6100, Description

Body

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 STAR+PLUS Home and Community Based Services (HCBS) program;
  • 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 mail Form 2442, Notification of Interest List Release Closure, as notification of STAR+PLUS HCBS program interest list closure to an individual when the individual does not meet STAR+PLUS HCBS program eligibility. PSU staff must always mail Form 2442 with Appendix XII, STAR+PLUS HCBS Program Description. Form 2442 does not provide the right to request a state fair hearing. Individuals only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff mail an applicant or member Form H2065-D when denied or terminated from the STAR+PLUS HCBS program. Form H2065-D provides the applicant or member with the right to request a state fair hearing. Applicants and members 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 the adverse action notification period 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 §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:

  1. The agency has factual information confirming the death of an individual, applicant or member;
  2. The agency receives a clear written statement signed by a member that:
    1. They no longer want to receive services; or
    2. 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;
  3. The  individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
  4. 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);
  5. 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;
  6. A change in the level of medical care is prescribed by the applicant’s or member’s physician; or
  7. The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act;
  8. 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 STAR+PLUS HCBS Program Eligibility Requirements

Revision 25-2; Effective June 6, 2025

An individual, applicant or member must meet the following criteria stated in Title 1 Texas Administrative Code (TAC) Chapter 353.1153(a)(1) to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:

  • be 21 years or older;
  • live in Texas;
  • meet the medical necessity (MN) for a nursing facility (NF) level of care (LOC) as determined by Texas Health and Human Services Commission (HHSC);
  • have an unmet need for support in the community that can be met through one or more of the STAR+PLUS HCBS program services;
  • choose the STAR+PLUS HCBS program as an alternative to NF services, described in Title 42 Code of Federal Regulations (CFR) Section 441.302(d);
  • not be enrolled in another Medicaid HCBS waiver program approved by Centers for Medicaid & Medicare Services (CMS); and
  • be determined by HHSC to be financially eligible for Medicaid, described in Title 1 TAC Chapter 358, relating to Medicaid Eligibility for the Elderly and People with Disabilities, and Title 1 TAC Chapter 360, relating to Medicaid Buy-In Program.