Revision 19-13; Effective November 5, 2019

The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living (ADLs), minor home modifications (MHM), respite care (short-term supervision) and personal assistance services (PAS). These services are delivered through providers contracted with managed care organizations (MCOs).

The STAR+PLUS program provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.

Service coordination, available to all members, is the main feature of the STAR+PLUS program. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.

The STAR+PLUS Home and Community Based Services (HCBS) program is a program approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility (NF) care to receive LTSS to be able to live in the community.

Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to the STAR+PLUS HCBS program. For a dictionary of acronyms used in the STAR+PLUS HCBS Program, refer to Appendix VII, Acronyms.

The STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) includes operational procedures for the Texas Health and Human Services Commission (HHSC) Program Support Unit (PSU) staff.

The STAR+PLUS Handbook (SPH) includes policies and procedures to be used by MCOs, contractors and service providers in the delivery of STAR+PLUS HCBS program services to eligible members.

1110 Legal Basis

Revision 25-2; Effective June 6, 2025

Statutory basis for the STAR+PLUS program:

• Title 1 Texas Administrative Code (TAC), Section 353.601-607 and Chapter 353.1153; and
• Title 4 Government Code, Executive Branch, Subtitle I, Health and Human Services, Chapter 533, Medicaid Managed Care Program.

1120 Values

Revision 18-0; Effective September 4, 2018

The principles and practices that form the foundation for the STAR+PLUS Home and Community Based Services (HCBS) program are based on the following values:

• Members receive services based on their choices and ongoing assessment of their medical and functional needs.
• The service delivery system is accessible to the member, responsive to his or her needs and preferences, and flexible in honoring choices regarding living arrangement, services and mode of service delivery.
• Members use available family, community and third-party services and resources, as well as those provided through the STAR+PLUS HCBS program to meet their needs and identified goals.
• Services provided to the member must provide safe, cost-effective, and medically or functionally necessary alternatives to nursing facility (NF) placement that allow the member the opportunity to use and maintain family and community contacts and services.
• The individual service plan (ISP) reflects the member's active participation in the assessment and planning process and his or her responsibility to provide as much self-care as possible.
• Services must support the member's efforts to retain or regain as much independence as possible in the activities of daily living (ADLs), living arrangement and other areas of personal choice, and in meeting any goals.
• Individuals and members are provided the education, support and services needed to support the member's efforts to remain in or return to the community.
• Within the constraints imposed by the cost limit on a member's ISP, the program promotes the member's active involvement and choices regarding the services provided.

1130 Mission Statement

Revision 19-13; Effective November 5, 2019

The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to adults 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+PLUS 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;
• foster program innovation; and
• achieve cost efficiency and cost containment.

1140 STAR+PLUS HCBS Program

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program is a home and community based services program authorized under 1915(c) of the Social Security Act. The STAR+PLUS HCBS program provides respite care, minor home modifications (MHMs), adaptive aids, Transition Assistance Services (TAS), employment assistance (EA), supported employment (SE) and financial management services (FMS) through a STAR+PLUS managed care organization (MCO). This section provides an overview of the STAR+PLUS HCBS program, including its eligibility requirements.

1150 STAR+PLUS HCBS Program Goal

Revision 19-13; Effective November 5, 2019

The goal of the STAR+PLUS Home and Community Based Services (HCBS) program is to support and encourage de-institutionalization of adults age 21 years or older who reside in nursing facilities (NFs).

The STAR+PLUS HCBS program accomplishes this goal by:

• enabling adults who are to remain safely in their homes and/or community;
• offering cost-effective alternatives to placement in NFs; and
• supporting families in the role as the primary caregiver.

Revision 25-2; Effective June 6, 2025

An individual is eligible to be assessed for the STAR+PLUS Home and Community Based Services (HCBS) program when their name reaches the top of the STAR+PLUS HCBS program interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) Interest List Management (ILM) unit or their managed care organization (MCO) if he or she is already enrolled in STAR+PLUS. For medical assistance only (MAO) individuals, once their name reaches the top of the interest list, select an MCO who begins the STAR+PLUS HCBS program eligibility determination process. For individuals currently receiving Medicaid and who are already enrolled with an MCO, they may be able to bypass the interest list through the upgrade process. An individual living in a nursing facility (NF) may become eligible for the STAR+PLUS HCBS program by pursuing the Money Follows the Person (MFP) process.

An interest list release individual becomes an applicant when he or she is released from the interest list, confirm interest in the STAR+PLUS HCBS program, and have submitted Form H1200, Application for Assistance – Your Texas Benefits. A non-STAR+PLUS individual pursuing the MFP process becomes an applicant when PSU staff submit a referral to the MCO to begin initial assessment activities. A STAR+PLUS individual pursuing the MFP or upgrade process becomes an applicant when the MCO submits a notice that an assessment has been conducted.

The STAR+PLUS HCBS program is provided by authority granted to the state of Texas. It allows delivery of long-term services and supports (LTSS) that help members live in the community in lieu of a nursing facility (NF). To be eligible for services under the STAR+PLUS HCBS program, the applicant or member must meet the following criteria:

• be 21 years or older;
• have full Medicaid financial eligibility;
• be a U.S. citizen;
• be a resident of Texas;
• have an approved medical necessity (MN) for an NF level of care (LOC);
• have an individual service plan (ISP) with services under the established cost limit;
• have an unmet need for at least one STAR+PLUS HCBS program service; and
• be living in an appropriate living situation.

Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1)(F) states STAR+PLUS HCBS program members cannot be enrolled in more than one Medicaid waiver program at the same time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

1210 Age

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(A), STAR+PLUS Home and Community Based Services (HCBS) Program, states an applicant or member must be age 21 or older to be eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff verify the applicant’s age in the Texas Integrated Eligibility Redesign System (TIERS) upon initial entry into the STAR+PLUS HCBS program.

1220 Medicaid Financial Eligibility

Revision 25-2; Effective June 6, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1)(G) states an applicant or member must be determined financially eligible for Medicaid to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must determine if an applicant or member is eligible for Medicaid by checking the Texas Integrated Eligibility Redesign System (TIERS).

For individuals who do not have Medicaid eligibility, PSU staff must mail Form H1200, Application for Assistance – Your Texas Benefits, to the individual. PSU staff must fax Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for a Medicaid eligibility determination once Form H1200 is received back from the applicant.

An individual who does not have Medicaid eligibility may have Form H1200 on file with the Texas Health and Human Services Commission (HHSC). These individuals may not need to complete a new Form H1200 if Form H1200 was received by HHSC within 60 days for an initial application or 90 days for an interest list release (ILR) reopen. PSU staff must encourage the individual to submit a new Form H1200 if there have been changes in the individual’s financial situation since the last submission of Form H1200. PSU staff must verify if the individual has a current Form H1200 on file if the individual claims that they do by checking the Health and Human Services (HHS) Benefits Portal.

For individuals who have Medicaid eligibility, PSU staff must refer to Appendix V, MEPD Referral Crosswalk, to determine if:

• Form H1200 must be mailed to the individual;
• Form H1746-A must be faxed to the MEPD specialist; or
• no action is required.

PSU staff must wait for the individual to complete and send Form H1200 back to PSU staff if Form H1200 is required. PSU staff must fax Form H1746-A and Form H1200 to the MEPD specialist once PSU staff receive Form H1200.

The MEPD specialist may respond using the MEPD Communication Tool to inform PSU staff if the individual is eligible for Medicaid. PSU staff can monitor TIERS for updates to Medicaid eligibility. 

1230 U.S. Citizenship

Revision 19-13; Effective November 5, 2019

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 a Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Verification of citizenship and identity for eligibility purposes is a one-time activity conducted by an MEPD specialist, as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by an MEPD specialist, 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 in those programs.

1240 Texas Residency

Revision 25-2; Effective June 6, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1)(B), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must be a Texas resident to be eligible for the STAR+PLUS HCBS program. Upon initial entry into the STAR+PLUS HCBS program, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist verify Texas residency. Upon annual assessment, the managed care organization (MCO) verifies ongoing Texas residency.

1250 Medical Necessity Determination

Revision 25-2; Effective June 6, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1)(C), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) to be eligible for the STAR+PLUS HCBS program.

The MCO must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for those transitioning to adult programs, interest list releases (ILRs), upgrades and reassessments. The MCO may use the nursing facility (NF) Minimum Data Set (MDS) or submit a MN/LOC Assessment in the TMHP LTCOP for Money Follows the Person (MFP) cases.

The MCO must get a physician signature before submitting the MN/LOC Assessment for applicants not living in a NF. The MCO is not required to get a physician signature for:

• STAR+PLUS HCBS program applicants currently living in an NF; and
• STAR+PLUS HCBS program member reassessments.

TMHP staff will review the MN/LOC Assessment to determine if the applicant or member has an MN for an NF LOC. PSU staff must monitor TMHP LTCOP to determine the MN/LOC Assessment approval status. A MN/LOC Assessment with a BC1 code does not have all the information necessary for TMHP staff to calculate the ISP cost limit accurately for the applicant or member. The MCO must correct a MN/LOC Assessment record resulting in a BC1 code by inactivating the record and resubmitting a new MN/LOC Assessment record, with correct information, in the TMHP LTCOP.

Medical Necessity, Level of Service, and Diagnosis records will automatically be transferred to the Service Authorization System Online (SASO) when the MN/LOC Assessment is submitted electronically in the TMHP LTCOP.

The MCO must submit the ISP in the TMHP LTCOP for interest list release, upgrade, and reassessment cases. The MCO must upload the ISP to the MCOHub for MFP cases and for those transitioning to the STAR+PLUS HCBS program because they have aged out of a children’s program. PSU staff must manually enter authorizing agent, enrollment, service plan, and service authorization records in SASO when the MCO uploads the ISP to the MCOHub.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when a medical assistance only (MAO) applicant meets MN and an ISP was received. PSU staff must indicate the start of care (SOC) for the STAR+PLUS HCBS program on Form H1746-A.

1260 Individual Service Plan Cost Limit

Revision Notice 25-5; Effective Dec. 17, 2025

The cost of STAR+PLUS HCBS program services on the individual service plan (ISP) should not exceed 202 percent of the cost of care Texas Health and Human Services Commission (HHSC) would pay if the individual was served in a nursing facility (NF). This is per Title 1 Texas Administrative Code (TAC)  Chapter 353.1153(c)(1)(H), STAR+PLUS Home and Community Based Services (HCBS) Program.

Texas Medicaid & Healthcare Partnership (TMHP) calculates the applicant's or member’s ISP cost limit. It is based on information the managed care organization (MCO) service coordinator gathered through the Medical Necessity and Level of Care (MN/LOC) Assessment. The ISP cost limit is represented as a three-digit Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level. A PDPM LTC is a measure of NF staffing intensity. It is used in 1915(c) Medicaid waiver programs to categorize needs for applicants or members.

The MCO service coordinator must develop an ISP that includes STAR+PLUS HCBS program services requested by the applicant or member and the cost of those services. The cost should be developed at or below 202 percent of the cost to provide services to the applicant or member, based on the PDPM LTC level in an NF.

The MCO must notify the Office of the Medical Director (OMD), Utilization Review (UR) unit staff, and Program Support Unit (PSU) staff when the cost of an ISP exceeds the cost limit. The OMD and UR staff must review the ISP and determine if eligibility can be provided through the Medically Fragile group or general revenue (GR) funds process if the cost exceeds the cost limit. UR Unit staff provide a determination to PSU program managers (PMs) if an applicant or member meets the criteria for the Medically Fragile group or GR funds process.

Applicants or members exceeding the cost limit who are not approved for the Medically Fragile group or GR funds process cannot choose to receive reduced services for the STAR+PLUS HCBS program if Medicaid state plan services and STAR+PLUS HCBS program services would pose a risk to the individual’s health, safety or welfare.

Refer to 5000, Medically Fragile Group and General Revenue Funds Process, for more information on processing cases submitted for Medically Fragile group and GR funds process consideration.

1270 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 25-2; Effective June 6, 2025

Title 42 Code of Federal Regulations (CFR) Section 441.302(c) and Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1)(D) states individuals must have a need for at least one STAR+PLUS Home and Community Based Services (HCBS) program service to be eligible for the STAR+PLUS HCBS program. For initial and continued eligibility for the STAR+PLUS HCBS program, a member must have an unmet need for support in the community, and therefore use at least one STAR+PLUS HCBS program service during the individual service plan (ISP) year. Therefore, a STAR+PLUS HCBS program ISP which has $0.00 as the Total Est. Waiver Cost in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) will be rejected by Program Support Unit (PSU) staff. Members who do not use at least one STAR+PLUS HCBS program service per ISP year are subject to disenrollment from the STAR+PLUS HCBS program. For medical assistance only (MAO) Medicaid members, disenrollment from the STAR+PLUS HCBS program may result in a loss of Medicaid eligibility.

MAO Medicaid members receiving Community First Choice (CFC) services through a 1915(c) Medicaid waiver program must meet eligibility requirements stated in Title 42 CFR Section 441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all STAR+PLUS HCBS program requirements and must receive one STAR+PLUS HCBS program service per month. Managed care organization (MCO) service coordinators are responsible for tracking monthly services and notifying PSU staff if an MAO member with CFC services is not receiving the minimum requirement of one service per month.

1280 Appropriate Living Arrangement

Revision 26-1; Effective Feb. 20, 2026

Members receiving STAR+PLUS Home and Community Based Services (HCBS) program services may live alone, with family members or others at locations of their choice. The location can be in the community, including adult foster care (AFC) homes or licensed assisted living facilities (ALFs).

Title 42 Code of Federal Regulations (CFR) Section 441.301(b)(1)(ii) states applicants or members enrolled in the STAR+PLUS Home and Community Based (HCBS) program must not be an inpatient of a hospital, nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID). Non-state group homes are ICF/IID.  

Applicants or members who are incarcerated may or may not be able to maintain STAR+PLUS Home and Community Based Services (HCBS) program enrollment. Program Support Unit (PSU) staff must not deny an applicant or member due to incarceration. PSU staff must wait until the applicant or member loses Medicaid eligibility and deny them due to loss of Medicaid eligibility. PSU staff may fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist advising of the incarceration status.

Revision 26-1; Effective Feb. 20, 2026

The STAR+PLUS Home and Community Based Services (HCBS) program provides individuals with many services necessary to allow the individual to remain in, or return to, a community setting. Providers contracted with managed care organizations (MCOs) provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.  The STAR+PLUS HCBS program offers acute and long-term services and supports (LTSS). Refer to 4000, STAR+PLUS HCBS Program Services, for additional information on available services.  

STAR+PLUS members choose to participate in the agency option (AO), consumer directed services (CDS) option or service responsibility option (SRO) delivery models.

• The member works with the MCO to coordinate service delivery for each service in the ISP, in the AO model.
• The member is given the authority to self-direct designated services, in the CDS model. The MCO coordinates delivery of non-member-directed designated services if the member chooses to self-direct these services. Providers employed by the member or authorized representative (AR) must be qualified personnel to provide authorized services when services are necessary in the CDs model. These personnel may be employed directly by, or through, personal service agreements or subcontracts with the providers. A member's services and service providers must be based on an MCO assessment of the member’s individual needs. 
• The provider is the attendant's employer and handles the business details, in the SRO model. Business detail examples include paying taxes and doing the payroll. The provider also orients attendants to provider policies and standards before sending them to members' homes. The member or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities. This starts with interviewing and selecting the person who will be the attendant.

Revision 26-1; Effective Feb. 20, 2026

Managed care organizations (MCOs) must contact all members at enrollment and at least annually thereafter. The MCO must contact the member at least once by phone and at least once face-to-face per year if a member receives long term services and supports (LTSS), has a history of behavioral health issues or substance use disorders (SUD), or is dual eligible. The MCO must visit with the member face-to-face at least twice a year if the member receives the STAR+PLUS Home and Community Based Services (HCBS) program or has a complex medical condition. The MCO must meet with the member face-to-face at a minimum of four times per year if a member lives in a nursing facility (NF).

All applicants or members of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the applicant or member and his or her acute care and LTSS providers to ensure all an applicant or member’s medically and functionally necessary services are provided. This includes referring and helping the applicant or member get appointments with specialists, participating in discharge planning for applicants or members in hospitals, or the NF, referring members to community organizations for services and assistance not covered by Medicaid. 

1510 Confidential Nature of Medical Information - HIPAA

Revision 19-13; Effective November 5, 2019

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect 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 individual's date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number and demographic data.

1511 Confidential Nature of a Case Record

Revision 19-13; Effective November 5, 2019
 
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 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.

1512 Custody of Records

Revision 19-13; Effective November 5, 2019

Texas Health and Human Services Commission (HHSC) staff must use reasonable diligence to safeguard, protect and preserve records and prevent disclosure of the information they contain, except as provided by 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.

1520 Responsible Party to Authorize Disclosure

Revision 19-13; Effective November 5, 2019

1520.1 Authorized Representative

Revision 19-13; Effective November 5, 2019

Only the member's authorized representative (AR) can exercise the applicant’s or member's rights with respect to protected health information (PHI). Therefore, only an applicant or member's 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 AR if the applicant or member is subjected to domestic violence, abuse or neglect by the AR. Consult the HHSC Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, if it is believed that health information should not be released to the AR.

Note: A responsible party is not automatically an AR.

1520.2 Unemancipated Minors

Revision 19-13; Effective November 5, 2019

A parent is the authorized representative (AR) 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 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.

1520.3 Adults and Emancipated Minors

Revision 19-13; Effective November 5, 2019

The applicant’s or member’s authorized representative (AR) has authority to make health care decisions for the applicant or member if the applicant or member is an adult, emancipated minor or married minor. An AR may be a:

• person the applicant or 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 the Texas Health and Human Services Commission (HHSC) Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, for approval.

1520.4 Deceased Applicant or Member

Revision 19-13; Effective November 5, 2019

The 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 the Texas Health and Human Services Commission (HHSC) Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, about whether a particular person is the AR of an applicant or member.

1521 Verifying the Identity of an Applicant, Member, Authorized Representative or Third-Party Individual

Revision 19-13; Effective November 5, 2019

1521.1 Phone Communication

Revision 23-3; Effective Aug. 21, 2023

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

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

PSU staff must verify that the person who self-identifies as an AR over the phone is listed as the AR in:

• the Texas Integrated Eligibility Redesign System (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.  

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

Refer to Section 1530, 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 or AR; or 
• PSU staff must obtain Form 1826.

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

1521.2 In-Person Communication

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must establish the identity of the individual who presents himself or herself as an applicant, member or authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) office by examining two forms of valid identification (ID) with at least one form of ID being a government-issued photo ID:

• 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 ID card containing the 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, research staff 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 protected health information (PHI) through one of the following:

• official correspondence or a telephone call from a state or regional office; or
• contact with an HHSC Office of Chief Counsel.

Program Support Unit (PSU) staff must contact the HHSC Office of Chief Counsel staff when other HHSC or MCO staff, federal agency staff, research staff or contractors come to the office without prior notification or inadequate identification and request permission to access records.

1521.3 Electronic Mail Communication

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must respond to electronic mail, also known as email, from an applicant, member, authorized representative (AR) or a third party that contains protected health information (PHI) by 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 by mail or fax.

PSU staff must not send PHI by email to non-government entity individuals, including applicants, members, ARs or third-party individuals. Refer to Section 1531, Verification and Documentation of Disclosure, for approved methods of transmitting PHI to applicants, members, ARs and third-party individuals to whom the applicant, member 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."

PSU staff must include the first three letters of the applicant’s or member’s first and last name in the subject line of emails for case-specific communications. For example, an email subject line for an applicant named John Smith would include “JOH.SMI.” in the email’s subject line.

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

1530 Information That May Be Disclosed

Revision Notice 23-3; Effective Aug. 21, 2023

The Texas Health and Human Services Commission (HHSC) follows Title 20 Code of Federal Regulations (CFR) Section 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 1521.1, Phone  Communication, Section 1521.2, In-Person Communication, and Section 1521.3, Electronic Mail Communication, when:

• the Texas Integrated Eligibility Redesign System (TIERS) indicates that the person requesting the information is the AR; 
• a signed Form H1200, Application for Assistance – Your Texas Benefits, indicates the person requesting the information is the AR; or
• 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 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 a 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 or AR 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 or AR.

A valid Form H1826 is:

• signed by the individual, applicant, member or AR; 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 or AR, 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 or AR to the Office of the Chief Counsel if there are questions and problems concerning releasing information.

PSU staff must notify a person who requests copies of an individual, applicant, or member’s records maintained by HHSC to email the HHSC Open Records Coordinator mailbox.

PSU staff may refer to Title 20 CFR Section 401-403 for more information about the disclosure of PHI.

1531 Verification and Documentation of Disclosure

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff may only disclose protected health information (PHI) to the applicant, member, authorized representative (AR) or a third-party individual if written consent is provided.

PSU staff verify the identity of the person who requests disclosure of PHI by examining two forms of valid identification (ID), with at least one form of ID being a government-issued photo ID:

• U.S. passport;
• Texas Department of Public Safety (DPS) ID card;
• DPS driver license;
• DPS Texas Education Identification Certificate;
• DPS handgun license;
• U.S. military ID 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 stubs.

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 fax or by mail.

1532 Communication with the Applicant or Member

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant’s, member’s or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member 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.

1533 Confidential Information on Notifications

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member 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 the member’s income of $2,892 exceeds the eligibility limit of $2,313. 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 $2,313.” The comment should simply state, “You are no longer eligible for Medicaid.”
• Another applicant is being denied STAR+PLUS Home and Community Based Services (HCBS) program services because the presence of weapons in the member’s 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’s or member’s income or the condition of the home environment is a violation of the member’s 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.

1534 PSU Communication with the MCOs

Revision 19-13; Effective November 5, 2019

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for an applicant’s or member's protected health information (PHI) to be shared only with the selected managed care organization (MCO). Program Support Unit (PSU) staff can securely upload documents with PHI by using TxMedCentral. PSU staff must follow Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading documents to TxMedCentral. If PSU staff upload a document containing member PHI to the incorrect MCO ISP or SPW folder in TxMedCentral, it must be corrected immediately upon realization an error was made.

PSU staff must send notification of all TxMedCentral upload errors to PSU Operations staff. Include the document identifying information, the name of the folder in which it was erroneously uploaded, the name of the folder into which it should have been uploaded and the time the correction was made.

Example: Uploaded XX_2067_123456789_ABCD_1P.doc in SUPSPW at 8:54 a.m. on December 20. Should have been uploaded to MOLSPW. Corrected at 9:22 a.m. December 20.

1535 Applicant or Member Correction of Information

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) has a right to correct any information the Texas Health and Human Services Commission (HHSC) or the managed care organization (MCO) has about the applicant or member and any other individual on the applicant’s 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 or the MCO can contact the applicant or member.

HHSC or the MCO must add corrected information to the case record when HHSC or the MCO agrees to change protected health information (PHI). The incorrect information remains in the file with a note that the information was amended per the member's request.

Notify the applicant, member or AR in writing within 60 days (using agency letterhead) 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.

HHSC or the MCO must ask the member for permission before sharing with third parties if HHSC or the MCO makes a correction to PHI. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if they may have relied, or could rely, on the information and if it is to the disadvantage of the member. HHSC staff must contact the HHSC Office of Chief Counsel for a record of disclosure. MCOs must follow HHSC procedures as stated in the Uniform Managed Care Contract (UMCC), Section 11.03, Member Records.

Note: Do not follow above procedures when the accuracy of information provided by a member 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.

1536 Disposal of Records

Revision 19-13; Effective November 5, 2019

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 25-2; Effective June 6, 2025

Member rights and responsibilities are included in the member handbook. The required critical elements for member handbooks is found on the Texas Medicaid and CHIP - Uniform Managed Care Manual webpage. 

The member handbook must be provided to the applicant, member, or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.

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

1710 PSU Staff Notification Requirements for Applicants and Members

Revision 24-4; Effective Dec. 1, 2024

Form H2065-D, Notification of Managed Care Program Services (PDF), is the legal notice showing program-level eligibility for approvals, denials, and terminations for the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff are responsible for preparing and mailing Form H2065-D to the applicant, member, or authorized representative (AR) advising of actions taken for STAR+PLUS HCBS program eligibility. PSU staff must mail English and Spanish versions of Form H2065-D to the applicant, member or AR.

Form H2065-D includes:

• approval, denial or termination effective dates;
• plain language that can be understood by the applicant, member or AR;
• room and board (R&B) and copayment charges, if applicable;
• cost-of-living adjustment (COLA) for room and board (R&B) charges, if applicable; and
• fair hearing rights.

PSU staff generate Form H2065-D manually or electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) depending on the case action being taken. PSU staff must follow the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, to ensure language entered on the form can be understood by the applicant, member or AR.

PSU staff must notify the applicant, member, or AR of program eligibility approval within five business day of verifying eligibility criteria was met by using Form H2065-D. This time frame applies to all case types, including:

• interest list releases (ILRs);
• upgrades;
• Money Follows the Person (MFP) process; and
• reassessments.

PSU staff must notify the applicant, member or AR of a program eligibility denial or termination using Form H2065-D upon notification eligibility criteria is not being met. PSU staff time frames for mailing Form H2065-D varies depending on the denial or termination type. For example, PSU staff must mail Form H2065-D for a denial or termination within:

• three business days for upgrades; and
• two business days for all other denials and terminations.

PSU staff must provide the English version of Form H2065-D to the MCO. PSU staff can generate Form H2065-D manually or electronically through the TMHP LTCOP. PSU staff must upload Form H2065-D to the MCOHub, if Form H2065-D is generated manually. The MCO must retrieve a copy of Form H2065-D through the TMHP LTCOP if Form H2065-D is generated electronically.

1720 PSU Staff Notification Requirements for MCOs

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must use Form H2067-MC, Managed Care Programs Communication, for all communications sent to the managed care organization (MCO). PSU staff upload Form H2067-MC to TxMedCentral in the MCO’s STAR+PLUS folder, following the instruction in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Time frames for PSU staff uploading Form H2067-MC can vary between one and five business days depending on the situation. PSU staff must refer to policy in this handbook for specific time frame direction.

