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.