Form H2067-MC, Managed Care Programs Communication

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Effective Date

4/2026

Instructions

Updated: 4/2026

Purpose

Form H2067-MC is the main communication tool for Program Support Unit (PSU) and managed care organization (MCO) staff. The form keeps the units informed on activities related to managed care applicants and members.

Procedure

When to Prepare

PSU staff and the MCO prepare Form H2067-MC to request and share case information not available through data inquiry.

Copies or Transmittal

PSU staff and MCO upload Form H2067-MC to the MCOHub in the MCO's folder. PSU staff and the MCO must name Form H2067-MC per the naming conventions identified in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH), STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH), STAR+PLUS Handbook (SPH), or STAR Kids Handbook (SKH). PSU staff uploads Form H2067-MC to the HHS Enterprise Administrative Report and Tracking System (HEART) case record. The MCO follows established record-keeping procedures for form copies.

Form Retention

HEART is the PSU staff’s repository for the electronic case record. PSU staff do not retain paper copies of Form H2067-MC. The MCO must keep copies of the completed form according to the retention requirements found in all Medicaid managed care contracts and federal regulations. The MCO must retain all originals/electronic copies of this form in the member's folder/electronic record for five years after the member loses eligibility.

Supply Source

This form may be found in the SPOPH, SKOPH, SPH, and SKH on the HHS website.

Detailed Instructions

Applicant or Member Information Section

PSU staff or the MCO must complete the following fields when using this form.

Program — Check the box for either STAR+PLUS Home and Community Based Services (HCBS) program or Medically Dependent Children Program (MDCP).

Service Area — Enter the applicant’s or member’s service area. Select “Statewide” for individuals enrolled in STAR Health.

Applicant or Member Name — Enter the name of the applicant or member.

Area Code and Phone No. — Enter the applicant’s or member’s phone number, including the area code. For STAR Health members, enter the primary medical consenter’s phone number.

Social Security No. — Enter the applicant’s or member’s Social Security number (SSN).

Medicaid No. — Enter the applicant’s or member’s Medicaid identification (ID) number, if applicable.

Physical Address — Enter the applicant’s or member’s physical address, including street name, city, state and ZIP Code.

Mailing Address — Enter the mailing address, if different from the physical address.

Action Type Section

PSU staff or the MCO must check one of the following checkboxes to communicate the action type requested on this form.

  • Status Update — use this checkbox when PSU staff or the MCO are providing information or an update on an applicant or member. For example, the MCO may use the Status Update to report delays in completing an initial or annual assessment. PSU staff or the MCO enter detailed status update information in the Comments field.
  • Approval — use this checkbox when the MCO is requesting an eligibility approval. For example, the MCO may use this checkbox when requesting the Form H2065-D, Notification of Managed Care Program Services, approval notice due to a Money Follows the Person (MFP) applicant discharging from the nursing facility (NF). Additional information must be entered in the Approval Section, if this box is selected.
  • Denial or Termination — use this checkbox when the MCO is requesting denial or termination of eligibility. For example, the MCO may use this checkbox when requesting the Form H2065-D termination notice due to unable to locate member. Additional information must be entered in the Denial or Termination Section, if this box is selected.
  • Appeal Request Received by PSU — use this checkbox when PSU staff or the MCO are advising of the applicant’s or member’s request to appeal a program-level denial or termination. Additional information must be entered in the Appeal Section, if this box is selected.

Approval Section

PSU staff or the MCO must select one of the following checkboxes when advising of an eligibility approval.

