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Revision 25-2; Effective June 6, 2025
Title 1 Texas Administrative Code (TAC) Chapter 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.
A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days, or up to 90 days, if it is necessary to get a disability determination to complete the application process.
An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of:
- the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
- upon receipt of an incomplete or unsigned Form H1200.
PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.
Refer to section 3112, Medicaid Eligibility, for more information about financial eligibility for the STAR+PLUS HCBS program.
3210 Reserved for Future Use
Revision 26-2; Effective June 1, 2026
3220 Eligible Groups
Revision 18-0; Effective September 4, 2018
3221 STAR+PLUS Mandatory Groups
Revision 25-2; Effective June 6, 2025
The following groups of individuals must receive services through the STAR+PLUS program. The program designations are used in the following list.
- Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) type of assistance (TA) 01, TA 02 and TA 22 — Individuals 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
- Pickle Amendment Group, TIERS type program (TP) 03 — Individuals 21 or over who would continue to be eligible for SSI benefits if cost of living adjustment (COLAs) increases were deducted from his or her countable income.
- Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), 60-65 and with a disability, who:
- were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
- are ineligible for Medicare; and
- would continue to be eligible for SSI benefits in the absence of those early aged widow's or widower's benefits and any increases in those benefits.
- Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), 50-60 and with a disability, who:
- are ineligible for Medicare and were denied SSI due to an increase in widow's or widower's benefits because of the relaxing of disability criteria; and
- would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
- Disabled Adult Children (DAC), TIERS TP 18 — Adults over 21 with a disability that began before 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
- Medicaid Buy-In, TIERS TP 87 - designated in TIERS as ME — Medicaid Buy In — Disabled working adults over 21 who receive full Medicaid benefits because of buying into the Medicaid program.
- Medicaid for Breast and Cervical Cancer (MBCC) recipients, TIERS TA 67 — Individuals 18 to the 65th birth month who meet eligibility requirements defined in Title 1 Texas Administrative Code (TAC) Chapter 366, Subchapter D.
- STAR+PLUS Home and Community Based Services (HCBS) program members who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program.
- Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (medical assistance only (MAO)) — Most individuals living in an NF.
The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact Program Support Unit (PSU) staff and provide the details for disenrollment from STAR+PLUS.
3222 STAR+PLUS Excluded Groups
Revision 25-2; Effective June 6, 2025
Refer to Title 1 Texas Administrative Code (TAC) Chapter 353.603, Member Participation for excluded groups.
3230 Financial Eligibility
Revision 25-2; Effective June 6, 2025
Title 1 Texas Administrative Code (TAC) Chapter 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.
A STAR+PLUS HCBS program individual or applicant who is not already Medicaid eligible must complete Form H1200, Application for Assistance – Your Texas Benefits, to be evaluated for financial eligibility. PSU staff must fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days, or up to 90 days, if it is necessary to get a disability determination to complete the application process.
An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual or applicant within two business days of:
- the 30th day of the mail date of the enrollment packet, if the individual has not returned Form H1200; or
- upon receipt of an incomplete or unsigned Form H1200.
PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.
Refer to section 3112, Medicaid Eligibility, for more information about financial eligibility for the STAR+PLUS HCBS program.
3231 Individual with a Qualified Income Trust
Revision 22-3; Effective Sept. 27, 2022
An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. A person or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their individual service plan (ISP).
PSU staff must refer questions regarding QIT to Access and Eligibility Services (AES) by generating and faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist.
3232 Payments from the Qualified Income Trust
Revision 25-1; Effective Feb. 19, 2025
An Applicant or member with a qualified income trust (QIT) is responsible for a copayment if they are living in an adult foster care (AFC), assisted living facility (ALF) or home setting. The managed care organization (MCO) must explain to the applicant or member that the funds from the QIT made available for the copayment must be used to purchase STAR+PLUS Home and Community Based Services (HCBS) program services. The member must make payments directly to the AFC, ALF or other service providers. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determine the copayment amount for members with a QIT.
PSU staff must document the copayment amount for services other than AFC or ALF using Form H2065-D, Notification of Managed Care Program Services (PDF). PSU staff must refer to Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, when generating Form H2065-D.
The total available QIT copayment amount is not entered on Form H1700-1, Individual Service Plan (PDF), and is not reflected in SASO copayment screens for a QIT member that lives at home.
3233 Reserved for Future Use
Revision 25-1; Effective Feb. 19, 2025
3234 Qualified Income Trust Copayment Agreement
Revision 18-0; Effective September 4, 2018
The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:
- service purchased;
- amount available for copayment;
- unit rate;
- units purchased; and
- monthly copayment amount for the specific services.
