination date and the enrollment effective date for the new Medicaid waiver program;
• upload all applicable documents to the HEART case record;
• document all contacts with the IDD waiver program staff, member, LAR or MCO and any delays; and
• close the HEART case record.

Adverse Action is not required when an MDCP member transfers to an IDD waiver program.

3440 Transfer from Community Care Services Eligibility to STAR Kids

Revision 24-4; Effective Dec. 1, 2024

PSU staff must coordinate the termination of Community Care Services Eligibility (CCSE) with the CCSE case worker for individuals entering STAR Kids through the Medically Dependent Children Program (MDCP). This ensures the individual does not experience a break in services and does not receive concurrent services through CCSE services.

CCSE services are terminated by the CCSE case worker in the Service Authorization System Online (SASO) by the day before MDCP enrollment. This is crucial since no MDCP member may receive CCSE and MDCP services on the same day.

PSU staff are not required to provide Form H2065-D, Notification of Managed Care Program Services, as notification of MDCP certification to the CCSE case manager when requesting CCSE termination in SASO.

Revision 24-4; Effective Dec. 1, 2024

All STAR Kids members begin transition activities at 15 and periodically meet with a transition specialist to plan their transition to an adult program.

A person receiving Medically Dependent Children Program (MDCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC):

• is no longer eligible for these services at 21 years old;
• must transition to an adult program; and
• may choose to transition to the STAR+PLUS Home and Community Based Services (HCBS) program.

The Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the MDCP-PDN Transition Report each month to:

• Program Support Unit (PSU) supervisors and managers; and
• UR unit for the Intellectual and Developmental Disability (IDD) 1915(c) waivers.

The report lists members enrolled in STAR Kids:

• receiving MDCP, PDN or PPECC services; and
• who may transition to STAR+PLUS or the STAR+PLUS HCBS program in the next 12 months.

3510 Twelve Months Before the Member's 21st Birthday

Revision 25-1; Effective May 16, 2024

The STAR Kids managed care organization (MCO) identifies all members turning 21 within the 12 months before the member’s 21st birthday. The STAR Kids MCO schedules a face-to-face visit with the member and the member’s available supports to initiate the transition process to:

• provide an overview of the STAR+PLUS program, including the STAR+PLUS Home and Community Based Services (HCBS) program; and
• discuss the changes that will occur in the first month following the member's 21^st birthday.

The STAR Kids MCO follows up with the member or legally authorized representative (LAR) every 90 days during the year before the member turns 21 to ensure all transition activities specified in Appendix VI, STAR Kids Transition Activities, are completed.

The enrollment broker (EB) contacts members who meet the STAR+PLUS enrollment criteria 30 days before their 21st birthday and mails the STAR+PLUS enrollment packet. The EB selects an MCO for the member if no selection was made within 15 days, as outlined in Title 1 Texas Administrative Code (TAC) Section 353.403(3).  

Members who receive MDCP, private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) may apply for the STAR+PLUS HCBS program to continue receiving medically necessary nursing services that are unavailable at 21. These services may not be the same level of nursing services they receive through STAR Kids.

Members receiving MDCP, PDN or PPEC are referred to the STAR+PLUS HCBS program through the MDCP-PDN Transition Report. Program Support Unit (PSU) staff for the STAR+PLUS HCBS program begin the enrollment process for these members by 12 months before their 21st birthday. PSU staff must refer to 3420, Individuals Transitioning Services for Adults, of the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) for detailed information on the STAR+PLUS HCBS enrollment process.

Members who meet the STAR+PLUS HCBS program enrollment criteria transition to the STAR+PLUS HCBS program on the first of the month following their 21st birthday. MDCP eligibility terminates on the last day of the member's 21st birth month.

PSU staff must refer to 6300.9, No Longer Meets the Age Requirement for MDCP, for PSU staff denial procedures for MDCP members transitioning out of MDCP due to turning 21.

3520 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only

Revision 25-1; Effective May 16, 2025

STAR Kids and STAR Health eligibility terminates the last day of the month that the non-waiver program individual or applicant turns 21. The non-waiver program individual or applicant with STAR Kids or STAR Health must receive services through programs serving adults beginning the first day of the month following the non-waiver program individual or applicant’s 21st birthday.

Individuals or applicants with STAR Kids and STAR Health must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program. Some individuals or applicants with STAR Kids and STAR Health may continue to receive PCS or CFC through STAR Health until 22 depending on eligibility requirements.

The Texas Health and Human Services Commission’s (HHSC’s) state contracted enrollment broker will reach out to the individual or applicant 30 days before the individual or applicant turns 21 and provide the individual or applicant with a STAR+PLUS enrollment packet. The individual or applicant is allowed 15 days to make a managed care organization (MCO) selection. HHSC’s contracted enrollment broker selects an MCO for the individual or applicant if the individual or applicant has not made an MCO selection after 15 days, as outlined in Title 1 Texas Administrative Code (TAC) Section 353.403(3).

4100.1 Community First Choice

Revision 22-3; Effective Sept. 9, 2022 

Community First Choice (CFC) is available to all STAR Kids members who meet an institutional level of care (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. CFC services include personal care services (CFC-PCS), Emergency Response Services (CFC-ERS), support management, and habilitation (CFC-HAB). 

The managed care organization (MCO) must ensure the member receives at least one waiver service per month to maintain CFC eligibility. 

CFC-PCS provides help with activities of daily living (ADLs), instrumental activities of daily living (IADLs) through hands-on assistance, supervision, cueing or both, to include nurse-delegated tasks. Members may not be authorized for State Plan PCS and CFC-PCS at the same time. 

CFC-HAB provides assistance with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish ADLS, IADLs and health-related tasks. 

CFC-ERS provides assistance for members who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an emergency response services (ERS) provider who notifies local authorities, like paramedics of a member's emergency. 

CFC support management provides voluntary training on how to select, manage and dismiss attendants. 

Refer to the STAR Kids Handbook (SKH) for more information about CFC services. 

4100.2 Personal Care Services

Revision 22-3; Effective Sept. 9, 2022 

Personal Care Services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP).

PCS provides help 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. 

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time. 

Refer to the STAR Kids Handbook (SKH) for more information about PCS. 

4100.3 Private Duty Nursing

Revision 22-3; Effective Sept. 9, 2022

Private duty nursing (PDN) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP).

PDN is nursing services for members who:

• meet medical necessity (MN) criteria outlined in the STAR Kids Screening and Assessment Instrument (SK-SAI); and
• require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services. 

Refer to the STAR Kids Handbook (SKH) for more information about PDN. 

4100.4 Prescribed Pediatric Extended Care Centers

Revision 22-3; Effective Sept. 9, 2022 

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). 

PPECC is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic, and developmental services to medically dependent or technologically dependent members under 21 years for up to 12 hours per day. 

Refer to the STAR Kids Handbook (SKH) for more information about PPECC. 

4100.5 Day Activity and Health Services

Revision 22-3; Effective Sept. 9, 2022 

Day activity health services (DAHS) for members 18 through 20. DAHS includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services.

Refer to the STAR Kids Handbook (SKH) for more information about DAHS.

Revision 22-3; Effective Sept. 9, 2022 

The Medically Dependent Children Program (MDCP) is a 1915(c)-waiver program for eligible members. It prevents placement in long-term care facilities who are medically dependent and under 21 years old. Only members who are assessed as meeting medical necessity (MN) for Medically Dependent Children Program (MDCP) and who have a slot in MDCP are eligible for MDCP services.

The applicant or member’s managed care organization (MCO) uses the STAR Kids Screening and Assessment Instrument (SK-SAI) to assess for MN for MDCP. Receipt of MDCP services does not impact a member's eligibility for other long-term services and supports (LTSS) available in STAR Kids. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

MDCP services include respite, flexible family support services (FFSS), minor home modifications, adaptive aids, transition assistance services (TAS), supported employment (SE), employment assistance (EA) and financial management services (FMS).

4200.1 Medically Dependent Children Program Respite

Revision 22-3; Effective Sept. 9, 2022 

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.

Refer to the STAR Kids Handbook (SKH) for more information about respite services.

4200.2 Flexible Family Support Services

Revision 22-3; Effective Sept. 9, 2022 

Flexible family support services (FFSS) are direct care services needed because of a member's disability that help a member participate in childcare, post-secondary education, employment, independent living, or support a member's move to an independent living situation. 

Refer to the STAR Kids Handbook (SKH) for more information about flexible family support services.

4200.3 Adaptive Aids

Revision 22-3; Effective Sept. 9, 2022

Adaptive aids are devices necessary to treat, rehabilitate, prevent, or compensate for conditions resulting in disability or loss of function and enable members to:

• perform activities of daily living (ADL); or
• control the environment in which they live.

Adaptive aids are available through the Medically Dependent Children Program (MDCP), if:

• determined medically necessary; and
• only after exhausting all Medicaid state plan services and other third-party resources.

After any applicable benefits are exhausted, adaptive aids covered through MDCP include but are not limited to:

• van lifts;
• vehicle modifications;
• jump seats;
• tumble form chairs;
• feeder seats;
• medically appropriate strollers;
• barrier-free lifts;
• stair lifts;
• environmental control units;
• alarm systems;
• support rails;
• electrical work related to use of authorized adaptive aids;
• installation of authorized adaptive aids; and
• repairs to adaptive aids. 

Refer to the STAR Kids Handbook (SKH) for more information about adaptive aids.

4200.4 Minor Home Modifications

Revision 22-3; Effective Sept. 9, 2022

A minor home modification (MHM) is a physical modification to a member’s residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare, and safety of the member or to enable the member to function with greater independence in their home. 

Refer to the STAR Kids Handbook (SKH) for more information about minor home modifications.

4200.5 Transition Assistance Services

Revision 22-3; Effective Sept. 9, 2022

Transition assistance services (TAS) are a one-time service provided to a Medicaid-eligible resident of a nursing facility (NF) located in Texas to assist the resident in moving from the NF into the community to receive Medically Dependent Children Program (MDCP) services.

Refer to the STAR Kids Handbook (SKH) for more information about TAS.

4200.6 Employment Assistance

Revision 22-3; Effective Sept. 9, 2022 

Employment assistance (EA) helps a member locate paid employment in the community. EA services include:

• identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions;
• locating prospective employers offering employment compatible with a member’s identified preferences, skills, and requirements; and
• contacting a prospective employer on behalf of a member and negotiating the member’s employment.

Refer to the STAR Kids Handbook (SKH) for more information about EA. 

4200.7 Supported Employment

Revision 22-3; Effective Sept. 9, 2022 

Supported employment (SE) helps 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 where members without disabilities are employed. SE services include:

• assistance provided to a member to sustain competitive employment and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed;
• employment adaptations, supervision and training related to a member’s assessed need; and
• ensuring members earn at least minimum wage, if not self-employed.

Refer to the STAR Kids Handbook (SKH) for more information about SE.

4200.8 Financial Management Services (FMS)

Revision 22-3; Effective Sept. 9, 2022 

Financial management services (FMS) are available to members who choose the Consumer Directed Services (CDS) option. FMS helps members with managing funds related to the services elected for self-direction. The service includes initial orientation and ongoing training about responsibilities of being an employer and adhering to legal requirements for employers. 

Refer to the STAR Kids Handbook (SKH) for more information about FMS.

Revision 26-1; Effective March 16, 2026

First position is an interest list (IL) option. It is available to members under 21 who are denied the medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) at reassessment. Members who request first position can move to the top of the Medically Dependent Children Program (MDCP) IL to be reassessed when an MDCP IL slot becomes available. 

First position can be requested verbally or in writing, either alone or with a request for: 

• a state fair hearing; and 
• advanced placement.

Note: Written notification is required if:

• first position is requested; and 
• the member or legally authorized representative (LAR) decline a state fair hearing.

First position may be requested only once, on or before the 120^th day from the Date of Notice on Form H2065-D, Notification of Managed Care Program Services. Requests for first position received after 120 days from the Date of Notice on Form H2065-D require PSU supervisor approval before processing.

A state fair hearing decision sustaining the MN denial must be received before a member is eligible for first position. If a state fair hearing is also requested, PSU staff may accept Appendix XXIV, MDCP Medical Necessity Denial Attachment - Members, as written notification the member or LAR want to forgo a state fair hearing. PSU staff must advise the member or LAR that MDCP services and Medicaid eligibility, if applicable, will not continue if the member declines a state fair hearing.

First position is not available to applicants denied MN or members who aged out of MDCP. Members who aged out of MDCP can only request the advancement placement IL option. 

PSU staff must complete the actions in:

• 6300.5, Medical Necessity and Level of Care, when a member is denied MN at reassessment. 
• 7221.1, Medical Necessity Denial by Texas Medicaid & Healthcare Partnership, upon receipt of a state fair hearing request. 

Revision 26-1; Effective March 16, 2026

Advanced placement is an interest list (IL) option available to members terminated from the Medically Dependent Children Program (MDCP) due to:

• no longer meeting the medical necessity (MN) determination for a nursing facility (NF) level of care (LOC); or
• aging out of the program.

Members who choose advanced placement may be eligible to move up on the IL for one of the following 1915(c) Medicaid waiver programs: 

• Community Living Assistance and Support Services (CLASS) 
• Home and Community-based Services (HCS) 
• Texas Home Living (TxHmL)
• Deaf Blind with Multiple Disabilities (DBMD)

The original MDCP IL request date is used to move an eligible member up on the selected 1915(c) Medicaid waiver program IL. A member must have been previously or currently on the IL, to be eligible to move up the list. This includes members who were previously on the 1915(c) Medicaid waiver program IL, but the IL record was closed. A member is placed at the bottom of the requested 1915(c) Medicaid waiver program IL if the member was never on the IL. 

A member or legally authorized representative (LAR) can request advanced placement verbally or in writing, either alone or with a request for:

• a state fair hearing; and 
• first position, if the member was denied MN at reassessment.

A member or LAR must request advanced placement on or before the 120^th day from the Date of Notice on Form H2065-D, Notification of Managed Care Program Services. Requests for advanced placement received after 120 days from the Date of Notice on Form H2065-D require supervisor approval.

Written notification selecting advanced placement is not required. However, PSU staff may accept Appendix XXIV, MDCP Medical Necessity Denial Attachment - Members or Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, as written notification the member or LAR wants to pursue advanced placement. 

Members who aged out of MDCP will only receive the advancement placement IL option to move up on another 1915(c) Medicaid waiver program’s IL. These members do not qualify for first position. 

PSU staff must complete the actions in:

• 6300.5, Medical Necessity and Level of Care, when a member is denied MN at reassessment.
• 6300.9, No Longer Meets the Age Requirement for MDCP, when notified a member is aging out of MDCP. 
• 7200, State Fair Hearing Procedures for Medically Dependent Children Program, upon receipt of a state fair hearing request.

Revision 26-1; Effective March 16, 2026

A member or legally authorized representative (LAR) may request the first position and advanced placement interest list (IL) options any time on or before the 120^th day from the Date of Notice on Form H2065-D, Notification of Managed Care Services.

A member or LAR can request the following options in writing or verbally, unless otherwise noted, for members denied medical necessity (MN) for the Medically Dependent Children Program (MDCP) at reassessment:

• state fair hearing;
• first position:
  • written notification is required, if the member declines a state fair hearing; 
  • will not be processed until a sustained state fair hearing decision is issued, if a state fair hearing is also requested; and
• advanced placement.

A member or LAR can request the following options in writing or verbally for members who aged out of MDCP:

• state fair hearing; and
• advanced placement.

The table below lists options available for the member based on their denial reason. It provides the Fair Hearing and Interest List Option Attachment mailed with Form H2065-D. The option is available for the member:

• if an X appears in the square; or 
• with more requirements noted below the table, if a number appears in the square. 

Notes:

1. A written request to decline a state fair hearing must be received before the option can be processed, if the member or LAR opt out of a state fair hearing and request the first position option.
2. A sustained state fair hearing decision must be issued before the option is processed, if a state fair hearing is requested along with the first position option.

Program Support Unit (PSU) staff may refer to Appendix XXXIII, Scenario Guide for MDCP State Fair Hearing, First Position and Advanced Placement Requests, for guidance on handling different request scenarios for a state fair hearing, first position and advanced placement.

Revision 26-1; Effective March 16, 2026

Program Support Unit (PSU) staff must create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record for all first position and advanced placement interest list (IL) requests received on or before the 120^th day from the Date of Notice on Form H2065-D, Notification of Managed Care Program Services. The HEART case record is assigned to Interest List Management (ILM) unit staff for processing.

PSU staff must refer to 5400.3, First Position and Advanced Placement Assignments Beyond 120 Days, on receipt of a first position or advanced placement request received after 120 days from the Date of Notice on Form H2065-D. 

5400.1 Advanced Placement Assignments and First Position Assignments Without a State Fair Hearing 

Revision 26-1; Effective March 16, 2026

Program Support Unit (PSU) staff must create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record within two business days from request receipt for:

• advanced placement; and
• first position, if the member or legally authorized representative (LAR) decline a state fair hearing.

Note: The request for first position must be received with written notification declining a state fair hearing before PSU staff can process the request.  

PSU staff must complete the following activities on the same day the HEART case record is created:

• in HEART:
  • select the following for the:
    • Action Type: SB1207;
    • Issue Type, as applicable:
      • MDCP First Position/Advanced Placement/New IL when creating a HEART case record for first position and advanced placement at the same time;
      • MDCP First Position;or
      • Advanced Placement;
• inform the member or LAR who declined a state fair hearing to pursue first position that: 
  • Medically Dependent Children Program (MDCP) services and Medicaid eligibility, if applicable, will not continue if the member or LAR decline a state fair hearing; 
  • the request to decline the state fair hearing and pursue first position will not be processed unless a written request is received on or before the 120^th day from the Date of Notice on Form H2065-D, Notification of Managed Care Program Services, if applicable; and
  • the member may request the following, if this information was not received:
    • a new MCO or to remain with their previous or current MCO upon interest list release; and
    • a different service coordinator if they choose to remain with their previous or current MCO;
• document the: 
  • outcome of the contact with a member or LAR who declined a state fair hearing and requested first position verbally instead of in writing, if applicable;
  • date first position or advanced placement were requested;
  • Medically Dependent Children Program (MDCP) termination effective date; 
  • member’s request for:
    • first position and advanced placement; and
    • the following, if first position is selected:
      • a new managed care organization (MCO) or to remain with their previous or current MCO upon interest list; and
      • a different service coordinator with the previous or current MCO, if applicable; 
• upload the following documents to the HEART case record:
  • the written request:
    • declining a state fair hearing to pursue first position; and
    • to pursue advanced placement, if received; and
  • Form H2065-D; and
• assign the HEART case record to the Interest List Management (ILM) unit manager.

ILM unit staff place the member on the correct interest list, as applicable.   

PSU staff may need to create two HEART case records, if written notification declining a state fair hearing and requesting first position is received after an advanced placement request. PSU staff must follow the steps above to create a new first position HEART case record within two business days from receipt of the written notification and:

• relate the first position HEART case record to the advanced placement HEART case record as follows:
  • find the Tracking Number of the advanced placement HEART case record and copy this number;
  • select the Relationships tab in the first position HEART case record;
  • paste the copied Tracking Number for the advanced placement HEART case record in the Associated Assignment field of the Relationships tab in the first position HEART case record;
  • select Refer To in the Relationships dropdown;
  • enter Refer to assignment for request of Advanced Placement, in the Brief Summary field; and
  • ensure Save Relation was selected to complete the relationship.

PSU staff must close a first position HEART case record created due to a verbal request to decline a state fair hearing and pursue first position, if:

• written notification is not received within 120 days from the Date of Notice on Form H2065-D; and
• the member or LAR did not also request advanced placement.

5400.2 First Position and Advanced Placement Assignments Following a Sustained MN Denial

Revision 26-1; Effective March 16, 2026

Program Support Unit (PSU) staff must complete the following activities within two business days from receiving notification that the hearings officer sustained a member’s medical necessity (MN) denial:

• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record for the first position and advanced placement requests;
• select the following in the HEART case record for the:
  • Action Type: SB1207;
  • Issue Type, as applicable:
    • MDCP First Position/Advanced Placement/New IL, when creating a HEART case record for first position and advanced placement at the same time;
    • MDCP First Position; or 
    • Advanced Placement;
• document the following in the HEART case record:
  • sustained MDCP denial after a state fair hearing;
  • date of first position and advanced placement request; 
  • effective date of MDCP termination; 
  • the member’s request for:
    • first position and advanced placement; 
    • the following, if first position is selected:
      • a new managed care organization (MCO) or to stay with their previous or current MCO upon interest list; and
      • a different service coordinator with the previous or current MCO, if applicable;
• upload the following documents to the HEART case record:
  • the written request to pursue first position and advanced placement, if received; and
  • Form H2065-D, Notification of Managed Care Program Services; and
• assign the HEART case record to the Interest List Management (ILM) unit manager. 

ILM unit staff place the member on the correct interest list, as applicable.

5400.3 First Position and Advanced Placement Assignments Beyond 120 Days

 Revision 26-1; Effective March 16, 2026

Program Support Unit (PSU) staff must receive PSU supervisor approval before assigning a first position or advanced placement request to the Interest List Management (ILM) unit manager, if the request is received after 120 days from the Date of Notice on Form H2065-D, Notification of Managed Care Program Services. 

PSU staff must complete the following activities within two business days of receiving a request for first position and advanced placement beyond the 120^th day:

• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record for the first position and advanced placement requests;
• document the member or legally authorized representative’s (LAR’s) request for first position and advanced placement in the HEART case record. 
  • if the request is verbal, advise the member or LAR: 
    • the request is past 120 days from the Date of Notice on Form H2065-D and requires supervisor approval; and 
    • they may call ILM unit staff to be added to the bottom of any interest list; 
• email the PSU supervisor an email with:
  • this email subject line: 120 Day Request for First Position or Advanced Placement XX [first letter of the member's first and last name];
  • the following items in the body of the email:
    • member’s name;
    • Medicaid identification (ID) number;
    • date member or LAR requested first position or advanced placement; 
    • reason the member or LAR could not provide their request within 120 days from the Date of Notice on Form H2065-D; and 
  • Form H2065-D as an attachment;
• upload all applicable documents, including the written request for first position and advanced placement, if received, to the HEART case record; and
• document the HEART case record. 

PSU staff must complete the following activities within two business days of receiving the PSU supervisor’s decision that the request was approved:

• document the outcome of the member’s 120-day request in the HEART case record;
• upload the 120-day approval email and all applicable documents to the HEART case record; 
• close the HEART case record; 
• create a new HEART case record selecting the following for the:
  • Action Type: SB1207;
  • Issue Type, as applicable:
    • MDCP First Position/Advanced Placement/New IL, when a request for first position and advanced placement are received at the same time;
    • MDCP First Position; or
    • Advanced Placement;
• document the following in the new HEART case record:
  • the member’s request for:
    • first position and advanced placement noting the dates these options were requested;
    • the following, if first position is selected:
      • a new managed care organization (MCO) or to remain with their previous or current MCO upon interest list; and
      • a different service coordinator with the previous or current MCO, if applicable; 
  • member’s request was past 120 days;
  • outcome of the member’s 120-day request; 
  • Medically Dependent Children Program (MDCP) effective termination date; 
  • Date of Notice on Form H2065-D; and
  • the statement: Please see relationship case for request of First Position or Advanced Placement, if a first position or advanced placement HEART case record was already created on or before 120 days from the Date of Notice on Form H2065-D;
• upload the following documents to the new HEART case record:
  • the written request for first position or advanced placement, if received;
  • the 120-day approval email; and 
  • Form H2065-D; 
• relate the new HEART case record to the older first position or advanced placement case record created on or before 120 days from the Date of Notice on Form H2065-D, if applicable, by:
  • finding the Tracking Number of the older first position or advanced placement case record and copying this number;
  • selecting the Relationships tab in the new HEART case record;
  • pasting the copied Tracking Number for the older first position or advanced placement HEART case record in the Associated Assignment field of the Relationships tab in the new HEART case record;
  • selecting Refer To in the Relationships dropdown;
  • entering Refer to assignment for request of First Position or Advanced Placement, in the Brief Summary field; and
  • ensuring Save Relation has been selected to complete the relationship; and
• assign the new HEART case record to the ILM unit manager.

Interest List Management (ILM) unit staff place the member on the correct interest list, as applicable.   

PSU staff must complete the following activities within two business days of receiving the PSU supervisor’s decision the request was denied:

• document the outcome of the member’s 120-day request in the HEART case record;
• mail Form 2128, 120 Day Notice, to the member or LAR;
• upload Form 2128 and the email denying the 120-day request to the HEART case record; and 
• close the HEART case record.

Revision 22-1; Effective January 31, 2022

This section contains policy for Program Support Unit (PSU) staff when processing:

• case closure for an individual applying for the Medically Dependent Children Program (MDCP);
• denials and terminations for an applicant or member; and
• information regarding adequate notice of an applicant’s or member’s right to due process.

PSU staff must mail Form 2442, Notification of Interest List Release Closure, as notification of an MDCP interest list closure to an individual when the individual does not meet MDCP eligibility. PSU staff must always mail Form 2442 with Appendix XX, MDCP Program Description. Form 2442 does not provide the right to request a state fair hearing. An individual will only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff must mail an applicant or member Form H2065-D when the applicant or member is denied or terminated from MDCP. Form H2065-D provides an applicant or member with the right to request a state fair hearing. An applicant or member will never receive Form 2442.

Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), provides the rules for adverse action for members required by Title 42 Code of Federal Regulations (CFR) Part 431, Subpart E, including requiring that: 

• the written notice to the member of their right to a hearing must:
  • contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and
  • be delivered by mail, and postmarked at least 10 business days, before the date the member’s Medicaid eligibility or service is scheduled to be terminated, suspended or reduced, except as provided by Title 42 CFR §431.213 or Title 42 CFR §431.214; and
• if a hearing is requested before the date a member’s service, including a service that requires prior authorization, is scheduled to be terminated, suspended or reduced, Texas Health and Human Services Commission (HHSC) may not take that proposed action before a decision is rendered after the hearing unless:
  • it is determined at the hearing that the sole issue is one of federal or state law or policy; and
  • the agency promptly informs the recipient in writing that services are to be terminated, suspended or reduced pending the hearing decision.