  • Interest List Release — use this checkbox for applicants being released from the interest list.
  • Upgrade – STAR+PLUS HCBS only — use this checkbox for STAR+PLUS members who are requesting an upgrade into STAR+PLUS HCBS program. This box is N/A for STAR Kids MDCP.
  • Money Follows the Person (MFP) — use this checkbox for applicants pursuing the MFP process. Check one of the boxes below to show the type of MFP, and enter associated dates based upon available information. The MCO may enter additional information in the Comments field in the Initiator Section or Respondent Section. For example, the MCO may enter the community residence address that the member is discharging to.
    • Traditional — use this checkbox for an applicant with Medicaid eligibility who is requesting to pursue enrollment through the traditional MFP. A person without Medicaid may qualify for NF Medicaid after living in a NF for 30 days or longer. The MCO enters the NF Admission Date and NF Discharge Date.
    • Limited NF Stay — use this checkbox for MDCP applicants who are too medically fragile to pursue the traditional MFP process. The MCO enters the NF Admission Date and NF Discharge Date.
    • Demonstration Consent Obtained — use this checkbox for an applicant who meets the MFP Demonstration institutional setting time frame requirement and consents to participate in the MFP Demonstration. The MCO enters the NF Discharge Date.
    • Demonstration Enrollment Period Reporting — use this checkbox to report that a member has reached the end of their 365-day MFP Demonstration enrollment period. The MCO enters the MFP Demonstration enrollment period Begin Date and End Date.

PSU staff and the MCO may provide more information in the Comments field in the Initiator Section or the Respondent Section. For example, the MCO may enter the MFP relocation specialist’s contact information.

Denial or Termination Section

PSU staff or the MCO must select one of the following checkboxes when advising of an eligibility denial or termination.

  • Medical Necessity Denial — use this checkbox for those who do not to meet medical necessity (MN). The MCO enters the MN Denial Date.
  • Voluntarily Declined Services — use this checkbox for those who decline the program voluntarily.
  • Unable to Locate — use this checkbox for those who are unable to locate.
  • Unable to Get Physician Signature — use this checkbox for those who are unable to get a physician’s signature.
  • Moved Out of State — this checkbox is used for those who move out of state.
  • No Unmet Need — use this checkbox for those who do not have an unmet need for the program.
  • ISP Exceeds Cost Limit — use this checkbox for those whose individual service plan (ISP) exceeds the cost limit.
  • MFP NF Discharge Before Eligibility Determination — use this checkbox for those who discharge from a NF before PSU staff can confirm they meet eligibility criteria. The MCO enters the NF discharge date in the Comments field.
  • Other — use this checkbox for denial or termination reasons not covered by the previous checkbox selections. MCO enters a brief description of the denial or termination reason.
  • Admitted to Institution for 90 Days — use this checkbox for those who have been admitted to an institution for 90 days or longer. The MCO enters the Admission Date.
  • Waiver or Program Transfer — use this checkbox for those who are transferring to another waiver or program. PSU staff or the MCO  enters the name of the other program.
  • Death — use this checkbox for those who are deceased. PSU staff or the MCO enters the Date of Death.

PSU staff and the MCO may provide more information in the Comments field in the Initiator Section or Respondent Section. For example, the MCO may enter the denial date of the MN.

Appeal Section

PSU staff must complete this section when an applicant or member is requesting to appeal a program-level eligibility denial or termination. PSU staff and the MCO enter checkboxes in this section as information becomes known during the fair hearing process.

Date Appeal Requested — Enter the date the appeal is requested.

Continued Benefits? — Select Yes if the member requests continued benefits during the appeal. Select No if the member does not request continued benefits during the appeal.

PSU staff and the MCO may provide more information in the Comments field. For example, the MCO may enter the date the fair hearing is scheduled, the status of the fair hearing or the fair hearing decision in the Comments field.

Initiator Section

From: MCO or PSU — the person initiating the form enters either PSU or MCO.

Staff Name — the person initiating the form enters their name.

Area Code and Phone No. — the person initiating the form enters their direct phone number, including the area code.

MCOHub Post Date — enter the date the person initiating the form uploads it to the MCOHub.

Comments — enter any relevant comments for communication.

Respondent Section

From: MCO or PSU — The receiving party enters either PSU or MCO.

Staff Name — The person responding enters their name.

Area Code and Phone No. — the person responding enters their direct phone number, including the area code.

MCOHub Post Date — The person responding enters the date the form is uploaded to the MCOHub.

Comments — Enter comments in response to the information requested or shared. This ensures a complete and responsive communication to the initiating party.