The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or an assisted living facility (ALF), the copayment amount is first applied to the cost of AFC or ALF. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase nursing, PAS or medical supplies.
Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.
3235 Reserved for Future Use
Revision 25-1; Effective Feb. 19, 2025
3236 Copayment and Room and Board
Revision 25-4; Effective Oct. 6, 2025
Members determined to be financially eligible based on the institutional income limit may have to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program 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 the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.
Medical assistance only (MAO) members who are eligible based on the institutional income limit are required to pay R&B and copayment. Supplemental Security Income (SSI) members will only be required to pay R&B and will not have a copayment.
Program Support Unit (PSU) staff use Form H2065 -D, Notification of Managed Care Program Services, to notify the member and managed care organization (MCO) of R&B and copayment amounts. The begin date entered on Form H2065-D for the initial R&B and copayment charges for interest list release (ILR) or upgrade cases will match the STAR+PLUS HCBS program eligibility effective date. The begin date for the initial R&B and copayment for a Money Follows the Person (MFP) case will match the date of relocation from the nursing facility (NF) to the adult foster care (AFC) home or assisted living facility (ALF).
The amount of copayment and R&B for the month is prorated if the member is admitting to an AFC or ALF on a day that is not the first of the month. PSU staff indicate the full amount, noting it should be prorated, on Form H2065-D. The use of prorate language provides assurance to the member that the full amount is not required for the first month since the facility admission was mid-month.
Refer to the Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, for more information on the use of prorate language and comments in plain language to be entered on Form H2065-D.
The MCO must also explain to the individual that the individual must pay the copayment and R&B amounts directly to the provider contracted to deliver STAR+PLUS HCBS program services. The member may be disenrolled from the STAR+PLUS HCBS program if they fail to pay the agreed-upon copayment and R&B amounts. Refer to 6400, Disenrollment Request Policy, if a member refuses to pay their R&B charges.
3237 Determining Room and Board Charges
Revision 25-4; Effective Oct. 6, 2025
All members who live in an adult foster care (AFC) or assisted living facility (ALF) must pay room and board (R&B) charges.
The R&B amount is determined by the Social Security Administration (SSA). The SSA determines the R&B amount by applying the following post-eligibility calculations:
- for individuals, the R&B amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance (PNA);
- for SSI couples, the R&B amount is the SSI FBR for a couple minus the PNA for an individual multiplied by two; or
- for couples with incomes that exceed the SSI FBR for couples, the R&B amount is the couple's income minus the PNA for an individual multiplied by two. This amount cannot exceed double the R&B amount for an individual.
The AFC or ALF can negotiate a lower R&B amount with the member, but they cannot waive it. There is no impact to PSU staff processes if there is an agreement for a lower R&B amount between the AFC or ALF and the member. PSU must continue to enter the R&B fixed amount on the Form H2065-D, Notification of Managed Care Program Services.
3238 Determining Copayment Amounts
Revision 25-4; Effective Oct. 6, 2025
Members who live in an adult foster care (AFC) or assisted living facility (ALF) and members who have a qualified income trust (QIT) may have to pay a copayment.
The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determines the amount of money available for copayment after determining financial eligibility for Medicaid. The copayment amount leaves a personal needs allowance (PNA) of $85 for a single person and $170 for a couple. The MEPD specialist must notify Program Support Unit (PSU) staff of the amount available for the monthly copayment through the MEPD Communication Tool.
The copayment amount is applied only to the cost of services funded through the STAR+PLUS Home and Community Based Services (HCBS) program. The copayment must not exceed the cost of services delivered.
Supplemental Security Income (SSI) recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance (RSDI) will not have a copayment.
3239 Copayment Changes
Revision 25-4; Effective Oct. 6, 2025
A member's copayment may change during the time he or she is receiving the STAR+PLUS Home and Community Based Services (HCBS) program. Copayment changes are typically due to a change in income, medical expenses or other circumstances.
The Medicaid for the Elderly and People with Disabilities (MEPD) specialist is responsible for calculating copayment amounts. The MEPD specialist notifies Program Support Unit (PSU) staff through the MEPD Communication Tool of copayment amounts. PSU staff may also determine the copayment amount has changed in Texas Integrated Eligibility Redesign System (TIERS) at reassessment. The MEPD specialist 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 complete the following activities within five business days of getting the copayment amounts:
- mail Form H2065-D, Notification of Managed Care Program Services, to the member;
- 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 is increasing. 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.
The MEPD specialist and the managed care organization (MCO) handle issues for underpayments, refunds and copayment amount appeals.