6100, Description

Revision 22-1; Effective January 31, 2022

This section contains policy for Program Support Unit (PSU) staff when processing:

• case closure for an individual applying for the Medically Dependent Children Program (MDCP);
• denials and terminations for an applicant or member; and
• information regarding adequate notice of an applicant’s or member’s right to due process.

PSU staff must mail Form 2442, Notification of Interest List Release Closure, as notification of an MDCP interest list closure to an individual when the individual does not meet MDCP eligibility. PSU staff must always mail Form 2442 with Appendix XX, MDCP Program Description. Form 2442 does not provide the right to request a state fair hearing. An individual will only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff must mail an applicant or member Form H2065-D when the applicant or member is denied or terminated from MDCP. Form H2065-D provides an applicant or member with the right to request a state fair hearing. An applicant or member will never receive Form 2442.

Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), provides the rules for adverse action for members required by Title 42 Code of Federal Regulations (CFR) Part 431, Subpart E, including requiring that: 

• the written notice to the member of their right to a hearing must:
  • contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and
  • be delivered by mail, and postmarked at least 10 business days, before the date the member’s Medicaid eligibility or service is scheduled to be terminated, suspended or reduced, except as provided by Title 42 CFR §431.213 or Title 42 CFR §431.214; and
• if a hearing is requested before the date a member’s service, including a service that requires prior authorization, is scheduled to be terminated, suspended or reduced, Texas Health and Human Services Commission (HHSC) may not take that proposed action before a decision is rendered after the hearing unless:
  • it is determined at the hearing that the sole issue is one of federal or state law or policy; and
  • the agency promptly informs the recipient in writing that services are to be terminated, suspended or reduced pending the hearing decision.

Title 42 CFR Part 431, Subpart E, governs fair hearing rights for Medicaid individuals, applicants and members. However, Title 42 CFR §431.213 specifies situations where an adverse action notification period is not required. The agency may mail a notice not later than the date of action if:

• The agency has factual information confirming the death of an individual, applicant or member;
• The agency receives a clear written statement signed by a member that:
  • they no longer want to receive services; or
  • gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information; and
• The individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
• The individual’s, applicant’s or member’s whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See Title 42 CFR §431.231(d) of this subpart for procedure if the individual’s, applicant’s or member’s whereabouts become known);
• The agency establishes the fact that the individual, applicant or member has been accepted for Medicaid services by another local jurisdiction, state, territory or commonwealth;
• A change in the level of medical care is prescribed by the applicant’s or member’s physician;
• The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
• The date of action will occur in less than 10 days, in accordance with Title 42 CFR §483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30 days’ notice requirements of Title 42 CFR §483.15(b)(4)(i) of this chapter.

6110 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022

An individual, applicant or member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

• be birth through 20;
• live in Texas;
• have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
• need at least one MDCP service not being addressed by other services and supports;
• not be enrolled in another waiver program;
• live in an appropriate living situation;
• have a STAR Kids individual service plan (SK-ISP) with services under the established cost limit; and
• have full Medicaid eligibility.

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

6110.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 25-1; Effective May 16, 2025

An individual, applicant or member must meet the following criteria 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 the Texas Health and Human Services Commission (HHSC);
• have an unmet need for support in the community that can be met through one or more MDCP services;
• 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 Medicaid Home and Community Based Services (HCBS) waiver programs approved by the Centers for Medicaid & Medicare Services (CMS):
  • Community Living Assistance and Support Services (CLASS) Program;
  • Deaf Blind with Multiple Disabilities (DBMD) Program;
  • Home and Community-based Services (HCS) Program;
  • Texas Home Living (TxHmL) Program; or
  • Youth Empowerment Services waiver;
• live in:
  • the person's home; or
  • an agency foster home defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and
• be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title which relates to Medicaid Eligibility for the Elderly and People with Disabilities. 

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.