1730 PSU Staff Notification Requirements for Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff may be required to coordinate STAR+PLUS Home and Community Based Services (HCBS) program eligibility determinations with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, depending on the applicant or member’s Medicaid type of assistance (TOA). PSU staff must refer to Appendix V, MEPD Referral Crosswalk, to determine if MEPD coordination is required. PSU staff coordinate by faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist. The MEPD specialist may respond using the MEPD Communication Tool. PSU staff can monitor Texas Integrated Eligibility Redesign System (TIERS) for updates to Medicaid eligibility.

PSU staff must fax Form H1746-A to the MEPD specialist when:

• Form H1200, Application for Assistance – Your Texas Benefits, is received from an applicant;
• Medical Necessity (MN) is approved or denied in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); and
• the individual service plan (ISP) is received and the applicant is authorized to enroll in the STAR+PLUS HCBS program.

PSU staff must fax Form H1746-A to the MEPD specialist for denials and terminations not related to a Medicaid financial denial. PSU staff is not required to fax Form H1746-A to the MEPD specialist for applicants and members receiving Supplemental Security Income (SSI) who are being denied or terminated. 

1740 PSU Staff Notification Requirements for Enrollment Resolution Services Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Enrollment Resolution Services (ERS) Unit for medical assistance only (MAO) applicants that meet STAR+PLUS Home and Community Based Services (HCBS) program eligibility and do not show a managed care organization (MCO) enrollment in the Texas Integrated Eligibility Redesign System (TIERS). PSU staff must also notify the ERS Unit of MAO members having their STAR+PLUS HCBS program eligibility terminated.

The email to the ERS Unit mailbox must include:

• a subject line including the type of request with the applicant’s first and last initial;
• applicant or member name;
• Social Security number (SSN) or Medicaid identification (ID) number;
• eligibility or termination effective date;
• any other relevant information; and
• any supporting documentation (e.g., Form H2065-D, Notification of Managed Care Program Services).

1750 PSU Staff Notification Requirements for Managed Care Compliance and Operations Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Managed Care Compliance and Operations (MCCO) Unit staff for managed care organization (MCO) noncompliance or delinquency within two business days.

The email to the MCCO Unit mailbox must include:

• a brief statement explaining the complaint;
• applicant or member name;
• Social Security number (SSN) or Medicaid identification (ID) number;
• date of birth (DOB);
• name of the MCO;
• individual service plan (ISP) effective dates; and
• any other relevant information.

1760 MCO Notification Requirements for Applicants and Members

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) is responsible for notifying the applicant, member or authorized representative (AR) when a service is denied, reduced or terminated. This is considered an adverse action and the applicant, member or AR has a right to appeal. Appeal rights of STAR+PLUS Home and Community Based Services (HCBS) program applicants or members are in the Uniform Managed Care Contract (UMCC).

1770 MCO Notification Requirements for PSU Staff

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must use Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, and Form H2067-MC, Managed Care Programs Communication, 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 TxMedCentral. PSU staff will retrieve all MCO postings daily from TxMedCentral.

The MCO has 45 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral, to upload Form H3676, Section B, for individuals or applicants. 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.

Revision 19-13; Effective November 5, 2019

The Client Assignment and Registration (CARE) System is an online database used by Program Support Unit (PSU) staff. CARE maintains the enrollment records for the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs. PSU staff use CARE to prevent dual enrollment in another Medicaid waiver program.

1820 Community Services Interest List

Revision 19-13; Effective November 5, 2019

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 and to prevent dual enrollment in another Medicaid waiver program when an individual is entering the STAR+PLUS HCBS program. PSU staff are required to select the appropriate closure reasons and close the CSIL record when an individual is enrolled in the STAR+PLUS HCBS program.

1830 Health and Human Services Commission Benefits Portal

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) Benefits portal is an online database used by Program Support Unit (PSU) and Fair Hearings Unit staff. The HHSC Benefits portal maintains state fair hearing documentation, forms and case statuses.

PSU staff use the HHSC Benefits portal to:

• enter and submit state fair hearing requests;
• upload state fair hearing documentation and forms;
• view documents and forms uploaded by the hearings officer; and
• view the outcome of state fair hearing decisions.

1840 Health and Human Services (HHS) Enterprise Administrative Report and Tracking System

Revision 19-13; Effective November 5, 2019

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 applicants and members.

PSU staff use HEART to:

• review an individual’s, applicant’s 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 must search for an individual, applicant or member when any contact or correspondence is received from, or relating to, an individual, applicant or member to determine if there is already a case record open. PSU must open a new case record if one does not already exist.  

For medical assistance only (MAO) individuals and applicants, the patient control number (PCN) field will initially be completed with the individual’s Social Security number (SSN). Once a Medicaid identification (ID) number is assigned to the applicant, PSU staff must update the PCN field to the Medicaid ID number in HEART.

PSU staff will document every case action in the narrative, including telephone calls, mail dates, fax dates, form receipt dates and any other relevant information in the HEART narrative. The HEART documentation should be completed so that someone with no prior knowledge of the case can follow along in HEART and come to the same case action decision. PSU staff must follow the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions, when uploading documents.

PSU staff must close the HEART case record when there is no further PSU staff action required. Once a HEART case record is closed, PSU staff cannot add notes or documentation. PSU staff must send a request to the PSU supervisor when a HEART case record needs to be reopened.

1850 Service Authorization System Online

Revision 25-1; Effective Feb. 19, 2025

Service Authorization System Online (SASO) is an online database. It is used by Program Support Unit (PSU) staff as the primary system of record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility records.

SASO uses numerical codes to specify the type of program and services a member is receiving. The STAR+PLUS HCBS program uses:

• service group (SG) 19; and
• service code (SC) 12 and 13.

The MCO submits Medical Necessity and Level of Care (MN/LOC) Assessments through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for those transitioning to the STAR+PLUS HCBS program when they have aged out of a children’s program, interest list releases (ILRs), upgrades, Money Follows the Person (MFP), and reassessment cases. The TMHP LTCOP electronically transfers MN/LOC Assessment records to SASO. PSU staff must verify SASO MN/LOC Assessment records are in alignment with TMHP LTCOP records.

The MCO submits individual service plans (ISPs) through the TMHP LTCOP for ILRs, upgrades and reassessment cases. The TMHP LTCOP electronically transfers ISP records when PSU staff use the Submit to SAS feature in the TMHP LTCOP. PSU staff must verify SASO ISP records are in alignment with TMHP LTCOP records.

The MCO must upload ISPs to the MCOHub for those transitioning to the STAR+PLUS HCBS program because they have aged out of a children’s program and for MFP cases. PSU staff must manually enter ISP records in SASO when the ISP is uploaded to the MCOHub and is not appearing in the TMHP LTCOP. 

MN/LOC Assessment records in SASO include:

• Level of Service (LOS);
• Diagnosis (DG); and
• Medical Necessity (MN).

ISP records in SASO include:

• Authorizing Agent;
• Enrollment;
• Service Plan; and
• Service Authorization.

PSU staff must ensure the appropriate SC is in place based on the following:

• SC 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days before the end date of the current ISP.
• SC 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using SC 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using SC 12 with an effective date one day after the SC 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2019, for an ISP that ended May 31, 2019. To register this reassessment, register one service authorization record using Service Code 13 — Nursing with a begin date of June 1, 2019, and an end date of June 30, 2019. Then, register a second service authorization record using Service Code 12 — Case Management with a begin date of July 1, 2019, and an end date of May 31, 2020.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTCOP on June 5, 2019, for an ISP that ended May 31, 2019. One service authorization record with Service Code 13 — Nursing will be system-generated with a begin date of June 1, 2019, and an end date of June 30, 2019. A second service authorization record with Service Code 12 — Case Management will be system-generated with a begin date of July 1, 2019, and an end date of May 31, 2020.

PSU staff must contact Provider Claims Services (PCS) staff for help to close SASO nursing facility (NF) records for an applicant who will be discharging a NF to receive STAR+PLUS HCBS program services in the community. PSU staff must contact PCS staff within five business days from the date of NF discharge. PSU staff must confirm the member has been discharged from the NF and community services are negotiated to begin on or after the date of discharge before contacting PCS staff.

PSU staff must complete the following activities when contacting PCS staff:

• call 512-438-2200 and select Option 1 when prompted to do so;
• identify themselves as HHSC employees;
• provide the member’s date of discharge from the NF; and
• request the NF records in SASO be closed so STAR+PLUS HCBS program services can be authorized.

PCS staff will close SG 1 and 3 Service Authorization, Enrollment, and Authorizing Agent records in SASO, including any SC 60 records. This procedure applies even if the individual is leaving the NF using the MFP process.

PSU staff also use SASO to prevent dual enrollment in another Medicaid waiver program. The following Medicaid waiver programs maintain ISPs in SASO:

• Medically Dependent Children Program (MDCP);
• Community Living Assistance & Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS); and
• Texas Home Living (TxHmL).

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. 

1860 Texas Integrated Eligibility Redesign System

Revision 25-1; Effective Feb. 19, 2025

Texas Integrated Eligibility Redesign System (TIERS) is an online database used by Program Support Unit (PSU) staff. TIERS maintains Medicaid eligibility, age and mailing addresses for individuals, applicants and members. PSU staff use TIERS to verify an individual’s, applicant’s or member’s Medicaid eligibility, age and mailing address, and to prevent dual enrollment in another Medicaid waiver program.

PSU staff must complete the following activities to identify managed care members in TIERS:

• Enter the individual’s, applicant’s or member’s information in the Individual-Search screen and select Search. The results of the search will appear in the Search Results field.
• Select the hyperlink of the individual’s name in the Search Results field. The Individual-Summary screen will appear.
• Hover over the Individual # field and select Managed Care from the dropdown menu. The managed care information will appear in the Individual Managed Care History field. The data elements in the Individual Managed Care History field include:
  • Provider — The name of the provider contracted by the managed care organization (MCO) to deliver services to members.
  • Plan — The name and plan code of the MCO providing Medicaid services to the member.
  • Program — For managed care members, STARPLUS 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.

1870 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision Notice 25-5; Effective Dec. 17, 2025

The Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) is an online database. It is used by Program Support Unit (PSU), managed care organizations (MCOs) and TMHP staff. TMHP LTCOP maintains the medical necessity and level of care (MN/LOC) and individual service plan (ISP) that hold the services and cost limits for members.

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

• initial MN/LOC Assessment for an applicant being assessed for the STAR+PLUS Home and Community Based Services (HCBS) program;
• annual MN/LOC Assessment for a member’s ongoing eligibility for the STAR+PLUS HCBS program;
• a significant change in status MN/LOC Assessment for a STAR+PLUS HCBS program member requesting a change to their cost limit.

The MCO must generate an amended ISP when the member’s condition significantly changes. The MCO must keep amended ISPs in the MCO’s member case file. The MCO does not provide the amended ISP to PSU staff and does not enter the amended ISP in the TMHP LTCOP. PSU staff must advise the MCO that PSU staff do not process ISPs resulting from a significant change if the MCO uploads an amended 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 MN/LOC Assessment or the ISP;
• manage and act in response to workflow messages; and
• submit Form H1700-1, Individual Service Plan, for initials, significant changes and reassessments, except for age-outs and nursing facility (NF) residents transitioning to the STAR+PLUS HCBS program; and
• monitor for Form H2065-D, Notification of Managed Care Program Services.

Submittal of the MN/LOC Assessment through the TMHP LTCOP creates MN, Level of Service (LOS) and Diagnosis (DG) records in the Service Authorization System Online (SASO). The cost limit can be found in the LOS record.

PSU staff use the TMHP LTCOP to:

• review an applicant’s or member’s case history;
• verify the MCO has submitted the MN/LOC and ISP timely;
• verify the MN/LOC has an approved MN with a Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level under the cost limit;
• verify the ISP has the correct date range and identifies at least one unmet need;
• adjust ISP date ranges, if applicable;
• monitor the status of MN denials;
• approve, invalidate and terminate ISPs;
• add case notes to the narrative history;
• generate Form H2065-D, for approvals not related to age-outs and NF residents transitioning to the STAR+PLUS HCBS program and MN denials; and
• generate reports.

1880 MCOHub

Revision 25-1; Effective Feb. 19, 2025

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.
• Are 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. 

3111 Interest List Procedures

Revision 26-2; Effective June 1, 2026

3112 Medicaid Eligibility

Revision 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must verify each applicant's current eligibility for Medicaid through the Texas Integrated Eligibility Redesign System (TIERS). PSU staff initiate the Medicaid financial eligibility determination process if there is no existing acceptable Medicaid coverage. Refer to Appendix V, MEPD Referral Crosswalk, for individuals with Medicaid eligibility to determine if a program transfer by the MEPD specialist is required.

An applicant who currently has Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200. PSU staff must check with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist about the need for a new Form H1200.

PSU staff must maintain Form H1200 in the applicant’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable.

3113 Transmittal of Form H1200

Revision 18-0; Effective September 4, 2018

When transmitting Form H1200, Application for Assistance – Your Texas Benefits, Program Support Unit (PSU) staff fax all pages of Form H1200 along with any supporting documentation and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. PSU staff will upload all pages of Form H1200 and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) with the applicant's valid signature.

The original Form H1200 must be kept for three years after the HEART case record is denied or closed. PSU staff must also retain a copy of the successful fax transmittal confirmation in the HEART case record. Scanning Form H1200 and sending by electronic mail is prohibited.

3114 Applicants with Medicaid Eligibility

Revision 18-0; Effective September 4, 2018

At the time of the initial intake for the STAR+PLUS HCBS program, Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. PSU staff must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or through inquiry in the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for the STAR+PLUS HCBS program, refer to the mandatory population described in Section 3221, STAR+PLUS Mandatory Groups.

An applicant who receives Supplemental Security Income (SSI) is financially eligible for Medicaid and does not require a financial determination; the Social Security Administration (SSA) has already made this determination.

An applicant receiving services through Community Attendant Services (CAS) (TP14) is not automatically eligible for the STAR+PLUS HCBS program.

MEPD specialists must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.

3115 Applicants Without Medicaid Eligibility

Revision 22-3; Effective Sept. 27, 2022

Title 42 Code of Federal Regulations (CFR) Section 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas state plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for medical assistance only (MAO) Medicaid cases. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist exclusively determines MAO Medicaid financial eligibility for STAR+PLUS Home and Community Based Services (HCBS) program applicants and members. An individual, applicant or member who does not receive Supplemental Security Income (SSI) may apply for MAO Medicaid.

The individual, applicant or member applies for MAO Medicaid by completing and submitting Form H1200, Application for Assistance – Your Texas Benefits, to the enrollment broker, Program Support Unit (PSU) staff or the MEPD specialist. PSU staff must fax Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist within two business days of an applicant or member submitting Form H1200 to PSU staff.

3116 Monthly Income Below the SSI Standard Payment

Revision 18-0; Effective September 4, 2018

An applicant in the community (with no ineligible spouse) who has income less than the Supplemental Security Income (SSI) federal benefit rate (FBR) must apply for SSI through the Social Security Administration (SSA). The Texas Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except for cases in which the SSI application for disability has been pending more than 90 days and a decision is made by HHSC Disability Determination Unit (DDU) staff.

If there is a question whether the applicant should apply for SSI or medical assistance only (MAO), Program Support Unit (PSU) staff may consult the regional Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

3117 Coordination with the MEPD Specialist

Revision 18-0; Effective September 4, 2018

The Program Support Unit (PSU) staff must inform the applicant or member without pre-existing Medicaid coverage and/or his or her authorized representative (AR) that the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will complete a financial eligibility (Medicaid) determination. PSU staff must encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program according to regional procedures. For those applicants or members already on an appropriate type of Medicaid program, PSU staff must fax:

• Form H1200, Application for Assistance – Your Texas Benefits; and
• Form H1746-A, MEPD Referral Cover Sheet.

An applicant for the STAR+PLUS HCBS program who has medical assistance only (MAO) coverage type Medicaid services may only receive the STAR+PLUS HCBS program after a program transfer to Medicaid waivers is completed by the MEPD specialist. When an applicant or member for the STAR+PLUS HCBS program has MAO coverage type, as indicated in the Texas Integrated Eligibility Redesign System (TIERS), a completed Form H1200 must be sent to the applicant or member. The completed application must be forwarded to the MEPD specialist for processing.

PSU staff must also send an email to MEPD at the HHSC OES MEPD IC mailbox that includes the following information:

• the applicant’s or member’s name;
• applicant’s or member’s Medicaid identification (ID) number;
• individual has MAO coverage-type Medicaid, which will require a program transfer; and
• name and telephone number of the PSU staff contact.

The MEPD specialist will make the necessary changes to allow the MAO coverage-type Medicaid individual to receive the STAR+PLUS HCBS program.

ID of MAO Coverage-Type Medicaid

PSU staff can check TIERS to determine an applicant’s or member’s coverage type. In TIERS, the coverage type on the Search/Summary screen is displayed with the preface of MAO.

Form H1200 is not required for members receiving Supplemental Security Income (SSI).

Note: If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA.

3117.1 Income and Resource Verifications for MEPD

Revision 25-2; Effective June 6, 2025

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by faxing:

• Form H1746-A, noting if:
  • the applicant is pending a Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP); or
  • the applicant has an approved MN/LOC and ISP;
• Form H1200, if received; and
• any supporting documents, if received.

Texas Health and Human Services Commission (HHSC) Disability Determination unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination, if a STAR+PLUS HCBS applicant’s application for SSI disability has been pending for more than 90 days. The SSI decision must be adopted upon receipt from SSA.

PSU staff must send a second Form H1746-A noting the applicant’s start of care (SOC) for the STAR+PLUS HCBS program if the applicant’s MN/LOC and ISP were pending when the initial Form H1746-A was sent to the MEPD specialist.

3117.2 Reserved for Future Use

Revision 24-4; Effective Dec. 1, 2024

3117.3 Unsigned Applications

Revision 18-0; Effective September 4, 2018

Unsigned applications received by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are returned to the sender. Program Support Unit (PSU) staff must ensure applications are signed prior to referring to the MEPD specialist; if not, PSU staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

• Form H1200, Application for Assistance – Your Texas Benefits; and
• Form H1200-A, Medical Assistance Only (MAO) Recertification.

If the MEPD specialist receives an unsigned application from HHSC with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns the application to PSU staff with an annotation on the cover form (Form H1746-A) that the application is unsigned and must be signed before PSU staff can establish a file date. Once PSU staff receive an unsigned application from the MEPD specialist, it is the responsibility of PSU staff to coordinate with the applicant or member to obtain a signed application and return it to the MEPD specialist for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to applicants or members.

3117.4 Medicaid Eligibility Decisions Pending Past the Program Due Date

Revision 18-0; Effective September 4, 2018

For most Medicaid for the Elderly and People with Disabilities (MEPD) applications, eligibility decisions are due by the 45th day. However, applications for individuals under the age of 65 may require a 90-day time frame to allow the agency to obtain a disability determination. This applies when the person's age is less than 65 and the person does not receive Retirement, Survivors and Disability Insurance (RSDI), Supplemental Security Income (SSI) or Railroad Retirement (RR). A disability determination by the Texas Health and Human Services Commission (HHSC) is required even if the person has received a Medical Necessity and Level of Care (MN/LOC) Assessment determination under the STAR+PLUS Home and Community Based Services (HCBS) program eligibility component criteria.

For other case actions (for example, program transfers) the MEPD specialist may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income or resources. Program Support Unit (PSU) staff will email MEPD at the HHSC OES MEPD IC mailbox, requesting a status update, if the case has been pending more than 45 days.

3117.5 Inquires and Complaints

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff can direct other general inquiries and complaints regarding Medicaid for the Elderly and People with Disabilities (MEPD) applications and programs to the HHSC OES MEPD IC mailbox.

3118 Address Changes for Supplemental Security Income Individuals

Revision 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must not send address change requests for Supplemental Security Income (SSI) individuals to the Document Processing Center (DPC). PSU staff must inform the individual or authorized representative (AR) to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System (TIERS) after SSA makes the change.

Revision 25-2; Effective June 6, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days, or up to 90 days, if it is necessary to get a disability determination to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of:

• the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
• upon receipt of an incomplete or unsigned Form H1200.

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to section 3112, Medicaid Eligibility, for more information about financial eligibility for the STAR+PLUS HCBS program.

3210 Reserved for Future Use

Revision 26-2; Effective June 1, 2026

3220 Eligible Groups

Revision 18-0; Effective September 4, 2018

3221 STAR+PLUS Mandatory Groups

Revision 25-2; Effective June 6, 2025

The following groups of individuals must receive services through the STAR+PLUS program. The program designations are used in the following list.

• Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) type of assistance (TA) 01, TA 02 and TA 22 — Individuals 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
• Pickle Amendment Group, TIERS type program (TP) 03 — Individuals 21 or over who would continue to be eligible for SSI benefits if cost of living adjustment (COLAs) increases were deducted from his or her countable income.
• Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), 60-65 and with a disability, who:
  • were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
  • are ineligible for Medicare; and
  • would continue to be eligible for SSI benefits in the absence of those early aged widow's or widower's benefits and any increases in those benefits.
• Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), 50-60 and with a disability, who:
  • are ineligible for Medicare and were denied SSI due to an increase in widow's or widower's benefits because of the relaxing of disability criteria; and
  • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
• Disabled Adult Children (DAC), TIERS TP 18 — Adults over 21 with a disability that began before 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
• Medicaid Buy-In, TIERS TP 87 - designated in TIERS as ME — Medicaid Buy In — Disabled working adults over 21 who receive full Medicaid benefits because of buying into the Medicaid program.
• Medicaid for Breast and Cervical Cancer (MBCC) recipients, TIERS TA 67 — Individuals 18 to the 65th birth month who meet eligibility requirements defined in Title 1 Texas Administrative Code (TAC) Chapter 366, Subchapter D.
• STAR+PLUS Home and Community Based Services (HCBS) program members who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program.  
• Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (medical assistance only (MAO)) — Most individuals living in an NF.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact Program Support Unit (PSU) staff and provide the details for disenrollment from STAR+PLUS.

3222 STAR+PLUS Excluded Groups

Revision 25-2; Effective June 6, 2025

Refer to Title 1 Texas Administrative Code (TAC) Chapter 353.603, Member Participation for excluded groups.

3230 Financial Eligibility

Revision 25-2; Effective June 6, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days, or up to 90 days, if it is necessary to get a disability determination to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of:

• the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
• upon receipt of an incomplete or unsigned Form H1200.

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to section 3112, Medicaid Eligibility, for more information about financial eligibility for the STAR+PLUS HCBS program.

3231 Individual with a Qualified Income Trust

Revision 22-3; Effective Sept. 27, 2022

An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. A person or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their individual service plan (ISP).

PSU staff must refer questions regarding QIT to Access and Eligibility Services (AES) by generating and faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist.

3232 Payments from the Qualified Income Trust

Revision 25-1; Effective Feb. 19, 2025

An Applicant or member with a qualified income trust (QIT) is responsible for a copayment if they are living in an adult foster care (AFC), assisted living facility (ALF) or home setting. The managed care organization (MCO) must explain to the applicant or member that the funds from the QIT made available for the copayment must be used to purchase STAR+PLUS Home and Community Based Services (HCBS) program services. The member must make payments directly to the AFC, ALF or other service providers. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determine the copayment amount for members with a QIT.

PSU staff must document the copayment amount for services other than AFC or ALF using Form H2065-D, Notification of Managed Care Program Services (PDF). PSU staff must refer to Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, when generating Form H2065-D.

The total available QIT copayment amount is not entered on Form H1700-1, Individual Service Plan (PDF), and is not reflected in SASO copayment screens for a QIT member that lives at home.

3233 Reserved for Future Use

Revision 25-1; Effective Feb. 19, 2025

3234 Qualified Income Trust Copayment Agreement

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

• service purchased;
• amount available for copayment;
• unit rate;
• units purchased; and
• monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or an assisted living facility (ALF), the copayment amount is first applied to the cost of AFC or ALF. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase nursing, PAS or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

3235 Reserved for Future Use

Revision 25-1; Effective Feb. 19, 2025

3236 Copayment and Room and Board

Revision 25-4; Effective Oct. 6, 2025

Members determined to be financially eligible based on the institutional income limit may have to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program 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 are required to pay R&B and copayment. Supplemental Security Income (SSI) members will only be 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 for interest list release (ILR) or upgrade cases will match the STAR+PLUS HCBS program eligibility effective date. The begin date for the initial R&B and copayment for a Money Follows the Person (MFP) case will match the date of relocation from the nursing facility (NF) to the adult foster care (AFC) home or assisted living facility (ALF).

The amount of copayment and R&B for the month is prorated if the member is admitting to an AFC or ALF on a day that is not the first of the month. PSU staff indicate the full amount, noting it should be prorated, on Form H2065-D. The use of prorate language provides assurance to the member that the full amount is not required for the first month since the facility admission was mid-month.

Refer to the Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, for more information on the use of prorate language and comments in plain language to be entered on Form H2065-D.

The MCO must also explain to the individual that the individual must pay the copayment and R&B amounts directly to the provider contracted to deliver STAR+PLUS HCBS program services. The member may be disenrolled from the STAR+PLUS HCBS program if they fail to pay the agreed-upon copayment and R&B amounts. Refer to 6400, Disenrollment Request Policy, if a member refuses to pay their R&B charges. 

3237 Determining Room and Board Charges

Revision 25-4; Effective Oct. 6, 2025

All members who live in an adult foster care (AFC) or assisted living facility (ALF) must pay room and board (R&B) charges.

The R&B amount is determined by the Social Security Administration (SSA). The SSA determines the R&B amount by applying the following post-eligibility calculations:

• for individuals, the R&B amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance (PNA);
• for SSI couples, the R&B amount is the SSI FBR for a couple minus the PNA for an individual multiplied by two; or
• for couples with incomes that exceed the SSI FBR for couples, the R&B amount is the couple's income minus the PNA for an individual multiplied by two. This amount cannot exceed double the R&B amount for an individual.

The AFC or ALF can negotiate a lower R&B amount with the member, but they cannot waive it. There is no impact to PSU staff processes if there is an agreement for a lower R&B amount between the AFC or ALF and the member. PSU must continue to enter the R&B fixed amount on the Form H2065-D, Notification of Managed Care Program Services.

3238 Determining Copayment Amounts

Revision 25-4; Effective Oct. 6, 2025

Members who live in an adult foster care (AFC) or assisted living facility (ALF) and members who have a qualified income trust (QIT) may have to pay a copayment.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determines the amount of money available for copayment after determining financial eligibility for Medicaid. The copayment amount leaves a personal needs allowance (PNA) of $85 for a single person and $170 for a couple. The MEPD specialist must notify Program Support Unit (PSU) staff of the amount available for the monthly copayment through the MEPD Communication Tool.

The copayment amount is applied only to the cost of services funded through the STAR+PLUS Home and Community Based Services (HCBS) program. The copayment must not exceed the cost of services delivered.

Supplemental Security Income (SSI) recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance (RSDI) will not have a copayment.

3239 Copayment Changes

Revision 25-4; Effective Oct. 6, 2025

A member's copayment may change during the time he or she is receiving the STAR+PLUS Home and Community Based Services (HCBS) program. 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 of getting the copayment amounts:

• mail Form H2065-D, Notification of Managed Care Program Services, to the member;
• 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

Program Support Unit (PSU) staff operate in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. PSU staff provide support necessary for the coordination of long-term services and supports (LTSS), including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

• nursing facilities (NFs) to the community, and
• the Medically Dependent Children Program (MDCP) to the STAR+PLUS HCBS program.

Responsibilities of PSU staff include:

• acting as an intermediary in relaying communications between Community Care Services Eligibility (CCSE) staff and the managed care organization (MCO);
• receiving requests for services from CCSE staff performing intake tasks;
• coordinating the application process for the STAR+PLUS HCBS program for NF residents who wish to transition to the community;
• assisting applicants with enrollment through the Texas Health and Human Services Commission (HHSC) enrollment broker to select an MCO and primary care provider (PCP), if necessary;
• coordinating with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding Medicaid eligibility, as appropriate;
• sending service authorizations (Form H3676, Managed Care Pre-Enrollment Assessment Authorization to the MCO to initiate STAR+PLUS HCBS program assessments for applicants;
• serving as the primary contact for transitions in and out of STAR+PLUS service areas;
• assisting CCSE case managers in processing applications for non-Medicaid services by verifying the MCO denied the equivalent service under STAR+PLUS (Refer to section 3510, Money Follows the Person and Managed Care);
• assisting MCO members requesting placement on an interest list for services excluded from managed care (Refer to section 3222, STAR+PLUS Excluded Groups);
• processing applicants released from the STAR+PLUS HCBS program interest list;
• assisting members who are aging out of MDCP and/or Texas Health Steps (THSteps) Comprehensive Care Program (CCP) in transferring to the STAR+PLUS HCBS program (Refer to section 3420, Individuals Transitioning Services for Adults);
• coordinating continuity of care for members suspended or disenrolled from STAR+PLUS;
• approving the STAR+PLUS HCBS program based upon eligibility;
• making Service Authorization System Online (SASO) entries, as required for actions involving STAR+PLUS HCBS program members;
• handling the administrative claims process;
• researching and requesting disenrollment when the member is enrolled inappropriately;
• denying eligibility for the STAR+PLUS HCBS program; and
• handling requests for state fair hearings for applicants or members who are denied STAR+PLUS HCBS program eligibility.

3310 Intake and Enrollment

Revision 18-0; Effective September 4, 2018

When Community Care Services Eligibility (CCSE) staff receive a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

• Intellectual or Developmental Disabilities (IDD) Program Eligibility and Support;
• Texas Health and Human Services Commission (HHSC) enrollment broker;
• Program Support Unit (PSU) staff;
• Interest List Management (ILM) Unit staff; or
• appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS.

Due to member choice issues, MCOs are prohibited from contacting the applicant without the authorization from PSU staff to complete the required STAR+PLUS HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS program interest list, or MFP individuals, PSU staff:

• complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
• upload Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake staff must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the request and referral process when the individual requesting services is determined to be age 55 years or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.  
CCSE intake staff must be aware of the PACE service areas (SAs) and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care Services Eligibility (CCSE) program. Referrals to CCSE must be made for all active Medicaid individuals awaiting enrollment for managed care. CCSE case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

3311.1 Interest List Procedures

Revision 22-1; Effective January 31, 2022

Interest List Management (ILM) Unit staff are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the STAR+PLUS Home and Community Based Services (HCBS) program interest list. ILM Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the STAR+PLUS HCBS program. ILM Unit staff must release individuals from the STAR+PLUS HCBS program interest list as slots become available in the program.

ILM Unit staff must use the CSIL database to track nursing facility (NF) residents who are not SSI eligible when a request for the STAR+PLUS HCBS program is received on the interest list hotline. Program Support Unit (PSU) staff must use the CSIL database to track NF residents who are not SSI eligible when a request for the STAR+PLUS HCBS program is received from a Community Care Services Eligibility (CCSE) case manager. ILM Unit or PSU staff must check the CSIL database to verify if the NF resident is on the STAR+PLUS HCBS program interest list when a request for community transition to the STAR+PLUS HCBS program is received. ILM Unit or PSU staff must add, if applicable, and immediately release and assign the individual from the STAR+PLUS HCBS program interest list to pursue the Money Follows the Person (MFP) process if the individual is not in the CSIL database.

ILM Unit staff perform the following activities for individuals who request placement on the STAR+PLUS HCBS program interest list:

• Place individuals on the interest list;
• Maintain annual contact requirements;
• Release individuals from the interest list when funding is available;
• Track STAR+PLUS HCBS program slots allocated for use by individuals who are not mandatory participants; and
• Confirm individuals on the interest list are viable STAR+PLUS candidates before release by:
  • verifying all contact information is correct;
  • checking the Texas Integrated Eligibility Redesign System (TIERS) to determine the Medicaid eligibility status;
  • confirming Texas residency; and
  • verifying the individual is still interested in the STAR+PLUS HCBS program.

The interest list status will automatically update to an inactive status if no response is received from the individual within 120 days of the annual contact and will remain in that status until the individual notifies ILM Unit staff of continued interest.

The HHSC enrollment broker must contact all individuals by phone upon release from the STAR+PLUS HCBS program interest list to notify them of their names reaching the top of the list and a slot has become available.  

The enrollment broker will contact the individual to confirm if the individual wishes to pursue the STAR+PLUS HCBS program. The enrollment broker will mail the enrollment packet if the individual wishes to pursue the STAR+PLUS HCBS program. If the individual does not wish to pursue the STAR+PLUS HCBS program:

• the individual can be added back to the bottom of the interest list for an offer in the future, at the individual’s request; or
• the interest list release (ILR) will be closed with the appropriate closure code in the CSIL database.

The enrollment broker will mail a STAR+PLUS HCBS program enrollment packet to all individuals released from the interest list and interested in pursuing STAR+PLUS HCBS program services. The STAR+PLUS HCBS program enrollment packet includes:

• Form H2053-A, STAR+PLUS Selection Letter;
• Form H3675, Application Acknowledgement;
• Form H2053-B, Health Plan Selection;
• Form H1200, Application for Assistance – Your Texas Benefits;
• Appendix XII, STAR+PLUS HCBS Program Description;
• STAR+PLUS Comparison Charts;
• STAR+PLUS Report Cards; and
• a postage-paid envelope.

The enrollment broker contacts the individual every seven days from the date the enrollment packet is mailed. All enrollment broker contacts will cease when the completed packet is received by the enrollment broker or on the 30th day after mailing the enrollment packet, whichever is sooner. The enrollment broker’s contact attempts include the 14-day contact requirement.

The enrollment broker will contact the applicant or authorized representative (AR) to:

• give a general description of STAR+PLUS HCBS program services;
• provide a list of managed care organizations (MCOs) in their service area (SA) and encourage the member to contact one for service information;
• discuss the importance of choosing an MCO so an assessment and initial individual service plan (ISP) can be completed in order to avoid a delay in eligibility determination for the STAR+PLUS HCBS program; and
• inform the individual that their MCO selection can be changed at any time after the first month of service.

The enrollment broker will fax the signed and completed Form H1200, along with Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days of receipt from the applicant or AR. The applicant or AR will select an MCO by completing Form H2053-B, Health Plan Selection, or notifying the enrollment broker verbally.

Refer to section 3312, Managed Care Enrollment, for steps to be taken after an individual is released from the STAR+PLUS HCBS program interest list.

3311.2 Enrollment Procedures Following Release from the Interest List

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff complete the following activities within three business days of the receipt of the STAR+PLUS Home and Community Based Services (HCBS) program interest list release (ILR) case record assignment 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;
• ensure that the individual does not have an open enrollment with another Medicaid waiver program per the procedures below:
• check the Service Authorization System Online (SASO) for open Service Authorization and Enrollment records for:
  • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2);
  • Deaf Blind and Multiple Disabilities (DBMD) (SG 16);
  • Home and Community-based Services (HCS) (SG 21);
  • Texas Home Living (TxHmL) (SG 22); and
• upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), Section A, to the MCOHub.

The MCO must complete the following activities within 45 days from the date PSU staff upload Form H3676 to the MCOHub:

• upload Form H3676, Section B, to the MCOHub;
• conduct the Medical Necessity and Level of Care (MN/LOC) Assessment; and
• develop the individual service plan (ISP) using Form H1700-1, Individual Service Plan, and upload it 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 fax Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the applicant has an approved MN/LOC Assessment and ISP within two business days of receipt from the MCO.

PSU staff must notify Program Support Operations Review Team (PSORT) staff by email within two business days of an MCO failing to submit initial assessment information within the 45-day time frame. The email sent to PSORT staff must include:

• an email subject line that reads: STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name];
• 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
• attach any pertinent documents received from the MCO such as Form H2067-MC.

PSU staff must:

• ensure the medical necessity (MN) determination from the Texas Medicaid & Healthcare Partnership (TMHP) nurse or physician is valid by verifying the approval date does not exceed 120 days; and
• upload Form H2067-MC to the MCOHub, advising the MCO to submit a new initial MN/LOC Assessment if the MN approval date exceeds 120 days.

PSU staff must determine if the applicant meets the eligibility criteria for the STAR+PLUS HCBS program within five business days from the MEPD specialist advising the applicant meets Medicaid financial eligibility. PSU staff must complete the activities listed below if the applicant meets the eligibility criteria:

• Electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF) in the TMHP Long Term Care Online Portal (LTCOP). Note: The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month, following meeting all eligibility criteria. PSU staff processing does not delay the eligibility begin date.
• Mail Form H2065-D to the member.
• Verify SASO records are in alignment with TMHP LTCOP records.
• Upload Form H2065-D to the MCOHub.
• Fax Form H1746-A (PDF) to the MEPD specialist.
• Notify Enrollment Resolution Services (ERS) unit staff by email. Include in the email to ERS unit staff, this email subject line: STAR+PLUS HCBS Enrollment for XX [member’s first and last name initials];
  • the member’s name;
    • Medicaid ID number;
    • type of request: ILR enrollment;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
  • effective date of enrollment;
  • Form H2065-D as an attachment;
• Upload all applicable documents to the HEART case record; and
• Document and close the HEART case record.

Refer to 6000, Denials and Terminations, if the applicant does not meet STAR+PLUS HCBS program requirements at ILR.

3311.3 Interest List Slot Allocations

Revision 18-0; Effective September 4, 2018

Members receiving Medicaid services under any of the programs listed in the chart below must receive those services through managed care. This does not impact the STAR+PLUS member's right to access non-Medicaid services through the Texas Health and Human Services Commission (HHSC). STAR+PLUS Home and Community Based Services (HCBS) program members must receive all services through the STAR+PLUS HCBS program, excluding hospice care. Only STAR+PLUS HCBS members count against slot allocations, as the following table illustrates.

3311.4 Earliest Date for Adding a Member Back to the Interest List

Revision 18-0; Effective September 4, 2018

The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) database for STAR+PLUS HCBS is the date the applicant is determined to be ineligible for the program or the first date the member is no longer eligible for the program.

Example 1: The applicant is released from the STAR+PLUS HCBS program interest list on March 2, 2019. PSU staff send Form H2065-D, Notification of Managed Care Program Services, notifying the applicant is not eligible for the STAR+PLUS HCBS program on March 28, 2019. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2019.

Example 2: A STAR+PLUS HCBS program member is determined ineligible on March 28, 2019. PSU staff send Form H2065-D to the STAR+PLUS HCBS program member notifying of program termination. Termination is effective April 30, 2019. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2019.

If the applicant or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL database interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program.

3311.5 Updating Community Services Interest List Records

Revision 18-0; Effective September 4, 2018

The Community Services Interest List (CSIL) database must be updated to reflect accurate information. Program Support Unit (PSU) staff must complete data entry in the CSIL database for STAR+PLUS Home and Community Based Services (HCBS) program actions within five business days of the date:

• PSU staff sign Form H2065-D, Notification of Managed Care Program Services, certifying or denying applications, except Money Follows the Person (MFP) certifications; and
• the request for other CSIL database actions (updating information, transferring an individual to another region's interest list or removing a member from the interest list upon request by the individual).

For MFP certifications, the CSIL database is updated when the Service Authorization System Online (SASO) data entry is completed to register the initial individual service plan (ISP). Delaying data entry of the disposition in CSIL for an applicant certified through MFP provisions prevents removing the individual from the interest list before the actual discharge from the nursing facility (NF) is verified.

PSU staff must ensure CSIL database closures are recorded accurately by using the Community Services Interest List (CSIL) User's Guide, available to PSU staff on SharePoint.

3311.6 Contacting the Interest List Management Unit to Reopen a Closed Interest List Release

Revision 20-6; Effective December 18, 2020

Program Support Unit (PSU) staff must submit a request to Interest List Management (ILM) Unit staff to reopen an individual’s closed Community Services Interest List (CSIL) record.

Within two business days of receiving the request to reopen a closed interest list release, PSU staff must email their immediate supervisor requesting to reopen the CSIL record. The email must include the following:

• an email subject line that reads: “S+P Reopen Request for XX [individual’s first and last initials].” For example, the email subject line for a request to reopen a closed CSIL record for Ann Smith would be “S+P Reopen Request for AS”;
• individual’s name;
• interest list identification (ID) number;
• individual’s Medicaid ID number or Social Security number (SSN);
• the individual’s or authorized representative’s (AR’s) contact name and phone number; and
• reason for the request to reopen. For example, a statement indicating that the application for an alternate 1915(c) Medicaid waiver program was denied and the individual now wishes to reapply for STAR+PLUS HCBS.

The PSU supervisor will forward the reopen request to the ILM Unit manager at StarPlusWaiverInterestList@hhsc.state.tx.us if the PSU supervisor agrees the reopen request is appropriate. ILM Unit staff will email PSU staff to provide the outcome of the request within five business days.

If an exception is granted, PSU staff must:   

• contact the individual to begin the application process;
• document the reopen request in the Health and Human Services Enterprise Administrative Report and Tracking System (HEART) case record;
• upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
• keep the HEART case record open until STAR+PLUS HCBS program eligibility is approved or denied.

If an exception is not granted, PSU staff must:

• upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XXXIII; and
• close the HEART case record.

3312 Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) enrollment broker mails enrollment packets to all Medicaid individuals who are candidates for STAR+PLUS. The enrollment packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the individual can choose. Individuals can return enrollment forms by mail, complete an enrollment form at an enrollment event or presentation, or call the HHSC enrollment broker and enroll by telephone at 800-964-2777.

Individuals have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the individual will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Individual assignments to an MCO or PCP are automatic, using a default process. Individuals assigned through the default process may change their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, the individual must receive Medicaid services through the assigned MCO and PCP until the individual contacts the MCO or the HHSC enrollment broker at 800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity (MN) determination is required.

3313 Termination of CCSE Services Upon STAR+PLUS HCBS Program Enrollment

Revision 24-4; Effective Dec. 1, 2024

The STAR+PLUS Home and Community Based Services (HCBS) program is required to provide all the services needed to enable the member to live safely in the community. Therefore, an individual cannot receive non-managed care Community Care Services Eligibility (CCSE) services and STAR+PLUS HCBS program services concurrently.

Program Support Unit (PSU) staff must coordinate the termination of CCSE with the regional CCSE case manager. This is so the member does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

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

• identify the region the member lives in;
• email the regional CCSE mailbox the following information:
  • a subject line that reads “CCSE Closure – STAR+PLUS HCBS Enrollment XX [first letter of the member’s first and last name]”;
  • member’s name;
  • Medicaid ID;
  • start of care (SOC) date for STAR+PLUS Home and Community Based Services (HCBS) program; and
  • managed care organization (MCO).
• ensure the Service Authorization System Online (SASO) reflects the closure of CCSE records with Service Group 7 and have an end date one day before the SOC for the STAR+PLUS HCBS program; and
• follow instructions in section 3311.2, Enrollment Procedures following Release from the Interest List, to complete STAR+PLUS HCBS program enrollment.

PSU staff must encourage the member to contact the MCO to request any CCSE services not in the STAR+PLUS HCBS program individual service plan (ISP).

3313.1 Procedure for STAR+PLUS HCBS Program Applicants

Revision Notice 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care Services Eligibility (CCSE) services with the waiver or CCSE case manager for individuals entering the STAR+PLUS Home and Community Based Services (HCBS) program. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

The CCSE case manager terminates CCSE services in the Service Authorization System Online (SASO) no later than one day prior to the STAR+PLUS HCBS program enrollment. The adverse action notification period does not apply in this situation.

The CCSE case manager must send:

• Form 2065-A, Notification of Community Care Services, to the member denying ongoing CCSE services; and
• Form 2101, Authorization for Community Care Services, to the provider advising the member is transferring from CCSE to the STAR+PLUS HCBS program.

3313.2 Procedure for STAR+PLUS HCBS Program Members

Revision 18-0; Effective September 4, 2018

If it is determined an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care Services Eligibility (CCSE) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If CCSE services are authorized in SASO, the CCSE case manager must immediately send:

• Form H2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to the STAR+PLUS HCBS program; and
• Form 2101, Authorization for Community Care Services, to the provider Include a notation in the comments section that the individual is transferring from CCSE to the STAR+PLUS HCBS program.

3314 Managed Care Organization Changes

Revision 25-1; Effective Feb. 19, 2025

An applicant or member may change managed care organization (MCO) plans at any time, for any reason, and regardless of their living arrangement by contacting the Texas Health and Human Services Commission (HHSC) enrollment broker at 800-964-2777. However, for an applicant requesting an MCO change, the transfer will not go into effect until after one full calendar month of STAR+PLUS Home and Community Based Services (HCBS) program service provision.

The HHSC enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of each month. Depending on which day of the month, before or after the HHSC enrollment broker cutoff, the plan change will either occur the first day of the next month or the month after. The change will show up on the 834 daily enrollment file, notifying the MCO of the new member. 

Service Authorization System Online (SASO) records will be automatically updated if the MCO submits the individual service plan (ISP) through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the ISP record is in a Processed/Complete or PSU Processed/Complete status.

Program Support Unit (PSU) staff are not required to manually update SASO records to reflect the new MCO contract number and coverage date span for any ISP that was not captured by the above process.

3315 STAR+PLUS HCBS Program Individuals Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018

Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for the STAR+PLUS HCBS program member. A STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's (MCO’s) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

3316 Transfer from Another Medicaid Waiver Program to the STAR+PLUS HCBS Program

Revision 25-4; Effective Oct. 6, 2025

Individuals in the following Medicaid waiver programs may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program any time:

• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS);
• Home and Community Based Services – Adult Mental Health (HCBS-AMH) program; or
• Texas Home Living (TxHmL).

Program Support Unit (PSU) supervisors receive requests by:

• email from Interest List Management (ILM) unit staff;
• email from Medicaid waiver program staff;
• email from a Local Intellectual and Developmental Disability Authority (LIDDA); or
• Form H2067-MC, Managed Care Programs Communication uploaded to the MCOHub by the managed care organization (MCO).

The email from ILM unit staff identify STAR+PLUS HCBS program interest list release (ILR) individuals currently enrolled in another Medicaid waiver program.

PSU staff must refer a transfer request received from the LIDDA or MCO to the corresponding Medicaid waiver program staff to confirm the individual wants to pursue the STAR+PLUS HCBS program.

PSU staff must mail the following enrollment packet to the individual within three business days of the first request for a STAR+PLUS HCBS program assessment:

• Form H3675, Application Acknowledgement; and
• Appendix XII, STAR+PLUS HCBS Program Description.

PSU staff must contact the individual or authorized representative (AR) to verify receipt of the enrollment packet. PSU staff explains the STAR+PLUS HCBS program services within 14 days from the mail date of the above enrollment packet. PSU staff must:

• encourage the individual to complete the enrollment packet and mail it back; and
• inform the individual that there might be a delay in eligibility determination for the STAR+PLUS HCBS program if the individual does not return the enrollment packet.

PSU staff can accept the individual’s or AR’s verbal statement of interest in the STAR+PLUS HCBS program or through receipt of Form H3675.

PSU staff must document all attempted contacts with the individual or encountered delays in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub within two business days of the individual’s or AR’s confirmed interest in the STAR+PLUS HCBS program.

The MCO must complete the following activities within 45 days from the date PSU staff upload Form H3676 to the MCOHub:

• submit the Medical Necessity and Level of Care (MN/LOC) Assessment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
• submit the individual service plan (ISP) in the TMHP LTCOP; and
• complete and upload Section B of Form H3676 to the MCOHub.

PSU staff must:

• monitor the TMHP LTCOP for receipt of the ISP;
• monitor the MCOHub for receipt of Section B of Form H3676 which should not delay the certification of the case, if applicable; and
• document Form H2067-MC 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 the initial assessment information within the 45-day time frame. The email to PSORT must include:

• This email subject line: STAR+PLUS HCBS Initial 45-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 which is the 45th day for STAR+PLUS HCBS program;  
  • 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: STAR+PLUS HCBS 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’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 coordinate with all other Medicaid waiver program staff, as appropriate, ensuring the current Medicaid waiver program services end the day before enrollment in the STAR+PLUS HCBS program.

PSU staff must complete the following activities within five business days of receiving all required STAR+PLUS HCBS program eligibility documentation:

• confirm STAR+PLUS HCBS program eligibility by verifying:
  • in the Texas Integrated Eligibility Redesign System (TIERS) the applicant:
    • is over 21;
    • has Medicaid eligibility for the STAR+PLUS HCBS program;
  • in the TMHP LTCOP the applicant has an:
    • approved MN/LOC Assessment; and
    • ISP within the applicant’s cost limit which has at least one STAR+PLUS HCBS program service.

PSU staff must complete the following activities the same day they confirm all STAR+PLUS HCBS program eligibility criteria are met:

• manually or electronically generate Form H2065-D, Notification of Managed Care Program Services, with a start of care (SOC) date being the first day of the month following the other Medicaid waiver program's termination;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub, if manually generated;
• verify SASO records are in alignment with TMHP LTCOP records, if applicable;
• close the Community Services Interest List (CSIL) record, if applicable;
• notify Enrollment Resolution Services (ERS) unit staff by email with the following required information:
  • This email subject line: Waiver Transfer Request for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request: waiver transfer;
  • MN approval date;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • MCO;
  • termination effective date for the other Medicaid waiver program;
  • effective date of enrollment for the STAR+PLUS HCBS program; and
  • Form H2065-D as an attachment.
• for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the STAR+PLUS HCBS program SOC date and the termination date for the other Medicaid waiver program;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Title 1 Texas Administrative Code (TAC) Section 353.1153(a)(1)(F) states that STAR+PLUS HCBS program members cannot be enrolled in more than one Medicaid waiver program at a time. Refer to Appendix XVIII, Mutually Exclusive Services, to decide if two services may be received at the same time.

The MCO must upload Section B of Form H3676 to the MCOHub within two business days if the applicant fails to meet any STAR+PLUS HCBS program eligibility criteria other than Medicaid financial eligibility. PSU staff may accept Form H2067-MC as notification of a denial. However, PSU staff must document in the HEART case record that Section B of Form H3676 was not received at the time Form H2065-D was generated, if applicable.

PSU staff must refer to 6000, Denials and Terminations, for more information on processing STAR+PLUS HCBS applicant denials.

3317 Transfer from STAR+PLUS HCBS Program to Another Medicaid Waiver Program

Revision 25-4; Effective Oct. 6, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1153(a)(1)(F) states that STAR+PLUS Home and Community Based Services (HCBS) members cannot enroll in more than one Medicaid waiver program at a time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if a member may receive two services at the same time.

A STAR+PLUS HCBS program member may be on an interest list for an Intellectual and Developmental Disabilities (IDD) Medicaid waiver program, such as:

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

A STAR+PLUS HCBS program member may also be eligible for another waiver such as the Home and Community Based Services – Adult Mental Health (HCBS-AMH) program that does not have an interest list.

Program Support Unit (PSU) staff may receive notification from Medicaid waiver program staff or the managed care organization (MCO) that the STAR+PLUS HCBS program member:

• is eligible for another Medicaid waiver program;
• chooses to transfer to another Medicaid waiver program; or
• is already enrolled in another Medicaid waiver program.

PSU staff must:

• coordinate the program enrollment effective date with Medicaid waiver program staff; and
• request confirmation of the program enrollment and the enrollment effective date from the Medicaid waiver program staff if the MCO or Local Intellectual and Developmental Disability Authority (LIDDA) notifies PSU staff of a waiver transfer.

The Medicaid waiver program staff must confirm the member’s enrollment effective date.

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

• create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable;
• contact and coordinate with Medicaid waiver program staff by email to determine the STAR+PLUS HCBS program termination date and the start of care (SOC) date for the other Medicaid waiver program;
• terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) end the last day of the month before the member’s enrollment in the Medicaid waiver program:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization.
• manually generate Form H2065-D, Notification of Managed Care Program Services, with a termination effective date one day before other Medicaid waiver’s SOC date;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• notify Enrollment Resolution Services (ERS) unit staff by email. The email to ERS unit staff must include:
  • This email subject line: Waiver Transfer Request for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request: waiver transfer;
  • MN approval date;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • MCO selection;
  • termination effective date for the STAR+PLUS HCBS program;
  • enrollment effective date for the other Medicaid waiver program; and
  • Form H2065-D as an attachment;
• for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the STAR+PLUS HCBS program termination date and the SOC date for the other Medicaid waiver program;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: PSU staff must not close Medical Necessity, Level of Service, and Diagnosis SG 19 – STAR+PLUS records in SASO.

