3200, Member Reassessment

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Revision 25-4; Effective Dec. 12, 2025

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed timely. The MCO must initiate a reassessment to determine and validate continued need for services for each member before the end date of the annual SK-SAI.

The MCO uses the SK-SAI to create and submit a Medically Dependent Children Program (MDCP) member’s STAR Kids individual service plan (SK-ISP) to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The SK-ISP lists the member’s services and preferences for care and is valid for one year. The MCO does not submit an SK-ISP in the TMHP LTCOP for a service change or a change in condition. The MCO maintains amended SK-ISPs resulting from a service change or a change in condition SK-SAI in the member file.

The MCO must:

  • Complete all member reassessment activities within 30 days before the SK-ISP expiration date.
  • Not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the previous SK-SAI.
  • Submit the SK-SAI in the TMHP LTCOP no earlier than 90 days before or no later than 30 days before the expiration of the member’s current SK-ISP on file.
  • Upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub documenting any reason for a delay.

Program Support Unit (PSU) staff must:

Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility.

The assigned PSU staff must notify the Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the Individual Service Plan (ISP) Expiring Report to the PSORT mailbox monthly. The ISP Expiring Report details members with SK-ISPs that expire within the next 90 days. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs reported as an MCO non-compliance. The subject line for the email must read: MDCP Reassessment Delinquencies for [Month].

PSU staff do not have to send a follow-up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

  • Form H2067-MC;
  • the SK-SAI; or
  • the SK-ISP.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and document the HEART case record.

PSU staff must refer to 3327, Individual Service Plan Expiring Report, for more information about the ISP Expiring Report.

3210 Reassessment of Medical Necessity Determination

Revision 25-4; Effective Dec. 12, 2025

A Medically Dependent Children Program (MDCP) member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before Program Support Unit (PSU) staff recertifies the member for MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

PSU staff must refer to 1200, MDCP Eligibility, for more information on the eligibility criteria for MDCP including an MN determination.

The MCO completes and submits a reassessment SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) annually. The TMHP LTCOP automatically processes the SK-SAI and redetermines the member’s Patient-Driven Payment Model (PDPM) Long-Term Care (LTC) level and MN. The TMHP LTCOP sends the SK-SAI to the Office of the Medical Director (OMD) staff for manual review if the SK-SAI fails automatic MN approval.

PSU staff must monitor the TMHP LTCOP every five business days from the MN denial date in the TMHP LTCOP, until the MN status updates to one of the final statuses below:

  • MN Approved: The status may change to MN Approved if the OMD physician overturns the denial because more information is received; or
  • Overturn Doctor Review Expired: The status may change to Overturn Doctor Review Expired when the 14-business day period for the OMD physician to overturn the denied MN has expired, and no more or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the member or legally authorized representative (LAR) requests a state fair hearing.

The MCO must notify PSU staff of a member’s MN denial and request Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must complete actions in the following sections when notified a member is denied MN or requests an appeal of an MN denial: