Form H3676, Managed Care Pre-Enrollment Assessment Authorization

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Effective Date

4/2026

Instructions

Updated: 4/2026

Purpose

Program Support Unit (PSU) staff uses Form H3676 to:

  • record information pertinent to the nursing assessment and development of the individual service plan (ISP) on a STAR+PLUS Home and Community Based Services (HCBS) program or a Medically Dependent Children Program (MDCP) applicant;
  • authorize the managed care organization (MCO) to conduct a pre-enrollment assessment for a STAR+PLUS HCBS program or an MDCP applicant; and
  • verify qualifying institutional stays for the Money Follows the Person Demonstration (MFPD) to the MCO.

MCO staff use Form H3676 to:

  • document results of the assessment; and
  • report assessment results to PSU staff.

Procedure

When to Prepare

PSU staff complete Section A, Assessment Authorization, to request the MCO complete an initial assessment for the applicant. PSU staff upload the form to the MCOHub for MCO retrieval.

The MCO must date stamp Form H3676 upon receipt. The MCO completes Section B, Assessment Report. They submit the form to PSU staff within 45 days for STAR+PLUS HCBS program and 60 days for MDCP of the date specified in Section A, Item 5, Date Completed and Posted. The MCO uploads the form to the MCOHub for PSU staff retrieval.

Copies and Transmittal

PSU staff must complete the following activities after completing Section A:

  • post the original to the MCOHub in the MCO's folder; and
  • upload a copy to the HHS Enterprise Administrative Report and Tracking System (HEART).

PSU staff must upload a copy of Form H3676 to HEART after the MCO completes and posts Section B to the MCOHub.

Record Retention

HEART is the PSU staff’s repository for the electronic case record. Paper copies of Form H3676 are not retained. The MCO must keep a copy of the completed form in the applicant's or member's case record five years after case closure.

Supply Source

This form may be found in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH), STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH), STAR+PLUS Handbook (SPH), and STAR Kids Handbook (SKH) on the HHS website.

Detailed Instructions

A. Assessment Authorization – PSU staff complete Items 1 through 5.

1. Program Type – select the appropriate box to show which program the assessment authorization is for from the following:

  • Medically Dependent Children Program (MDCP); or
  • STAR+PLUS Home and Community Based Services (HCBS) program.

2. Referral Type –select one of the following:

  • Interest List Release (ILR) – for applicants who are released from the interest list.
  • Money Follows the Person (MFP) - Traditional – for applicants who live in a nursing facility (NF) and are pursuing the traditional MFP process.
  • MFP Limited Nursing Facility Stay – for MDCP applicants pursuing the MFP limited nursing facility stay process.
  • Transition to Adult Program from – for applicants transitioning to an adult program. Select the corresponding children’s program or service the applicant is transferring out of:
    • MDCP;
    • Private Duty Nursing (PDN);
    • PDN with Intellectual or Developmental Disability (IDD); or
    • Prescribed Pediatric Extended Care Center (PPECC).
  • Waiver Program Transfer from – for an applicant transferring to MDCP or STAR+PLUS HCBS from another Medicaid waiver program. Select the corresponding program the applicant is transferring out of:
    • CLASS – Community Living Assistance and Support Services (CLASS) program;
    • DBMD – Deaf Blind with Multiple Disabilities (DBMD);
    • HCS – Home and Community-based Services (HCS);
    • TxHmL – Texas Home Living (TxHmL); or
    • Other – for applicants who leave a program not listed. Enter the name of the program in the designated blank. For example, Home and Community Based Services - Adult Mental Health (HCBS-AMH).

3. Medicaid Type – Select one of the following:

  • Social Security Income (SSI) – for applicants with SSI eligibility in the Texas Integrated Eligibility Redesign System (TIERS).
  • Medical Assistance Only (MAO) – for applicants with ME-Waivers eligibility in TIERS.
  • Medicaid Eligible – for applicants with an active Medicaid type of assistance (TOA) in TIERS, including SSI-related Medicaid TOAs.
  • Medicaid Pending – for applicants who do not have a Medicaid eligibility status in TIERS.