Title 42 CFR Part 431, Subpart E, governs fair hearing rights for Medicaid individuals, applicants and members. However, Title 42 CFR §431.213 specifies situations where an adverse action notification period is not required. The agency may mail a notice not later than the date of action if:

• The agency has factual information confirming the death of an individual, applicant or member;
• The agency receives a clear written statement signed by a member that:
  • they no longer want to receive services; or
  • gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information; and
• The individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
• The individual’s, applicant’s or member’s whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See Title 42 CFR §431.231(d) of this subpart for procedure if the individual’s, applicant’s or member’s whereabouts become known);
• The agency establishes the fact that the individual, applicant or member has been accepted for Medicaid services by another local jurisdiction, state, territory or commonwealth;
• A change in the level of medical care is prescribed by the applicant’s or member’s physician;
• The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
• The date of action will occur in less than 10 days, in accordance with Title 42 CFR §483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30 days’ notice requirements of Title 42 CFR §483.15(b)(4)(i) of this chapter.

6110 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022

An individual, applicant or member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

• be birth through 20;
• live in Texas;
• have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
• need at least one MDCP service not being addressed by other services and supports;
• not be enrolled in another waiver program;
• live in an appropriate living situation;
• have a STAR Kids individual service plan (SK-ISP) with services under the established cost limit; and
• have full Medicaid eligibility.

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

6110.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 25-1; Effective May 16, 2025

An individual, applicant or member must meet the following criteria 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 the Texas Health and Human Services Commission (HHSC);
• have an unmet need for support in the community that can be met through one or more MDCP services;
• 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 Medicaid Home and Community Based Services (HCBS) waiver programs approved by the Centers for Medicaid & Medicare Services (CMS):
  • Community Living Assistance and Support Services (CLASS) Program;
  • Deaf Blind with Multiple Disabilities (DBMD) Program;
  • Home and Community-based Services (HCS) Program;
  • Texas Home Living (TxHmL) Program; or
  • Youth Empowerment Services waiver;
• live in:
  • the person's home; or
  • an agency foster home defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and
• be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title which relates to Medicaid Eligibility for the Elderly and People with Disabilities. 

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. 

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, to the member no later than 12 business days before the termination effective date. This requirement ensures:

• the member maintains services while Form H2065-D travels through the mail; and
• the member has enough time to request a state fair hearing with the option of maintaining continued Medically Dependent Children Program (MDCP) services until a state fair hearing decision is rendered. 

Day zero is the day PSU staff mail Form H2065-D to the member.

The MDCP termination dates are typically on the last day of the month. PSU staff must manually extend the individual service plan (ISP) record’s end date in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to the last day of the following month if:

• the 12th business day is beyond the current ISP end date; and
• the adverse action notification period applies.

See the example chart below for further clarification.

Example Chart:

The adverse action notification period does not apply to all member terminations. The adverse action notification period does not apply when: 

• PSU staff has factual information confirming the death of a member;
• the member submits a signed written statement waiving their right to the adverse action notification period and understands their services will end;
• the member is denied Medicaid financial eligibility for MDCP;
• the member is admitted to an institution for 90 consecutive days where MDCP services cannot be delivered;
• the member accepts Medicaid services by another jurisdiction, state, territory or commonwealth; or
• the member chooses to enroll in another Medicaid waiver program. 

Revision 22-1; Effective January 31, 2022

The following sections contain Program Support Unit (PSU) staff procedures for individual case closures, applicant denials and member terminations.

6300.1 Death

Revision Notice 25-2; Effective July 11, 2025

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility once notified that an individual, applicant or member is deceased.

PSU staff may receive notification of an individual, applicant or member’s date of death by:

• Managed Care Operations;
• Enrollment Resolution Services (ERS) unit staff;
• Medicaid for Elderly and People with Disabilities (MEPD) specialist;
• the legally authorized representative (LAR) or family member;
• the managed care organization (MCO); or
• other reliable sources.

PSU staff may learn of an individual, applicant or member’s death while reviewing records in the Texas Integrated Eligibility Redesign System (TIERS). There may be times when an individual, applicant or member is deceased, and information is not updated in TIERS. PSU staff must receive verification of death from other sources, in those cases.

PSU staff must complete the following activities for individuals within two business days of notification of death:

• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

MFP Individuals

PSU staff do not close the CSIL record for individuals applying for MDCP through the Money Follows the Person (MFP) process.

PSU staff must complete the following activities for MFP individuals within two business days of notification of death:

• email the Interest List Management (ILM) unit the following information for the CSIL record:
  • an email subject line that reads: MDCP MFP Denial for XX [first letter of the individual’s first and last name];
  • the following items in the body of the email:
    • individual's name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification of death:

• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of the applicant’s date of death and case closure, if applicable;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist if TIERS does not show the applicant is deceased;
• complete the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • inactivate the MDCP Enrollment Form;
• for non-MFP applicants, document and close the CSIL record, if applicable;
• for MFP applicants, email the ILM unit the following information for the CSIL record closure:
  • an email subject line reads: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • SSN or Medicaid ID number;
    • contact name and phone number;
    • reason for the denial;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • an email subject line that reads: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification of death:

• upload Form H2067-MC to the MCOHub notifying the MCO of the member’s date of death and case closure, if applicable;
• for MAO members, fax Form H1746-A to the MEPD specialist if TIERS does not show the member is deceased;
• complete the following tasks in the TMHP LTCOP:
  • adjust the SK-ISP record and the MDCP Enrollment Form end dates to the date of death; and
  • terminate the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• upload the applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must not mail Form 2442, Notification of Interest List Release Closure, or Form H2065-D, Notification of Managed Care Services, to the individual, applicant, member, LAR or family’s address. The applicant or member’s denial or termination effective date is the date of death and may be a mid-month date.

Example: PSU staff receive notification from the MEPD specialist that the member passed away on July 26, 2021. The member’s termination effective date is July 26, 2021.

The adverse action notification period does not apply in this situation.

6300.2 Living Arrangement is Not an Allowable Setting

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not live in an allowable living situation. Title 42 CFR Section 441.301(c)(5) states the following living arrangements are not allowable settings for MDCP:

• a nursing facility (NF);
• an institution for mental diseases;
• an intermediate care facility for people with intellectual disabilities;
• a hospital;
• any other location that has qualities of an institutional setting, as determined by the U.S. Department of Health and Human Services (HHS) Secretary;
• any setting in a building that is also a publicly or privately operated facility providing inpatient institutional treatment or in a building on the grounds of or immediately adjacent to a public institution; or
• any other setting that isolates people receiving Medicaid Home and Community Based Services (HCBS) from the broader community of individuals not receiving Medicaid HCBS is presumed to be a setting with the qualities of an institution; unless
• the HHS Secretary determines through heightened scrutiny, based on information presented by the state or other parties, that the setting does:
  • not have the qualities of an institution; and
  • have the qualities of home and community-based settings.

PSU staff may receive notification of the applicant or member’s living arrangement by:

• Managed Care Contracts and Oversight (MCCO);
• Enrollment Resolution Services (ERS) unit staff;
• the applicant, member, legally authorized representative (LAR) or family member;
• the managed care organization (MCO); or
• other reliable sources.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant or member has not returned to an allowable living arrangement by the 90th day.

The MCO notifies PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub within 14 days following the 90th day that the applicant or member has not returned to an allowable living arrangement.

PSU staff must email the MCCO unit advising that the MCO is not timely in their notification if the MCO fails to meet this notification time frame. PSU staff must include the following components when emailing MCCO unit staff:

• this email subject line: MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name];
• the following items in the body of the email:
  • applicant or member’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must deny the applicant by the end of the month that the 90th day occurred within two business days of notification by:

• manually generating Form H2065-D, Notification of Managed Care Program Services;
• mailing Form H2065-D to the applicant or LAR;
• uploading Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, faxing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• completing the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidating the STAR Kids individual service plan (SK-ISP) record; and
  • inactivating the MDCP Enrollment Form;
• for non-Money Follows the Person (MFP) applicants, documenting and closing the Community Services Interest List (CSIL) record, if applicable;
• for MFP applicants, emailing the Interest List Management (ILM) unit the following information for the CSIL record:
  • this email subject line: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • SSN or Medicaid ID number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the applicant to the MDCP interest list using their original MDCP request date;
• emailing the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • this email subject line: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• uploading applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• documenting and closing the HEART case record.

Note: PSU staff must document Form H2067-MC was received instead of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, in the HEART case record, if applicable.

PSU staff must terminate the member by the end of the month that the 90th day occurred within two business days of notification by:

• manually generating Form H2065-D;
• mailing Form H2065-D to the member or LAR;
• uploading Form H2065-D to the MCOHub;
• for MAO members:
  • faxing Form H1746-A to the MEPD specialist;
  • emailing the ERS unit the following information:
    • this email subject line: MDCP Termination for XX [first letter of the member’s first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid ID number;
      • type of request: MDCP termination;
      • SK-ISP end date;
      • effective date of termination; and
    • Form H2065-D as an attachment;
• completing the following tasks in the TMHP LTCOP:
  • adjusting the SK-ISP record and the MDCP Enrollment Form end dates to the termination effective date; and
  • terminating the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• uploading applicable documents to the HEART case record; and
• documenting and closing the HEART case record.

An applicant or member denied or terminated due to an extended stay in a nursing facility (NF) may pursue the Money Follows the Person (MFP) process to reapply for MDCP and return to the community with services. Refer to 2400, Money Follows the Person, for procedures for the traditional MFP process and to 2420, Money Follows the Person Limited NF Stay Options for Medically Fragile Individual, for procedures for the nursing facility limited stay process.

The process for applicants and members living in Truman Smith does not apply to this section. An applicant or member enrolled in STAR Kids who enters the Truman Smith NF or a state veteran’s home is excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied or terminated, as applicable.

The adverse action notification period does not apply in this situation.

6300.3 Voluntarily Declined Services

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member no longer wants to receive MDCP services. PSU staff must process a case closure upon notification that an individual voluntarily declines services.

PSU staff may receive notification of the individual’s, applicant’s, member’s or legally authorized representative’s (LAR’s) request to voluntarily decline MDCP from:

• Managed Care Operations;
• receipt of Form 2602, Application Acknowledgment, indicating no interest in MDCP;
• Enrollment Resolution Services (ERS) Unit staff;
• the individual, applicant, member or LAR;
• the managed care organization (MCO); or
• other reliable sources.

PSU staff must complete the following activities for individuals within two business days of notification:

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XX, MDCP Program Description to the individual or LAR;
• upload Form H2067-MC, Managed Care Programs Communication, and Form 2442 to TxMedCentral notifying the MCO of case closure following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification:

• manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
• mail Form H2065-D to the applicant or LAR;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
• for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
• document and close the CSIL record, if applicable;
• invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

• manually generate Form H2065-D following the instructions in Appendix II;
• mail Form H2065-D to the member or LAR;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
• adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP.

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

• complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
• email ERS Unit staff the following information:
  • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for a MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., MDCP eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record.

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must:

• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

Note: See the Uniform Managed Care Manual (UMCM) Chapter 16.2 for procedures for STAR Health individuals.

The medical consenter appointed by the Department of Family and Protective Services (DFPS) is the only person who can accept or decline to pursue MDCP on behalf of the individual, applicant or member.

Per Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), the adverse action notification period applies in this situation unless PSU staff receive a clear written statement signed by the member or LAR indicating that the member no longer wants to receive services. The termination effective date is the last day of the current month if the adverse action notification period is waived.

Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.4 Financial Eligibility

Revision Notice 25-2; Effective July 11, 2025

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant or member’s Medicaid financial eligibility for MDCP is determined by the:

• Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients;
• Medicaid for the Elderly and People with Disabilities (MEPD) specialist; or
• Texas Worker (TW) advisor.

The applicant or member may appeal the financial denial using SSA, MEPD or TW fair hearing processes, as appropriate.

PSU staff may receive notification of the denial or termination of an applicant or member’s Medicaid financial eligibility from:

• the Texas Integrated Eligibility Redesign System (TIERS);
• the monthly loss of enrollment (LOE) reports;
• MEPD specialist;
• Enrollment Resolution Services (ERS) unit staff;
• the managed care organization (MCO); or
• other reliable sources.

PSU staff must complete the following activities for applicants within two business days of the denial notification:

• verify Medicaid financial eligibility was terminated by reviewing the TIERS Medicaid/CHIP/CHIP perinatal History screen, if applicable;
• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail the applicant or legally authorized representative (LAR):
  • Form H2065-D;
  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form 2606, Managed Care Enrollment Processing Delay;
• upload Form H2065-D to the MCOHub;
• complete the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • inactivate the MDCP Enrollment Form;
• for non-Money Follows the Person (MFP) applicants, document and close the Community Services Interest List (CSIL) record, if applicable;
• for MFP applicants, email the Interest List Management (ILM) unit the following information for the CSIL record:
  • an email subject line reads: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the applicant to the MDCP interest list (IL) using their original MDCP request date;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • an email subject line that reads: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.
  • PSU staff must close the HEART case record no earlier than the 31st day, but no later than two business days following the 31st day that PSU staff mailed Form 2606.

