1200, MDCP Eligibility

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Revision 25-3; Effective Oct. 20, 2025

An individual can be assessed for services through the Medically Dependent Children Program (MDCP) when their name reaches the top of the MDCP interest list (IL). Title 1 Texas Administrative Code (TAC) Section 353.1155 (b)(1) states an individual’s name may be added to the MDCP IL by:

  • calling the Texas Health and Human Services Commission (HHSC) Interest List Management (ILM) unit at 877-438-5658;
  • submitting a written request to the ILM unit; or
  • generating a referral through YourTexasBenefits.com using the Find Support Services screening and referral tool.

An individual becomes an applicant when they are released from the IL, confirm interest in MDCP and:

A member is a person who is currently enrolled in and receiving services through MDCP.

An applicant or member must meet the following criteria stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 to be eligible for the Medically Dependent Children Program (MDCP):

  • Be under 21 years old.
  • Live in Texas.
  • Meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care as determined by HHSC. Note: This requirement is verified through an approved STAR Kids Screening and Assessment Instrument (SK-SAI).
  • Have an unmet need for support in the community that can be met through one or more MDCP services. Note: This requirement is verified through a STAR Kids individual service plan (SK-ISP) with services under the established cost limit.
  • Choose MDCP as an alternative to NF services, described in 42 Code of Federal Regulations (CFR) Section 441.302(d).
  • Not be enrolled in one of the following waiver programs:
    • the Community Living Assistance and Support Services (CLASS) Program;
    • the Deaf Blind with Multiple Disabilities (DBMD) Program;
    • the Home and Community-based Services (HCS) Program;
    • the Texas Home Living (TxHmL) Program; or
    • the Youth Empowerment Services (YES) waiver.
  • Live in:
  • Be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title relating to Medicaid Eligibility for the Elderly and People with Disabilities (MEPD).

An applicant receiving NF Medicaid is approved for MDCP if the applicant requests services while living in a NF and meets the eligibility criteria listed above.

PSU staff must refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an individual, applicant or member.

1210 Medical Necessity Determination

Revision 25-4; Effective Dec. 12, 2025

Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(C) states to be eligible for the Medically Dependent Children Program (MDCP), an applicant or member must have an approved medical necessity (MN) determination for a nursing facility (NF) level of care (LOC). The MN determination comes from a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) conducts and submits the SK-SAI to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

The TMHP LTCOP automatically processes the SK-SAI, determines MN and calculates the Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level. The PDPM LTC level determines cost limits in MDCP. The MCO uses the SK-SAI to create and submit the applicant or member’s STAR Kids individual service plan (SK-ISP) to the TMHP LTCOP. The SK-ISP lists the applicant or member’s services and preferences for care and is valid for a 12-month period, if they remain eligible for the program.

The MCO must conduct and submit an initial SK-SAI for an applicant in the TMHP LTCOP within 60 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff. The MCO must conduct and submit the SK-SAI to the TMHP LTCOP for members annually, or when the member has a change in condition after initial enrollment. The MCO must not submit a reassessment SK-SAI in the TMHP LTCOP before 90 days of the expiration of the member’s current SK-ISP. The reassessment SK-SAI must be submitted at least 30 days before the member’s current SK-ISP expires.

The TMHP LTCOP automatically creates an MDCP Enrollment Form when the MCO submits a new SK-SAI for MDCP. This is if there is no existing MDCP Enrollment Forms or all other MDCP Enrollment Forms are in an invalid, denied or terminated status. PSU staff must verify data populated in the MDCP Enrollment Form is correct, update incorrect information, populate blank fields and save the form for all applicable MDCP cases. PSU staff must consult their supervisor before trying to manually create an MDCP Enrollment Form.

Refer to the STAR Kids Handbook (SKH) for more information on the MN determination.

1210.1 Reserved for Future Use

Revision 25-4; Effective Dec. 12, 2025

1210.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 25-1; Effective May 16, 2025

A medical necessity (MN) approval is valid for 120 days from the Texas Medicaid & Healthcare Partnership (TMHP) MN approval date for an initial applicant. The managed care organization (MCO) must complete another initial STAR Kids Screening and Assessment Instrument (SK-SAI) if the applicant is not enrolled in the Medicaid for Dependent Children Program (MDCP) within 120 days from the MN approval date. 

1220 Individual Cost Limit

Revision 25-1; Effective May 16, 2025

A Medically Dependent Children Program (MDCP) applicant or member’s STAR Kids individual service plan (SK-ISP) must fall within the applicant or member’s cost limit. The managed care organization (MCO) conducts a STAR Kids Screening and Assessment Instrument (SK-SAI) to assess the applicant or member. The MCO submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP LTCOP automatically processes the SK-SAI and calculates the applicant or member’s Resource Utilization Group (RUG) value and determines if medical necessity (MN) is approved. The MCO uses the SK-SAI to create the applicant or member’s SK-ISP. The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the RUG value.

Program Support Unit (PSU) staff must not calculate the SK-ISP cost limit as it is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field. PSU staff must verify the applicant or member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than then Annual Cost Limit in the TMHP LTCOP SK-ISP.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

1230 Unmet Need for at Least One Medically Dependent Children Program Service

Revision 18-0; Effective September 4, 2018

The §1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a §1915(c) Medicaid waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) Section 441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.

