2000, Medically Dependent Children Program Intake and Initial Application

Revision 22-2; Effective September 1, 2022

2010 Initial Requests for Medically Dependent Children Program

Revision 22-2; Effective September 1, 2022

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list according to the date and time of the request, regardless of the program's enrollment status. Individuals are released from the interest list in the order of the request date. An individual or their legally authorized representative (LAR) may request that the individual be placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual's name may only be added to the MDCP interest list if the individual is younger than age 21 and resides in Texas.

2020 Individual Enrolled in STAR Health

Revision 22-2; Effective September 1, 2022

See the Uniform Managed Care Manual (UMCM) for STAR Health members. The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

A member disenrolling from the STAR Health program due to exiting conservatorship may be eligible to continue their MDCP services through a STAR Kids MCO of their choice. Additional information on MDCP STAR Health members is in the STAR Health MDCP Policy Section 16.2 of the UMCM.

2030 Managed Care Organization Coordination

Revision 25-2; Effective Sept.1, 2025

The STAR Kids managed care organization (MCO) must complete all required activities in. the established time frames This ensures a member does not experience a delay in services. The MCO has 30 days from receipt of the initial authorization by Program Support Unit (PSU) staff to:

• begin the assessment process in Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment and Authorization; and
• complete all assessments for an individual applying for the Medically Dependent Children Program (MDCP).

The MCO has 30 more days to submit all required documentation to PSU staff, for a total of 60 days following receipt of the initial notice from PSU staff. Within 60 days of the MCO receiving Form H3676, the MCO must:

• verify if the individual meets all other eligibility criteria referenced in 1000, Overview and Eligibility;
• complete and submit the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module, to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP;
• get the member’s or legally authorized representative’s (LAR's) signature on Form 2605, Member SK-SAI MDCP Review Signature, or if the member or LAR refuses to sign, the MCO must document the refusal on the form;
• get the individual's physician's signature on Form 2601, Physician Certification;
• complete Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and keep in the member's file once the Medical Necessity (MN) is approved and the SK-SAI is in the status of processed and complete;
• complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool;
• submit the ISP electronically to the TMHP LTC Online Portal following the requirements in Appendix I; and
• complete Section B, Waiver Assessment Report, of Form H3676 and upload to MCOHub.

If the MCO does not perform the actions above within 60 days from the date PSU staff uploaded Form H3676, Section A, the MCO must upload Form H2067-MC, Managed Care Programs Communication to MCOHub to advise PSU staff of the reason(s) for the delay. PSU staff notify Managed Care Compliance & Operations (MCCO) of the delay and the reason for the delay.

Note: Refer to 2200, MDCP Start of Care and MN Expiration, for more information on MN expiration.

The MCO must submit the SK-SAI to TMHP within 72 hours of completion once the SK-SAI is complete. For the purposes of this MCO requirement, the SK-SAI is considered complete when:

• the MCO has the physician's signature on Form 2601;
• the MCO has the member’s or LAR’s signature on Form 2605, or documented the member’s or LAR’s refusal to sign Form 2605;
• Forms 2601 and 2605 are in the individual's or member’s case file; and
• Form H3676 Section B is uploaded to MCOHub.

Physician Signature

The MCO must make best efforts to get Form 2601 signed by the individual’s physician.

Form 2601:

• Must be completed for all initial assessments and change in condition assessments.
• Does not need to be completed for annual reassessments when no change in condition is identified, but the MCO may request it.

The MCO must:

• Notify the member or LAR of the Form 2601 requirement.
• Submit the form to the individual's physician for review and signature once Section A of Form H3676 is received from PSU staff.
• Submit within three business days after conducting the SK-SAI.
• Complete and upload Form H3676, Section B, to MCOHub informing PSU the SK-SAI is complete, once signed Form 2601 is received.

If Form 2601 is not received by the MCO within five business days of the first request to the individual’s physician, the MCO must:

• Attempt and document at least one phone contact per week to the individual’s physician to get Form 2601.
• Make at least three phone contacts up to a three-week period to get Form 2601 before the MCO can request PSU staff deny the individual.
• Upload Form H2067-MC to MCOHub to advise PSU staff if the MCO needs more time to make required phone contacts to get Form 2601.
• Notify the member or LAR and offer them the opportunity to contact the physician directly to request the physician submit the form to the MCO if at least three phone attempts up to a three-week period have occurred and the MCO does not have Form 2601 signed.
• Upload Form H3676, Section B, to MCOHub requesting PSU staff deny the individual MDCP due to MCO inability to get the individual’s physician’s signature on Form 2601 if the MCO completed the activities above and the MCO has not received Form 2601.

SK-SAI Review Signature

The MCO must complete Form 2605 for all initial assessments, reassessments, and change in condition assessments.

The MCO must:

• allow the member or LAR the opportunity to review the information gathered in the SK-SAI during the home visit;
• document the member’s acknowledgement and feedback on Form 2605 during the home visit; and
• document the refusal on the form during the home visit if the member or LAR refuse to sign Form 2605.

On Form 2605, the MCO must:

• document any of the member’s or LAR’s comments about the information gathered in the SK-SAI;
• document the member’s or LAR’s request on how they want to receive a copy of the final SK-SAI that is submitted to TMHP; and
• have the MCO service coordinator sign to acknowledge completion of the form at the time of the home visit.

During the home visit, the MCO must educate the member or LAR about the process to request a peer-to-peer review with a physician chosen by the member or LAR if MN is denied.

Note: If the result of the assessment is a denial, the MCO must follow the policy in 6250, Denial or Termination of Medical Necessity.

The MCO must contact the member to affirm and document any changes made to the SK-SAI after the home visit. If the member or LAR has any more comments at the time of this contact, the MCO must document the comments.

Authorization of MDCP Services

MN is required for MDCP. An MN determination for MDCP must be based on information collected as part of the SK-SAI assessment.

TMHP The LTC Online Portal processes an individual’s SK-SAI. The system calculates a Resource Utilization Group (RUG) value if the individual’s assessment is submitted on or before Aug. 31, 2025, or a Patient Driven Payment Model Long-Term Care (PDPM LTC) level if the individual’s assessment is submitted on or after Sept.1, 2025. The RUG value or PDPM LTC level is a measure of medical acuity level and nursing facility (NF) staffing needs and is automatically calculated from the MDCP module of the SK-SAI. The MDCP service plan cost limit is based on 50% of the RUG value’s or PDPM LTC level’s limit for an NF. The RUG value or PDPM LTC level is not used for other purposes in STAR Kids.

Once an SK-SAI is processed, the MCO receives a substantive response file with a three-digit RUG value if the individual’s assessment is submitted on or before Aug. 31, 2025, or a three-digit PDPM LTC level if the individual’s assessment is submitted on or after Sept.1, 2025. The RUG value and PDPM LTC level are alphanumeric and may be viewed in the TMHP LTC Online Portal. Under the RUG system, an SK-SAI with incomplete information results in a BC1 code instead of a RUG value. Under the PDPM LTC system, an SK-SAI with incomplete information results in a Z01 code instead of a PDPM LTC level. Code BC1 is not a valid RUG value and code Z01 is not a valid PDPM LTC level. These codes show the individual’s SK-SAI does not have all the information needed for TMHP to accurately calculate a RUG value or PDPM LTC level for the individual or member.

The MCO must correct the information on the SK-SAI within 14 business days of submitting the assessment that resulted in a BC1 code for a SK-SAI submitted on or before Aug. 31, 2025, or a Z01 code for a SK-SAI submitted on or after Sept. 1, 2025. After 14 business days, the MCO must inactivate the SK-SAI and submit a new SK-SAI in its place. Information about the process of transmitting, correcting, and inactivating an SK-SAI is in Appendix I.

As a part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit linked to the RUG value or PDPM LTC level assigned. The MCO must not terminate MDCP services for any reason. Only HHSC can terminate member enrollment.

Information for MDCP members exceeding the cost limit is in 3324, Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services. If a denial of services is required, the MCO must follow the denial procedure in 6240, Denial/Termination as a Result of Exceeding the Cost Limit.

Service authorizations for MDCP must include the amount, frequency, and duration of each service to be provided and the schedule for when services will be rendered. The MCO must ensure the member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.

The MCO must also adopt a methodology to track each member's monthly MDCP-related expenditures and provide an update on those expenditures to the member or LAR no less than once per month.