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 18-0; Effective September 4, 2018

3321 General Eligibility Issues

Revision 18-0; Effective September 4, 2018

At the initial contact, Program Support Unit (PSU) staff must inform the medical assistance only (MAO) applicant, member or authorized representative (AR) that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by PSU staff, must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialists of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by faxing a completed and signed Form H1200, Application for Assistance – Your Texas Benefits, along with Form H1746-A, MEPD Referral Cover Sheet, following the guidelines provided in Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, within two business days of receipt. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

3321.1 Disability Determinations

Revision 18-0; Effective September 4, 2018

The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have no role in this process.

If a STAR+PLUS HCBS program applicant or member's application for Supplemental Security Income (SSI) disability has been pending over 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

• Form H3034, Disability Determination Socio-Economic Report;
• Form H3035, Medical Information Release/Disability Determination; and
• a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment.

3322 Actions Pending Past the MEPD Due Date

Revision 18-0; Effective September 4, 2018

Because Program Support Unit (PSU) staff depend on the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to determine eligibility for medical assistance only (MAO) applicants, there are times when PSU staff must check with the MEPD specialist regarding the status of an application or program change.

PSU staff must contact the MEPD specialist by sending an email to the HHSC OES MEPD IC mailbox. PSU staff must ensure the MEPD time frame has expired. MEPD specialists have 45 days to complete applications for individuals over age 65. MEPD specialists have 90 days for individuals under age 65 whose disability has not yet been determined by the Social Security Administration (SSA).

3330 STAR+PLUS Individual Requesting an Upgrade to the STAR+PLUS HCBS Program

Revision 26-2; Effective June 1, 2026

The managed care organization (MCO) must:

• Use Form H2067-MC, Managed Care Programs Communication, to advise Program Support Unit (PSU) staff that a STAR+PLUS individual requests an upgrade into the STAR+PLUS Home and Community Based Services (HCBS) program. 
• Note the following in the comments section of Form H2067-MC:
  • the Medicaid type of assistance (TOA); 
  • if the MCO will use an existing Medical Necessity and Level of Care (MN/LOC) Assessment or will be completing a new one; and
  • if a Supplemental Security Income (SSI) individual is receiving Community First Choice (CFC) services or not.
• Upload Form H2067-MC to the MCOHUB within three business days of the request for an upgrade.

PSU staff do not have to respond to the Form H2067-MC received from the MCO.

The MCO may choose to use an existing MN/LOC Assessment on file if the assessment date does not exceed 120 days from the upgrade start of care (SOC) date. PSU staff must take the following actions depending on if the MN/LOC Assessment is valid and with consideration to the MCO’s assessment preference:

• close the Medical Necessity (MN), Level of Service (LOS), and Diagnosis (DG) records in the Service Authorization System Online (SASO) with an end date one day before the STAR+PLUS HCBS program SOC date if the MCO requests to submit a new initial MN/LOC Assessment; or
• extend the end date of the MN, LOS, and DG records in SASO to align with the STAR+PLUS HCBS individual service plan (ISP) end date if the MCO requests to use an existing valid MN/LOC Assessment.

A significant change MN/LOC Assessment and nursing facility (NF) Minimum Data Set (MDS) cannot be used for an upgrade. 

A STAR+PLUS individual with one of the following Medicaid types of assistance TOAs may be eligible to upgrade to the STAR+PLUS HCBS program:

• Pickle (type program (TP)-03)
• Earnings Transitional (TP-07)
• Texas Temporary Assistance for Needy Families (TANF) Family Level (TP-08)
• SSI (TP-12 and TP-13)
• Medicaid for Breast and Cervical Cancer (MBCC) (TP-14)
• Disabled Adult Child (TP-18)
• Disabled Widow(er) (TP-21)
• Early Aged Widow(er) (TP-22)
• Pregnant Women (TP-40)
• Former Foster Care Children (FFCC) (type assistance (TA)-82)
• Medicaid Buy-in (TP-87)

The above Medicaid TOAs represent full Medicaid eligibility. PSU staff do not require review by the MEPD specialist except for applicants receiving MBCC. PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist for upgrade applicants who are receiving MBCC. This must be done within two business days of receipt of the upgrade request. PSU must check the Program Transfer box. They must note in the Comments section on Form H1746-A that this case requires a financial eligibility determination. The MEPD specialist provides PSU staff with a determination on if the MBCC applicant meets financial eligibility. The MEPD specialist updates Texas Integrated Eligibility Redesign System (TIERS) to reflect a program transfer to ME-Waivers if the MBCC applicant meets financial eligibility for the STAR+PLUS HCBS program.

An individual who receives TANF Level Families or Pregnant Women TOAs must be enrolled in STAR+PLUS to be eligible for an upgrade into the STAR+PLUS HCBS program. An individual enrolled in STAR must go through the interest list release (ILR) process.

The MCO must complete and submit:

• the initial MN/LOC Assessment, as applicable; and 
• Form H1700-1, Individual Service Plan.

This must be done in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 45 days of an applicant’s identified need or request to upgrade into the STAR+PLUS HCBS program.

PSU staff complete the following activities within five business days of verifying all eligibility criteria is met:

• email the regional Community Care Services Eligibility (CCSE) mailbox requesting the closure of all Service Group (SG) 7 records in SASO, if applicable;
  • identify the CCSE region by referring to Appendix XXXVIII, CCSE Region by Service Area; 
  • the closure date must be one day before the start of care (SOC) for the STAR+PLUS HCBS program;
• electronically generate Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTCOP;
• mail Form H2065-D to the member;
• verify SASO records are in alignment with TMHP LTCOP records;
• 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.

The start of care (SOC) date on Form H2065-D is the first day of the month after all eligibility criteria is met.

Refer to 6000, Denials and Terminations, if the applicant does not meet STAR+PLUS HCBS program requirements during the upgrade process.

Revision 25-1; Effective Feb. 19, 2025

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, 2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to his or her MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to 3315, STAR+PLUS HCBS Program Individuals Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for the Medically Fragile group or general revenue (GR) funds process. For these applicants or members, the losing service area (SA) MCO must inform the gaining SA MCO of the Medically Fragile group or GR funds status. The gaining SA MCO must follow the Medically Fragile group or GR funds process.

3410 MCO Transfer Scenarios

Revision Notice 25-2; Effective June 6, 2025

The applicant, member, or authorized representative (AR) must contact the enrollment broker by phone at 800-964-2777 to change from one managed care organization (MCO) to another MCO. The MCO transfer may occur within the same service area (SA) or in another SA.

An applicant, member, or AR may request to change MCOs at any time, for any reason, and regardless of their living arrangement. However, for an applicant requesting an MCO change, the transfer will not go into effect until after one full calendar month of STAR+PLUS Home and Community Based Services (HCBS) program service provision. All MCO enrollment changes become effective based on the date the MCO change is requested and processed, in relation to the state cutoff. Refer to Appendix XVII, State Cutoff Dates, for more information.

3411 Transferring from One MCO to Another Within the Same Service Area

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff may become aware of an applicant or member transferring from one managed care organization (MCO) to another within the same service area (SA):

• by finding a child individual service plan (ISP) H1700 record in Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); or 
• from the MCO uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must make sure the contract number in the Service Authorization System Online (SASO) is updated to reflect the new managed care organization’s (MCO’s) contract number.

PSU staff must complete the following manual actions in the Service Authorization System Online (SASO), within three business days from notification, if applicable: 

• close service authorization record using the MCO transfer date; and
• create a new service authorization record using the new MCO’s contract number.

The old MCO must transfer all relevant information to the new MCO using a secure file transfer protocol (SFTP) or secure email. Relevant information includes: 

• the individual service plan (ISP); 
• Medical Necessity and Level of Care (MN/LOC) Assessment; and 
• Form H2065-D, Notification of Managed Care Program Services. 

The new MCO is responsible for service delivery beginning the first day of enrollment. The new MCO must honor authorizations included in the prior ISP until the member requires a new MN/LOC Assessment.

The new MCO must notify Managed Care Contracts and Oversight (MCCO) unit staff if they encounter issues getting the transfer packet from the old MCO. MCCO unit staff may contact PSU staff for help transferring member information to the gaining MCO.

3412 Transferring from One MCO to Another in a Different Service Area

Revision Notice 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff may become aware of an applicant or member transferring from one managed care organization (MCO) to another in a different service area (SA):

• by finding a child individual service plan (ISP) H1700 record in Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); or
• from the MCO uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

Program Support Unit (PSU) staff must complete the following activities. This must be done within five business days of being aware of the transfer of an applicant or member to another MCO in a different SA:

• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
• verify the applicant or member’s address and managed care enrollment is updated in Texas Integrated Eligibility Redesign System (TIERS);
• manually close the Service Authorization System Online (SASO) Service Authorization record using the MCO transfer date, if applicable; and
• manually create a new SASO Service Authorization record using the new MCO’s contract number, if applicable.

PSU staff must complete the following activities. This must be done within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

• advise the MCO to help the Supplemental Security Income (SSI) applicant or member contact the Social Security Administration (SSA) to update their address; or
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the address change for medical assistance only (MAO) applicants and members.

TIERS tries to assign an applicant or member to a companion plan automatically when their address is updated in TIERS and reflects an SA change. A companion plan is defined as an MCO that operates the same managed care line in multiple SAs. TIERS systematically refers the applicant or member to the enrollment broker if a companion plan is unavailable.

The enrollment broker tries to get a new MCO selection from the member. The enrollment broker defaults the member to an MCO if a selection is not provided within 15 days. The defaulted MCO selection is made using the Texas Health and Human Services Commission (HHSC) approved default logic and is processed at the next state cutoff. The HHSC-approved default logic considers the member’s medical history, including prior enrollments, primary care providers (PCPs), claims data, and any family plans about the program type and SA.

PSU staff must make sure the MCO submits the Medical Necessity and Level of Care (MN/LOC) Assessment and ISP for applicants. The MCO must do this within 45 days from the date PSU staff upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub.

For members, PSU staff must confirm all STAR+PLUS Home and Community Based Services (HCBS) program eligibility within five business days of receipt of Form H1700-1. The process is abbreviated since the member already has the following:

• an MN/LOC Assessment;
• a Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level; and
• financial eligibility determination by the MEPD specialist, if applicable.

PSU staff coordinates all appropriate activities between the MCOs, applicant, member or authorized representative (AR), Enrollment Resolution Services (ERS) unit staff and other key parties. This helps make sure there is a successful transition.

PSU staff must complete the following activities within five business days from notification of the transfer:

• confirm the applicant or member’s address and managed care enrollment is updated in TIERS;
• make sure the contract number in SASO is updated to reflect the new MCO’s contract number;
• for MAO members, email ERS unit staff the following information:
  • this subject line: STAR+PLUS HCBS MCO Transfer Enrollment Request for XX [member’s first and last name initials]”;
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request: MCO change;
  • medical necessity (MN) approval date;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • MCO selection;
  • effective date of enrollment;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following activities within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

• contact the applicant or member by phone to select an MCO from the new SA; or
• mail an enrollment packet containing the following documents, if the applicant or member does not provide an MCO selection:
  • Form H2053-B, Health Plan Selection;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for more information, and for SA changes occurring for a Money Follows the Person (MFP) case.

3420 Individuals Transitioning Services for Adults

Revision 18-0; Effective September 4, 2018

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults beginning the first day of the first month following the individuals 21st birthday. The following services end at the end of the month following the member's 21st birthday.

• Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
• Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

In addition to the programs and services above, individuals for Community First Choice (CFC) services and personal care services (PCS) must transition to an adult program.

Members who receive MDCP, PDN, PPECC, CFC or PCS and transition to adult programs may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018

Members may receive a combination of the following services:

• Medically Dependent Children Program (MDCP);
• private duty nursing (PDN); or
• prescribed pediatric extended care center (PPECC) services.

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 26-2; Effective June 1, 2026

The Texas Health and Human Services Commission (HHSC) Utilization Review (UR) unit provides a copy of the Medically Dependent Children Program (MDCP)-Private Duty Nursing (PDN) Transition Report, to the following each quarter:

• Program Support Unit (PSU) staff; and
• UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice staff.

The MDCP-PDN Transition Report lists STAR Kids or STAR Health members who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months and are receiving:

• MDCP,
• PDN;
• Comprehensive Care Program (CCP) services; or 
• Prescribed Pediatric Extended Care Center (PPECC) services. 

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning 21 within the next 12 months and schedule a face-to-face home visit with the member and the member's support person, including the authorized representative (AR), if applicable, to initiate the transition process.

The MCO must present an overview of the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to the adult program during the home visit.  The MCO must make a referral to the Utilization Review (UR) unit mailbox if they believe the member meets high needs criteria. 

Designated PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members receiving MDCP, PDN or PPECC services turning 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
  • CLASS;
  • DBMD;
  • HCS; or
  • TxHmL;
• create a case record in HEART noting:
  • if the MCO determines the member is high needs; 
  • the program type the member is transitioning from; and
  • the due date for the nine-month contact; and
• assign the HEART case record to regional PSU staff.

PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub earlier than five months before the member's 21st birthday.

3421.2 Nine Months Before the Member's 21st Birthday

Revision 23-4; Effective Dec. 7, 2023

Nine months before the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO) must:

• monitor transition activities with the member and the member's available supports, including his or her authorized representative (AR), every 90 days during the year before the member turns 21; and
• notify Program Support Unit (PSU) staff of any issues or concerns by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and PDN or PPECC turning 21 in nine months and not enrolled in one of the following 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);
• mail the STAR Kids member or AR a STAR+PLUS enrollment packet, including:
  • Form 2114, Nine-Month Transition Letter;
  • Form H2053-B, Health Plan Selection;
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Appendix XII, STAR+PLUS HCBS Program Description;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards.

PSU staff must update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record by:

• documenting the date Form 2114 was sent out to the member or AR;
• documenting the due date for the phone contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
• upload all applicable documents to the HEART case record.

Note: PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub no earlier than five months before the member's 21st birthday.

PSU staff must contact the member or AR within 30 days from the date the enrollment packet was mailed to discuss:

• The transition process and review the enrollment packet.
• STAR Kids eligibility, MDCP, PDN and PPECC services will terminate on the last day of the month that the member's 21st birthday occurs.
• The STAR+PLUS HCBS program is an option available to eligible members at 21. PSU staff must also present an overview of the array of services available within the STAR+PLUS HCBS program.
• The STAR+PLUS HCBS program enrollment packet sent to the member is reviewed. The enrollment packet contains a list of the STAR+PLUS MCOs in the SA and a comparison chart to help the member in making an MCO selection. The member will choose a STAR+PLUS MCO in their SA to conduct the Medical Necessity and Level of Care (MN/LOC) Assessment for services and oversee the delivery of services.
• The importance of choosing an MCO six months before the 21st birthday to avoid having a gap in services.
• The member can change MCOs any time after the first month of enrollment.
• The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the MN/LOC Assessment. The assessment determines the cost limit for the individual service plan (ISP).
• To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit, meet the member's needs and ensure health and safety.
• The STAR+PLUS HCBS program will be denied if an ISP cannot be developed within the cost limit that ensures member's health and safety in the community.
• The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
• The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. The member has 30 days to select an MCO. An MCO will be selected for the member after 30 days if one has not been selected.
• The MCO service coordinator will contact the member to begin the MN/LOC Assessment for services and assist the member or AR identify and develop additional resources and community supports to help meet the member's needs.
• The MCO service coordinator will help the member determine the services needed within this service array to meet his or her needs and ensure health and safety. Example: A member who primarily requires nursing services can have an ISP developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
• Reassure the member or AR every effort will be made to ensure a successful transition to the STAR+PLUS HCBS program.
• The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

PSU staff must update the HEART case record by noting the due date for the six-month contact.

The following chart outlines the responsibilities to monitor the MDCP-PDN Transition Report and contact members transitioning from STAR Kids or STAR Health and receiving MDCP and PDN or PPECC nine months before the member's 21st birthday:

Nine-Month Transition Chart

3421.3 Six Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Six months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care (PPECC) services, the following process begins.
The Utilization Review (UR) Unit must:

• monitor the MDCP-PDN Transition Report and identify all members turning age 21 in six months receiving CCP/PDN through fee-for-service (FFS) or STAR Health and not enrolled in one of the following Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waivers:
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL).
• coordinate with Program Support Unit (PSU) staff if it is determined the member is high needs and/or will need to be assessed for the STAR+PLUS Home and Community Based Services (HCBS) program.

The IDD Waiver/Community Services/Hospice UR Unit staff will:

• monitor the MDCP-PDN Transition Report for members enrolled in one of the following 1915(c) Medicaid waivers for IDD and who are turning age 21 in the next six months:
  • CLASS;
  • DBMD;
  • HCS; or
  • TxHmL; or
• make a STAR+PLUS HCBS program referral to PSU staff by email using Form H2067-MC, Managed Care Programs Communication, for members requesting a STAR+PLUS HCBS program assessment, or whose proposed waiver plan exceeds the member cost limit for the IDD 1915(c) Medicaid waiver listed above.

PSU staff must:

• monitor the MDCP-PDN Transition Report and identify all members referenced in 3421, Children Transitioning from STAR Kids or STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC, turning age 21 in six months and not enrolled in one of the IDD 1915(c) Medicaid waivers listed above;
• not reach out to members in CLASS, DBMD, HCS or TxHmL, unless the IDD Waiver/Community Services/Hospice UR Unit submits a referral, as documented above;
• send Form H2116, Age-Out MDCP and PDN Contact Letter, to the member if the MCO choice has not been obtained;
• contact the member or authorized representative (AR) if the MCO choice has not been obtained by telephone to:
  • review the STAR+PLUS enrollment packet discussed at the 12-month or the nine-month contact;
  • inform the member or AR of a 30-day time frame to choose a managed care organization (MCO) and a primary care physician (PCP);
  • explain if the member or AR does not timely choose an MCO, the Texas Health and Human Services Commission (HHSC) will assign an MCO for the member; and
  • explain that the member can change MCOs any time after the first month of enrollment.
• email the UR Unit at the HHSC UR High Needs CCR mailbox regarding all possible high needs situations; and
• update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, documenting the:
  • contact or contact attempt date;
  • MCO selection; and
  • due date for the five-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for agency referrals and PSU staff action for members enrolled in STAR Kids or STAR Health and receiving MDCP, PDN or PPECC transitioning six months prior to the member's 21st birthday.

Six-Month Transition Chart

3421.4 Five Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

• the member or AR receiving MDCP-PDN or PPECC informs PSU staff of the MCO choice; and
• PSU staff inform the:
  • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
  • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions; and
  • MCO of members receiving 50 or more PDN hours, by noting the PDH hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

• PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU staff contact, one will be assigned; and
• if the selection is not made within seven days from the PSU staff contact, PSU staff:
  • select an MCO for the member;
  • inform the member that:
    • an MCO has been selected; and
    • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
• inform the MCO of the choice by uploading Form H3676 to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

Note: Within 14 days of the PSU staff uploading date of Form H3676, the MCO must schedule the initial home visit with the MDCP or CCP or PDN member or AR.

3421.5 MCO Actions After Receiving Form H3676 Referral

Revision 23-2; Effective May 15, 2023

The managed care organization (MCO) must complete the following activities within 45 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff:

• conduct and submit the Medical Necessity and Level of Care (MN/LOC) Assessment to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • Note: The MCO must not submit the initial MN/LOC Assessment earlier than 150 days prior to the member’s 21st birthday;
• complete Form H1700-1, Individual Service Plan, Form H1700-2, Individual Service Plan – Addendum and Form H1700-3, Individual Service Plan – Signature Page;
• upload Form H1700-1 to TxMedCentral, once an approved MN/LOC Assessment is received; and
• complete Form H3676, Section B, and upload to TxMedCentral.

3421.6 Confirm STAR+PLUS HCBS Program Eligibility

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must confirm ongoing Medicaid eligibility in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, from the managed care organization (MCO).

PSU staff must coordinate with Medicaid waiver program staff by email, if the member is enrolled in an Intellectual or Developmental Disability (IDD) waiver program, within five business days of receipt of the following from the MCO:

• Form H3676, Section B;
• an approved and valid Medical Necessity and Level of Care (MN/LOC) assessment; and
• the STAR+PLUS Home and Community Based Services (HCBS) program individual service plan (ISP).

The email to the Medicaid waiver program staff must include:

• a subject line that reads: [IDD waiver program acronym] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name];
• member’s name;
• Medicaid identification (ID) number;
• the Medicaid waiver program termination date; and
• the STAR+PLUS HCBS program start of care (SOC) date.

PSU staff must confirm STAR+PLUS HCBS program eligibility:

• no earlier than 45 days before the transition to an adult program; and
• by verifying the following eligibility criteria:
  • an approved and valid MN/LOC Assessment submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and updated in the Service Authorization System Online (SASO);
  • an ISP within the cost limit that includes at least one STAR+PLUS HCBS program service; and
  • continued Medicaid financial eligibility in the Texas Integrated Eligibility Redesign System (TIERS).

Note: A valid medical necessity (MN) does not exceed 150 days from the date of TMHP approval for applicants transitioning to an adult program. PSU staff must upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub requesting the MCO submit a new initial MN/LOC Assessment in the TMHP LTCOP if the MN exceeds 150 days from the date of TMHP approval.

PSU staff must complete the following activities within five business days of confirming approval of STAR+PLUS HCBS program eligibility:

• establish the SOC date which is the first of the month following the member's 21st birthday;
  • SOC Date Examples:
    • A member receiving Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Centers (PPECC) services has their 21st birthday on March 3, 2019. STAR+PLUS enrollment is effective April 1, 2019.
    • A member receiving MDCP or CCP, PDN or PPECC services has their 21st birthday on April 1, 2019. STAR+PLUS enrollment is effective May 1, 2019.
• manually or electronically generate Form H2065-D, Notification of Managed Care Program Services;
• upload Form H2065-D to the MCOHub, if manually generated;
• mail Form H2065-D to the member;
• email Enrollment Resolution Services (ERS) unit staff the following information:
  • an email subject line that reads: [MDCP or Medicaid waiver program] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name];
  • the member's name;
  • Medicaid ID number;
  • ISP begin and end date for the STAR+PLUS HCBS program;
  • MCO selection and plan code; and
  • Form H2065-D as an attachment;
• fax Form H1746-A, MEPD Referral Cover Sheet to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist as notification of the program change from MDCP or an Medicaid waiver program to the STAR+PLUS HCBS program;
• verify Medicaid waiver program staff have closed IDD records in SASO, if applicable;
• verify SASO records are aligned with TMHP LTCOP records;
• upload 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.

Refer to 6000, Denials and Terminations, for more information on denying an applicant trying to transition to an adult program.

3421.7 ISP Cost Exceeds 202% of the Cost Limit

Revision 25-1; Effective Feb. 19, 2025

The managed care organization (MCO) must provide documentation to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator if the individual service plan (ISP) cost exceeds 202 percent of the cost limit.

The UR Unit may request a clinical review of the case to consider the use of the Medically Fragile group or General Revenue (GR) funds process to cover costs more than 202 percent of the cost limit. The UR Unit provides the final determination letter to the MCO and Program Support Unit (PSU) staff if a clinical review is conducted.

Note: HHSC UR staff coordinates with the member, authorized representative (AR) and the MCO to discuss the process for HHSC to request the use of the Medically Fragile group GR funds process for services above the cost limit.

Refer to 5000, Medically Fragile Group and General Revenue Process, for more information on processing cases submitted for Medically Fragile group and GR funds process consideration.

3422 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only

Revision 25-2; Effective June 6, 2025

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

Individuals and applicants with STAR+PLUS must transition their personal care services (PCS) and Community First Choice (CFC) services to an adult program. Some individuals or applicants may continue to receive PCS or CFC through STAR Health until 22, depending on eligibility requirements.

The Texas Health and Human Services Commission (HHSC) enrollment broker will reach out to the individual or applicant 30 days before the individual's or applicant's 21st birthday 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. The HHSC enrollment broker selects an MCO for the individual or applicant if the individual or applicant has not made a selection after 15 days, as outlined in Title 1 Texas Administrative Code (TAC) Chapter 353.403(d)(3), Enrollment and Disenrollment.

3423 Intrapulmonary Percussive Ventilator

Revision 18-0; Effective September 4, 2018

Members who were approved for, and are using, an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by the Texas Health and Human Services Commission (HHSC) Office of the Medical Director (OMD).

Revision 18-0; Effective September 4, 2018

Refer to section 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List (CSIL) database to track Money Follows the Person (MFP) applications from individuals who are not yet members of a managed care organization (MCO).

3510 Money Follows the Person and Managed Care

Revision 24-3; Effective Sept. 10, 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) must perform the functional assessment and service planning for residents who need the STAR+PLUS Home and Community Based Services (HCBS) program.

The MCO may use an NF’s Minimum Data Set (MDS) medical necessity (MN) as long as the MN/LOC Assessments are approved and have not yet expired. A MN/LOC Assessment will expire 120 days after the assessment date. The MCO may not use the NF’s MN/LOC Assessment for upgrades. Refer to Section 3330, STAR+PLUS Individual Requesting an Upgrade to the STAR+PLUS HCBS Program, for more information about upgrades.

One of the eligibility requirements for MFP is that the individual be approved for the STAR+PLUS HCBS program before leaving the NF. The applicant must reside in the NF until a final determination by PSU staff is made indicating approval of the STAR+PLUS HCBS program. PSU staff must deny the applicant if they discharge from the NF before receiving Form H2065-D, Notification of Managed Care Program Services, approval. PSU staff must deny the applicant by generating Form H2065-D.

Refer to Section 3310, Intake and Enrollment, for more information about MFP.