1240 Age

Revision 18-0; Effective September 4, 2018

To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

1250 Citizenship and Identity Verification

Revision 18-0; Effective September 4, 2018

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 the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD specialists, 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 of those programs.

1260 Living Arrangement and Texas Residency

Revision 25-1; Effective May 16, 2025

The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services. These services are outlined in Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(B), Medically Dependent Children Program.

If the applicant is under 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, outlined in Title 1 TAC Section 353.1155(b)(1)(G)(ii).

Managed care organization (MCO) service coordinators must confirm the applicant or member, if under 18, lives with a family member, such as a parent, guardian, grandparent or sibling, defined in the Glossary. The MCO service coordinator must review guardianship documentation or get a statement from the applicant, member, legally authorized representative (LAR) or family member about the relationship. The MCO service coordinator must maintain this documentation in the member’s case file.

1270 Financial Eligibility

Revision 25-4; Effective Dec. 12, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1155(a)(1)(H) states to be eligible for the Medically Dependent Children Program (MDCP), an applicant or member  must be determined by the Texas Health and Human Services Commission (HHSC) to be financially eligible.

Program Support Unit (PSU) staff review the Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

PSU staff do not have to get Form H1200, Application for Assistance – Your Texas Benefits, for an individual with an appropriate type of Medicaid assistance in TIERS. PSU staff must refer to Appendix XVI, MEPD Referral Crosswalk, to determine if the individual’s type of assistance (TOA) requires PSU staff to fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist to determine Medicaid financial eligibility for MDCP.

PSU staff must get the following completed forms, if an individual is not already Medicaid eligible:

PSU staff must fax the forms noted above, with Form H1746-A as a cover sheet, to the MEPD specialist within two business days of receipt. The MEPD specialist has 45 days, or up to 90 days if a disability determination is necessary, to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200, Form H3034 and Form H3035 within 30 days from the mail date of the application.

PSU staff must return an unsigned Form H1200 to the individual or legally authorized representative (LAR) within two business days of receipt. A completed Form 2606, Managed Care Enrollment Processing Delay, must be mailed with the original unsigned Form H1200. PSU staff must ensure that a copy of the unsigned Form H1200 and Form 2606 are uploaded to the Texas Health and Human Services HHS Enterprise Administrative Report and Tracking System (HEART) case record.

1270.1 Individual with a Qualified Income Trust

Revision 25-1; Effective May 16, 2025

An individual or applicant with a qualified income trust (QIT) may be determined financially eligible for the Medically Dependent Children Program (MDCP) even though their income is more than the special institutional income limit for the program.

PSU staff must refer questions about QIT to Access and Accessibility Services (AES). This is done by faxing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist.

1270.2 Copayment and Room and Board

Revision 26-2; Effective June 1, 2026

Members determined to be financially eligible based on the institutional income limit may have to share in the cost of Medically Dependent Children Program (MDCP) services. These shared costs are paid by the member through room and board (R&B) and copayment charges. The R&B amount is determined by the Social Security Administration (SSA). The copayment amount is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Medical assistance only (MAO) members who are eligible based on the institutional income limit must pay R&B and copayment. Supplemental Security Income (SSI) members are only required to pay R&B and will not have a copayment.

Program Support Unit (PSU) staff use Form H2065 -D, Notification of Managed Care Program Services, to notify the member and managed care organization (MCO) of R&B and copayment amounts. The begin date entered on Form H2065-D for the initial R&B and copayment charges will match the:

  • MDCP eligibility effective date for:
    • interest list release (ILR) cases; and 
    • transfers from another Medicaid waiver program; and 
  • first day of the month that the applicant discharged from the nursing facility (NF) for traditional Money Follows the Person (MFP) and MFP limited NF stay cases. 

The MCO must explain to the member that they must pay the copayment and R&B amounts directly to the provider contracted to deliver MDCP services. 

1270.3 Copayment Changes

Revision 26-2; Effective June 1, 2026

A member's copayment may change during the time they are enrolled in the Medically Dependent Children Program (MDCP). Copayment changes are typically due to a change in income, medical expenses or other circumstances.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist is responsible for calculating copayment amounts. The MEPD specialist notifies Program Support Unit (PSU) staff through the MEPD Communication Tool of copayment amounts. PSU staff may also determine the copayment amount has changed in Texas Integrated Eligibility Redesign System (TIERS) at reassessment. The MEPD specialist informs PSU staff if corrections to the member's copayment are necessary based on a change in the income amount available for copayment.

PSU staff must complete the following activities within five business days from getting the copayment amounts:

  • mail Form H2065-D, Notification of Managed Care Program Services, to the member or legally authorized representative (LAR);
  • upload Form H2065-D to the MCOHub;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

Copayment changes are always effective on the first day of the month. Adverse action is required if the copayment amount is increasing. The copayment increase is effective the first day of the month after the adverse action period has expired.

Adverse action is not required when:

  • the initial Form H2065-D is generated advising the member of the copayment amounts for the first time;
  • no changes are happening to ongoing copayment amounts; or
  • copayment amounts are decreasing.

The copayment amount is effective the first day of the month after the copayment amount is determined when adverse action is not required.

The MEPD specialist and the managed care organization (MCO) handle issues for underpayments, refunds and copayment amount appeals.