4. Authorization Referral – enter the following information, as it appears in TIERS, if available:

  • First Name – enter the applicant’s first name.
  • Middle Name – enter the applicant’s middle name.
  • Last Name – enter the applicant’s last name.
  • Date of Birth – enter the applicant’s date of birth using the following format MM/DD/YYYY.
  • Social Security No. – enter the applicant’s Social Security number.
  • Medicaid No. – enter the applicant’s Medicaid number, if applicable.
  • Medicare No. – enter the applicant’s Medicare number, if applicable.
  • Current Physical Street Address, City, State and ZIP Code – enter the applicant’s current physical living address.
  • Area Code and Phone No. – enter the applicant’s phone number including the area code.
  • Name of Contact Other Than Applicant – enter the contact’s name.
  • Contact's Area Code and Phone No. – enter the contact’s phone number including area code.
  • Contact's Mailing Street Address, City, State and ZIP Code – enter the mailing address.
  • Current Living Arrangement of Applicant – select one of the following that reflects the applicant’s current living arrangement:
    • Assisted Living/Residential Care (AL/RC);
    • Adult Foster Care (AFC);
    • Nursing Facility;
    • Home; or
    • Unknown.
  • Living Arrangement if enrolled in the STAR+PLUS HCBS Program – select one of the following that reflects the applicant’s expected living arrangement if they meet eligibility and are enrolled in the STAR+PLUS HCBS program:
    • AL/RC;
    • AFC;
    • Home; or
    • Unknown.
  • Home Street Address, City, State and ZIP Code – enter the applicant’s home address if different than the current physical address entered above. This field is primarily used for MFP cases to identify the location the applicant will be discharging to in the community.
  • MCO Selected – enter the name of the MCO selected.
  • Plan Code – enter the MCO’s plan code.

5. PSU Contact Information — enter the following information:

  • PSU Name – enter the name of the PSU staff completing this form.
  • Area Code and Phone No. – enter the direct phone number of the PSU staff completing this form.
  • Date Completed and Posted – enter the date Section A is completed by PSU staff and uploaded to the MCOHub.
  • Comments – enter any relevant comments for communication to the MCO. For example, STAR+PLUS PSU staff may provide the following information for an ILR:
    • the physician’s name and phone number; and
    • who PSU staff or the enrollment broker spoke to when confirming interest in the waiver program and that person’s phone number.

B. Assessment Report — The MCO completes Items 1 through 2 after receiving Section A of this form from PSU staff.

1. Waiver Assessment — Enter the following information:

  • Date of Assessment – enter the date the medical necessity assessment is completed.
  • Medical Necessity Approved – select Yes or No to indicate if the applicant met the medical necessity criteria for the MDCP or STAR+PLUS HCBS program.
  • Form H1700-1, Individual Service Plan – select Yes or No to indicate if Form H1700-1 is completed and posted to the MCOHub or TMHP LTCOP.
  • Form 2604, STAR Kids ISP – select Yes or No to show that Form 2604 is completed and posted to the MCOHub or TMHP LTCOP.
  • MFP Demonstration Participant (Not Applicable for STAR Kids) – select Yes or No to show that the STAR+PLUS HCBS program applicant meets the criteria to participate in the MFP Demonstration.

2. MCO Contact Information — Enter the following information:

  • MCO Name – enter the name of the MCO staff completing this form.
  • Area Code and Phone No. – enter the direct phone number including area code of the MCO staff completing this form.
  • Date Completed and Posted – enter the date Section B is completed by the MCO and uploaded to the MCOHub.
  • Comments – enter any relevant comments for communication to PSU staff.

The MCO must use Form H2067-MC, Managed Care Programs Communication, to report any delays in completing the assessment and ISP.