3511 Money Follows the Person Procedure

Revision 18-0; Effective September 4, 2018  
   
A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) when a nursing facility (NF) resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. Community Care Services Eligibility (CCSE) intake staff must refer all Money Follows the Person (MFP) requests to Program Support Unit (PSU) staff. Referrals can be made by anyone, including family members, NF staff, relocation specialists and HHSC case managers.

3512 MFP Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018

In keeping with the Promoting Independence (PI) Initiative, the Program Support Unit (PSU) and managed care organizations (MCOs) staff are obligated to assist the nursing facility (NF) applicant or member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, PSU staff have the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four calendar month time frame is the guideline used in determining pending, or denying, requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the member is ready to discharge from the NF.

Examples:

• A STAR+PLUS Home and Community Based Services (HCBS) program applicant has a definite date of discharge within four calendar months from the date services were requested. Allow the referral to remain open until the applicant is ready to discharge and coordinate the transfer to the community.
• A STAR+PLUS HCBS program applicant is in the process of making living arrangements that will allow him to leave the NF within four calendar months from the date services were requested. Allow the application to remain open.

If the applicant has an estimated date of discharge that may or may not go beyond the four calendar month period, PSU staff should keep the request for services open. Refer to Section 3513, Applications Pending More than Four Calendar Months Due to Delay in NF Discharge, for information about applications pending more than four calendar months.

3513 Applications Pending More than Four Calendar Months Due to Delay in NF Discharge

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but not finalized. PSU staff should keep the request for services open if the applicant has an estimated discharge date that goes beyond a four calendar month period.

PSU staff must refer Money Follows the Person (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.

3514 STAR+PLUS Individual Residing in a Nursing Facility

Revision Notice 25-5; Effective Dec. 17, 2025

The managed care organization (MCO) must upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub to inform Program Support Unit (PSU) staff of an individual’s request to transition to the community through the Money Follows the Person (MFP) process.

PSU staff must complete the following within two business days of receipt of Form H2067-MC:

• create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
• check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program (TP);
• check the Community Services Interest List (CSIL) database to check if the individual is on an Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waiver interest list;
• determine, per the procedures below, if the member has either an open enrollment or services are temporarily suspended in an IDD 1915(c) Medicaid waiver:
• check the Service Authorization System Online (SASO) Enrollment and Service Authorization records to see if a record exists with an end date and termination code for:
  • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2)
  • Deaf Blind with Multiple Disabilities (DBMD) (SG 16)
  • Home and Community-based Services (HCS) (SG 21)
  • Texas Home Living (TxHmL) (SG 22)
  • Note: A service authorization record containing an end date, but no termination code indicates the 1915(c) Medicaid waiver program is temporarily suspended
• upload Form H2067-MC to  the MCOHub to inform the MCO if the individual is:
  • on an IDD 1915(c) Medicaid waiver interest list; or
  • enrolled in an IDD 1915(c) Medicaid waiver, including the enrollment status.

The MCO must complete the following activities within 45 days of becoming aware of an individual’s requesting to transition to the community:

• Determine if the individual wants to pursue the STAR+PLUS Home and Community Based Services (HCBS) program if he or she is temporarily suspended from a 1915(c) Medicaid waiver program.
• Use the nursing facility (NF) Minimum Data Set (MDS) to determine medical necessity (MN) or conduct the Medical Necessity and Level of Care (MN/LOC) Assessment in lieu of the MDS.
  • The MCO must conduct the MN/LOC Assessment if there is no valid MDS.
  • A denied MN/LOC Assessment decision cannot be used to deny an applicant who has a valid MDS. The MDS and Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level must be used for the MN determination.
  • A MN record must be in SASO so the individual service plan (ISP) registration does not suspend. The SASO MN record must match the ISP effective dates. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
• Upload Form H2067-MC to the MCOHub if a Supplemental Security Income (SSI) or SSI-related member is receiving personal assistance services (PAS) or emergency response services (ERS).
• Develop the ISP using Form H1700-1, Individual Service Plan.

PSU staff must send an email to the Program Support Operations Review Team (PSORT) mailbox within two business days of an MCO failing to submit initial assessment information within the 45-day time frame. The email sent to the PSORT mailbox must include:

• this email subject line: STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name];
• 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
• attach any pertinent documents received from the MCO such as Form H2067-MC.

Refer to Appendix XXXV, SASO Data Entry Guide, MFP Authorization for STAR+PLUS HCBS Program Applicant, for more information on SASO actions.

3514.1 STAR+PLUS Individual Transitioning to the Community with STAR+PLUS HCBS Program

Revision 25-4; Effective Oct. 6, 2025

The managed care organization (MCO) must determine if the individual wants to pursue the STAR+PLUS Home and Community Based Services (HCBS) program if he or she is temporarily suspended from another Medicaid waiver program. The person has the option to remain in their current Medicaid waiver program or choose the STAR+PLUS HCBS program. The MCO must:

• get the person’s waiver selection within the initial 45-day time frame for assessment; and
• notify Program Support Unit (PSU) staff of the individual’s waiver selection by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must complete the following activities within two business days of receipt of Form H2067-MC from the MCO advising that the individual has selected another Medicaid waiver program:

• 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.

PSU staff must complete the following activities within five business days of receipt of Form H2067-MC from the MCO notifying PSU staff the individual has selected the STAR+PLUS HCBS program:

• add the individual to the STAR+PLUS HCBS program interest list in the Community Services Interest List (CSIL) database, if applicable;
• immediately release and assign the individual from the interest list in the CSIL database;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

The MCO must upload the following information to the MCOHub within 45 days of the individual’s request to transition into the STAR+PLUS HCBS program:

• Form H1700-1, Individual Service Plan, if the individual service plan (ISP) has expired or one did not previously exist; and
• Form H2067-MC notifying PSU staff if the nursing facility (NF) discharge date is known.

PSU staff must email the Program Support Operations Review Team (PSORT) within two business days of an MCO failing to submit the initial assessment information within the 45-day time frame. The email to PSORT must include:

• an email subject line that reads: STAR+PLUS HCBS Initial 45-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 which will be the 45th day for STAR+PLUS HCBS program;  
  • 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 Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (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:

• an email subject line that reads: STAR+PLUS HCBS 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’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 complete the following activities within five business days of receipt of all required documentation from the MCO:

• confirm STAR+PLUS HCBS program eligibility based upon:
  • Medicaid financial eligibility;
  • an approved Medical Necessity and Level of Care (MN/LOC) Assessment; and
  • an ISP with:
    • at least one STAR+PLUS HCBS program service per ISP year; and
    • a cost within the individual's cost limit; and
• manually generate the initial Form H2065-D, Notification of Managed Care Program Services;
• mail the initial Form H2065-D to the member;
• upload the initial Form H2065-D to the MCOHub;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

Note: refer to Form H2065-D instructions for more information on field entries.

The MCO collaborates with the relocation specialist, NF, applicant and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC to the MCOHub within two business days of the discharge date being determined. PSU staff must upload Form H2067-MC to the MCOHub within two business days of being notified by any other entity of a different NF discharge date, inquiring which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to the MCOHub advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to the MCOHub within two business days following the date of the applicant discharge from the NF.

PSU staff must complete the following activities within five business days of being notified of the NF discharge:

• manually generate the second Form H2065-D;
• mail the second Form H2065-D to the member;
• upload the second Form H2065-D to the MCOHub;
• fax Form H1746-A, MEPD Referral Cover Sheet to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable, to advise of the start of care (SOC) for the STAR+PLUS HCBS program and request a program transfer in Texas Integrated Eligibility Redesign System (TIERS);
• verify that NF records in the Service Authorization System Online (SASO), Service Groups (SG) 1 and 3, reflect the NF end date;
  • contact the Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) Provider Claims Services at 512-438-2200; and
  • select option 1 to request closure of the NF service authorization in SASO if the NF end date has not processed within five business days from the date of discharge;
• close the CSIL database record using the appropriate closure code;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: Refer to Form H2065-D instructions for more information on field entries.

PSU staff must create SASO entries within one business day of mailing the second Form H2065-D to the MFP member. Refer to Appendix XXXV, SASO Data Entry Guide, and Appendix XVI, SASO Service Group, Service Code and Termination Code, for more information on SASO entries.

Refer to 6300, Denials and Terminations, if the individual or applicant is denied eligibility for the STAR+PLUS HCBS program.

Refer to 6300.10, Other Reasons, for more information on denying an individual or applicant choosing to leave the NF before being determined eligible for the STAR+PLUS HCBS program.

3515 Non-STAR+PLUS Individual Residing in a Nursing Facility

Revision Notice 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff may receive a referral for a non-STAR+PLUS individual living in a nursing facility (NF) who requests to transition to the community through the Money Follows the Person (MFP) process from the:

• regional Community Care Services Eligibility (CCSE) staff; or
• individual’s legally authorized representative (LAR).

PSU staff must complete the following within two business days of the referral:

• create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
• check the Community Services Interest List (CSIL) database to determine if the member is on an Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waiver interest list;
• determine if the member has either an open enrollment or suspended services in an IDD 1915(c) Medicaid waiver by reviewing the:
  • Service Authorization System Online (SASO) Enrollment and Service Authorization records for a record with an end date and termination code for:
    • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2);
    • Deaf Blind with Multiple Disabilities (DBMD) (SG 16);
    • Home and Community-based Services (HCS) (SG 21); or
    • Texas Home Living (TxHmL) (SG 22).

Note: A service authorization record with an end date but no termination code indicates the 1915(c) Medicaid waiver program is suspended.

PSU staff complete the following within two business days of being notified the individual wants to pursue a 1915(c) Medicaid waiver program:

• notify the appropriate IDD waiver unit staff by email;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following within two business days of notification the individual chooses to apply for the STAR+PLUS HCBS program:

• check the Texas Integrated Eligibility Redesign System (TIERS) to verify if Form H1200, Application for Assistance – Your Texas Benefits, was already submitted for the nursing facility (NF) stay;
• contact or attempt to contact the individual, or authorized representative (AR) by phone to explain the Medicaid application process, the selection of a managed care organization (MCO) and the importance of promptly returning the application packet that PSU staff mail to the individual, if applicable;
• mail an enrollment packet to the individual including:
  • Form H1200, if applicable;
  • Appendix XII, STAR+PLUS HCBS Program Description;
  • Form H2053-B, Health Plan Selection;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards;
• inform the individual during the phone contact that their MCO selection can be changed at any time after the first month of service;
• add the individual to the STAR+PLUS HCBS program interest list in the CSIL database; and
• immediately release and assign the individual from the interest list in the CSIL database.

PSU staff must complete the following within 14 days of mailing the enrollment packet to the individual:

• discuss with the individual the importance of: 
  • immediately submitting Form H1200 if PSU staff have not received Form H1200 from the individual and TIERS does not have a record of submission;
  • choosing an MCO, if the individual did not select one during the initial contact, explaining the MCO conducts the Medical Necessity and Level of Care (MN/LOC) Assessment and develops the initial individual service plan (ISP) to facilitate an eligibility determination for the STAR+PLUS HCBS program; and
• document all contacts and attempted contacts in the HEART case record.

PSU staff must:

• Check TIERS to verify Form H1200 was submitted if the individual states Form H1200 was submitted during the 14-day follow-up contact.
• Fax MEPD Form H1746-A, Referral Cover Sheet, and Form H1200 to the MEPD specialist within two business days of receipt of Form H1200. 
• Notate the individual is requesting to pursue the MFP process on From H1746-A.

PSU staff must deny the individual requesting the STAR+PLUS HCBS program if Form H1200 is not received within 30 days from the date PSU staff mailed Form H1200 to the individual. They do this within two business days of the 30^th day that PSU staff mailed Form H1200 by:

• documenting in the HEART case record Form H1200 was not received within 30 days;
• Uploading applicable documents to the HEART case record; and
• Closing the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual makes an MCO selection. This can be done verbally or in writing, or from the date the member is defaulted to an MCO:

• check SASO to determine if the applicant has a current MN/LOC Assessment;
• complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating:
  • if the applicant is on a 1915(c) Medicaid waiver program interest list;
  • if the applicant has a current medical necessity (MN) by entering the Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level; and
  • expiration date in Item 6;
• upload Form H3676 to the MCOHub; and
• upload applicable documents to the HEART case record.

PSU staff must default the individual to an MCO if a selection is not made within 30 days of mailing the enrollment packet to the individual. 

The MCO must complete the following activities within 45 days from receipt of Form H3676:

• Conduct the MN/LOC Assessment if there is no valid Minimum Data Set (MDS) or complete its own MN/LOC Assessment in lieu of using the NF MDS. The MCO must complete the MN/LOC Assessment if there is no valid MDS.
  • A denied MN/LOC Assessment decision cannot be used to deny an applicant who has a valid MDS. The MDS and PDPM LTC level must be used for the MN determination.
  • A MN record must be found in SASO so the ISP registration does not suspend. The SASO MN record must match the ISP effective dates. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
  • Develop the ISP using Form H1700-1, Individual Service Plan.

PSU staff must send an email to the Program Support Operations Review Team (PSORT) mailbox within two business days of an MCO failing to submit initial assessment information within the 45-day time frame. The email sent to the PSORT mailbox must include:

• this email subject line: STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name];
• 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
• attach any pertinent documents received from the MCO such as Form H2067-MC. 

3515.1 Non-STAR+PLUS Individual Transitioning to the Community with STAR+PLUS HCBS Program

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must:

• collaborate with involved parties throughout the STAR+PLUS Home and Community Based Services (HCBS) program eligibility determination process to help with problem resolution and to document any delays; and
• track and document all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record until all STAR+PLUS HCBS program enrollment activities are complete.

The managed care organization (MCO) must upload the following information to the MCOHub within 45 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, from PSU staff:

• Form H1700-1, Individual Service Plan;
• Form H3676 with Section B completed; and
• Form H2067-MC, Managed Care Programs Communication, notifying PSU staff of the NF proposed discharge date.

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 fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days of receiving the approved individual service plan (ISP) and Medical Necessity and Level of Care (MN/LOC) Assessment if Medicaid is pending. PSU staff must note the individual is asking to pursue the Money Follows the Person (MFP) process on Form H1746-A. The MEPD specialist notifies PSU staff upon completion of the evaluation for financial eligibility through the MEPD Communications Tool.

PSU staff must complete the following activities within two business days of receiving all required eligibility documentation from the MCO and the MEPD specialist, when applicable:

• confirm STAR+PLUS HCBS program eligibility based upon:
  • Medicaid eligibility;
  • an approved MN/LOC Assessment;
  • an ISP with:
    • at least one STAR+PLUS HCBS program service per ISP year; and
    • a cost within the individual's cost limit.
• manually generate the initial Form H2065-D, Notification of Managed Care Program Services*;
• *Note: refer to Form H2065-D instructions for more information on field entries;
• mail the initial Form H2065-D to the member;
• upload the initial Form H2065-D to the MCOHub;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

The MCO:

• collaborates with the relocation specialist, nursing facility (NF), member and PSU staff to identify a proposed discharge date; and
• must upload Form H2067-MC to the MCOHub within two business days of the discharge date being determined.

PSU staff must:

• upload Form H2067-MC to the MCOHub within two business days of being notified by any other entity of a different NF discharge date; and
• ask which discharge date is acceptable.

The MCO must:

• respond within two business days by uploading Form H2067-MC to the MCOHub advising of the correct discharge date; and
• upload Form H2067-MC to the MCOHub within two business days of the date the applicant is discharging from the NF.

PSU staff must complete the following within five business days of being notified of the NF discharge:

• manually generate the second Form H2065-D*;
• * Note: refer to Form H2065-D instructions for more information on field entries;
• mail the second Form H2065-D to the member;
• upload the second Form H2065-D on the MCOHub;
• fax Form H1746-A to the MEPD specialist to advise of the start of care (SOC) for the STAR+PLUS HCBS program and request a program transfer in Texas Integrated Eligibility Redesign System (TIERS);
• verify that NF records in the Service Authorization System Online (SASO) reflect the NF end date;
  • contact the Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) Provider Claims Services at 512-438-2200; and
  • select option 1 to request closure of the NF service authorization in SASO, if the NF end date has not processed within five business days from the date of discharge;
• create one-day STAR+PLUS HCBS program service authorization record in SASO for the first day of the month that an MFP applicant is discharged from the NF.
• close the Community Services Interest List (CSIL) database record using the appropriate closure code;
• notify Enrollment Resolution Services (ERS) unit staff by email, for Medical Assistance Only (MAO) members. The email to ERS unit staff must include the following:
  • the email subject line: STAR+PLUS HCBS MFP Enrollment Request for XX [member’s first and last name initials];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request: MFP NF discharge;
  • medical necessity (MN) approval date;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • MCO selection;
  • effective date of enrollment which is the date of NF discharge; and
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to  6300, Denials and Terminations, if the individual or applicant is denied eligibility for the STAR+PLUS HCBS program.

Refer to  6300.10, Other Reasons, for more information on denying an individual or applicant who chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program.

3520 Money Follows the Person Demonstration

Revision Notice 23-3; Effective Aug. 21, 2023

3521 Money Follows the Person Demonstration Introduction

Revision Notice 23-3; Effective Aug. 21, 2023

The Money Follows the Person Demonstration (MFPD) was implemented to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities (NFs) to the community and receive necessary long-term services and supports (LTSS) in the setting of the individual's choice. Participation in MFPD does not affect the type or amount of services received or how the individual receives the services. A member participating in MFPD receives the same services delivered to other STAR+PLUS Home and Community Based Services (HCBS) program members.

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

Revision Notice 23-3; Effective Aug. 21, 2023

The managed care organizations (MCO) must apply the following screening criteria to determine if an applicant is potentially eligible to participate in the Money Follows the Person Demonstration (MFPD). To be eligible for MFPD, the applicant must be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program and meet the following criteria:

• reside continuously in an institutional setting, including days during a Medicare certified skilled nursing facility (SNF) stay following a stay in a Medicaid certified nursing facility (NF), for at least 60 days before  the STAR+PLUS HCBS eligibility date;
• be enrolled in MFPD before leaving a Medicaid certified NF;
• be Medicaid eligible under Title XIX of the Social Security Act;
• be transitioning from an NF into a qualified residence that includes:
  • a home owned or leased by the applicant or the applicant's family;
  • an apartment with an individual lease that includes living, sleeping, bathing and cooking areas where the applicant or applicant’s family has domain;
  • Assisted Living (AL) apartment (Service Code 19);
  • Residential Care apartment (Service Code 19A); or
  • Adult Foster Care (AFC) home with no more than four unrelated individuals living in the home; and
• agree to participate in the MFPD by completing Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation.

3522.1 Screening for 60-Day Qualifying Institutional Stay

Revision Notice 23-3; Effective Aug. 21, 2023

For purposes of the Money Follows the Person Demonstration (MFPD), an institutional setting is defined as a: 

• Medicaid certified nursing facility (NF);
• Medicaid certified skilled nursing facility (SNF);
• intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
• state supported living center; or
• hospital.

A continuous stay in a combination of the settings above may meet the 60-day qualifying institutional stay. 

Example: An MFPD applicant resides continuously in a Medicaid certified NF for 30 days, in a hospital for 15 days and then re-enters the NF for another 15 days. This applicant would meet the 60-day institutional residency requirement for MFPD.

The MFPD applicant does not have to live in the Medicaid certified NF or other institution for 60 days at the time they indicate a desire to transition to the community. The MFPD applicant meets the screening criteria if it appears likely they will live in a Medicaid certified NF or other institution for at least 60 days before the discharge date from the NF.

3522.2 MCO Reporting of 60-Day Qualifying Institutional Stay

Revision Notice 23-3; Effective Aug. 21, 2023

The managed care organization (MCO) must notify Program Support Unit (PSU) staff of a Money Follows the Person Demonstration (MFPD) applicant using Form H2067-MC, Managed Care Programs Communication. The MCO must check box 10, MFP Demonstration Consent Obtained, and enter the institutional admission and discharge dates in the Comments section. PSU staff are not required to verify if the applicant has met the 60-day institutional stay requirement.

3523 Enrollment in Money Follows the Person Demonstration

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must designate a member as being enrolled in the Money Follows the Person Demonstration (MFPD) by modifying Service Authorization System Online (SASO) records. Refer to Section 9480, MFPD for STAR+PLUS HCBS Program Applicant, for more information on PSU staff actions in SASO for MFPD members.

PSU staff must select the fund type "19MFP-Money Follows the Person" in the SASO Service Authorization record for the first individual service plan (ISP) participation period in MFPD. PSU staff must remove this fund type after the MFPD entitlement period or if the member withdraws from MFPD. Refer to Section 3524, Money Follows the Person Demonstration Entitlement Period Tracking, for more information on SASO entries once the enrollment period has ended.

The member may withdraw from MFPD at any time by informing the managed care organization (MCO). The MCO must upload Form H2067-MC, Managed Care Program Communications, to TxMedCentral to notify PSU staff of the member’s withdrawal from MFPD. Although MFPD eligibility may end upon withdrawal from MFPD, the member continues to receive STAR+PLUS Home and Community Based Services (HCBS) program services if the member continues to meet all STAR+PLUS HCBS eligibility criteria.

3524 Money Follows the Person Demonstration 365-Day Entitlement Period Tracking

Revision 24-4; Effective Dec. 1, 2024

A Money Follows the Person Demonstration (MFPD) member is entitled to 365 days of participation in MFPD. Time spent in an institutional setting does not count toward the 365-day entitlement period. The managed care organization (MCO) tracks the enrollment period to ensure the MFPD member receives the full 365 days.

The entitlement period begins the date the MFPD member enrolls in the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO must notify Program Support Unit (PSU) staff once the MFPD period has ended by uploading Form H2067-MC, Managed Care Program Communications, to the MCOHub. The MCO must notate the MFPD entitlement period start and end dates in the Comments section of Form H2067-MC.

Example: The member chose to participate in MFPD and was enrolled in the STAR+PLUS HCBS program, effective June 1, 2019, with an initial individual service plan (ISP) effective June 1, 2019, through May 31, 2020.

• If there are no institutional stays during the initial ISP period, the MFPD entitlement period ends when the ISP period ends on May 31, 2020.
• If the MFPD member enters an institution for 10 days in April 2020, the MFPD entitlement period is suspended during the period of institutionalization. The MFPD enrollment period resumes when the members return to the community and continues until the end of the 365-day entitlement period. In this example, the MFPD entitlement period ends on June 10, 2020, after the ISP end date of May 31, 2020.
• If the MFPD member is authorized for a new MFPD service during the initial ISP period and there are no institutional stays, the MFPD entitlement period would still end on May 31, 2020.

PSU staff must complete the following activities within two business days of notification that the MFPD entitlement period has ended:

• close the Service Authorization record in Service Authorization System Online (SASO) containing the Fund Type 19MFP-Money Follows the Person with an end date that matches the MFPD enrollment period;
• create a new Service Authorization record without the Fund Type 19MFP-Money Follows the Person for the remaining individual service plan (ISP) period, as applicable;  
• notify the MFPD reporting coordinator by email and include the following required text:
  • An email subject line that reads: MFPD Entitlement Period End [MM/YYYY]; and
  • Form H2067-MC received from the MCO notating MFPD entitlement period information as an attachment;
• 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. 

Example: the email subject line for an MFPD member with an entitlement period ending Nov. 30, 2022, would be MFPD Entitlement Period Ending 11/2022.

• Form H2067-MC received from the MCO notating MFPD entitlement period information as an attachment;
• 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.

3525 MFPD Entitlement Tracking and SASO Data Entry

Revision 25-4; Effective Oct. 6, 2025

Time spent in a nursing facility (NF) does not count toward the Money Follows the Person Demonstration (MFPD) 365-day period. Therefore, the managed care organization (MCO) tracks to ensure MFPD members receive the full 365-day entitlement period. The entitlement period starts the date the member is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO uploads Form H2067-MC, Managed Care Programs Communication, to the MCOHub, showing the total number of days the member spent in the NF. The MCO must send this information to Program Support Unit (PSU) staff after the 365^th day.

3530 Reserved for Future Use

Revision 25-1; Effective Feb. 19, 2025

Revision 25-1; Effective Feb. 19, 2025

3610 Reserved for Future Use

Revision 25-1; Effective Feb. 19, 2025

3620 Reassessment

Revision 18-0; Effective September 4, 2018

3621 Individual Service Plan Expiring Report

Revision 24-4; Effective Dec. 1, 2024

The assigned Program Support Unit (PSU) staff reviews the Individual Service Plan (ISP) Expiring Report for the STAR+PLUS Home and Community Based Services (HCBS) program monthly to ensure reassessments are conducted on time. The ISP Expiring Report details members with ISPs that expire within the next 90 days.

The assigned PSU staff provides this report to the managed care organizations (MCOs) before the monthly call with PSU staff. The MCOs must provide a status update for all members who have ISPs expiring within the next 45 days. Only ISPs expiring within 45 days require a status update from the MCO.

The process to manage the ISP Expiring Report follows:

• PSU staff provide the ISP Expiring Report to the MCO point of contact, the Program Support Operations Review Team (PSORT), and to the Managed Care Contracts and Oversight (MCCO) Unit staff by email five business days before the scheduled monthly call. The day of the call is considered the sixth business day.
• The MCO must research and provide a written status for each member whose ISP expires within 45 days by completing the columns highlighted in red on the spreadsheet.
• The MCO must return a completed report to PSU staff within two business days before the monthly call.
• PSU staff review the MCO responses to determine if the MCO needs to provide clarification about any member’s ISP status. Only 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 ISP if the MCO response is sufficient. PSU staff use the columns in blue on the spreadsheet for internal tracking purposes.

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 ISP before the 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 ISPs being reported as delinquent. The subject line for the email must read: STAR+PLUS HCBS 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 (PDF);
• the MN/LOC; or
• the ISP.

