1200, MDCP Eligibility

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Revision 26-3; Effective Aug. 14, 2026

An individual is eligible for assessment for services through the Medically Dependent Children Program (MDCP). This happens when their name reaches the top of the MDCP interest list (IL). Title 1 Texas Administrative Code (TAC) Chapter 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:

An MDCP 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) Chapter 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 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 an 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 at the same time by an individual, applicant or member.

1210 Age

Revision 26-3; Effective Aug. 14, 2026

An applicant or member must be under 21 to be eligible to participate in the Medically Dependent Children Program (MDCP) per Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(A). Program Support Unit (PSU) staff verify an applicant’s age in the Texas Integrated Eligibility Redesign System (TIERS) on initial entry into MDCP.

1220 Texas Residency

Revision 26-3; Effective Aug. 14, 2026

An applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services per Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(B).

Upon initial entry into MDCP, Medicaid for the Elderly and People with Disabilities (MEPD) verifies Texas residency. Upon annual assessment, the managed care organization (MCO) verifies ongoing Texas residency.

1230 Medical Necessity Determination

Revision 26-3; Effective Aug. 14, 2026

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 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 more than 90 days before 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 occurs if there are no preexisting 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.

1230.1 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 26-3; Effective Aug. 14, 2026

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. 

1240 Unmet Need for at Least One MDCP Service

Revision 26-3; Effective Aug. 14, 2026

Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(D) states to be eligible for the Medically Dependent Children Program (MDCP), an applicant or member must have a need for at least one MDCP service. For initial and continued eligibility for MDCP, a member must have an unmet need for, and also use, at least one MDCP service during the STAR Kids individual service plan (SK-ISP) year. Therefore, an MDCP ISP which has $0.00 as the Total Estimated Waiver Costs will not be accepted in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). 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), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals who are:

  • receiving Community First Choice (CFC) services through a 1915(c) Medicaid waiver program; and 
  • certified for medical assistance only (MAO) Medicaid must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) Section 441.510(d).

This CFR rule mandates that qualified MAO Medicaid individuals must:

  • meet all MDCP waiver requirements; and 
  • receive one MDCP waiver service per month. 

Managed care organizations (MCOs) must track monthly services. MCOs must notify PSU staff if an MAO member with CFC services is not receiving the minimum requirement of one service per month.

1240.1 Individual Service Plan Cost Limit

Revision 26-3; Effective Aug. 14, 2026

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) submits a STAR Kids Screening and Assessment Instrument (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 Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level and determines if medical necessity (MN) is approved. 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. It is valid for a 12-month period, if they remain eligible for the program.

The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the PDPM LTC level.

Program Support Unit (PSU) staff do not calculate the SK-ISP cost limit. 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 the Annual Cost Limit in the TMHP LTCOP SK-ISP.

1250 Living Arrangement

Revision 26-3; Effective Aug. 14, 2026

An applicant or member must choose the Medically Dependent Children Program (MDCP) as an alternative to nursing facility (NF) services to be eligible for MDCP services per Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(E). This is described in 42 Code of Federal Regulations (CFR) Section 441.302(d).

Title 1 TAC Chapter 353.1155(a)(1)(G) states to be eligible for MDCP an applicant or member must live in:

Managed care organizations (MCOs) must confirm the applicant or member, if under 18, lives with a family member. Family members include a parent, guardian, grandparent or sibling. It is defined in the Glossary. The MCO must review guardianship documentation or get a statement from the applicant, member, legally authorized representative (LAR) or family member about the relationship. The MCO must maintain this documentation in the member’s case file.

1260 Financial Eligibility

Revision 26-3; Effective Aug. 14, 2026

The Texas Health and Human Services Commission (HHSC) must determine the applicant or member is financially eligible for Medicaid to be eligible for the Medically Dependent Children Program (MDCP). This is per Title 1 Texas Administrative Code (TAC) Chapter 353.1155(a)(1)(H).

Program Support Unit (PSU) staff review the Texas Integrated Eligibility Redesign System (TIERS) to determine if an applicant is eligible for an appropriate Medicaid type or if a new financial eligibility determination is required.

PSU staff do not have to request Form H1200, Application for Assistance – Your Texas Benefits, from 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 Medicaid for Elderly and People with Disabilities (MEPD) to determine Medicaid financial eligibility for MDCP.

An individual without Medicaid must complete and return the following forms within 30 days from the mail date of the application:

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

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.

1260.1 Individual with a Qualified Income Trust

Revision 26-3; Effective Aug. 14, 2026 

An individual or applicant with a qualified income trust (QIT) may be determined financially eligible for the Medically Dependent Children Program (MDCP). This is even if 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, Medicaid for Elderly and Persons with Disabilities (MEPD).

1260.2 Copayment and Room and Board

Revision 26-3; Effective Aug. 14, 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 Medicaid for the Elderly and People with Disabilities (MEPD).

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. 

MEPD notifies Program Support Unit (PSU) staff of copayment amounts through the MEPD Communication Tool. PSU staff must notify an MDCP member and managed care organization (MCO) of R&B and copayment amounts only if the member is entering an assisted living facility (ALF) or group foster home. PSU staff must use Form H2065 -D, Notification of Managed Care Program Services, to notify the member and the MCO. The begin date entered on Form H2065-D for the initial R&B and copayment charges will match the first day of the month the member is eligible for the ALF or group foster home. 

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. 

1260.3 Copayment Changes

Revision 26-3; Effective Aug. 14, 2026

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

Medicaid for the Elderly and People with Disabilities (MEPD) is responsible for calculating copayment amounts. MEPD notifies Program Support Unit (PSU) staff of copayment amounts through the MEPD Communication Tool. MEPD 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 also determine if the copayment amount has changed in the Texas Integrated Eligibility Redesign System (TIERS) at reassessment. PSU staff can find the copayment amount in TIERS by:

  • selecting Inquiry under the My TIERS Functions;
  • choosing the option Individual; and 
  • entering the following information for the member on the Individual-Search page:
    • first and last name;
    • Social Security number (SSN);
    • Medicaid identification (ID) number noted in TIERS as the Individual #;
    • date of birth (DOB); or 
    • case number.

Information for the member populates in the Search Results field at the bottom of the Individual-Search page. PSU staff can check the copayment amount by selecting the hyperlink of the member’s name. The Individual-Summary screen will appear. In the Individual-Summary screen, PSU staff can find the copayment amount by hovering over the Individual # field and selecting Copay.

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

  • 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 increases. 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.

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