PSU staff must complete the following activities for members within two business days of notification of termination:

• create a HEART case record, if applicable;
• verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP perinatal History screen;
• manually generate Form H2065-D;
• mail the following forms to the member or LAR:
  • Form H2065-D;
  • Form H1200; and
  • Form 2606;
• upload Form H2065-D to the MCOHub;
• complete the following tasks in the TMHP LTCOP:
  • adjust the SK-ISP record and the MDCP Enrollment Form end dates to the Medicaid financial termination; and
  • terminate the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.
  • PSU staff must close the HEART case record no earlier than the 31st day, but no later than two business days following the 31st day that PSU staff mailed Form 2606.

The adverse action notification period does not apply in this situation. The member’s MDCP termination effective date in the TMHP LTCOP must match the TIERS Medicaid/CHIP/CHIP perinatal History screen end date. This is true even if the TIERS end date is in the past.

The table below lists examples of PSU staff actions when the MEPD specialist determines a member no longer meets Medicaid financial eligibility.

PSU staff must refer to 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the applicant or member requests a state fair hearing.

Medicaid Reinstatement

PSU staff must reinstate MDCP eligibility if a member reestablishes Medicaid with a gap of six months or less. Texas Health and Human Services Commission (HHSC) staff processing does not impact the time frame that a member is denied, and the date Medicaid is reestablished.

PSU staff must process a Medicaid reinstatement approval for a member within five business days from receiving notification the member regains eligibility.

SK-ISP Period Not Expired and No Gap in Medicaid Coverage

PSU staff must:

• refer to 6500, Resetting ISPs and MDCP Enrollment Forms in the TMHP LTCOP, for instructions on requesting supervisor help with resetting the status of the SK-ISP record and the MDCP Enrollment Form;
• complete the following in the TMHP LTCOP after the SK-ISP record and the MDCP Enrollment Form have been reset:
  • adjust the current SK-ISP record begin and end dates to align with historical SK-ISP periods; and
  • adjust the MDCP Enrollment Form begin date to align with the historical SK-ISP begin date and the end date to the last day of the month the individual turns 21.

SK-ISP Period Not Expired with a Gap in Medicaid Coverage

PSU staff must:

• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub advising the MCO to submit a new SK-ISP;
• complete the following in the TMHP LTCOP upon receipt of the new SK-ISP:
  • adjust the new SK-ISP record begin date to reflect the date Medicaid is reinstated and adjust the end date to reflect the historical SK-ISP end date range; and
  • create a new MDCP Enrollment Form. The new MDCP Enrollment Form begin date will reflect the date Medicaid is reinstated and end date will be the last day of the month the individual turns 21.

Note: The begin date of the new SK-ISP record reflects the gap from the previous SK-ISP date range. However, the historical 365-day SK-ISP date range remains in place.

SK-ISP Period Expired without a Gap in Medicaid Coverage

PSU staff must:

• upload Form H2067-MC to the MCOHub advising the MCO to submit a new STAR Kids Screening and Assessment Instrument (SK-SAI) and SK-ISP;
• refer to 6500, Resetting ISPs and MDCP Enrollment Forms in the TMHP LTCOP, for instructions on requesting supervisor help with resetting the status of the SK-ISP record and the MDCP Enrollment Form, if applicable;
• complete the following in the TMHP LTCOP after the SK-ISP record and the MDCP Enrollment Form have been reset, if applicable:
  • adjust the:
    • expired SK-ISP record end date to align with the historical SK-ISP period or the end of Medicaid eligibility;
    • new SK-ISP record begin and end date to align with historical SK-ISP periods; and
    • MDCP Enrollment Form begin date to align with the historical SK-ISP begin date and the end date to the last day of the month the individual turns 21.

SK-ISP Period Expired with a Gap in Medicaid Coverage

PSU staff must:

• upload Form H2067-MC to the MCOHub advising the MCO to submit a new SK-SAI and SK-ISP;
• in the TMHP LTCOP:
  • adjust the new SK-ISP record begin date to reflect the date Medicaid is reinstated and the end date to reflect the historical SK-ISP end date range; and
  • create a new MDCP Enrollment Form. The new MDCP Enrollment Form begin date reflects the date Medicaid is reinstated and end date will be the last day of the month the individual turns 21.

Note: The begin date of the new SK-ISP record reflects the gap from the previous SK-ISP date range. However, the historical 365-day ISP date range stays in place.

For All Reinstatement Cases

PSU staff must:

• electronically generate Form H2065-D;
• mail Form H2065-D to the member or LAR;
• for MAO members, fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by:
  • selecting the Significant Change action type;
  • noting that the member is approved medical necessity (MN) and SK-ISP; and
  • requesting MDCP program reinstatement effective the day Medicaid was reinstated.
• email Enrollment Resolution Services (ERS) Unit staff the following information, if applicable:
  • an email subject line that reads: MDCP Reinstatement for XX [member’s first and last initials];
  • the following items in the body of the email:
    • member’s name;
    • Medicaid ID number;
    • type of request: MDCP eligibility reinstatement;
    • SK-ISP begin date;
    • SK-ISP end date;
    • effective date of reinstatement;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Reinstatement Examples

Member is reinstated within their historical SK-ISP date range:

• A member whose SK-ISP ends on Sept. 30, 2024, is denied Medicaid on Jan. 31, 2024.
• Medicaid is reestablished on June 1, 2024. However, PSU staff are not notified until Nov. 15, 2024.
• PSU staff must reinstate the member’s MDCP eligibility using a start of care (SOC) date of June 1, 2024, with an end date that matches the historical SK-ISP end date.

Member is reinstated after historical SK-ISP has expired:

• A member is denied Medicaid on Jan. 31, 2024. Medicaid is reestablished on June 1, 2024. However, PSU staff are not notified until Nov. 15, 2024.
• PSU staff must upload Form H2067-MC to the MCOHub requesting the MCO conduct an annual assessment since the SK-ISP has expired.
• PSU staff must reinstate the member’s MDCP program eligibility using a SOC date of June 1, 2024, with an end date that holds true to the historical SK-ISP date ranges.

The member must go to the bottom of the interest list to reapply for services if Medicaid is reestablished with a gap of more than six months.

6300.5 Medical Necessity and Level of Care

Revision Notice 26-1; Effective March 16, 2026

Medical necessity (MN) is the prerequisite for participation in Medicaid (Title XIX) Long-term Care programs including the Medically Dependent Children Program (MDCP). Title 26 TAC Section 554.2401 applies to the MN requirements for participation in MDCP. An applicant or member must meet the following conditions to verify MN exists:

• The applicant or member must demonstrate a medical condition that:
  • is serious enough that the applicant or member’s needs exceed the routine care that an untrained person can give; and
  • requires licensed nurses' supervision, assessment, planning and intervention available only in an institution.
• The applicant or member must require medical or nursing services that:
  • a physician orders;
  • are dependent upon the applicant or member's documented medical conditions;
  • require the skills of a registered or licensed vocational nurse;
  • are provided either directly by, or under the supervision of, a licensed nurse in an institutional setting; and
  • are required on a regular basis.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant or member’s MN does not meet the level of care (LOC) required for a nursing facility (NF). An applicant or member’s approval and continued eligibility for MDCP is dependent on meeting the MN requirements listed above.

The tool used to determine MN for MDCP is the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) completes the SK-SAI and submits it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP).

The TMHP LTCOP automatically processes the SK-SAI to determine if the applicant or member meets the MN criteria required for MDCP. The Office of the Medical Director (OMD) staff must manually review the SK-SAI if it fails automatic MN approval. The OMD physician reviews the SK-SAI if the OMD nurse cannot approve the SK-SAI.

The MCO conducts:

• initial SK-SAIs for each applicant;
• reassessment SK-SAIs annually for each member; and
• change in condition (CIC) SK-SAIs for members, when applicable.

The MCO must notify PSU staff of an applicant or member’s MN denial by uploading the following forms to the MCOHub:

• Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), Section B; or
• Form H2067-MC, Managed Care Programs Communication (PDF).

Note: PSU staff must document receipt of Form H2067-MC in lieu of Form H3676, Section B, in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable.

PSU staff must monitor the TMHP LTCOP every five business days from the date the MN Denied status first appears in the TMHP LTCOP, until the MN status updates to one of the final statuses below:

• MN Approved if the OMD physician overturns the denial because more information is received; or
• Overturn Doctor Review Expired when the 14-business day period for the OMD physician to overturn the denied MN expired and no more information, or inadequate information, was submitted for the physician’s review. The denied MN remains in this status unless the applicant, member or legally authorized representative (LAR) requests a state fair hearing.

The MN status updates to Overturn Doctor Review Expired on the 15th business day from the date the MN Denied status first appears in the TMHP LTCOP, when no more information was provided to reverse the MN denial finding.

PSU staff must monitor the TMHP LTCOP every two business days after the 15th business day from the date the MN Denied status initially appears in TMHP LTCOP, if the final status of Overturn Doctor Review Expired does not appear on the 15th business day.

Applicant MN Denial Process

PSU staff must complete the following activities for applicants within two business days of the date the MN status of Overturn Doctor Review Expired appears in the TMHP LTCOP:

• electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), in the TMHP LTCOP;
• mail Form H2065-D and Appendix XXVII, MDCP Medical Necessity Denial Attachment - Applicants, to the applicant or LAR;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• complete the following tasks in the TMHP LTCOP, if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • deny the MDCP Enrollment Form using denial reason Denied Medical necessity and level of care;
• document and close the Community Services Interest List (CSIL) record for interest list release (ILR) applicants, if applicable;
• email the Interest List Management (ILM) unit the following information for Money Follows the Person (MFP) applicants, for the CSIL record:
  • this email subject line: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the applicant to the MDCP interest list (IL) using their original MDCP request date;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • this email subject line: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Follow Up Contact for an Applicant Denied MN 

PSU staff must contact an applicant or their LAR to notify the applicant or LAR of the MN denial. The call must occur on or before the tenth day after mailing Form H2065-D and Appendix XXVII. PSU staff must:

• discuss the applicant’s state fair hearing rights; and
• document the outcome of the call using the following format: Contact [made on MM/DD/YYYY] or [attempted on MM/DD/YYYY] to phone number [XXX-XXX-XXXX] to explain state fair hearing rights. PSU staff spoke to [first and last name of the person contacted].

Note: A second contact must be completed within two business days of the initial contact if the member or LAR does not answer or does not have voice mail.

Member MN Denial Process

PSU staff must complete the following activities for members within two business days of the date the MN status of Overturn Doctor Review Expired appears in the TMHP LTCOP:

• electronically generate Form H2065-D in the TMHP LTCOP;
• mail Form H2065-D and Appendix XXIV, MDCP Medical Necessity Denial Attachment - Members, to the member or LAR;
• for MAO members:
  • fax Form H1746-A to the MEPD specialist;
  • email the Enrollment Resolution Services (ERS) unit the following information:
    • this email subject line: MDCP Termination for XX [first letter of the member’s first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid ID number;
      • type of request: MDCP termination;
      • SK-ISP end date;
      • effective date of termination; and
    • Form H2065-D as an attachment;
• complete the following tasks in the TMHP LTCOP:
  • adjust the SK-ISP record and the MDCP Enrollment Form end dates to the termination effective date; and
  • terminate the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

The adverse action notification period applies to MN denials.

PSU staff must refer to 6200, Adverse Action Notification Period, to determine the termination effective date.

Follow Up Contact for a Member Denied MN 

PSU staff must contact a member or their LAR to notify them of the MN denial at reassessment. The call must occur after mailing Form H2065-D and Appendix XXIV, but at least seven days before the MDCP termination date. PSU staff must:

• Discuss the member’s state fair hearing rights and the first position or advanced placement interest list options during the contact:
  • A member who previously requested first position can only be offered the advanced placement option. Note: first position can only be pursued one time. 
  • PSU staff must attempt a second contact within two business days of the initial contact if the member or LAR does not answer or does not have voice mail.
• Document the following in the HEART case record:
  • Outcome of the call using the following format: Contact [made on MM/DD/YYYY] or [attempted on MM/DD/YYYY] to phone number [XXX-XXX-XXXX] to explain state fair hearing rights, first position and advanced placement. PSU staff spoke to [first and last name of the person contacted].
  • The member’s request for:
    • A state fair hearing, first position and advanced placement, if received during the call.
    • The following, if first position is selected:
      • A new MCO or to remain with their previous or current MCO on interest list release.
      • A different service coordinator with the previous or current MCO, if applicable. 

PSU staff complete the actions in:

• 5400.1, Advanced Placement Assignments and First Position Assignments Without a State Fair Hearing, within two business days from receiving an advanced placement request or a first position request without a state fair hearing. 
• 7221.1, within two business days from receiving a request for a state fair hearing. This includes a request for a state fair hearing with first position and advanced placement.

6300.6 Unable to Locate

Revision 22-1; Effective January 31, 2022
 
Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member cannot be located. PSU staff must process a case closure upon notification that an individual cannot be located.

PSU staff may receive notification that an individual, applicant or member cannot be located by:

• monthly reports;
• Enrollment Resolution Services (ERS) Unit staff;
• the managed care organization (MCO); or
• other reliable sources.

The MCO must conduct the required contact attempts established in the STAR Kids Handbook (SKH) before requesting a denial or termination from PSU staff. PSU staff are not required to verify the MCO’s contact attempts.