3621.1 Reassessment Procedures

Revision 25-2; Effective June 6, 2025

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 Medical Necessity and Level of Care (MN/LOC) assessment;
• developing Form H1700-1, Individual Service Plan (PDF); and
• submitting the MN/LOC and 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 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:

• verify ongoing Medicaid financial eligibility and managed care enrollment is active in Texas Integrated Eligibility Redesign System (TIERS);
• check the TMHP LTCOP to verify the member has:
  • an approved MN/LOC Assessment;
  • an ISP that is within the cost limit that includes at least one STAR+PLUS HCBS program service;
• verify that personal assistance services (PAS) and emergency response services (ERS) are not included in the ISP services for a member who receives Supplemental Security Income (SSI) or SSI-related Medicaid, such as Medicaid for Disabled Adult Children (DAC) or Pickle Medicaid;
  • Note: PAS and ERS must be authorized through Community First Choice (CFC) for a SSI or SSI-related Medicaid recipient;
• verify the Service Authorization System Online (SASO) service authorization records are accurate;
• electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), if the member continues to meet STAR+PLUS HCBS program requirements;
• mail Form H2065-D to the member;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

Refer to 9200, Reassessment Service Authorization, for more information on SASO record verifications.

PSU staff must ensure the member's ISP is entered into the SASO annually. The MCO must upload the ISP to the MCOHub if they are experiencing issues submitting it electronically in the TMHP LTCOP. PSU staff must manually enter the ISP into SASO within five business days of receipt of the reassessment HEART case record, but not after the ISP end date if the MCO cannot submit the ISP electronically.

Refer to 6000, Denials and Terminations, if the member does not meet STAR+PLUS HCBS program requirements at reassessment.

Refer to 7000, Applicant or Member Complaints and State Fair Hearings, if the member files a state fair hearing within the adverse action notification period.

Revision 25-1; Effective Feb. 19, 2025

3710 Managed Care Data in the Texas Integrated Eligibility Redesign System

Revision 25-1; Effective Feb. 19, 2025

3711 County Code Issues Affecting Enrollment

Revision 25-1; Effective Feb. 19, 2025

The Service Authorization System Online (SASO) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Correction to the county code must be done in TIERS. Program Support Unit (PSU) staff must inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by faxing Form H1746-A, MEPD Referral Cover Sheet (PDF), to correct the county code. Incorrect county code records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.

Supplemental Security Income Cases

TIERS derives the county based on the residential Zoning Improvement Plan (ZIP) code provided by the Social Security Administration (SSA) if an individual receives Supplemental Security Income (SSI). A ZIP code may appear incorrectly in TIERS because of one of the following reasons:

• data entry error; or
• a ZIP code crosses county lines.

Either of these issues can cause TIERS to assign the wrong county.

Non-SSI Cases

TIERS contains the county code entered by the MEPD specialist if the individual has any SSI type program (TP) other than TP 12 or TP 13. The following may be the cause of an individual not having TP 12 or TP 13:

• an individual moves without notifying the MEPD specialist; or
• an MEPD specialist enters an incorrect county code.

What to Do to Resolve Address Issues Affecting Enrollment

1. Perform an inquiry in TIERS.
2. Identify the TP in TIERS by cross referencing Appendix III, Medicaid Type Program Codes for STAR+PLUS HCBS Program and CFC.
3. Refer the matter to the MEPD specialist to correct the residence county field if the TP is anything but 12 or 13 and the residence county is incorrect.
4. If the TP is 12 or 13:

• Determine the residence ZIP code recorded in TIERS.
• If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.

4. PSU staff must email the Data Integrity Unit (DIU) mailbox the following information if the residence ZIP code in TIERS is correct but the county is incorrect:

• individual’s name as recorded in TIERS;
• individual’s Medicaid identification (ID) number;
• residence ZIP code; and
• residence county as it should be reflected in TIERS.

The DIU can update TIERS to correct the error. The correction takes place during the next TIERS cutoff processing, usually around the 20th day of the month. SASO should reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

3712 Service Interruptions Resulting from County Code Mismatches in TIERS

Revision 25-1; Effective Feb. 19, 2025

Participation in managed care programs is based on an individual’s residence county, as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Therefore, service interruptions can occur when the TIERS record shows the wrong residence county code.

The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through a monthly interface. As a result of this, incorrect county code data in SASO must be corrected in TIERS. The manner in which this correction occurs depends on the individual’s type program (TP).

PSU must complete the following activities if a residential county code is incorrect and the individual receives services under:

• Perform an inquiry in TIERS.
• Identify the TP in TIERS by cross referencing Appendix III, Medicaid Type Program Codes for STAR+PLUS HCBS Program and CFC.
  • For TP 12 or 13 in TIERS: advise the applicant, member or authorized representative (AR) to contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
    • individual’s name as recorded in TIERS;
    • individual’s Medicaid identification (ID) number; and
    • correct ZIP code and residence county as it should be reflected in TIERS.
  • For TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TP 88 in TIERS: fax Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist assigned to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and request a correction.
  • For Supplemental Nutrition Assistance Program (SNAP): fax Form H1746-A to the MEPD specialist assigned to the HEART case record and request a correction.

3720 Administrative Payment Process

Revision 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must authorize the managed care organization (MCO) to start services on the date the member who is aging out of the following programs becomes eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:

• the Texas Health Steps-Comprehensive Care Program (THSteps-CCP);
• the Medically Dependent Children Program (MDCP); or
• was approved for a nursing facility diversion (NFD) slot.

The start of care (SOC) date for the STAR+PLUS HCBS program may not be the first of the month. The MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable, if the eligibility date is not the first of the month. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.

The MCO must complete the following activities once PSU staff authorize the MCO to provide services:

• prepares Form 1500, Health Insurance Claim; and
• submits Form 1500 to the MCO within the 95-day filing deadline.

The MCO verifies the following within five business days of receiving Form 1500 from the provider:

• the provider was authorized to deliver the services billed on the form;
• the information on the form meets the clean claim requirements, defined in the Uniform Managed Care Manual (UMCM), Section 2.0; and
• the claim met the 95-day filing deadline.

Once the MCO verifies this information, the MCO:

• sends Form 1500 by secure email to the PSU staff if approved; or  
• denies payment by the MCO denial process if the provider:
  • is not authorized to deliver the services;
  • did not meet the clean claim requirements; or
  • did not meet the 95-day filing deadline.

PSU staff must complete the following activities within two business days of receiving Form 1500:

• verify the member is Medicaid eligible and has a valid Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP);
• prepare Form 4116, Authorization for Expenditures;
• email Form 4116, Form 1500, a screenshot of the Service Authorization screen from Service Authorization Services Online (SASO), and screenshots of the Medicaid eligibility and Managed Care enrollment screens in Texas Integrated Eligibility Redesign System (TIERS) to the Enrollment Resolution Services (ERS) unit mailbox; and
• create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload applicable documents.

The assigned ERS unit staff must complete the following activities within two business days from the receipt of the email from PSU staff:

• verify the member is Medicaid eligible; and
• review the claim to determine if it will be paid or denied.

The ERS unit staff complete the following activities if the decision is to approve to pay the administrative payment:

• email the approved Form 4116 to the Contract Compliance and Support (CCS) unit mailbox for processing; and
• notify by email the PSU staff who emailed the request that the administrative payment was approved.

The following activities occur if the decision is to approve the administrative payment:

• the CCS Unit sends the approved payment voucher to the state comptroller for processing and payment to the MCO; and
• the MCO pays the provider within one week of receipt of payment from the state comptroller.

The ERS unit staff will notify by email the PSU staff who submitted the request for administrative payment if the decision is to deny the administrative payment. This email response also includes the reason for denial.

PSU staff must complete the following activities within two business days of receipt of email from ERS unit staff:

• notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub;
• upload the email from ERS unit and the MCO notification to the HEART case record; and
• close the HEART case record.

Revision 26-1; Effective Feb. 20, 2026

Acute care services offered through the STAR+PLUS program include:

• ambulance services;
• audiology services, including hearing aids;
• behavioral health services, including:
  • inpatient mental health services;
  • outpatient mental health services;
  • outpatient chemical dependency services;
  • mental health rehabilitation for non-duals;
  • mental health targeted case management for non-duals;
  • detoxification services;
  • psychiatry services; and
  • counseling services;
• birthing services provided by a certified nurse midwife in a birthing center;
• chiropractic services;
• dialysis;
• durable medical equipment (DME) and supplies;
• Emergency Response Services (ERS);
• family planning services;
• home health care services for acute conditions;
• hospital services;
• laboratory;
• long-term services and supports (LTSS);
• medical checkups and Comprehensive Care Program (CCP) services for Medicaid for Breast and Cervical Cancer (MBCC) members under 21;
• oncology services;
• optometry, glasses and contact lenses, if medically necessary;
• podiatry;
• prenatal care;
• prescription drugs;
• primary care services (PCS);
• preventive services including an annual adult well check;
• radiology, imaging and X-rays;
• specialty physician services;
• therapies, including physical, occupational and speech for acute conditions;
• transplantation of organs and tissues; and
• vision services.

Revision 26-1; Effective Feb. 20, 2026

Long-term services and supports (LTSS) offered through the STAR+PLUS program include:

• Community First Choice (CFC) - Available to members who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. CFC is not available for medical assistance only (MAO) members. Members with CFC 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 psychiatric hospital, also called an institution for mental disease. CFC services are provided in a community-based setting. Community-based settings do not include:
  • hospitals;
  • NFs;
  • institutions for mental disease (IMD);
  • ICF/IID; and
  • any setting with the characteristics of an institution.
• CFC services include:
  • Emergency Response Services (ERS), which are backup systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports;
  • habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
  • personal assistance services (PAS), which help with ADLs, IADLs and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks; and
  • support management, which is training provided to members or authorized representatives (ARs) on how to manage and dismiss their attendants.
• Day Activity and Health Services (DAHS) — All members of a STAR+PLUS managed care organization (MCO) may receive medically and functionally necessary DAHS. DAHS includes nursing and PAS, therapy extension services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed by the state.
• Nursing facilities (NFs) — Institutional care for members whose physician certified that the member has a medical condition that requires 24-hour nursing care that meets medical necessity (MN) requirements. The need for custodial care solely does not constitute MN for an NF placement. Institutional care includes coverage for the medical, social and psychological needs of each resident, including room and board (R&B) charges, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.
• PAS, formerly known as Primary Home Care (PHC) PAS — All members may receive medically and functionally necessary PAS. PAS includes helping the member perform ADLs and household chores necessary to keep the home in a clean, sanitary and safe environment. The level of help given is determined by the member's need and the plan of care (POC). To be eligible for Medicaid state plan PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. To be eligible for PAS through programs other than CFC or the STAR+PLUS Home and Community Based Services (HCBS) program, members must score at least 24 on Form H2060. PAS includes three service delivery options:
  • Agency Option (AO);
  • Consumer Directed Services Option (CDS); and
  • Service Responsibility Option (SRO).

STAR+PLUS HCBS program — This is for those members who qualify for such services. The state also provides an enriched array of services to members who would otherwise qualify for NF care through the STAR+PLUS HCBS program. The MCO must also provide medically necessary services that are available to members who meet the functional and financial eligibility for the STAR+PLUS HCBS program.

Revision 26-1; Effective Feb. 20, 2026

The STAR+PLUS Home and Community Based Services (HCBS) program offers the following services:

• adaptive aids and medical supplies;
• adult foster care (AFC);
• assisted living (AL) services;
• cognitive rehabilitation therapy (CRT);
• dental services;
• emergency Response Services (ERS);
• employment Assistance (EA) services;
• financial Management Services (FMS);
• home-delivered meals (HDM);
• minor home modifications (MHMs);
• nursing services;
• occupational therapy (OT) services;
• personal assistance services (PAS);
• physical therapy (PT) services;
• respite care services;
• speech therapy (ST) services;
• employment assistance (EA); 
• supported Employment (SE) services; and
• transition Assistance Services (TAS).

Revision 26-1; Effective Feb. 20, 2026

The managed care organization (MCO) must identify all authorized services on the individual service plan (ISP). The ISP consists of the following documents:

• Form H1700-1, Individual Service Plan;
• Form H1700-2, Individual Service Plan – Addendum; 
• Form H1700-3, Individual Service Plan – Signature Page; 
• Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services; 
• Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
• Form H2060-A, Addendum to Form H2060;     
• Form H2060-B, Needs Assessment Addendum; 
• Form H6516, Community First Choice Assessment; or
• other forms and assessments related to the services provided.

The MCO must upload Form H1700-1 to the MCOHub if the MCO manually completes it. The MCO is not required to upload Form H1700-1 to the MCOHub if the MCO electronically generates this form  through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The MCO maintains all other forms in the member case file.

Revision 26-1; Effective Feb. 20, 2026

An adult foster care (AFC) home is a living arrangement that provides personal care services (PCS) to members who cannot continue independent functioning in their own homes due to physical or mental limitation. These residences provide a home-like environment offering services such as help with daily living, meal preparation, housekeeping, companion services, personal care, nursing tasks and transportation. The member must live with a contracted STAR+PLUS HCBS program AFC home provider.

The managed care organization (MCO) determines AFC home services to develop the individual service plan (ISP) through completion of Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide. 

STAR+PLUS HCBS program AFC members must pay for their own room and board (R&B) charges and copayment charges to the AFC home provider. The only time the R&B charge is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home.

Revision 26-1; Effective Feb. 20, 2026

Assisted living facility (ALF) is a living arrangement that provides personal care services (PCS) to between four and 16 unrelated residents. These facilities provide a home-like environment for individuals who cannot live independently due to physical or mental limitations. ALFs offer services such as home management, supervision, meal services, transportation and escort, housekeeping, 24-hour supervision, and medication assistance. The member must live with an ALF licensed by the Texas Health and Human Services Commission (HHSC).

The managed care organization (MCO) determines AFC home services to develop the individual service plan (ISP) through completion of Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide.

STAR+PLUS HCBS program ALF members must pay for their own room and board (R&B) charges and copayment charges, if applicable, to the AFC.

Revision 26-2; Effective June 1, 2026

Federal 1115 waiver requirements dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services needed to allow the member to live safely in the community. These services exclude hospice. Hospice services may be authorized with STAR+PLUS services or the STAR+PLUS HCBS program.

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of hospice services. Hospice provides services for terminal illness that are not available under the STAR+PLUS program. For example, hospice providers can administer pain control medications that are not available to STAR+PLUS providers.

NF hospice services can be identified in the Service Authorization System Online (SASO) as service group (SG) 8, service code (SC) 31. The NF counter is activated by non-hospice NF authorizations, which appear in SASO as SG1/SC1 or SG1/SC3.

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of an approved case assignment from Utilization Review (UR) staff for the Medically Fragile group or General Revenue (GR) funds process:

• confirm the applicant meets all eligibility criteria for the STAR+PLUS Home and Community Based Services (HCBS) program with the allowance of the individual service plan (ISP) exceeding the cost limit;
• manually or electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF);
• upload Form H2065-D to the MCOHub, if manually generated;
• mail Form H2065-D to the member;
• for Medical Assistance Only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• email Enrollment Resolution Services (ERS) Unit staff the following information:
  • an email subject line that reads STAR+PLUS HCBS Enrollment for XX [member’s first and last name initials];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request: ILR, MFP or upgrade enrollment;
  • effective date of enrollment;
  • Form H2065-D as an attachment;
• upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART record.

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of an approved case assignment from Utilization Review (UR) staff for the Medically Fragile group or General Revenue (GR) funds process:

• confirm the member continues to meet all eligibility criteria for the STAR+PLUS Home and Community Based Services (HCBS) program with the allowance of the individual service plan (ISP) exceeding the cost limit;
• electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
• mail Form H2065-D to the member;
• upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART record.

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities for applicants within two business days of receipt of a denied case assignment for the Medically Fragile group or General Revenue (GR) funds process:

• manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), using the exceeds the individual service plan (ISP) cost limit denial reason;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the CSIL record, if applicable;
• invalidate the ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• upload applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (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 receipt of a denied case assignment for the Medically Fragile group or GR funds process:

• manually generate Form H2065-D using the exceeds the ISP cost limit denial reason;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

• for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
• for MAO members, email ERS Unit staff the following information:
  • an email subject line that reads: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request: STAR+PLUS Home and Community Based Services (HCBS) program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

The managed care organization (MCO) will not be able to modify the ISP to make it under the cost limit for an applicant or member who was attempting to pursue the Medically Fragile group or GR funds process, unless the applicant or member experiences a change in medical condition.

PSU staff must follow all other existing policies and procedures for processing a STAR+PLUS HCBS program denial or termination.

PSU staff are not required to notify the PSU supervisor or Utilization Review (UR) Unit staff if Medically Fragile group member is denied for reasons not related to clinical criteria. UR staff monitor the Texas Integrated Eligibility Redesign System (TIERS) monthly to determine if a Medically Fragile group member has been denied for reasons not related to clinical criteria.

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must enter an appeal in Texas Integrated Eligibility Redesign System (TIERS) if a fair hearing request is received from the applicant, member, or authorized representative (AR) for an individual service plan (ISP) that exceeds the cost limit.

PSU staff must use the issue code 88-ISP Over the Cost Cap (Medically Fragile) when the data entry representative (DER) is completing Form 4800-D, Fair Hearing Request Summary, or when PSU staff are creating an appeal in TIERS.

PSU staff must enter the following information in TIERS when a fair hearing request for a Medically Fragile group case is received:

• Office of Medical Director (OMD) staff as the Agency Representative;
• OMD Unit staff supervisor as the Agency Supervisor;
• Managed care organization (MCO) representative and MCO supervisor as the Agency Witness; and
• PSU staff and PSU supervisor as the Observer.
• MCO representative as the Agency Representative;
• MCO supervisor as the Agency Supervisor;
• no Agency Witness is entered; and
• PSU staff and PSU supervisor as the Observer.

PSU staff must enter the following information in TIERS when any other fair hearing request is received for an ISP more than the cost limit, including cases reviewed for the general revenue (GR) funds process:

• MCO representative as the Agency Representative;
• MCO supervisor as the Agency Supervisor;
• no Agency Witness is entered; and
• PSU staff and PSU supervisor as the Observer. 

PSU staff must not put an applicant or member name back on the STAR+PLUS Home and Community Based Services (HCBS) program interest list while a denial related to an ISP exceeding the cost limit for the Medically Fragile group or GR funds process is in the state fair hearing process.

PSU staff must take appropriate action to certify or deny the case once the state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

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 STAR+PLUS Home and Community Based Services (HCBS) program;
• 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 mail Form 2442, Notification of Interest List Release Closure, as notification of STAR+PLUS HCBS program interest list closure to an individual when the individual does not meet STAR+PLUS HCBS program eligibility. PSU staff must always mail Form 2442 with Appendix XII, STAR+PLUS HCBS Program Description. Form 2442 does not provide the right to request a state fair hearing. Individuals only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff mail an applicant or member Form H2065-D when denied or terminated from the STAR+PLUS HCBS program. Form H2065-D provides the applicant or member with the right to request a state fair hearing. Applicants and members 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 the adverse action notification period 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 §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:

1. The agency has factual information confirming the death of an individual, applicant or member;
2. The agency receives a clear written statement signed by a member that:
   1. They no longer want to receive services; or
   2. 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;
3. The  individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
4. 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);
5. 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;
6. A change in the level of medical care is prescribed by the applicant’s or member’s physician; or
7. The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act;
8. 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 STAR+PLUS HCBS Program Eligibility Requirements

Revision 25-2; Effective June 6, 2025

An individual, applicant or member must meet the following criteria stated in Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1) to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:

• be 21 years or older;
• live in Texas;
• meet the medical necessity (MN) for a nursing facility (NF) level of care (LOC) as determined by Texas Health and Human Services Commission (HHSC);
• have an unmet need for support in the community that can be met through one or more of the STAR+PLUS HCBS program services;
• choose the STAR+PLUS HCBS program as an alternative to NF services, described in Title 42 Code of Federal Regulations (CFR) Section 441.302(d);
• not be enrolled in another Medicaid HCBS waiver program approved by Centers for Medicaid & Medicare Services (CMS); and
• be determined by HHSC to be financially eligible for Medicaid, described in Title 1 TAC Chapter 358, relating to Medicaid Eligibility for the Elderly and People with Disabilities, and Title 1 TAC Chapter 360, relating to Medicaid Buy-In Program.

Revision 22-2; Effective March 4, 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 prior to 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 STAR+PLUS Home and Community Based Services (HCBS) program services until a state fair hearing decision is rendered. 

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

The STAR+PLUS HCBS program termination dates are typically on the last day of the month. PSU staff must manually extend the end date all service group (SG) 19 records in the Service Authorization System Online (SASO) 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 the STAR+PLUS HCBS program;
• the member is admitted to an institution for 90 consecutive days where STAR+PLUS HCBS program 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 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility once notified of a deceased individual, applicant or member.

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;
• authorized representative (AR) 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). Sometimes an individual, applicant, or member is deceased and information is not updated in TIERS. In those cases, PSU staff must receive verification of death from other sources.

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.

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;
• document and close the CSIL record, if applicable;
• fax Form H1746-A, MEPD Referral Cover Sheet for medical assistance only (MAO) applicants, to the MEPD specialist if TIERS does not show the applicant is deceased;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• 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;
• fax Form H1746-A to the MEPD specialist, for MAO members, if TIERS does not show the member is deceased;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• close the following Medical Necessity and Level of Care (MN/LOC) Assessment records in the Service Authorization System Online (SASO) to align with the date of termination:
  • Level of Service (LOS);
  • Diagnosis (DG); and
  • Medical Necessity (MN);
• verify the following service group (SG) 19 records in SASO are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• 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 or member’s address 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 Institutional Stay

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program 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 settings are not allowed for the STAR+PLUS HCBS program:

• a nursing facility (NF);
• an institution for mental diseases;
• an intermediate care facility for individuals 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; or
• any setting in a building:
  • that is also a publicly or privately operated facility providing inpatient institutional treatment; or
  • on the grounds of, or immediately adjacent to, a public institution; or
• any other setting with the effect of isolating individuals 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 that the setting does 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 Operations;
• 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.

The MCO must notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, Managed Care Programs Communication, to the MCOHub within 14 days after the 90th day the applicant or member has not returned to an allowable living arrangement. PSU staff must email Managed Care Compliance Operations (MCCO) if the MCO is not timely in their notification.

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, Notification of Managed Care Program Services;
• mailing Form H2065-D to the applicant;
• uploading Form H2065-D to the MCOHub;
• faxing Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) applicants, MEPD Referral Cover Sheet to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• documenting and closing the Community Services Interest List (CSIL) record, if applicable;
• invalidating the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• uploading all 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.

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;
• uploading Form H2065-D to the MCOHub;
• terminating the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verifying the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• uploading applicable documents to the HEART case record; and
• documenting the HEART case record.

PSU staff must complete the following activities for MAO members within two business days after the termination effective date if the member has not requested a fair hearing:

• fax Form H1746-A to the MEPD specialist;
• email ERS unit staff the following information:
  • this email subject line: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

A Medicare Part A skilled nursing facility (SNF) provides short-term acute care.  Therefore, it does not count toward the 90-day institutional stay count. The intent of the institutional stay denial reason is for applicants and members entering an institution for a long-term stay.

PSU staff must start the 90-day count for a denial or termination when a STAR+PLUS HCBS program applicant or member enters a nursing facility (NF) and Service Authorization System Online (SASO) reflects a continuous stay of the following records:

• SG 1 – Nursing Facility, Service Code (SC) 1 – Daily Care; or
• SG 1 – Nursing Facility, SC 3 – ECF.

PSU staff must not count days as part of the 90-day institutional stay count when SASO reflects the following records:  

• SG 1 – Nursing Facility, SC 3A – SNF Part A Full Medicare; or
• SG 8 – Hospice, SC 31 – Nursing Facility Room and Board.

PSU staff must honor the admission date given by the MCO on Form H2067-MC if NF records are not in SASO.

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a state fair hearing.

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 procedures in 3500, Money follows the Person, to reapply for the STAR+PLUS HCBS program and return to the community with services.

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

6300.3 Voluntarily Declined Services

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member no longer wants to receive STAR+PLUS HCBS program services. PSU staff must take similar action once notified that an individual voluntarily declines services.

PSU staff may receive notification of the individual, applicant, member or authorized representative’s (AR’s) request to voluntarily decline the STAR+PLUS HCBS program from:

• Managed Care Operations;
• receipt of Form H3675, Application Acknowledgment, indicating no interest in STAR+PLUS HCBS program services;
• Enrollment Resolution Services (ERS) unit staff;
• Community Care Services Eligibility (CCSE) case manager for those enrolling in the Program of All-Inclusive Care for the Elderly (PACE);
• the individual, applicant, member or AR;
• 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 XII, STAR+PLUS HCBS Program Description, to the individual;
• 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.

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;
• 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;
• document and close the CSIL record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• 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:

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities for MAO members within two business days after the termination effective date if the member did not request a fair hearing:

• fax Form H1746-A to the MEPD specialist;
• email ERS unit staff the following information:
  • This email subject line: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to  7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a state fair hearing.

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 AR 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  6200, Adverse Action Notification Period, to determine the termination effective date, if the adverse action period is not waived.

6300.4 Financial Eligibility

Revision 26-2; Effective June 1, 2026

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant or member’s Medicaid financial eligibility for the STAR+PLUS HCBS program is determined by the:

• Social Security Administration (SSA);
• Medicaid for the Elderly and People with Disabilities (MEPD) specialist; or
• Texas Works (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 eligibility (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:

• create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable;
• verify Medicaid financial eligibility was terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail the applicant Form H2065-D;
• upload Form H2065-D to the MCOHub;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• document and close the Community Services Interest List (CSIL) database record, if applicable;
• upload applicable documents to the HEART case record;
• document the HEART case record; and
• close the HEART case record.
  • PSU staff must close the HEART case record not before the 31st day, but by two business days after 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 member:
  • Form H2065-D;
  • Form H1200, Application for Assistance – Your Texas Benefits, for all SSI denials and as applicable for MAO denials; and
  • Form 2606, Managed Care Enrollment Processing Delay, for all SSI denials and as applicable for MAO denials;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date, if applicable;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record;
• document the HEART case record; and
• close the HEART case record.

Note: PSU staff must close the HEART case record not before the 31st day, but by two business days after the 31st day that PSU staff mailed Form 2606.

