|(a) The MCO assesses an individual's eligibility for
(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
(E) choose the STAR+PLUS HCBS program as an alternative
to nursing facility services, as described in 42 CFR §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 YourTexasBenefits.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 §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 §533.00281.