PSU staff must complete the following activities for individuals within two business days of notification:

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or legally authorized representative (LAR);
• upload Form H2067-MC, Managed Care Programs Communication, and Form 2442 to TxMedCentral notifying the MCO of case closure, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification:

• manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
• mail Form H2065-D to the applicant or LAR;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
• for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
• document and close the CSIL record, if applicable;
• invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

• manually generate Form H2065-D following the instructions in Appendix II;
• mail Form H2065-D to the member or LAR;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
• adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document the HEART case record. 

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

• complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
• email ERS Unit staff the following information:
  • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., MDCP eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D; and
• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

PSU staff must reinstate MDCP using the historical ISP if the member is located within the historical ISP date range. The ISP begin date must be the first day of the month that the member is located. The ISP end date must be the historical ISP end date.

Note: PSU staff must refer to the Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM) for information on processing STAR Health members.

PSU staff must refer to Section 2120, Inability to Contact the Individual, for procedures when unable to contact individuals who have been released from the interest list.

6300.7 Exceeding the ISP Cost Limit

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant’s or member’s individual service plan (ISP) exceeds the cost limit. The intent of MDCP is to serve applicants and members who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems when determining if the ISP meets the needs of the applicant or member. As part of the individual service planning process, the MCO must establish an ISP that does not exceed the applicant’s or member’s cost limit.

The MCO must notify PSU staff when an applicant’s or member’s ISP exceeds the cost limit by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. 

PSU staff must complete the following activities for applicants within two business days of notification:

• manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
• mail Form H2065-D to the applicant or legally authorized representative (LAR);
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
• for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

• manually generate Form H2065-D following the instructions in Appendix II;
• mail Form H2065-D to the member or LAR;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
• adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

• complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
• email ERS Unit staff the following information:
  • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
  • the member’s name;
  • Medicaid ID number;
  • type of request (e.g., MDCP eligibility termination);
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

• terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
• upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
• document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.8 Failure to Obtain Physician’s Signature

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must deny Medically Dependent Children Program (MDCP) eligibility when the managed care organization (MCO) cannot get a physician’s signature at an initial assessment. The physician’s signature is required to complete the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The physician’s signature is not required for the annual SK-SAI.

The MCO must:

• make and document at least three more tries to get the physician’s signature if they do not receive a signed copy of the physician’s signature page within five business days of the first request to the applicant’s physician;
• contact the applicant for help getting the physician’s signature if they are unsuccessful getting the signature from the physician;
• notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub, if the MCO needs more time beyond 60 days to make the required contacts to get the physician’s signature;
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, to the MCOHub requesting PSU staff deny the applicant if the MCO cannot get a physician’s signature and is requesting the applicant be denied.

Note: PSU staff must document Form H2067-MC was received instead of Form H3676, Section B, in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable.

PSU staff must complete the following activities for applicants within two business days of notification:

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant or legally authorized representative (LAR);
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist;
• complete the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • inactivate the MDCP Enrollment Form;
• for non-Money Follows the Person (MFP) applicants, document and close the Community Services Interest List (CSIL) record, if applicable;
• for MFP applicants, email the Interest List Management (ILM) unit the following information for the CSIL record:
  • this email subject line: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial; and
    • request to return the applicant to the MDCP interest list (IL) using their original MDCP request date;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • this email subject line: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

The adverse action notification period does not apply in this situation.

6300.9 No Longer Meets the Age Requirement for MDCP

Revision Notice 25-2; Effective July 11, 2025

A Medically Dependent Children Program (MDCP) individual, applicant or member must be under 21 years old to be eligible for MDCP. This is per Title 1 Texas Administrative Code (TAC) Section 353.1155.

Program Support Unit (PSU) staff may receive notification that an individual, applicant or member no longer meets the age requirement for MDCP by:

• the MDCP-PDN Transition Report;
• the managed care organization (MCO);
• the individual, applicant, member or legally authorized representative (LAR); or
• other reliable sources.

PSU staff must complete the following activities for individuals within two business days from notification:

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

MFP Individuals

PSU staff do not complete the following activities for individuals applying for the Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) process:

• generate and mail Form 2442; or
• close the CSIL record.

PSU staff must complete the following activities for MFP individuals within two business days of notification:

• email the Interest List Management (ILM) unit the following information to document the CSIL record:
  • an email subject line that reads: MDCP MFP Denial for XX [first letter of the individual’s first and last name];
  • the following items in the body of the email:
    • individual's name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the individual to the MDCP interest list (IL) using their original MDCP request date;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days from notification:

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant or LAR;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• complete the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • inactivate the MDCP Enrollment Form;
• for non-MFP applicants, document and close the CSIL record, if applicable;
• for MFP applicants, email the ILM unit the following information for the CSIL record:
  • an email subject line that reads: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • SSN or Medicaid ID number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the applicant to the MDCP IL using their original MDCP request date;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • an email subject line that reads: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received in lieu of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, in the HEART case record, if applicable.

PSU staff must process a case termination notification for an MDCP member no earlier than 45 days, but by 30 days, before the last day of the month the member turns 21. The member will no longer receive MDCP services effective the first day of the month after the member’s 21st birth month.

PSU staff must complete the following activities for members no earlier than 45 days, but by 30 days, before the last day of the month the member turns 21:

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• remove page 2 of Form H2065-D and replace with Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP;
• mail Form H2065-D and Appendix XXIX to the member or LAR;
• upload page 1 of Form H2065-D to the MCOHub;
• for MAO members:
  • fax Form H1746-A to the MEPD specialist indicating the member aged out of MDCP and the termination effective date;
  • email the Enrollment Resolution Services (ERS) unit the following information:
    • an email subject line that reads: MDCP Termination for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid ID number;
      • the type of request: MDCP termination;
      • SK-ISP end date;
      • effective date of termination; and
  • Form H2065-D as an attachment;
• complete the following tasks in the TMHP LTCOP:
  • adjust the SK-ISP record and the MDCP Enrollment Form end dates to the last day of the member's 21st birth month; and
  • terminate the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• email the appropriate Intellectual and Developmental Disability (IDD) waiver program staff to advise of the MDCP termination date as the last day of the member’s 21st birth month if the member is transitioning from MDCP to an IDD waiver program;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

Adverse action is not required when an MDCP member transitions to another waiver.

6300.10 Other Reasons

Revision Notice 25-2; Effective July 11, 2025

Program Support Unit (PSU) staff must notify the PSU supervisor:

• if they encounter a scenario where an individual, applicant or member may need a case closure, denial or termination; and
• the reasons are not listed in 6300.1 through 6300.9.

The PSU supervisor will notify PSU staff:

• if the case closure, denial or termination can be processed; and
• what denial reason to use.

PSU staff must complete the following activities for individuals within two business days from PSU supervisor approval to proceed with case closure:

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or legally authorized representative (LAR);
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
• document and close the HEART case record.

MFP Individuals

PSU staff do not complete the following activities for individuals applying for the Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) process:

• generate and mail Form 2442; or
• close the CSIL record.

PSU staff must complete the following activities within two business days of notification an MFP individual has discharged a nursing facility (NF) before establishing eligibility for MDCP:

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the individual or LAR;
• email the Interest List Management (ILM) unit the following information:
  • an email subject line that reads: MDCP MFP Denial for XX [first letter of the individual’s first and last name];
  • the following items in the body of the email:
    • individual’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • contact name and phone number;
    • reason for the denial: MFP NF Discharge Prior to Eligibility Determination;
    • request to return the individual to the MDCP interest list (IL) using their original MDCP request date;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: This is the only situation where PSU staff generates Form H2065-D for an individual.

PSU staff must complete the following activities for applicants within two business days from PSU supervisor approval to deny the applicant:

• manually generate  Form H2065-D;
• mail Form H2065-D to the applicant or LAR;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• complete the following tasks in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable:
  • invalidate the STAR Kids individual service plan (SK-ISP) record; and
  • inactivate the MDCP Enrollment Form;
• for non-MFP applicants, document and close the CSIL record, if applicable;
• for MFP applicants, email the ILM unit the following information for the CSIL record:
  • an email subject line reads: MDCP MFP Denial for XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • SSN or Medicaid ID number;
    • contact name and phone number;
    • reason for the denial;
    • request to return the applicant to the MDCP IL using their original MDCP request date;
• email the Department of Family and Protective Services (DFPS) Developmental Disability Specialist (DDS) Manager the following information, if the applicant is enrolled in STAR Health:
  • an email subject line that reads: MDCP Determination for STAR Health Member XX [first letter of the applicant’s first and last name];
  • the following items in the body of the email:
    • applicant’s name;
    • Medicaid ID number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • a brief description of the MDCP denial; and
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: PSU staff must document Form H2067-MC, Managed Care Programs Communication, was received in lieu of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, in the HEART case record, if applicable.

PSU staff must complete the following activities for members within two business days from PSU supervisor approval to terminate the member:

• manually generate Form H2065-D;
• mail Form H2065-D to the member or LAR;
• upload Form H2065-D to the MCOHub;
• for MAO members:
  • fax Form H1746-A to the MEPD specialist;
  • email the Enrollment Resolution Services (ERS) unit the following information:
    • an email subject line that reads: MDCP Termination for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member’s name;
      • Medicaid ID number;
      • type of request: MDCP termination;
      • SK-ISP end date;
      • effective date of termination; and
    • Form H2065-D as an attachment;
• complete the following tasks the TMHP LTCOP;
  • adjust the SK-ISP record and the MDCP Enrollment Form end dates to the termination effective date; and
  • terminate the SK-ISP record and the MDCP Enrollment Form using the applicable denial reason;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

The applicability of the adverse action notification period is scenario specific.

PSU staff must refer to:

• 6200, Adverse Action Notification Period, for more information on determining the termination effective date.
• 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the applicant or member requests a state fair hearing.

PSU staff is not required to notify the PSU supervisor for the following denial or termination reasons:

• discharged from a nursing facility (NF) before PSU staff determined program eligibility;
• does not have an unmet need;
• moved out of state;
• declines assessment or will not allow the MCO to conduct the assessment; or
• failed to return Form H1200, Application for Assistance – Your Texas Benefits.

Revision 24-3; Effective Aug. 26, 2024

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of non-compliance listed in Texas Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM) Section 11.5. These reasons for noncompliance include:

• misusing or loaning the member’s MCO membership card to another person to get services;
• disruptive, unruly, threatening, or uncooperative behavior unrelated to a physical or behavioral health condition to the extent that the member’s membership seriously impairs the MCO’s ability to provide services to the member or to get new members; or
• steadfast refusal to comply with managed care restrictions such as repeatedly using emergency room in combination with refusing to allow the MCO to treat the underlying medical condition.

A member may also request to be disenrolled from managed care. Disenrollment from managed care means the member wants to remove themselves from managed care and receive services through fee-for-service (FFS) only. The member must receive approval from HHSC to disenroll from managed care.

Disenrollment is not the same as voluntarily withdrawing from the program. A member may voluntarily withdraw from MDCP without HHSC approval. Examples where a member may request to voluntarily withdraw from MDCP include:

• the member’s name came to the top of another Medicaid waiver program’s interest list, and the member chose to pursue the other Medicaid waiver program and withdraw from MDCP; or
• the member states they no longer want MDCP because they do not use any MDCP services.

Refer to the HHSC UMCM Section 16.2, STAR Health Medically Dependent Children Program (MDCP), for specific requirements for STAR Health members.

Members who receive HHSC approval to disenroll from managed care and maintain Medicaid eligibility, such as Supplemental Security Income (SSI) or SSI-related Medicaid, may continue receiving non-waiver services available through FFS Medicaid. Medical assistance only (MAO) members will lose Medicaid eligibility as well as waiver services.

Program Support Unit (PSU) staff must refer a member who requests disenrollment from managed care to HHSC Ombudsman’s Managed Care Assistance Team to 866-566-8989 to request to disenroll.

PSU staff must refer MCOs requesting a member be disenrolled from managed care to follow the policy outlined in UMCM Sections 11.5 and 11.6.

PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Contracts and Oversight (MCCO) Unit staff and the HHSC Disenrollment Committee will review each member and MCO request to disenroll. MCCO Unit staff will notify Program Enrollment & Support (PES) state office staff of an approved disenrollment request. PES state office staff will notify the appropriate PSU supervisor and request disenrollment. The notification will include the Medicaid Managed Care Member Disenrollment Form and the disenrollment date.

The PSU supervisor will email the disenrollment request to the assigned PSU staff for processing. PSU staff must complete the following activities within two business days of PSU supervisor assignment:

• create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record selecting “Disenrollment” in the Action Type field;
• select “Disenrollment. HPM Request. Add Never Not” as the Issue Type in the HEART case record;
• terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the effective date provided by the MCCO Unit and the termination reason, “Member requests service termination”;
• for MAO members, complete Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid the Elderly and People with Disabilities (MEPD) specialist requesting Medicaid termination effective the date of disenrollment provided by the MCCO Unit;
• upload applicable documents to the HEART case record;
• document that the member disenrolled in the HEART case record; and
• close the HEART case record.

PSU staff must not generate Form H2065-D, Notification of Managed Care Program Services, for an approved disenrollment. PSU staff are not required to notify Enrollment Resolution Services (ERS) Unit staff or the member of the approved disenrollment. MCCO Unit staff will send a Notice of Ineligibility to the member and work with ERS Unit staff to disenroll the member from managed care.