The adverse action notification period does not apply in this situation. The member’s STAR+PLUS HCBS program termination effective date must match the TIERS Medicaid/CHIP/CHIP Perinatal History screen end date even if the TIERS end date is in the past.

The table below gives examples of PSU staff actions when the MEPD specialist determines a member stops meeting Medicaid financial eligibility.

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

Medicaid Reinstatement

PSU staff must reinstate the STAR+PLUS HCBS eligibility if a member restores Medicaid with a gap of six months or less. Texas Health and Human Services Commission (HHSC) staff processing does not affect the reinstatement effective date. 

PSU staff must process a Medicaid reinstatement approval for a member within five business days of being notified that the member regained eligibility.

ISP Period Not Expired and No Gap in Medicaid Coverage

PSU staff must:

• email PSU supervisor requesting a status reset of the H1700-1, Individual Service Plan, record in the TMHP LTCOP if Medicaid eligibility is reinstated without a gap; and
• adjust the current ISP begin and end date to align with historical ISP periods in the TMHP LTCOP.

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 ISP; 
• adjust the current ISP begin date to reflect the date Medicaid is reinstated in the TMHP LTCOP; and
• adjust the current ISP end date to reflect the historical ISP date range in the TMHP LTCOP.

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

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 MN/LOC Assessment and ISP;
• email PSU supervisor requesting a status reset of the expired H1700-1, Individual Service Plan, record in the TMHP LTCOP, if applicable;
• take the following actions in the TMHP LTCOP:
  • adjust the expired ISP end date to align with the historical ISP period; and
  • adjust the current ISP begin and end date to align with historical ISP periods. 

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 MN/LOC Assessment and ISP;
• adjust the current ISP begin to align with the Medicaid reinstatement date and the end date to align with historical ISP periods in the TMHP LTCOP.

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

For All Reinstatement Cases

PSU staff must:

• email the regional Community Care Services Eligibility (CCSE) mailbox requesting the closure of all SG 7 records in SASO, if applicable.
  • identify the CCSE region by referring to Appendix XXXVIII, CCSE Region by Service Area; 
  • the closure date must be one day before the start of care (SOC) for the STAR+PLUS HCBS program;
• manually or electronically generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub if manually generated;
• 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;
  • notate that the member has an approved medical necessity (MN) and ISP; and
  • requesting STAR+PLUS HCBS program reinstatement effective the day Medicaid was reinstated.
• email Enrollment Resolution Services (ERS) unit staff the following information, if applicable, once STAR+PLUS HCBS program SASO records are entered to reflect the reinstatement:
  • an email subject line that reads: STAR+PLUS HCBS Reinstatement for XX [member’s first and last initials];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request: STAR+PLUS HCBS program eligibility reinstatement;
  • ISP begin date;
  • 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 and the ISP is not 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 reinstate the member’s STAR+PLUS HCBS program eligibility using a start of care (SOC) date of June 1, 2024, with an end date that matches the historical ISP end date.

Member is reinstated and the ISP is 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 ISP has expired.
• PSU staff must reinstate the member’s STAR+PLUS HCBS program eligibility using a SOC date of June 1, 2024, with an end date that holds true to the historical ISP date ranges.

The member must go to the bottom of the interest list to reapply for the STAR+PLUS HCBS program if Medicaid is reestablished with a gap greater than six months.

6300.5 Medical Necessity and Level of Care

Revision 25-1; Effective Feb. 19, 2025

Medical necessity (MN) is the prerequisite to participate in Medicaid (Title XIX) Long-term Care programs including the STAR+PLUS Home and Community Based Services (HCBS) program. Title 26 TAC Section 554.2401 applies to the MN requirements for participation in the STAR+PLUS HCBS program. An applicant or member must meet the following conditions to verify MN exists:

• The applicant or member must demonstrate a medical condition that:
  • is sufficiently serious that the applicant or member’s needs exceed the routine care which may be given by an untrained person; and
  • requires licensed nurses' supervision, assessment, planning and intervention that are available only in an institution.
• The applicant or member must require medical or nursing services that:
  • are ordered by a physician;
  • 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 STAR+PLUS HCBS program 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 the STAR+PLUS HCBS program is dependent upon meeting the MN requirements listed above.

The tool used to determine MN for the STAR+PLUS HCBS program is the Medical Necessity and Level of Care (MN/LOC) Assessment. The managed care organization (MCO) completes the MN/LOC Assessment and submits it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP LTCOP automatically processes the MN/LOC Assessment to determine if the applicant or member meets the MN criteria required for the STAR+PLUS HCBS program. The TMHP LTCOP sends the MN/LOC Assessment to the TMHP nurse or physician for manual review if the MN/LOC fails automatic MN approval. The TMHP nurse and physician will review the MN/LOC Assessment to determine if the applicant or member meets the MN criteria required for the STAR+PLUS HCBS program.

The MCO conducts:

• an initial MN/LOC Assessment for each applicant;
• a reassessment MN/LOC Assessment annually for each member; and
• a change in condition (CIC) MN/LOC Assessment for members, when applicable.

The MCO must notify PSU staff of an applicant or member’s MN denial by uploading:

• Form H3676, Managed Care Pre-Enrollment Assessment Authorization; or
• Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must monitor the TMHP LTCOP every five business days from the date the MN denied status initially appears 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 TMHP doctor overturns the denial because additional 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 TMHP physician to overturn the denied MN has expired, and no additional information or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the applicant, member or authorized representative (AR) requests a fair hearing.

The MN status will update to Overturn Doctor Review Expired on the 15th business day from the date the MN Denied status initially appears in the TMHP LTCOP when no additional information has been provided to reverse the initial 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.

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, in the TMHP LTCOP;
• mail Form H2065-D and the Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment, to the applicant;
• for Medicaid Assistance Only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) in the TMHP LTCOP, 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.

Note: PSU staff may accept Form H2067-MC as notification of an MN denial for an applicant. PSU staff must document Form H2067-MC was received in lieu of Form H3676 in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

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 XI to the member;
• terminate the ISP in the TMHP LTCOP using the existing ISP end date as the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• 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 after the termination effective date if the member has not requested a fair hearing:

• for MAO members:
  • fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • email the Enrollment Resolution Services (ERS) Unit the following information:
    • an email subject line that reads: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request: STAR+PLUS HCBS program eligibility termination;
    • effective date of termination;
    • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing.

The adverse action notification period applies to MN denials. Refer to section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.6 Unable to Locate

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member cannot be located. PSU staff must take similar action once notified 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+PLUS Handbook (SPH), 3632.7, Denial/Termination Due to Inability to Locate the Member, 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 XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• upload all 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.

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

• upload Form H2067-MC to the MCOHub notifying the MCO of case closure;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• document and close the CSIL record, if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must complete the following activities for all other 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;
• upload Form H2065-D to the MCOHub;
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, for medical assistance only (MAO) applicants;
• document and close the CSIL record, if applicable;
• invalidate the ISP in the TMHP LTCOP, if applicable;
• 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:

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• manually close the following service group (SG) 19 records in the Service Authorization System Online (SASO), if applicable, and ensuring the closure date aligns with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

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

PSU staff must complete the following activities for MAO members within two business days after the termination effective date if the member has not requested a fair hearing:

• fax Form H1746-A to the MEPD specialist;
• email ERS unit staff the following information:
  • an email subject line that reads: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to  7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a state fair hearing.

PSU staff must reinstate the STAR+PLUS HCBS program 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 the member is found. The ISP end date must be the historical ISP end date.

6300.7 Exceeding the ISP Cost Limit

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member’s individual service plan (ISP) exceeds the cost limit. The STAR+PLUS HCBS program serves 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. The MCO must establish an ISP that does not exceed the applicant’s or member’s cost limit as part of the individual service planning process.

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

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;
• upload Form H2065-D to the MCOHub;
• fax Form H1746-A, MEPD Referral Cover Sheet for medical assistance only (MAO) applicants, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), 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.

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

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities for MAO members within two business days after the termination effective date if the member has not requested a fair hearing:

• fax Form H1746-A to the MEPD specialist;
• email ERS unit staff the following:
  • This email subject line: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request: STAR+PLUS HCBS program eligibility termination;
  • ISP end date, if applicable;
  • effective date of termination, if applicable;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to  7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a state fair hearing.

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

6300.8 Failure to Obtain Physician’s Signature

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must deny STAR+PLUS Home and Community Based Services (HCBS) program 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 Medical Necessity and Level of Care (MN/LOC) Assessment only. The physician’s signature is not required for the annual MN/LOC Assessment.

The MCO must:

• make at least three more attempts to get the physician’s signature if the MCO does not receive a signed copy of the physician’s signature page within five business days of the first request to the applicant or member’s physician;
• contact the applicant or member for help getting the physician’s signature if the MCO is unsuccessful getting the signature from the physician;
• notify PSU staff if the MCO cannot get a physician’s signature within two business days of the 45-day time frame for completing all initial assessment activity expiring; and
• notify PSU staff by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub notating that the MCO could not get a physician’s signature and the MCO is requesting the applicant be denied.

PSU staff may accept Form H2067-MC, Managed Care Programs Communication, as notification of a denial. However, PSU staff must document in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record that Form H3676, was not received at the time Form H2065-D for a denial was generated, 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;
• upload Form H2065-D to the MCOHub;
• document and close the Community Services Interest List (CSIL) record, if applicable;
• 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, if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

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

6300.9 Failure to Meet Other Program Requirements

Revision 25-4; Effective Oct. 6, 2025

Program Support Unit (PSU) staff must notify the PSU supervisor if an applicant or member fails to meet other program requirements not listed in 6200.1 through 6200.8. The PSU supervisor will notify PSU staff if the denial or termination can be processed. PSU staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet the eligibility requirements in Title 1 Texas Administrative Code (TAC) Chapter 353.1153.

PSU staff may receive notification that an individual, applicant or member does not meet other program requirements by:

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

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

• manually generate Form 2442, Notification of Interest List Release Closure;
• mail Form 2442 and Appendix XII, STAR+PLUS HCBS Program Description, to the individual;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
• document and close the Community Services Interest List (CSIL) database 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.

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

• manually generate Form H2065-D, Notification of Managed Care Program Services;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• fax Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) applicants, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
• document and close the CSIL database record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• 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 PSU supervisor approval to terminate the member:

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• fax Form H1746-A for MAO Medicaid members, to the MEPD specialist;
• email ERS unit staff the following information for MAO members:
  • This email subject line: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request such as STAR+PLUS HCBS program eligibility termination
  • individual service plan (ISP) end date;
  • effective date of termination;
  • Form H2065-D as an attachment;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
• verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, if an MAO member requests a state fair hearing with continued benefits within the adverse action notification period.

Refer to 6200, Adverse Action Notification Period, for more information on deciding the termination effective date if the PSU supervisor determines the adverse action notification period is applicable.

PSU staff are not required to notify their supervisor for the following denial or termination reasons:

• failure to return Form H1200, Application for Assistance – Your Texas Benefits;
• does not have an unmet need;
• moved out of the state of Texas;
• declined assessment; and
• under 21.

6300.10 Other Reasons

Revision 25-4; Effective Oct. 6, 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 XII, STAR+PLUS HCBS Program Description, to the individual;
• 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.

Note: Form 2442 is not used for individuals applying for the STAR+PLUS Home and Community Based Services (HCBS) program through the Money Follows the Person (MFP) process.

PSU staff are approved to complete Form H2065-D, Notification of Managed Care Program Services, for an individual when notification is received that an MFP individual has discharged the nursing facility (NF) before establishing eligibility for the STAR+PLUS HCBS program. This is the only situation where PSU staff will generate Form H2065-D for an individual.

PSU staff must complete the following activities within two business days of notification that an MFP individual has discharged the NF. This is done before establishing eligibility for the STAR+PLUS HCBS program:

• manually generate Form H2065-D;
• mail Form H2065-D to the individual;
• document and close the CSIL record, if applicable;
• 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 supervisor approval to deny the applicant:

• manually generate Form H2065-D;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to the MCOHub;
• fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, for medical assistance only (MAO) applicants;
• document and close the CSIL record, if applicable;
• invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Note: PSU staff may accept Form H2067-MC, Managed Care Programs Communication, as notification of a denial for an applicant. PSU staff must document in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record that Form H3676, was not received at the time Form H2065-D for a denial was generated for this situation.

PSU staff must complete the following activities for members within two business days from supervisor approval to terminate the member:

• manually generate Form H2065-D;
• mail Form H2065-D to the member;
• upload Form H2065-D to the MCOHub;
• terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date, if applicable;
• verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
  • Authorizing Agent;
  • Enrollment;
  • Service Plan;
  • Service Authorization;
• upload applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities for MAO members within two business days after the termination effective date if the member has not requested a fair hearing:

• fax Form H1746-A to the MEPD specialist;
• email Enrollment Resolution Services (ERS) Unit staff the following:
  • This email subject line: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid identification (ID) number;
  • type of request such as STAR+PLUS HCBS program eligibility termination;
  • effective date of termination;
  • Form H2065-D as an attachment;
• upload applicable documents to the HEART case record; and
• document and close the HEART case record.

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a state fair hearing.

The applicability of the adverse action notification period is scenario specific.

Refer to 6200, Adverse Action Notification Period, for more information on deciding the termination effective date if the supervisor determines the adverse action notification period is applicable.

PSU staff is not required to notify the PSU supervisor for the following denial or termination reasons:

• declines assessment or will not allow the MCO to conduct the assessment; and
• an MFP individual discharge from a NF before PSU staff determine program eligibility.

Revision 24-1; Effective Feb. 22, 2024 

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of noncompliance listed in the Texas Health and Human Services Commission (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5 (PDF). These reasons for noncompliance include: 

• misusing or loaning the member’s MCO membership card to another person to obtain 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;
• steadfast refusal to comply with managed care restrictions such as repeatedly using the emergency room along with refusing to allow the MCO to treat the underlying medical condition; or 
• a member’s failure to pay room and board (R&B) or copayment charges.

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 by 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 the STAR+PLUS Home and Community Based Services (HCBS) program without HHSC approval. Examples where a member may request to voluntarily withdraw from the STAR+PLUS HCBS program voluntarily 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 the STAR+PLUS HCBS program; or
• member states they no longer want the STAR+PLUS HCBS program because they do not use any STAR+PLUS HCBS program services.

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 the HHSC Ombudsman’s Managed Care Assistance Team at 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 Chapters 11.5 and 11.6.

PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Compliance & Operations (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;
• manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) 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 for 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 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must notify the PSU supervisor by email if an individual service plan (ISP) record needs to be reset in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within one business day of discovering the need for a reset. 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];
• applicant’s or member’s name;
• Medicaid identification (ID) number or Social Security Number (SSN);
• the ISP record’s document locator number (DLN) number; and
• an explanation of the error and reason for the reset request. The explanation of the reset request must include the correct termination date if the ISP record was terminated on an incorrect date.

PSU staff must refer to Appendix XXVII, PSU Users H1700/ISP Form User Guide, for more direction on moving an ISP record into an invalidated or terminated status in the TMHP LTCOP.

Revision 26-1; Effective Feb. 20, 2026

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+PLUS managed care organization (MCO) should contact the Member Services hotline number first 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. They do this 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 who are not enrolled in a MCO can call the Medicaid helpline at 800-335-8957.

7110 PSU Staff Compliant Escalation Procedures

Revision 26-1; Effective Feb. 20, 2026

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;
• 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 activities 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 – show 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 pertains to 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 auto populates a unique identification number for each escalation entered in the tracker. No PSU action is required for this field.

The Escalation Intake Tracker record may require updates as the escalation is processed.

PSU staff do not log loss of Medicaid eligibility referrals in the Escalation Intake Tracker.

The PSU supervisor, designated PSU staff or assigned PSU staff must complete all the following activities 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 in the email from PSU management showing detailed actions used to resolve the escalation. PSU staff must provide weekly updates to all parties if issues or concerns cannot be immediately resolved.
• Upload all applicable documents to the HEART case record.
• 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 Notice 25-5; Effective Dec. 17, 2025

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 STAR+PLUS Home and Community Based Services (HCBS) applicant, member or authorized representative (AR) can request an appeal within 90 days from the effective date of a Texas Health and Human Services Commission (HHSC) action. Refer to 1 TAC Section 357.3, Authority and Right to Appeal. The appeal request may be verbal or in writing.

A fair hearing is an informal proceeding held before an impartial HHSC hearings officer where an applicant, member or AR appeals an agency action. Refer to 1 TAC Section 357.1. 
 

7210 Timely or Non-timely State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

Only an applicant, member, guardian or authorized representative (AR) may request a state fair hearing. The applicant, member or AR may request a state fair hearing orally or in writing.

A timely state fair hearing request for a STAR+PLUS Home and Community Based Services (HCBS) program denial is received by Program Support Unit (PSU) staff within 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for a STAR+PLUS HCBS program 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 the Centralized Representative Unit (CRU) 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 or the data entry representative (DER) must refer to Appendix XXI, Creating an Appeal in TIERS, and Appendix XXXII, Creating an Appeal Task in the HHSC Benefits Portal, when creating records. 

The hearings 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 hearings officer determines there is no good cause. 

7211 PSU Staff Procedures for Completing Form 4800-D

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive an oral or written appeal request related to STAR+PLUS Home and Community Based Services (HCBS) program eligibility denial or termination from an: 

• applicant;
• member; or
• authorized representative (AR). 

PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date a fair hearing request is received.

PSU staff must complete the following activities within three days of receipt of the state fair hearing request:

• complete Form 4800-D, Fair Hearing Request Summary, ensuring all persons who should attend the state fair hearing are documented; and
• email Form 4800-D to the data entry representative (DER) and DER supervisor.

The DER must enter the information on Form 4800-D in TIERS within two days.

Depending on the issue being appealed, PSU staff must enter the following staff on Form 4800-D:

• For medical necessity/level of care (MN/LOC) denial by Texas Medicaid & Healthcare Partnership (TMHP):
  • TMHP representative as the Agency Representative;
  • TMHP supervisor as the Agency Supervisor;
  • managed care organization (MCO) representative and MCO supervisor as the Agency Witness; and
  • PSU staff and PSU supervisor as the Observer.
• For Supplemental Security Income (SSI) denial by Social Security Administration (SSA):
  • PSU staff as the Agency Representative;
  • PSU supervisor as the Agency Supervisor;
  • no Agency Witness is entered; and
  • MCO representative and MCO supervisor as the Observer
• For other denial reasons (excluding MEPD or TW financial denials):
  • MCO representative as the Agency Representative;
  • MCO supervisor as the Agency Supervisor;
  • MCO representative as the Other Participants; and
  • PSU staff and PSU supervisor as the Observer.

PSU staff must contact the MCO if there is any doubt as to who should be listed on Form 4800-D.

PSU must complete the following activities when completing Form 4800-D:

• answer all questions in Section 3, Appellant Details Programs;
• always answer “No” to the question, “Is there a good cause for non-timely?” in Subsection D, Summary of Agency Action and Citation, since this question only applies to TW programs; and
• indicate the individual service plan (ISP) begin and end dates, as applicable, in Subsection D.

PSU staff must refer to Form 4800-D instructions for more specific directions for form completion and transmittal.

PSU staff must refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

7212 DER Procedures for Entering State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

The data entry representative (DER) creates a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to document the state fair hearing request when the DER receives Form 4800-D, Fair Hearing Request Summary, from Program Support Unit (PSU) staff. The HEART case record and Community Services Interest List (CSIL) record must remain open until a state fair hearing decision is rendered.

The DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form 4800-D, following the instructions in Appendix XXI, Creating an Appeal in TIERS. The DER must use the Manage Office Resources (MOR) search function in TIERS when adding PSU staff, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP), or Texas Health and Human Services Commission (HHSC) representatives as participants. TIERS will assign an appeal identification (ID) number once the DER completes all required fields. The DER must send a copy of the TIERS generated Form H4800, Fair Hearing Request Summary, to PSU staff and upload a copy to the HEART case record.

7213 Generation of the State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet, which is available to state fair hearing participants other than the applicant, member or authorized representative (AR), such as Texas Health and Human Services Commission (HHSC), the managed care organization (MCO) or Texas Medicaid & Healthcare Partnership (TMHP). 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 has been 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 the hearing 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, which the hearings officer sends to the applicant, member or AR. 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.

7214 State Fair Hearing Evidence Packet

Revision 23-2; Effective May 15, 2023

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 a state fair hearing evidence packet;
• mail the state fair hearing evidence packet to the applicant, member or authorized representative (AR);
• upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal following the instructions in Section 7231, Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal;
• 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 XXXIII, STAR+PLUS HEART Naming Conventions; 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. The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to MEPD and TW financial denials. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

PSU staff must ensure documentation on Form 4800-D, Fair Hearing Request Summary, clearly states the state fair hearing is for the STAR+PLUS Home and Community Based Services (HCBS) program. 

The STAR+PLUS HCBS state fair hearing evidence packet includes:

• Form 4801, State Fair Hearing Evidence Packet Cover Page;
• Form H2065-D, Notification of Managed Care Services;
• the appropriate handbook section, as notated on Form H2065-D;
• Appendix XX, STAR+PLUS HCBS Program Eligibility TAC; and
• for MN/Level of Care (MN/LOC) denials or terminations, Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment.

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), Centralized Representation Unit (CRU) or 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 AR.

The hearings officer mails Form H4803 to the applicant, member or AR when the state fair hearing is first requested. The applicant, member or AR may fax or mail evidence to the hearings officer if desired. The applicant, member or AR gets the hearings officer’s contact information from Form H4803, Notice of Fair Hearing. The hearings officer shares any evidence submitted by the applicant, member or AR with HHSC.

7215 Changes to the State Fair Hearing Request Summary

Revision 24-4; Effective Dec. 1, 2024

Program Support Unit (PSU) staff may learn of changes to an applicant or member’s information after entering the fair hearing into the Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must complete the following activities as soon as possible but by five days from notification of the change:

• complete Form H4800-A, Fair Hearing Request Summary - Addendum (PDF), with the updated information; and
• email Form H4800-A to the data entry representative (DER).

PSU staff must include the following on Form H4800-A:

• a clear statement showing that this is a state fair hearing for STAR+PLUS Home and Community Based Services (HCBS) program; and
• the appeal ID number assigned by TIERS in the designated field on Form H4800-A.

The DER must complete the following activities as soon as possible but no later than five days from the PSU staff notification:

• verify that a hearings officer has been assigned to the case by checking TIERS;
• upload Form H4800-A to the Texas Health and Human Services Commission (HHSC) State Portal;
• notify the hearings officer by email which 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 Portal appeal ID number;
  • the type of request such as notification of a change; and
  • Form H4800-A as an attachment.
• 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.

The DER may also email Form H4800-A to the hearings officer if they encounter issues with uploading Form H4800-A to the HHSC State Portal.

PSU staff delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for appeal requests related to Medicaid for Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denials.

7220 Processing a State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

7221 Type of Denials

Revision Notice 25-5; Effective Dec. 17, 2025

An applicant, member, guardian or authorized representative (AR) may appeal a decision verbally or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member or AR requests a state fair hearing for program denials. PSU staff notify the Appeals and Mitigation (A&M) unit if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits portal. PSU staff create all other state fair hearing requests in TIERS. The method that the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

• a medical necessity (MN) denial -refer to 7221.1, Medical Necessity Denial by TMHP below;
• a financial denial by MEPD or TW - refer to 7221.2, Financial Denial by MEPD or TW;  
• a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) - refer to 7221.3, SSI Denial by the SSA; or
• for any other denial reasons - refer to 7221.4, Other Denial Reasons.

PSU staff must not put an applicant or member back on the STAR+PLUS Home and Community Based Services (HCBS) program interest list during the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

7221.1 Medical Necessity Denial by TMHP

Revision 19-13; Effective November 5, 2019

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

• TMHP representative as the Agency Representative;
• TMHP supervisor as the Agency Representative Supervisor;
• MCO representative and MCO supervisor as the Agency Witness; and
• PSU staff and PSU supervisor as the Observer.

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the Observer will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down menu.

When Form 4800-D is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the STAR+PLUS HCBS program interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the MN denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as Observer are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

7221.2 Financial Denial by MEPD or TW

Revision Notice 25-5; Effective Dec. 17, 2025

Program Support Unit (PSU) staff must forward the request for a state fair hearing to the Appeals and Mitigation (A&M) unit. This is if the denial is related to 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 STAR+PLUS Home and Community Based Services (HCBS) program financial denials.

PSU staff must complete the following within one business day of receipt of the request:

• Create an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits portal in the Appeals/RFR tab for A&M unit about a financial denial for an non-SSI applicant or member. Refer to Appendix XXXII, Create an Appeal Task in the HHSC Benefits Portal.
• Email A&M unit at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox including:
  • this subject line: STAR+PLUS HCBS Program Appeal Request – XX [first letter of the applicant’s or member’s first and last name] #### [last 4-digits of the case number];
  • applicant or member’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
  • program type: STAR+PLUS HCBS program;
  • timeliness of receipt of the appeal;
  • specific information requesting the MEPD or TW financial denial 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; and
  • a copy, signed if available, of Form H2065-D, Notification of Managed Care Program Services.
• Create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) documenting:
  • the receipt date of the state fair hearing request; and
  • notification to the A&M unit for completion of Form H4800, Fair Hearing Request Summary.

Refer to 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information.

A&M staff send the PSU staff and PSU supervisor listed as Observers an email with the appeal ID number within five days of receiving a state fair hearing request as notification 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 back on the STAR+PLUS HCBS program interest list while an MEPD or TW financial denial are in the state fair hearing process. PSU staff must 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 STAR+PLUS HCBS program 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 hearings officer’s decision once their decision is rendered.

Refer to 7400, State Fair Hearing Decision Actions, for more information about required actions following the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision Notice 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must prepare the evidence packet and attend the for Supplemental Security Income (SSI) denials by the Social Security Administration (SSA). Refer to 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that PSU staff must submit as evidence and are responsible for uploading in the Texas Health and Human Services (HHSC) Benefits Portal:

• Form H4803, Notice of Hearing, as a cover sheet;
• copy of the citation, Title 1 Texas Administrative Code (TAC) Chapter 353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
• 6200.4, Financial Eligibility; and
• Form H2065-D, Notification of Managed Care Program Services.

