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.