Revision Notice 25-2; Effective July 11, 2025

Program Support Unit (PSU) staff must notify the PSU supervisor by email if the status of a STAR Kids individual service plan (SK-ISP) and the Medically Dependent Children Program (MDCP) Enrollment Form needs to be reset in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The email must include the following:

• an email subject line that reads: TMHP ISP Reset Requested for XX [first letter of the applicant or member’s first and last name];
• the following items in the body of the email:
  • applicant or member’s name;
  • Social Security Number (SSN) or Medicaid identification (ID) number;
  • the SK-ISP record and the MDCP Enrollment Form’s document locator number (DLN); and
  • an explanation of the reason for the reset request.

Note: The explanation must include the correct termination date if the SK-ISP record was terminated on an incorrect date.

PSU staff must refer to Appendix I, PSU User Guide for the SK-ISP Form, for additional direction on moving an SK-ISP record into an invalidated or terminated status in the TMHP LTCOP.
 
 

Revision 25-4; Effective Dec. 12, 2025

Complaint is defined as any dissatisfaction expressed by a complainant, verbally or in writing, to the Texas Health and Human Services Commission (HHSC).

A complainant enrolled in a STAR Kids managed care organization (MCO) should first contact the Member Services hotline when they want to file a complaint against their MCO.

The complainant may contact the HHSC Office of the Ombudsman’s Managed Care Assistance Team to investigate the complaint if they are not satisfied with the outcome after exhausting the MCO's complaint process. A complainant may contact the HHSC Office of the Ombudsman’s Managed Care Assistance Team by:

• phone at:
  • 866-566-8989, 8 a.m. - 5 p.m., Monday – Friday; or
  • 7-1-1 or 800-735-2989, 8 a.m. - 5 p.m., Monday – Friday, if they have a hearing or speech disability;
• submitting the Online Question or Complaint Form;
• the internet: Ombudsman Managed Care Help;
• mail at the following address: Texas Health and Human Services Commission, Ombudsman for Managed Care, P.O. Box 13247, Austin, TX 78711-3247; or
• fax at 888-780-8099.

For the Medically Dependent Children Program (MDCP), the complainant may contact the HHSC Complex Care Services (CCS) to investigate a complaint. A complainant may contact the HHSC CCS by:

• phone at 844-999-9543; or
• email at MDCP_DBMD_Escalation@hhsc.state.tx.us.

Individuals not enrolled in a MCO can call the Medicaid helpline at 800-335-8957.

7110 PSU Staff Compliant Escalation Procedures

Revision 25-4; Effective Dec. 12, 2025

Program Support Unit (PSU) management may receive an escalation of a complaint by email from:

• the Texas Health and Human Services Commission (HHSC) Office of the Ombudsman;
• HHSC Managed Care Contracts and Oversight (MCCO) Compliance;
• Complex Care Services (CCS);
• Program Enrollment and Support (PES) leadership;
• staff-legislative inquires;
• HHSC Government Relations;
• HHSC Communications; or
• other reliable sources.

PSU management or their designee determine which PSU service area (SA) the escalation originates from. They forward the email to the assigned PSU staff and their supervisor within one business day of receipt. Legislative or media inquiries and escalations are subject to immediate review and response, less than a 24-hour turnaround.

The PSU supervisor or designated PSU staff must complete the following within two business days of receipt of the escalation email from PSU management:

• search the PES Escalation Intake Tracker to determine if an open escalation record exists for this person and issue;
• create a new Escalation Intake Tracker record, as needed; and
• update the Escalation Intake Tracker report with the following information:
  • Status – indicate the status of the escalation using a drop-down list of statuses.
    • Open – new escalation received;
    • Pending – escalation is pending completion; and
    • Closed – escalation complete, no further action needed.
  • Date Reported – record the date the escalation was received in MM/DD/YYYY format.
  • Issue Source – enter the source of the escalation.
  • Escalation Summary – provide a summary of the escalation.
  • Client/Reporter - enter the first and last name of the client the escalation is about or the person reporting the escalation, if applicable.
  • Medicaid ID or SSN – record the client’s Medicaid identification (ID) number or Social Security number (SSN). Always enter the Medicaid ID when it is available.
  • HEART Tracking Number – enter the unique tracking number assigned to the escalation record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).
  • Assigned To – specify the name of the PSU staff the escalation has been assigned to.
  • Progress Updates/Resolution – describe the steps taken to resolve the escalation. Note: Any new actions or developments must be dated and documented at least once a week.
  • Associated Files – attach relevant documents.
  • Issue Logged By – enter the person’s name or email address that is logging this escalation into the tracker.
  • ID – this field will auto populate a unique identification number for each escalation entered into the tracker. No PSU action is required for this field.

The Escalation Intake Tracker record may require more updates as the escalation is being processed.

PSU staff do not log loss of Medicaid eligibility referrals in the Escalation Intake Tracker.

The assigned PSU staff must complete the following within two business days of receipt of the escalation email from PSU management:

• create a new HEART case record using the Action Type Escalation;
• review the escalation and research all issues and concerns;
• provide a response to all parties listed on the email received from PSU management indicating detailed actions taken to resolve the escalation;
• provide weekly updates to all parties if issues or concerns cannot be immediately resolved;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record once all issues are resolved.

The PSU supervisor or designated PSU staff must review the Escalation Intake Tracker and provide an update on outstanding escalations at least once a week.

Revision 25-4; Effective Dec. 12, 2025

Title 1 Texas Administrative Code (TAC) Section 357.1, Definitions, states an appeal is a request for a review of an agency action or failure to act that may result in a fair hearing. A Medically Dependent Children Program (MDCP) applicant, member or  legally authorized representative has the right to request an appeal within 90 days from the effective date of a Texas Health and Human Services Commission (HHSC) action as shown in Title 1 TAC Section 357.3, Authority and Right to Appeal. The appeal request may be verbal or in writing.

A state fair hearing is an informal proceeding held before an impartial HHSC hearings officer where an applicant, member or LAR appeals an agency action, as shown in Title 1 TAC Section 357.1. 

7201 Timely or Non-timely State Fair Hearing Request

Revision 25-4; Effective Dec. 12, 2025

An applicant, member or legally authorized representative (LAR) may request a state fair hearing verbally or in writing.

A timely state fair hearing request for a Medically Dependent Children Program (MDCP) eligibility denial is received by Program Support Unit (PSU) staff no later than 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for an MDCP eligibility denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

PSU staff must create the appeal in the Texas Integrated Eligibility Redesign System (TIERS) for all state fair hearing requests that are received, except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. PSU staff must notify Appeals and Mitigation (A&M) staff by creating an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal if a fair hearing request is received for a MEPD or TW financial denial. PSU staff must refer to Appendix XXI, Creating an Appeal in TIERS and Appendix XII, Create an Appeal Task in the HHSC Benefits Portal, when creating records.

The hearing officer will determine if there is good cause for a non-timely state fair hearing request. The applicant or member is not eligible for a state fair hearing if the hearing officer determines if there is no good cause.

7210 Entering a State Fair Hearing In TIERS

Revision 24-4; Effective Dec. 1, 2024

Program Support Unit (PSU) staff may receive a verbal or written appeal request related to a Medically Dependent Children Program (MDCP) eligibility denial or termination from:

• an applicant;
• a member;
• the legally authorized representative (LAR); or
• the medical consenter.

PSU staff must complete the following activities within two business days of receipt of all appeal requests, except appeal requests resulting from a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial:

• create a new appeal case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), if necessary; and
• enter a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must refer to Appendix XXI, Creating an Appeal in TIERS, for detailed instructions on entering a state fair hearing in TIERS.

TIERS will assign an appeal identification (ID) number when PSU staff complete and submit the fair hearing in TIERS. PSU staff must document the appeal ID number in the HEART case record.

PSU staff must refer to:

• Section 7213, State Fair Hearing Evidence Packet, for additional activities PSU staff must complete on the same day as creating the fair hearing in TIERS.
• Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to an MEPD or TW financial eligibility denial.

7211 Reserved for Future Use

Revision 23-4; Effective Aug. 21, 2023

7212 Generation of the State Fair Hearing Packet

Revision 24-3; Effective Aug. 26, 2024

The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet. The packet is available to state fair hearing participants other than the applicant, member or legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), the Office of the Medical Director (OMD), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. A partial state fair hearing packet includes:

• Form H4800, Fair Hearing Request Summary; and
• Form H4803, Notice of Hearing.

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing is scheduled. The alert in TIERS identifies the hearings officer assigned to the state fair hearing and the date and time of the state fair hearing. PSU staff use this information to monitor for the decision of the state fair hearing. PSU staff do not attend state fair hearings unless it is related to a Supplemental Security Income (SSI) financial denial.

Once a state fair hearing has been scheduled, TIERS generates a full state fair hearing packet.  The hearings officer mails the packet to the applicant, member or LAR. A full state fair hearing packet includes:

• Form H4800;
• Form H4803;
• Fair Hearing Procedures (PDF); and
• Form H4806, Request for Another Appointment - Request to Withdraw.

7213 State Fair Hearing Evidence Packet

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS):

• prepare the state fair hearing evidence packet, as applicable;
• mail the state fair hearing evidence packet to the applicant, member or legally authorized representative (LAR);
• upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. Appeals and Mitigation (A&M) staff are responsible for creating all fair hearings related to MEPD and TW financial denials.

PSU staff must:

• refer to 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials; and
• ensure documentation clearly states the state fair hearing is for the Medically Dependent Children Program (MDCP).

The PSU state fair hearing evidence packet includes the following:

• Form 4801, State Fair Hearing Evidence Packet Cover Page;
• Form H2065-D,  Notification of Managed Care Services;
• the appropriate handbook section, notated on Form H2065-D;
• Appendix XVII, MDCP Eligibility TAC;
• Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, as applicable, for members transitioning from MDCP due to turning 21;
• the following documents, as applicable, for medical necessity (MN) denials or terminations:
  • Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants; or
  • Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members; and
  • any written requests for a state fair hearing, first position or advanced placement.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), the Office of the Medical Director (OMD), A&M or the Texas Medicaid & Healthcare Partnership (TMHP) will:

• generate their own state fair hearing evidence packet;
• upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
• mail their state fair hearing evidence packet to the applicant, member or LAR.

The hearings officer mails Form 4803, Notice of Fair Hearing, to the applicant, member, or LAR when the state fair hearings is first requested. The applicant, member, or LAR may fax or mail evidence to the hearings officer. The applicant, member or LAR gets the hearings officer’s contact information from Form H4803. The hearings officer shares any evidence submitted by the applicant, member, or LAR with HHSC.

7214 Changes to the State Fair Hearing Request Summary

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may learn of changes to an applicant or member’s information after entering the fair hearing into Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must complete the following activities as soon as possible but no later than 10 days from notification of the change:

• verify that a hearings officer has been assigned to the case by checking TIERS;
• complete Form H4800-A,  Fair Hearing Request Summary (Addendum), with the updated information;
• upload Form H4800-A to the Texas Health and Human Services Commission (HHSC) Benefits Portal;
• notify the hearings officer by email. The email to the hearings officer must include the following:
  • an email subject line that reads: Form H4800-A for XX [first letter of the applicant’s or member’s first and last name]
  • applicant or member’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number, as applicable;
  • HHSC State Benefits appeal ID number;
  • the type of request (i.e., notification of a change); and
  • Form H4800-A;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff must include the following on Form H4800-A:

• a clear statement indicating that this is a state fair hearing for Medically Dependent Children Program (MDCP); and
• the appeal ID number assigned by TIERS in the designated field on Form H4800-A.

PSU staff may also email Form H4800-A to the hearings officer if they encounter issues with uploading Form H4800-A to the HHSC Benefits Portal.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to Medicaid for Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denials. 

Delays in uploading documentation may delay the fair hearing or require the fair hearing to be rescheduled.

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

7221 Type of Denials

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff procedures to process a fair hearing vary based on the denial reason. For example, PSU staff notify Appeals and Mitigation (A&M) staff using the Texas Health and Human Services Commission (HHSC) Benefits Portal if the appeal request is a result of a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial. PSU staff create a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) for all other denial reasons when the applicant or member requests a fair hearing.

Refer to the following sections for more information about processing an appeal request for the following denial reasons:

• 7221.1, Medical Necessity Denial by the Office of the Medical Director , for a medical necessity (MN) denial reason;
• 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for a MEPD or TW financial eligibility denial reason;
• 7221.3, Supplemental Security Income Denial by the Social Security Administration, for a supplemental security income (SSI) denial reason; or
• 7221.4, Other Denial Reasons, for any other denial reason.
   

7221.1 Medical Necessity Denial by the Office of the Medical Director 

Revision 26-1; Effective March 16, 2026

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a medical necessity (MN) denial or termination:

• Create the following within two business days from receiving the appeal request:
  • A new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered.
  • A fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI, Creating an Appeal in TIERS.
• Prepare, mail and upload the state fair hearing evidence packet, as noted in 7213, State Fair Hearing Evidence Packet. Do this on the same date PSU staff create the fair hearing in the HHS Benefits Portal.
• Complete Form H4800-A, Fair Hearing Request Summary (Addendum) if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS.
• Maintain the applicant on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant requested the fair hearing.
• Monitor the fair hearing case for the receipt of the TIERS alert showing the hearings officer rendered their decision.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

PSU staff do not attend the fair hearing for MN denials or terminations.