Refer to Appendix XXI, Creating an Appeal in TIERS, for more information on PSU staff completion of Form H4800, Fair Hearing Request Summary.

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply to SSI denials. Refer to 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information. PSU staff must not return an applicant or member to the STAR+PLUS HCBS program interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the hearings officer renders a decision on the SSI denial. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the hearings officer sustains the denial.

The PSU staff and PSU supervisor entered as Agency Representative and Agency Representative Supervisor receive an alert in TIERS when the hearings officer renders a state fair hearing decision.

Refer to 7400, State Fair Hearing Decision Actions, for more information about notification requirements for required actions following a state fair hearing decision.

7221.4 Other Denial Reasons

Revision Notice 25-5; Effective Dec. 17, 2025

Other denial reasons include, but are not limited to:

• living arrangement is not an allowable setting;
• voluntarily declined services;
• cannot locate the applicant or member;
• cannot get the physician’s signature; or
• cost of the individual service plan (ISP) exceeds the maximum amount allowed.

Managed care organization (MCO) staff must prepare the evidence packet and attend the state fair hearing if the action is related to other denial reasons. PSU staff do not attend state fair hearings related to other denial reasons.

Program Support Unit (PSU) staff complete Form 4800-D, Fair Hearing Request Summary, entering the MCO staff as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) must complete the following activities for an appeal request not about a denial reason listed in 7221.1 through 7221.3:

• create the following within two business days from receiving 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).

PSU staff must:

• refer to 7215, 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 indicating the hearings officer rendered their decision;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

The PSU staff and PSU supervisor entered as Observer receive an alert in TIERS when the hearings officer renders a state fair hearing decision.

PSU staff must refer to 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information about continuing STAR+PLUS HCBS program services during the state fair hearing.

Refer to 7400, State Fair Hearing Decision Actions, for more information about notification requirements for required actions after the decision of a state fair hearing.

7222 Continuation or Termination of Services

Revision 19-13; Effective November 5, 2019

7222.1 Continuation of STAR+PLUS HCBS Program During a State Fair Hearing

Revision Notice 25-5; Effective Dec. 17, 2025

The STAR+PLUS HCBS program must continue until the hearings officer issues a decision. This is if the member or authorized representative (AR) files a state fair hearing requesting continued benefits:

• within the adverse action notification period of the STAR+PLUS HCBS program termination; or
• by the effective date of the action pending the state fair hearing.

The deadline is the later date.

Continuation of STAR+PLUS Home and Community Based Services (HCBS) program benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials.

Refer to 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

Program Support Unit (PSU) staff must complete the following activities within five business days of the member requesting a state fair hearing. It must be within the adverse action notification period or by the effective date of the action:

• extend the current individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) in four calendar month intervals until the fair hearing decision is rendered if the hearings officer’s decision will not be made until after the ISP expires;
  • PSU staff must not extend the medical necessity and level of care (MN/LOC) records in the Service Authorization System Online (SASO);
  • Example: The member’s four-month period would end on April 30, 2023, if the ISP expiration date is Dec. 31, 2022, and the state fair hearing decision date will not be made until after Dec. 31, 2022;
• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) to continue to provide services until the hearings officer renders a decision;
• for members not receiving SSI:
  • email the Appeals and Mitigation (A&M) unit at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox the following information:
    • this email subject line: STAR+PLUS HCBS Request for Continued Benefits – XX [first letter of the member’s first and last name] #### [last four digits of the case number];
    • member’s name;
    • Medicaid identification (ID) number;
    • HHSC Benefits Portal Appeal ID number, if available;
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service: STAR+PLUS HCBS program;
    • 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 denial case remain open during the state fair hearing;
    • example: the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision about MN;
    • the witnesses’ contact information, such as the MCO representative and the designated MCO back-up; and
• 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; and
• monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision.

PSU staff must not mail Form H2065-D, Notification of Managed Care Program Services, to the member or authorized representative (AR) notifying of continued STAR+PLUS HCBS program services until the hearings officer renders a state fair hearing decision.

HHSC continues services pending the state fair hearing decision if the state fair hearing is dismissed and then reopened and the member or AR requests continued services. The hearings officer voids the prior state fair hearing decision if the hearings officer sets a date for a new state fair hearing. The member must continue to receive services until the hearings officer renders a new state fair hearing decision.

7222.2 Discontinuation of STAR+PLUS HCBS Program Due to Member Not Requesting a State Fair Hearing

Revision 24-4; Effective Dec. 1, 2024

A member’s STAR+PLUS Home and Community Based Services (HCBS) program services must continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services (PDF). The program denial date is the last day of the month of the current individual service plan (ISP) or the last day of the month that the adverse action notification period ends, whichever is later. 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 STAR+PLUS HCBS program services during the state fair hearing. Program Support Unit (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+PLUS after STAR+PLUS HCBS 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), Day Activity and Health Services (DAHS), Emergency Response Services (ERS) and Personal Assistance Services (PAS).

7230 State Fair Hearing Actions

Revision 19-13; Effective November 5, 2019

7231 Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal

Revision 19-13; Effective November 5, 2019

The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits portal using the process described below. Refer to Section 7213, Generation of the State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

• upload the supporting documentation in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
• email the supporting documentation to Program Support Unit (PSU) staff and the PSU supervisor.

Within two business days after receipt of the evidence packet in the HHSC Benefits portal, the DER must:

• select the Appeals/RFR tab and ensure the appeal has been entered;
• 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); and
• select Upload.

If an error is made on the Agency Representative screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in Maintain Appeals.  If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits portal. The Agency Action Date cannot be changed.

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 25-2; Effective June 6, 2025
 
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 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 have information about the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide.
• Pages 11-15 have policy from the STAR+PLUS Handbook (SPH) that relates directly to the issue in question.
• Pages 16-20 has documents signed by the applicant, member or authorized representative (AR) related to individual rights.
• Page 21 has Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or authorized representative (AR) on March 2.

PSU Example: I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

• Page 1 has a copy of Form H4803, Notice of Fair Hearing.
• Page 2 has a copy of the Title 1 Texas Administrative Code (TAC) Chapter 353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program. It states that the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies, their contractors and providers in the delivery of STAR+PLUS HCBS program services to eligible applicants or members.  
• Page 3 has a copy of the SPOPH 6200.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR+PLUS HCBS program services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) requirements.
• Page 4 has Form H2065-D, which was mailed to the applicant, member or AR 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.

7233 State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or authorized representative (AR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or AR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or AR requested continued services during the state fair hearing period, PSU staff follow procedures, as described in Section 7400, State Fair Hearing Decision Actions.

7310 Action Taken on the State Fair Hearing Decision

Revision Notice 25-5; Effective Dec. 17, 2025

Program Support Unit (PSU) staff must update the hearings officer of actions taken on reversed state fair hearing decisions if PSU staff were at the 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 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 are unable to 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 defended the action on appeal, but meet a delay to act 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 25-5; Effective Dec. 17, 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 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 the STAR+PLUS Home and Community Based Services (HCBS) program.

The hearings officer specifies the corrective actions to be taken, and a 10-day time frame for the completion of the 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 went to the state fair hearing to defend the action on appeal, and the fair hearings officer issues a reversed decision. 

7410 Sustained State Fair Hearing Decision

Revision Notice 25-5; Effective Dec. 17, 2025

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the STAR+PLUS Home and Community Based Services (HCBS) program denial or termination. For example, if an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal request for the state fair hearing, sustaining the action on appeal.

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants and members who did not request continued benefits.

PSU staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued STAR+PLUS HCBS program 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 STAR+PLUS HCBS program termination effective date;
• terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7411, Sustained Decision – Termination Effective Date;
• close the Community Services Interest List (CSIL) record if the record is open;
• email the Appeals and Mitigation (A&M) unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox for medical assistance only (MAO) members;
  • the email to the A&M unit must include the following information:
    • an email subject line that states: “Sustained Denial for STAR+PLUS HCBS – 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;
    • the type of request for example notification of sustained denial of the STAR+PLUS HCBS program;
    • the type of service such as STAR+PLUS HCBS program;
    • HHSC Benefits Portal appeal ID number;
    • the Texas Integrated Eligibility Redesign System (TIERS) case number;
    • STAR+PLUS HCBS program termination effective date; and
    • the 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.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, Notification of Managed Care Program Services, to notify the applicant, member, or authorized representative (AR) of a sustained denial or termination.

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

When the STAR+PLUS Home and Community Based Services (HCBS) program is terminated at reassessment because the member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the termination effective date will vary depending on the following circumstances:

• In cases where the hearings officer's decision is 30 days or more prior to the end of the individual service plan (ISP) in effect when the state fair hearing was filed, STAR+PLUS HCBS program termination is effective at the end of the ISP in effect at the time the state fair hearing was filed. Refer to Example 1 below.
• When the hearings officer’s decision date is less than 30 days before the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date (the date the order is signed). Refer to Example 2 below.
• When the hearings officer's decision date is after the end of the ISP in effect when the state fair hearing was filed, and a new ISP was developed to continue services past the ISP end date until the state fair hearing decision was made, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date. Refer to Example 3 below.
• If the hearings officer assigns a specific medical necessity (MN) or ISP expiration date not equal to the last day of the month, but after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that the hearings officer identified as the expiration month. Refer to Example 4 below.
• When the hearings officer assigns a specific MN or ISP expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of that ISP period. Refer to Example 5 below.
• If the hearings officer assigns a specific MN or ISP expiration date that is before the end of the MN or ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN or ISP expiration date. Refer to Example 6 below.

Examples

7420 Reversed State Fair Hearing Decision

Revision 26-1; Effective Feb. 20, 2025

Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the hearings officer’s decision to reverse the denial or termination of STAR+PLUS Home and Community Based Services (HCBS) program within two business days. They do this by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub. PSU staff must notate the following on Form H2067-MC:

• STAR+PLUS HCBS program services should continue as directed in the hearings officer’s decision, as applicable; and
• the MCO must upload a new ISP to the MCOHub or to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable.

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

• Manually generate Form H2065-D, Notification of Managed Care Program Services. For all applicants, the ISP begin date is the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer.
• Mail Form H2065-D to the applicant.

Upload Form H2065-D to the MCOHub.

• Ensure the ISP is updated in the Service Authorization System Online (SASO) with the correct effective dates.
• For medical assistance only (MAO) applicants, notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Hearing Decision – STAR+PLUS HCBS Appeal for XX [first letter of the applicant’s first and last name]. For example, the email subject line for a STAR+PLUS HCBS program termination reversal for Ann Smith would be “Reversed Hearing Decision – STAR+PLUS HCBS Appeal for AS”;
  • the applicant’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
  • Texas Integrated Eligibility Redesign System (TIERS) case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• For MAO applicants, notify Appeals and Mitigation (A&M) staff by email at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to A&M staff must include:
  • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the applicant’s first and last name];
  • the applicant’s name;
  • Medicaid ID number or SSN;
  • type of request such as continue or reinstate Medicaid eligibility;
  • type of service such as  STAR+PLUS HCBS program;
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • TIERS Medicaid eligibility effective date;
  • Form H1746-A , MEPD Referral Cover Sheet;
  • Form H2065-D; and
  • the state fair hearing decision.
• Upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
• Document and close the HEART case record.

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

• electronically generate Form H2065-D in the TMHP LTCOP;
  • for a member who did not receive continued benefits, the ISP begin date is the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
  • for a member who did receive continued benefits, the ISP begin date is the first day of the month following the termination date;
• mail Form H2065-D to the member;
• ensure the ISP is updated in SASO with the correct effective dates;
• for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• for MAO members, notify A&M staff by email at the HHSC AES Fair Hearings mailbox. The email to A&M staff must include:
  • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request (i.e., continue or reinstate Medicaid eligibility);
  • type of service (i.e., STAR+PLUS HCBS program);
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • TIERS Medicaid eligibility effective date;
  • Form H1746-A;
  • Form H2065-D; and
  • the state fair hearing decision;  
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

7421 Reversed Decision – Effective Date

Revision Notice 26-2; Effective June 1, 2026

The STAR+PLUS Home and Community Based Services (HCBS) program individual service plan (ISP) effective date for a reversed fair hearing decision depends on if the:

• appellant is an applicant;
• member has continued STAR+PLUS HCBS program benefits; or
• member is without STAR+PLUS HCBS program continued benefits.

The ISP begin date for an applicant is the first day of the month after the hearings officer’s decision. This is unless otherwise specified by the hearings officer.

The ISP begin date for a member who received continued STAR+PLUS HCBS program benefits is the first day of the month after the end of the ISP in effect when the state fair hearing was filed.

The ISP begin date for a member who did not receive continued STAR+PLUS HCBS program benefits is the first day of the month after the hearings officer’s decision, unless otherwise specified by the hearings officer.

PSU staff must complete Section B of Form H4807, Action Taken on Hearing Decision, when a state fair hearing decision is reversed but PSU staff cannot implement the state fair hearing decision within the required time frame. PSU staff must attach and send Form H4807 by email to the data entry representative (DER), if applicable. Information on Form H4807 must be entered by PSU staff or the DER on the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Refer to 7233, State Fair Hearing Decision, and 7310, Action Taken on the State Fair Hearing Decision, for the required time frames. 

PSU staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the Appeals and Mitigation (A&M) staff. PSU staff coordinate with A&M staff by sending an email to the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. This email must include:

• a subject line that reads: STAR+PLUS HCBS Program Reversed Fair Hearing Decision – XX [first letter of the applicant’s or member’s first and last name] #### [last four digits of the Texas Integrated Eligibility Redesign System (TIERS) case number];
• applicant or member’s name;
• TIERS case number;
• Medicaid identification (ID) number or Social Security number (SSN);
• Health and Human Services (HHS) Benefits Portal appeal ID number, if available;
• TIERS case number;
• program type: STAR+PLUS HCBS program; and
• action type: Medicaid eligibility be reinstated on [date] as instructed in the reversed state fair hearing decision. 

PSU staff must refer to 7310, Action Taken on the State Fair Hearing Decision, for:

• more actions PSU staff must take if they attended the state fair hearing to defend the action on appeal; and 
• the fair hearing officer issues a reversed decision.

7422 New Assessment Required by State Fair Hearing Decision

Revision Notice 25-5; Effective Dec. 17, 2025

The state fair hearing is closed, pending the results of the new assessment if the hearings officer’s decision orders completion of a new:

• Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment; or
• Form H6516, Community First Choice Assessment.

Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) 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 AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, 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 AR 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 STAR+PLUS Home and Community Based Services (HCBS) program 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/LOC Assessment, which results in another MN denial. PSU staff send a notice to the member or AR informing him or her of the MN denial. The member or AR then requests 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 AR 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.

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) 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 AR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or AR 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 AR 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 AR and must be made to the hearings officer.

If the applicant, member or AR 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 AR 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 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) hearings officer must:

• notify all hearing participants of the date and time of the state fair hearing;
• prepare a final order disposing of a case through withdrawal and send copies of this order to the applicant, member or authorized representative (AR) and Program Support Unit (PSU) staff upon written notification from the applicant, member or AR to withdraw a state fair hearing;
• conduct the state fair hearing;
• consider all testimony and exhibits in making a decision;
• reserve the right to hold a hearing record open after a state fair hearing to obtain additional information;
• render a state fair hearing decision; and
• send a written copy of all state fair hearing decisions to the applicant, member or AR, Texas Medicaid & Healthcare Partnership (TMHP) and PSU staff within five days of making the decision.

Revision 19-7; Effective June 3, 2019

The Unusual End Dates report lists individual service plans (ISPs) with questionable end dates.

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

• "Y" means the MN was approved.
• "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

Program Support Unit (PSU) Entry Fields

Comments – PSU staff must enter appropriate comments after researching the ISP end dates. For example, an ISP with:

• an end date of Oct. 30, 2018, is questionable because there are 31 days in October.
• an end date of Nov. 1, 2018, is questionable because ISPs end on the last day of the month.
• a begin date of Jan. 1, 2018, and an end date of Dec. 31, 2018, is questionable because ISPs are not open-ended, nor do they end prior to the begin date.

Unusual End Dates is a periodic report sent on an as-needed basis. The PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Revision 19-7; Effective June 3, 2019

The Individual Service Plan (ISP) Expiring report is a check and balance method for the ISP expiring at the end of the report month.

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

• "Y" means the MN was approved.
• "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

Program Support Unit (PSU) Entry Fields

Date 2065D Sent – Enter the date PSU staff uploaded Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral if the:

• MN column has "N" (denied);
• PSU research shows the MN is denied;
• Managed care organization notifies PSU staff of the MN denial;
• PSU staff learn of the MN denial by any other method;
• PSU staff learn of no unmet need at the annual reassessment for the new ISP;
• PSU staff learn of loss of eligibility; or
• PSU staff learn of any other denial reasons.

If the MN column has "Y" (approved), leave the field blank.

Date MN Registered in SAS - The date the MN is registered in SASO.

Date ISP Registered – Enter the date PSU staff registered the ISP in SASO, if uploaded to TxMedCentral or Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Date ISP Posted – The date Form H1700-1, Individual Service Plan (Pg. 1), was uploaded by the MCO to TxMedCentral or TMHP LTC Online Portal.

Comments – PSU staff may enter appropriate comments.

Note: Enter information in the “Comments” field in situations where Form H2065-D is completed but the “Date ISP Registered” is not filled out. The reason entered must provide sufficient detail to ensure clarity.

For expired ISP, Date MCO Contacted – Enter the date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 2nd attempt – Enter the 2nd attempt date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 3rd attempt – Enter the 3rd attempt date the MCO was contacted if the ISP has expired.

The ISP Expiring Report is a monthly report. PSU staff are required to research, resolve and respond within 14 days of receipt.

Scan Call for ISP Expiring Report process:

• PSU staff provide the ISP Expiring Report five business days prior to the scheduled scan call.
• The MCOs research and provide a written status for each member whose ISP expires within 45 days, indicating the status of the member’s reassessment. The MCO must return a completed report to PSU staff two business days prior to the scan call.
• PSU staff review the MCO's responses to determine if the MCO needs to provide clarification regarding any member's ISP status. During the scan call, only the ISP status about which PSU staff have questions are reviewed. There will no longer be a need to review each member for the status of the ISP if the MCO's response is sufficient.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Revision 19-7; Effective June 3, 2019
 

The Mismatched Individual Service Plan (ISP) and Medical Necessity (MN) End Dates report shows ISP end dates with MN end dates that do not match.

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last MN registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

• "Y" means the MN was approved.
• "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

Program Support Unit (PSU) Entry Fields

Comments (Date and Action taken) – PSU staff must enter appropriate comments after researching the ISP/MN end dates, which should match. For example, an ISP ends on May 31, 2019, and the MN ends on April 30, 2019. PSU staff must research the reason for the mismatch.

There may be valid situations in which the two dates will not match. For example, a Money Follows the Person (MFP) case has an ISP registered for one day. The MN will not match the one-day registration in this case.

Mismatched ISP and MN End Dates is a periodic report sent on an as-needed basis. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Revision 26-1; Effective Feb. 20, 2026

The STAR+PLUS Loss of Enrollment Report gives Program Support Unit (PSU) staff a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have lost Medicaid eligibility or managed care enrollment. PSU staff must conduct coordination activities to either reestablish eligibility, managed care enrollment, or close the authorization(s) in the Service Authorization System Online (SASO).

Report Fields

PCN — The member’s nine-digit Medicaid number.

Name — The member’s last name, first name and middle initial when provided.

RG — The three-digit risk group number.

Plan Code — The two-digit managed care organization (MCO) plan code where the member is currently enrolled.

TP — The member’s two-digit Medicaid Type Program (TP).

PSU Entry Field

Eligibility Re-established? — PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to determine if Medicaid eligibility or managed care enrollment was reestablished. Enter yes, if it has and enter no, if not.

Is manual managed care enrollment needed, if yes? — PSU staff must check TIERS to determine if Medicaid eligibility and managed care enrollment were established if the response to the previous column was yes. PSU staff send an email to the Enrollment Resolution Services (ERS) mailbox if manual managed care enrollment is needed.

Provide the date Form H2065-D was sent, if no. — PSU staff enter the date Form H2065-D, Notification of Managed Care Program Services was sent.

Was the decision appealed? — PSU staff enter yes or no. No further action is needed if the response to this question is no. Continue to the next section, if yes.

Was eligibility re-established, if yes? — PSU staff check TIERS to determine if Medicaid eligibility or managed care enrollment was re-established. Enter yes, if it has enter no if not. No further action is necessary if the response to this question is no.

If eligibility was re-established, is manual managed care enrollment needed? — PSU staff must check TIERS to determine if managed care enrollment was established if the response to the previous column was yes. PSU staff send an email to the ERS mailbox if manual managed care enrollment is needed.

Pending at PSU — Enter yes or no.

Pending at MCO — Enter yes or no.

Pending at MEPD — Enter yes or no.

Comments — Enter any comments relevant to the actions taken.

The STAR+PLUS Loss of Enrollment Report is a monthly report. PSU staff must research, resolve and respond to the requestor within 14 days of receipt. Completion of the report itself is due within 14 days of receipt and does not negate policy about denial notifications. Refer to 1700, Notification Requirements. The notification must still be sent within two business days.

Note: SASO files used by PES staff to produce this report are a snapshot in time. They may not reflect registrations at the point of receipt.

Revision 25-2; Effective June 6, 2025

Program Support Unit (PSU) staff must use Appendix IV, Form H2065-D STAR+PLUS HCBS Program 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 additional 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 IV.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

Denial and Termination Language

This table contains Reason for Denial and Comments field language for Form H2065-D and Form H2065-DS generated for denials and terminations.

PSU staff must enter the associated STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) section supporting the denial reason on Form H2065-D and H2065-DS, listed in the SPOPH Section column.

Approval Language

This table contains Comments field language for Form H2065-D and Form H2065-DS generated for approvals.

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 being generated.

PSU staff must enter the full R&B and copayment amounts for members admitting to an ALF or AFC on the first day of the month. PSU staff must enter the full R&B and copayment amounts for the first month of eligibility along with (prorate) and (prorrateo) if the member is admitting to an ALF or AFC on any other day of the month.

Revision Notice 26-2; Effective June 1, 2026

The STAR+PLUS Home and Community Based Services (HCBS) Program uses the following acronyms.

Revision 25-3; Effective Aug. 4, 2025

English: Appendix XI, Fair Hearing Options for STAR+PLUS HCBS Program Denials (PDF)

Spanish: Appendix XI, Opciones de audiencia imparcial para las denegaciónes del programa HCBS de STAR+PLUS (PDF)

Revision 19-3; Effective April 10, 2019

English Word: Appendix XII, STAR+PLUS HCBS Program Description

Spanish Word: Appendix XII, Servicios en el Hogar y la Comunidad de STAR+PLUS

Revision 25-2; Effective June 6, 2025

Your Financial Rights in an Assisted Living Facility STAR+PLUS

Revision Notice 26-2; Effective June 1, 2026

Revision 22-1; Effective January 31, 2022

English Word: 1 Texas Administrative Code §353.1153 STAR+PLUS Home and Community Based Services (HCBS) Program

Spanish Word: Sección 353.1153 del Título 1 del Código Administrativo de Texas: Servicios en el Hogar y la Comunidad de STAR+PLUS

Revision 26-2; Effective June 1, 2026

Revision 24-3; Effective Sept. 10, 2024

Link to PSU Users H1700/ISP Form User Guide found here.

Revision 25-5; Effective Dec. 17, 2025

STAR+PLUS Plan Codes

Medicare-Medicaid Plan (MMP) Codes

9-2017

Purpose

The relocation function is a component of service coordination. The primary purpose of the relocation function is to support the transition of members and future members who desire to move from an institution to the community. A relocation specialist (RS) works for an entity contracted with a managed care organization (MCO) to perform the relocation function.

Overview of Relocation Function

• Conduct outreach and education to nursing facilities and residents on options for receiving long-term services and supports (LTSS) in the community;
• Identify members interested in relocating;
• Respond to referrals for relocation and conduct relocation assessments;
• Develop and implement person-centered relocation plans;
• Coordinate housing and non-covered community services, as mutually agreed;
• Provide support on day of relocation and conduct follow-up; and
• Collect data on relocations as specified by the Texas Health and Human Services Commission and/or MCOs.

Relocation Tasks

Minimum Qualifications

An MCO must offer a contract to provide the relocation function to an entity with at least five years contracting with the state to provide relocation functions as of Sept. 1, 2016, to members transitioning from institutions to Medicaid community-based LTSS.

An MCO may offer a contract to a new entity to provide the relocation function. The new entity must meet all of the following qualifications:

• Adherence to Health Insurance Portability and Accountability Act (HIPAA) compliant data management requirements and other stipulations of the MCO;
• Experience identifying barriers to relocation for members who express an interest in moving from nursing facilities in Texas to a home and community-based setting;
• Knowledge of community resources for members with disabilities of all ages and how to access those resources;
• Knowledge of community and federal housing resources and how to access those resources, as appropriate;
• Knowledge of Medicaid, including, but not limited to, Medicaid managed care, long term services and supports, eligibility requirements and how to apply and qualify for Medicaid;
• Ability to hire, train, supervise and direct RS staff that ensures the successful transition of members from nursing facilities. The entity is responsible for ensuring any RS is not listed in the HHSC employee misconduct registry, Inspector General (IG) list of excluded entities and individuals, and HHSC do not hire registries. The entity must conduct a fingerprint background check and share the results with the MCO prior to hiring an RS;
• Two years of experience developing transition plans for members; and
• Three years of experience working directly with people with disabilities of all ages or the entity must have at least three years of experience subcontracting with an entity described above to provide the relocation function.

Revision 25-4; Effective Oct. 6, 2025

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 when uploading documents to the HEART case record. Refer to Appendix XXXIV, STAR+PLUS 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.

PSU staff must include 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.

Upgrades

Money Follows the Person (MFP)

Annual Reassessment

Transition to Adult Programs (MDCP Age-Out)

Denials and Terminations

Note: PSU staff must upload Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.

Fair Hearings