| (a) An MCO assesses an individual's eligibility for
MDCP.
(1) To be eligible for MDCP, an individual must:
(A) be under 21 years of age;
(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 MDCP services;
(E) choose MDCP as an alternative to nursing facility
services, as described in 42 CFR §441.302(d);
(F) not be enrolled in one of the following Medicaid
HCBS waiver programs approved by CMS:
(i) the Community Living Assistance and Support Services
(CLASS) Program;
(ii) the Deaf Blind with Multiple Disabilities (DBMD)
Program;
(iii) the Home and Community-based Services (HCS) Program;
(iv) the Texas Home Living (TxHmL) Program; or
(v) the Youth Empowerment Services waiver;
(G) live in:
(i) the individual's home; or
(ii) an agency foster home as defined in Texas Human
Resource Code, §42.002, (relating to Definitions); and
(H) 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), Chapter
360 of this title (relating to Medicaid Buy-In Program), or Chapter
361 of this title (relating to Medicaid Buy-In for Children Program).
(2) An individual receiving Medicaid nursing facility
services is approved for MDCP if the individual requests services
while residing in a nursing facility and meets the eligibility criteria
listed in paragraph (1) of this subsection. If an individual is discharged
from a nursing facility into a community setting before being determined
eligible for Medicaid nursing facility services and MDCP, the individual
is denied immediate enrollment in the program.
(b) HHSC maintains a statewide interest list of individuals
interested in receiving services through MDCP.
(1) A person may request that an individual's name
be added to the MDCP interest list by:
(A) calling HHSC toll-free 1-877-438-5658;
(B) submitting a written request to HHSC; or
(C) generating a referral through the YourTexasBenefits.com,
Find Support Services screening and referral tool.
(2) If a request is made in accordance with paragraph
(1) of this subsection, HHSC adds an individual's name to the MDCP
interest list:
(A) if the individual is a Texas resident; and
(B) using the date HHSC receives the request as the
MDCP interest list date.
(3) For an individual determined diagnostically or
functionally ineligible during the enrollment process for the CLASS
Program, DBMD Program, HCS Program, or TxHmL Program:
(A) if the individual's name is not on the MDCP interest
list, at the request of the individual or LAR, HHSC adds the individual's
name to the MDCP interest list using the individual's interest list
date for the waiver program for which the individual was determined
ineligible as the MDCP interest list date;
(B) if the individual's name is on the MDCP interest
list and the individual's interest list date for the waiver program
for which the individual was determined ineligible is earlier than
the individual's MDCP interest list date, at the request of the individual
or LAR, HHSC changes the individual's MDCP interest list date to the
individual's interest list date for the waiver program for which the
individual was determined ineligible; or
(C) if the individual's name is on the MDCP interest
list and the individual's MDCP interest list date is earlier than
the individual's interest list date for the waiver program for which
the individual was determined ineligible, HHSC does not change the
individual's MDCP interest list date.
(4) This paragraph applies to an individual who is
enrolled in MDCP and, because the individual does not meet the level
of care criteria for medical necessity for nursing facility care,
is determined ineligible for MDCP after November 30, 2019. The individual
or the individual's LAR may request one time that HHSC add the individual's
name to the first position on the MDCP interest list.
(5) This paragraph applies to an individual who is
enrolled in MDCP and, because the individual does not meet the level
of care criteria for medical necessity for nursing facility care or
the requirement to be under 21 years of age, is determined ineligible
for MDCP after November 30, 2019. The individual or the individual's
LAR may request that HHSC add the individual's name to the interest
list for any of the following programs or change the individual's
interest list date for any of the following programs in accordance
with:
(A) 40 TAC §45.202 (relating to CLASS Interest
List) for the CLASS Program;
(B) 40 TAC §42.202 (relating to DBMD Interest
List) for the DBMD Program;
(C) 40 TAC §9.157 (relating to HCS Interest List)
for the HCS Program; and
(D) 40 TAC §9.566 (relating to TxHmL Interest
List) for the TxHmL Program.
(6) HHSC removes an individual's name from the MDCP
interest list if:
(A) the individual is deceased;
(B) the individual is assessed for MDCP and determined
to be ineligible and has had an opportunity to exercise the individual's
right to a fair hearing, as described in Chapter 357 of this title
(relating to Hearings);
(C) the individual, medical consenter, or LAR requests
in writing that the individual's name be removed from the interest
list; or
(D) the individual moves out of Texas, 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.
(7) An individual assessed for MCDP and determined
to be ineligible, as described in paragraph (6)(B) of this subsection,
may request to have the individual's name added to the MDCP interest
list as described in paragraph (1) of this subsection.
(c) An MCO develops a person-centered individual service
plan (ISP) for each member in MDCP, and all applicable documentation,
as described in the STAR Kids Handbook and the Uniform Managed Care
Manual (UMCM).
(1) An ISP must:
(A) include services described in the waiver approved
by CMS;
(B) include services necessary to protect a member's
health and welfare in the community;
(C) include services that supplement rather than supplant
the member's natural supports and other non-Medicaid supports and
services for which the member may be eligible;
(D) include services designed to prevent the member's
admission to an institution;
(E) include the most appropriate type and amount of
services to meet the member's needs in the community;
(F) be reviewed and revised if the member's needs or
natural supports change or at the request of the member or LAR; and
(G) be cost effective.
(2) If a member's ISP exceeds 50 percent of the cost
of the member's level of care in a nursing facility to safely serve
the member's needs in the community, HHSC must review the circumstances
and, when approved, provide funds through general revenue.
(d) An MCO is responsible for conducting a reassessment
and developing an ISP for each member's continued eligibility for
MDCP, in accordance with the policies and procedures outlined in the
STAR Kids Handbook, UMCM, or materials designated by HHSC and in accordance
with the timeframes outlined in the MCO's contract.
(e) An MCO is responsible for authorizing a provider
of a member's choice to deliver services outlined in the member's
ISP.
(f) A member participating in MDCP has the same rights
and responsibilities as any member 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 of this title.
(g) HHSC conducts utilization reviews of MCOs providing
MDCP services.
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