Refer to 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information about continuing MDCP benefits during the fair hearing. 
 

7221.2 Financial Denial by MEPD or Texas Works

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must forward the request for a state fair hearing to Appeals and Mitigation (A&M) staff. This is if the denial involves an applicant or member not receiving Supplemental Security Income (SSI) who does not meet financial criteria through the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) programs. A&M staff must attend the state fair hearing to represent Medically Dependent Children Program (MDCP) financial denials.

Within one business day of receipt of the request, PSU staff must create:

• An appeal task in the Texas Health and Human Services (HHS) Benefits Portal in the Appeals/RFR tab for A&M staff about a financial denial for an non-SSI applicant or member. Refer to Appendix XII, Create an Appeal Task in the HHSC Benefits Portal.
• An email to A&M staff at the HHSC Access and Eligibility Services (AES) Fair Hearing mailbox that includes:
  • this subject line: MDCP Appeal Request - XX [first letter of the applicant or member’s first and last name] #### [last 4-digits of the case number];
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service: MDCP;
    • timeliness of receipt of the appeal;
    • specific information requesting the MEPD or TW financial case remain open during the state fair hearing, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing;
    • observers contact information noted as the PSU staff and PSU supervisor;
  • a copy of Form H2065-D, Notification of Managed Care Program Services, signed, if available.
• A case record in the HHS Enterprise Administrative Report and Tracking System (HEART) documenting:
  • the receipt date of the state fair hearing request; and
  • notification to A&M staff for completion of Form H4800, Fair Hearing Request Summary.

PSU staff must refer to 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information.

A&M will send the PSU staff and supervisor listed as observers an email with the appeal ID number within five days of receipt of a state fair hearing request as notice Form H4800  was completed. PSU staff must upload the notification in the HEART case record and monitor the appeal until the state fair hearing decision is rendered.

PSU staff must:

• not put an applicant or member name back on the MDCP interest list while an MEPD or TW financial denial are in the state fair hearing process; and
• take appropriate action to certify or deny the case or resume services once the MEPD or TW financial denial state fair hearing decision is rendered.

The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

PSU staff and the PSU supervisor entered as observers are notified by an email alert from TIERS of the hearing officers rendered decision when the decision is rendered.

PSU staff must refer to 7500, State Fair Hearing Decision Actions, for more information about required actions after the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a supplemental security income (SSI) financial eligibility denial:

• create the following within two business days from the receipt of the appeal request:
  • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered; and
  • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS);
• prepare, mail and upload the state fair hearing evidence on the same day PSU staff create the fair hearing in TIERS;
• complete Form H4800-A, Fair Hearing Request Summary (Addendum), if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
• maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
• attend and present the state fair hearing evidence packet during the fair hearing;
• monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff attend the fair hearing for SSI denials and terminations. Refer to Section 7232, Presentation of the State Fair Hearing Evidence Packet, for more information about PSU procedures during the fair hearing.

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI terminations. 

7221.4 Other Denial Reasons

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff may receive a state fair hearing request for other denial and termination reasons. Other denial reasons include:

• living arrangement is not an allowable setting;
• voluntarily declined services;
• unable to locate the applicant or member;
• failure to get physician signature; or
• exceeding the STAR Kids individual service plan (SK-ISP) cost limit.

Managed care organization (MCO) staff must prepare the evidence packet and attend the state fair hearing if the action relates to other denial reasons. PSU staff do not attend state fair hearings related to other denial reasons.

PSU staff must complete the following activities for an appeal request not related to a denial reason listed in 7221.1 through 7221.3:

• create the following within two business days from receipt of the appeal request:
  • a new appeal case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), if necessary; and
  • a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS);
• refer to 7214, Changes to the State Fair Hearing Request Summary, as soon as possible but no later than 10 days from notification of changes to the applicant or member’s information after entering the state fair hearing in TIERS;
• monitor the state fair hearing case for the receipt of the TIERS alert showing the hearings officer rendered their decision;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must refer to 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information about continuing Medically Dependent Children (MDCP) benefits during the state fair hearing.

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

7222.1 Continuation of MDCP Benefits During a State Fair Hearing

Revision 25-3; Effective Oct. 20, 2025

Medically Dependent Children Program (MDCP) benefits must continue until the hearings officer issues a decision if the member or legally authorized representative (LAR) files a state fair hearing requesting continued benefits:

• within the adverse action notification period of the MDCP termination; or
• by the effective date of the action pending the state fair hearing.

The deadline is the date that is later.

Continuation of MDCP benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials.

PSU must refer to 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

PSU staff must complete the following activities within one business day of entering a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), if the member appeals within the adverse action notification period or by the effective date of the action:

• Extend the current STAR Kids individual service plan (SK-ISP) record and MDCP Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) in four calendar month intervals. Example: The member’s four-month period would end on April 30, 2023, if the SK-ISP expiration date is Dec. 31, 2022.
• Upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) to continue providing MDCP benefits until the hearings officer renders a decision.
• For members not receiving SSI, email Appeals and Mitigation (A&M) staff at the Texas HHSC Access and Eligibility Services (AES) Fair Hearings email the following:
  • this email subject line: MDCP Request for Continued Benefits – XX [first letter of the member’s first and last name] #### [last four digits of the case number];
  • the following items in the body of the email:
    • member's name;
    • Medicaid identification (ID) number;
    • HHS Benefits Portal Appeal ID number, if available;
    • TIERS case number;
    • type of service: MDCP;
    • reason for termination such as a medical necessity (MN) denial;
    • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD), or Texas Works (TW) financial termination case remain open during the state fair hearing such as;
      • the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision about MN; and
      • the witnesses’ contact information, such as the MCO representative and the designated MCO back-up.
• Upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
• Document the HEART case record.
• Monitor the case for the receipt of the TIERS alert showing the hearings officer’s decision.

Note: PSU staff must mail the member or LAR the following forms to be tested for medical assistance only (MAO) Medicaid, if the member loses Texas Works or Foster Care Medicaid during the state fair hearing:

• Form H1200, Application for Assistance – Your Texas Benefits; and
• Form 2606, Managed Care Enrollment Processing Delay.

PSU staff must not mail Form H2065-D, Notification of Managed Care Program Services, to the member or LAR notifying of continued MDCP benefits.

HHSC continues MDCP benefits pending the hearings officer’s decision if:

• the state fair hearing is initially dismissed;
• then reopened later; and
• the member or LAR requests continued benefits.

The hearings officer voids the past fair hearing decision if they set a date for a new state fair hearing. The member must continue to receive MDCP benefits until the hearings officer renders a new state fair hearing decision.

7222.2 Discontinuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 24-4; Effective Dec. 1, 2024

A member’s Medically Dependent Children Program (MDCP) services must continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services. The MDCP denial date is the last day of the month of the current STAR Kids individual service plan (SK-ISP) or the last day of the month that the adverse action notification period ends, whichever is later. Program Support Unit (PSU) staff must refer to section 6200, Adverse Action Notification Period, for more information.

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued MDCP services during the state fair hearing. PSU staff must monitor the case for the receipt of the Texas Integrated Eligibility Redesign System (TIERS) alert indicating the hearings officer’s decision.

Supplemental Security Income (SSI) members will remain enrolled in STAR Kids after MDCP termination. SSI members remain eligible for Medicaid state plan services, which include acute care and long-term services and supports (LTSS), such as Community First Choice (CFC) and Personal Care Services (PCS).

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal on the same day PSU staff enter the state fair hearing.

PSU staff must:

• select the Appeals/RFR tab and ensure the appeal was entered in the Texas Integrated Eligibility Redesign System (TIERS);
• select Hearing Evidence Packets Upload and enter the appeal identification (ID) number;
• select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
• select Validate;
• check the details to ensure the right person has been selected;
• browse for the document (e.g., Form H2065-D, Notification of Managed Care Program Services);  
• select Upload;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

PSU staff must refer to Section 7213, State Fair Hearing Packet, for documentation PSU staff must submit as evidence.

PSU staff must correct errors found in the state fair hearing task in TIERS.

PSU staff must correct errors made on: 

• the "Agency Representative" screen in TIERS using the "Maintain Appeals" screen in TIERS; and
• any other screen in TIERS by completing and uploading Form H4800-A, Fair Hearing Request Summary (Addendum), to the HHSC Benefits Portal. 

The "Agency Action Date" cannot be changed.

PSU staff must refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for Medicaid for Elderly and Persons with Disabilities (MEPD) or Texas Works (TW) financial denials.

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 22-1; Effective January 31, 2022

The hearings officer will not consider documentation in the evidence packet in the state fair hearing decision unless the packet is offered and admitted into evidence. The “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence and summarize what the packet contains. Program Support Unit (PSU) staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

MCO Example: "I want to offer the following packet as evidence in the state fair hearing filed on behalf of Ned Flanders.

• Pages 1-10 contain information relating to the completion of Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.
• Pages 11-15 contain policy from the STAR Kids Handbook (SKH) that relates directly to the issue in question.
• Pages 16-20 contain documents signed by the applicant, member or legally authorized representative (LAR) related to individual rights.
• Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or LAR on March 2."

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on behalf of Ned Flanders.

• Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
• Page 2 contains a copy of Appendix XVII, MDCP Eligibility TAC that states the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR Kids Medically Dependent Children Program (MDCP) services to eligible applicants or members.
• Page 3 contains a copy of the Section 6300.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR Kids MDCP services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) program requirements.
• Page 4 contains Form H2065-D, which was mailed to the applicant, member or LAR on March 2nd."

The hearings officer then asks for objections and admits the documents into evidence. The hearings officer explains the reasons for excluding the material if the hearings officer is not able to admit any documents. The hearings officer considers any documents admitted when rendering a decision.

7310 Action Taken on Reversed State Fair Hearing Decisions

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must update the hearings officer of actions taken on reversed state fair hearing decisions. This is if PSU staff attended the state fair hearing to defend the action on appeal.

PSU staff must complete the following activities for an applicant or member within 10 days from the date the hearings officer issues a reversed decision. This is if PSU staff were at the state fair hearing and defended the action on appeal:

• enter PSU staff actions taken in the Texas Integrated Eligibility Redesign System (TIERS), Hearings and Appeals, Decision Implementation screen; or
• complete Form H4807, Action Taken on Hearing Decision, and email it to the hearings officer and the PSU supervisor noting actions taken, if PSU staff cannot update the Decision Implementation screen in TIERS.

PSU staff must complete the following activities for an applicant or member  within 10 days from the date the hearings officer issues a reversed decision. This is if PSU staff were at the state fair hearing and defended the action on appeal, but face a delay in acting on the hearings officer’s decision:

• notify the PSU supervisor by email; and
• enter the reason for the delay in the Decision Implementation screen in TIERS, noting the begin and end delay dates; or
• complete Form H4807 and email it to hearings officer and the PSU supervisor, if PSU staff cannot enter the delay in the Decision Implementation screen in TIERS.
   

Revision Notice 25-4; Effective Dec. 12, 2025

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in the Texas Integrated Eligibility Redesign System (TIERS) advising that the hearings officer issued a decision. The hearings officer sends the written decision to all individuals entered on the state fair hearing in TIERS. This includes PSU staff and the PSU supervisor.

The hearings officer issues the following state fair hearing decisions:

• Sustained decision when the hearings officer determines the Texas Health and Human Services Commission’s (HHSC’s) action was appropriate per policy and law.
• Reversed decision when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) services.

The hearings officer specifies the corrective actions to take, and a 10-day time frame to complete these actions, if the hearing decision is reversed.

PSU staff must refer to 7310, Action Taken on Reversed State Fair Hearing Decisions, for more actions PSU staff must take if PSU staff were at the state fair hearing to defend the action on appeal, and the fair hearings officer issues a reversed decision. 

7510 Sustained State Fair Hearing Decision

Revision 26-1; Effective March 16, 2026

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the Medically Dependent Children Program (MDCP) denial or termination. 

The hearings officer dismisses the state fair hearing and sustains the action on appeal, if an applicant or member fails to appear for a state fair hearing without good cause. 

7510.1 Sustained State Fair Hearing Decision for Applicants

Revision 26-1; Effective March 16, 2026

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants. 

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the applicant or legally authorized representative (LAR) of the sustained termination. 

7510.2 Sustained State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 26-1; Effective  March 16, 2026

Program Support Unit (PSU) staff must complete the following activities within two business days from notification of the hearings officer’s decision to sustain the termination of a member who received continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) that the:
  • hearing decision sustained the action on appeal; and
  • MCO must deliver services through the MDCP services end date in 7511, Sustained Decision – Termination Effective Date;
• complete the following steps in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP):
  • adjust the STAR Kids individual service plan (SK-ISP) and MDCP Enrollment Form to the end date noted in 7511; and
  • terminate the SK-ISP and MDCP Enrollment Form using the applicable denial reason;
• for medical assistance only (MAO) members, email: 
  • Enrollment Resolution Services (ERS) unit staff the following information:
    • this subject line: Hearings Officer Decision – STAR Kids MDCP – Sustained Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member's name;
      • Medicaid identification (ID) number;
      • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
      • Texas Integrated Eligibility Redesign System (TIERS) case number;
      • MDCP termination effective date;
      • state fair hearing decision; and
    • Form H2065-D, Notification of Managed Care Program Services, as an attachment;
  • Appeals and Mitigation (A&M) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to A&M staff must include the following information:
    • this subject line: Sustained Benefits for MDCP – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member's name;
      • Medicaid ID number;
      • type of request: notification of sustained MDCP benefits;
      • type of service: MDCP;
      • HHSC Benefits Portal appeal ID number;
      • TIERS case number;
      • MDCP termination effective date; and
      • state fair hearing decision;
• 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.

