Current through Reg. 49, No. 38; September 20, 2024
(a) The MCO assesses an individual's
eligibility for STAR+PLUS HCBS.
(1) To be
eligible for the STAR+PLUS HCBS program, an individual must:
(A) be 21 years of age or older;
(B) reside in Texas;
(C) meet the level-of-care criteria for
medical necessity for nursing facility care as determined by HHSC;
(D) have an unmet need for support in the
community that can be met through one or more of the STAR+PLUS HCBS program
services;
(E) choose the STAR+PLUS
HCBS program as an alternative to nursing facility services, as described in
RSA
441.302(d);
(F) not be enrolled in another Medicaid HCBS
waiver program approved by CMS; and
(G) be determined by HHSC to be financially
eligible for Medicaid, as described in Chapter 358 of this title (relating to
Medicaid Eligibility for the Elderly and People with Disabilities) and Chapter
360 of this title (relating to Medicaid Buy-In Program).
(2) An individual receiving Medicaid nursing
facility services is approved for the STAR+PLUS HCBS program if the individual
requests services while residing in the nursing facility and meets eligibility
criteria listed in paragraph (1) of this subsection. If the individual is
voluntarily discharged from the nursing facility into a community setting
before being determined eligible for Medicaid nursing facility services and the
STAR+PLUS program, the individual is denied immediate enrollment in the
program.
(b) HHSC
maintains a statewide interest list of individuals not enrolled in STAR+PLUS
interested in receiving services through the STAR+PLUS HCBS program. There is
no interest list for individuals currently enrolled in STAR+PLUS who are
eligible to receive services through the STAR+PLUS HCBS program. Individuals
enrolled in STAR+PLUS may contact their MCO for more information about
STAR+PLUS HCBS.
(1) A person may request an
individual's name be added to the STAR+PLUS HCBS interest list by:
(A) calling HHSC toll-free at
1-855-937-2372;
(B) submitting a
written request to HHSC; or
(C)
generating a referral through Your TexasBenefits.com, Find Support Services
screening and referral tool.
(2) HHSC removes an individual's name from
the STAR+PLUS HCBS interest list if:
(A) the
individual is deceased;
(B) the
individual is assessed for the program and determined to be
ineligible;
(C) the individual or
LAR requests in writing that the individual's name be removed from the interest
list; or
(D) the individual is no
longer a Texas resident, unless the individual is a military family member
living outside of Texas as described in Texas Government Code §
RSA
531.0931:
(i) while the military member is on active
duty; or
(ii) for less than one
year after the former military member's active duty ends.
(c) The MCO develops a
person-centered individual service plan (ISP) for each member, and all
applicable documentation, as described in the STAR+PLUS Handbook.
(1) The ISP must:
(A) include services described in the Texas
Healthcare Transformation and Quality Improvement Program Waiver, governed by
§1115(a) of the Social Security Act.
(B) include services necessary to protect the
individual's health and welfare in the community;
(C) include services that supplement rather
than supplant the individual's natural supports and other non-STAR+PLUS HCBS
supports and services for which the individual may be eligible;
(D) include services designed to prevent the
individual's admission to an institution;
(E) include the most appropriate type and
amount of services to meet the individual's needs in the community;
(F) be reviewed and revised if an
individual's needs or natural supports change or at the request of the
individual or their legally authorized representative;
(G) be approved by HHSC; and
(H) be cost effective.
(2) If an individual's ISP exceeds 202
percent of the cost of the individual's level-of-care in a nursing facility to
safely serve the individual's needs in the community, the MCO must submit a
request for a clinical assessment for general revenue funds to HHSC.
(d) MCOs are responsible for
conducting reassessments and ISP development for their enrollees' continued
eligibility for STAR+PLUS HCBS, in accordance with the policies and procedures
outlined in the STAR+PLUS Handbook and in accordance with the timeframes
outlined in the managed care contracts governing STAR+PLUS.
(e) MCOs are responsible for authorizing a
network provider of the individual's choosing to deliver services outlined in
an individual's ISP.
(f)
Individuals participating in STAR+PLUS HCBS have the same rights and
responsibilities as any individual enrolled in managed care, as described in
Subchapter C of this chapter (relating to Member Bill of Rights and
Responsibilities), including the right to appeal a decision made by HHSC or an
MCO and the right to a fair hearing, as described in Chapter 357, Subchapter A,
of this title (relating to Uniform Fair Hearing Rules).
(g) HHSC conducts utilization reviews of
STAR+PLUS MCOs as described in Texas Government Code §
RSA
533.00281.