Note: A&M staff terminate Medicaid eligibility for MAO members.

PSU staff must complete the actions in 7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial. This must be done on the same day the activities above are completed, if the member’s MN denial was sustained.

PSU staff do not send Form H2065-D to notify the member or legally authorized representative (LAR) of the sustained termination.

7510.3 Sustained State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 26-1; Effective March 16, 2026

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for members not requesting continued Medically Dependent Children Program (MDCP) benefits. This is for any reason besides medical necessity (MN) denials by the Office of the Medical Director (OMD).

PSU staff must complete the actions in 7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial, once notified of the hearings officer’s decision to sustain an MN denial.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member or legally authorized representative (LAR) of the sustained termination. 

7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial 

Revision 26-1; Effective March 16, 2026 

Program Support Unit (PSU) staff must complete the following activities within two business days from notification of a hearings officer’s decision to sustain a Medically Dependent Children Program (MDCP) member’s medical necessity (MN) denial:

• contact the member or legally authorized representative (LAR) to discuss first position and advanced placement, if the member or LAR has not already requested first position or advanced placement: 
  • a member who previously requested first position can only be offered the advanced placement option; 
  • first position can only be pursued one time; 
  • PSU staff must attempt a second contact within two business days of this call if the member or LAR does not answer or does not have voice mail;
• document the following in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record:
  • outcome of the call using the following format: Contact [made on MM/DD/YYYY] or [attempted on MM/DD/YYYY] to phone number [XXX-XXX-XXXX] to explain state fair hearing decision, first position and advanced placement. PSU staff spoke to [first and last name of the person contacted];
  • the member’s request for:
    • first position and advanced placement, if received during the call; and
    • the following, if first position is selected:
      • a new MCO or to remain with their previous or current MCO upon interest list release (ILR); and
      • a different service coordinator with the previous or current MCO, if applicable;
• upload all applicable documents to the HEART case record; 
• document and close the HEART case record; and
• refer to 5400.2, First Position and Advanced Placement Assignments Following a Sustained MN Denial, for instructions on creating a first position and advanced placement HEART case record. 

7511 Sustained Decision – Termination Effective Date

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must adjust the member’s STAR Kids individual service plan (SK-ISP) end date and terminate the SK-ISP per the fair hearings officer’s sustained decision when the member received:

• continued Medically Dependent Children Program (MDCP) benefits during the fair hearing; and
• a sustained fair hearing outcome.

The final termination effective date varies depending on the following: 

• hearings officer’s decision date;
• original SK-ISP date; and
• SK-ISP expiration date as a result of the member receiving continued MDCP benefits during the fair hearing.

See below table for further clarification of each scenario.

Scenario 1: PSU staff must adjust the extended SK-ISP end date back to the historical SK-ISP end date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision is 30 days or more before the end of the historical SK-ISP end date. 

Scenario 2: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date (the date the order is signed) if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is 30 days or less before the end of the historical SK-ISP end date.

Scenario 3: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is:
  • after the end of the SK-ISP in effect when the member filed the state fair hearing; and
    • before the end of the extended SK-ISP date.

7520 Reversed State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A reversed fair hearing decision occurs when the hearings officer determines the Texas Health and Human Services Commission (HHSC) action was not appropriate per policy and law. HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits when the hearings officer issues a reversed fair hearing decision.

7520.1 Reversed State Fair Hearing Decision for Applicants 

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse an applicant’s denial: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision reversed the action on appeal;
• reactivate the STAR Kids individual service plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the Enrollment Form;
• edit the SK-ISP and Enrollment Form dates in the TMHP LTCOP using the effective dates noted in section 7521,  Reversed Decision – Effective Date;
• close the Community Services Interest List (CSIL) record if the record is open; and
• follow current policy noted in the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section 2000, Medically Dependent Children Program Intake and Initial Application,  for approving Medically Dependent Children Program (MDCP) applicants.

7520.2 Reversed State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 24-3; Effective Aug. 26, 2024

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who received continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) that the:
  • hearing decision reversed the action on appeal;
  • MDCP benefits must continue as directed in the hearings officer’s decision;
  • MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable; and
  • new SK-ISP is due within two business days of the fair hearing officer’s decision.
• edit the original SK-ISP end date in the TMHP LTCOP to match the historical SK-ISP end date, if applicable;
• update the MDCP Enrollment Form in the TMHP LTCOP, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must notify the Managed Care Contracts and Oversight (MCCO) Unit if the MCO fails to submit the new ISP within the required time frame.

PSU staff must include the following components when emailing the MCCO Unit staff:

• an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name];
• the following items in the body of the email:
  • member’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP effective date in the TMHP LTCOP using the effective date noted in section 7521, Reversed Decision – Effective Date, and adjust as needed;
• close the Community Services Interest List (CSIL) record if the record is open;
• generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7520.3 Reversed State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
• hearing decision reversed the action on appeal;
• MDCP benefits must be reinstated as directed in the hearings officer’s decision; and
• MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• edit the original SK-ISP and Enrollment Form end date in the TMHP LTCOP to match the historical SK-ISP and Enrollment Form end date, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of the new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP and Enrollment Form effective date in the TMHP LTCOP using the effective dates noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed;
• close the Community Services Interest List (CSIL) record if the record is open;
• generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• for medical assistance only (MAO) members, email the Enrollment Resolution Services (ERS) Unit staff. The email to the ERS Unit must include the following information:
  • a subject line that reads: “Hearings Officer Decision – STAR Kids MDCP – Reversed Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid identification (ID) number;
  • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
  • the Texas Integrated Eligibility Redesign System (TIERS) case number;
  • SK-ISP receipt date;
  • SK-ISP begin date;
  • SK-ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • the state fair hearing decision; and
  • Form H2065-D;
• for MAO members, email the Centralized Representation Unit (CRU) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
  • a subject line that reads: “Reinstatement of Benefits for MDCP – Appeal ID ####### for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid ID number;
  • the type of request (i.e., reinstate Medicaid eligibility);
  • the type of service (i.e., MDCP);
  • HHSC Benefits Portal appeal ID number;
  • the TIERS number;
  • TIERS Medicaid eligibility effective date;
  • the state fair hearing decision; and
  • Form H1746-A, MEPD Referral Cover Sheet;
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7521 Reversed Decision – Effective Date

Revision 23-4; Effective Aug. 21, 2023

The effective begin date for the STAR Kids individual service plan (SK-ISP) for a reversed fair hearing decision depends on if the appellant is an applicant, member with continued Medically Dependent Children Program (MDCP) benefits or member without MDCP continued benefits.

The SK-ISP begin date for an applicant is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer.

The SK-ISP begin date for a member who received continued MDCP benefits is the first day of the month following the end of the SK-ISP in effect when the state fair hearing was filed.

The SK-ISP begin date for a member who did not receive continued MDCP benefits is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer. 

Program Support Unit (PSU) staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the Central Representation Unit (CRU). 
 

7522 New Assessment Required by State Fair Hearing Decision

Revision 25-4; Effective Dec. 12, 2025

If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed because of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must show in the section labeled Summary of agency action and applicable handbook reference(s) or rules on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving before the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided before the first state fair hearing. If the new assessment results in MN approval but a lower Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level and the member or LAR requests a state fair hearing due to the lower PDPM LTC level, the MCO continues services at the same level services were provided before the first state fair hearing.

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018

An applicant, member or legally authorized representative (LAR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or LAR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or LAR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or LAR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or LAR and must be made to the hearings officer.

If the applicant, member or LAR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or LAR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.

Revision 25-1; Effective May 16, 2025

1 Texas Administrative Code (TAC) Section 357.5 indicates the Texas Health and Human Services Commission (HHSC) hearings officer:

• conducts the fair hearing as an informal proceeding, not as a formal court hearing, and is not required to follow the Texas Rules of Evidence or the Texas Rules of Civil Procedure;
• determines if an applicant, member, legally authorized representative (LAR) or medical consenter requested a fair hearing in a timely manner, or had good cause for failing to do so;
• schedules a pre-hearing conference to resolve issues of procedure, jurisdiction, or representation, if necessary;
• requires the attendance of agency representatives, or witnesses, as needed;
• is prohibited from engaging in ex parte communication, whether verbal or written, with a party or the party's representative or witness relating to matters to be adjudicated; and
• arranges for reasonable accommodations for disclosed disabilities.

During the fair hearing, the HHSC hearing’s officer:

• makes the official recording of the hearing;
• ensures the applicant, member, LAR, medical consenter and HHSC’s rights are protected;
  determines if there is a need for an interpreter;
• limits the number of people in attendance at the hearing if space is limited;
• controls the use by others of cameras, videos or other recording devices;
• administers oaths and affirmations;
• ensures consideration of all relevant points at issue and facts pertinent to the applicant, member, LAR or medical consenter’s situation at the time the action was taken;
• considers the applicant, member, LAR or medical consenter’s changed circumstances, when appropriate and possible;
• requests, receives, and makes part of the record all relevant evidence;
• regulates the conduct and course of the fair hearing to ensure due process and an orderly hearing;
• conducts the hearing in a way that makes the applicant, member, LAR or medical consenter feel most at ease; and
• orders, if determined to be necessary, an independent medical assessment or professional evaluation to be paid for HHSC or HHSC’s designee.

After the hearing, the hearings officer:

• makes a decision based on the evidence presented at the fair hearing;
• determines if HHSC’s action is in compliance with statutes, policies, or procedures;
• allows the applicant, member, LAR or medical consenter to request and receive a copy of the recording at no charge;
• issues a timely written decision, and includes findings of fact, conclusions of law, pertinent statutes, and a final order; and
• ensures compliance, orders HHSC to implement the order within the time limits specified in the relevant federal regulation, monitors compliance with the order, and notifies program management if the order is not implemented.
   

Revision 18-0; Effective September 4, 2018

Utilization Review (UR) is a division within the Medicaid and Children’s Health Insurance Program (CHIP) Division of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Title 4 Texas Government Code Section 533.00281 to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of appropriate utilization of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.

STAR Kids managed care organizations (MCOs) must allow UR access to documents, assessments, notes and authorizations contained in the MCO STAR Kids member’s file available upon request. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

6-2019

Appendix I, PSU User Guide for the SK-ISP Form

Revision Notice 25-2; Effective July 11, 2025

Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter more language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix II.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

PSU staff must enter the denial reason in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) associated with the denial reason on Form H2065-D and Form H2065-DS. The denial reason in the TMHP LTCOP associated with the denial reason on Form H2065-D and Form H2065-DS is listed in the TMHP Denial Reason column in the table below.

Denial and Termination Reason Language

The table below contains language PSU staff must enter in the Reason for Denial and Comments field on Form H2065-D and Form H2065-DS for denials and terminations.

PSU staff must enter the related STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section that supports the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.

Approval Language

The table below contains language PSU staff must enter in the Comments field on Form H2065-D and Form H2065-DS for approvals.

Note: PSU staff must enter Pending and Calculando in the Copayment fields on the English and Spanish versions of Form H2065-D, if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist has not provided copayment amounts at the time Form H2065-D is generated. This applies to cases where an applicant or member has or will have a copayment.

Revision 22-3; Effective Sept. 9, 2022

Documents:

• English (Word)
• Spanish (Word)

Revision 26-1; Effective March 16, 2026 

This appendix outlines the screenshots Program Support Unit (PSU) staff must upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below to upload documents to the HEART case record. Refer to Appendix IX, STAR Kids MCOHub Naming Conventions, for the MCOHub naming convention instructions.

PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2 and the third form sent or received as 1746_3. Continue this sequence numbering for as long as needed.

PSU staff must upload all screenshots, forms, documents, and emails marked as Yes, in the Required column in the HEART case record. PSU staff must include screenshots, forms, documents, and emails marked with an * in the Required column in the HEART case record if used by PSU staff while completing the case.

Interest List Release (ILR)

Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.

Money Follows the Person (MFP)

Annual Reassessment

Transition to Adult Programs (MDCP Age-Out)

Denials and Terminations

Note: PSU staff uploads Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.

Fair Hearings

Disenrollment

Revision 19-6; Effective March 25, 2019
 

English PDF: The Medically Dependent Children Program
Spanish PDF: El Programa para Niños Médicamente Dependientes

Revision 26-2; Effective June 1, 2026

Documents

• Fair Hearing and Interest List Options for MDCP Denials - Members (English PDF)
• Fair Hearing and Interest List Options for MDCP Denials - Members (Spanish PDF)

Revision 26-2; Effective June 1, 2026

Documents

• Fair Hearing Options for MDCP Denials – Applicants (English PDF)
• Fair Hearing Options for MDCP Denials - Applicants (Spanish PDF)

3-2019

PDF Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide

Revision 26-1; Effective March 16, 2026

English: Fair Hearing and Interest List Options for Aging Out of MDCP (PDF) 

Spanish: Fair Hearing and Interest List Options for Aging Out of MDCP (PDF)