The Texas Health and Human Services Commission (HHSC) adopts amendments to Chapter 353, Subchapter A, General Provisions, §353.2, concerning Definitions; Subchapter G, STAR+PLUS, §353.601, concerning General Provisions; and §353.603, concerning Member Participation; and Subchapter H, STAR Health, §353.701, concerning General Provisions; and §353.702, concerning Member Participation. HHSC adopts new Subchapter M, concerning Home and Community Based Services in Managed Care, including new §353.1151, concerning General Provisions; §353.1153, concerning STAR+PLUS Home and Community Based Services (HCBS) Program; and §353.1155, concerning Medically Dependent Children Program. HHSC also adopts new Subchapter N, concerning STAR Kids, including new §353.1201, concerning General Provisions; §353.1203, concerning Member Participation; §353.1205, concerning Service Coordination; §353.1207, concerning Participating Providers; and §353.1209, concerning STAR Kids Handbook. Sections 353.2, 353.603, 353.1153 and 353.1155 are adopted with changes to the proposed text as published in the July 22, 2016, issue of the Texas Register (41 TexReg 5287). The text of the rules will be republished. Sections 353.601, 353.701, 353.702, 353.1151, 353.1201, 353.1203, 353.1205, 353.1207 and 353.1209 are adopted without changes to the proposed text as published in the July 22, 2016, issue of the Texas Register (41 TexReg 5287) and the text of the rules will not be republished.

BACKGROUND AND JUSTIFICATION

The Texas Health and Human Services Commission (HHSC) adopts amendments to Subchapter A to update the definitions rule for Chapter 353, §353.2, concerning Definitions. HHSC also adopts amendments to Subchapters G (relating to STAR+PLUS) and H (relating to STAR Health) to make changes resulting from the STAR Kids implementation. These primarily include changes to the list of client populations who are now mandatory, voluntary, or excluded for STAR+PLUS and STAR Health.

Additionally, HHSC adopts amendments to STAR+PLUS eligibility and program rules under Subchapter G to implement Senate Bill 169 (84th Legislature, Regular Session, 2015), which enacted new Texas Government Code §531.0931 regarding military members and their dependents who are on interest or waiting lists for services.

HHSC adopts new Subchapter M, concerning Home and Community Based Services in Managed Care, which describes the eligibility and assessment requirements for the STAR+PLUS Home and Community Based Services (HCBS) program offered to qualified members in the STAR+PLUS managed care program and the Medically Dependent Children Program (MDCP).

HHSC adopts new Subchapter N, concerning STAR Kids, implementing Texas Government Code §533.00253, which directs HHSC to establish a mandatory, capitated STAR Kids managed care program tailored to provide Medicaid benefits to individuals with disabilities under the age of 21. HHSC intends for the STAR Kids program to improve coordination of care, access to care, health outcomes, and quality of care with an operational start date of November 1, 2016.

COMMENTS

The 30-day comment period ended on August 21, 2016. During the 30-day comment period, HHSC received written comments from PSA Healthcare and the Texas Association of Home Care and Hospice. Neither commenter was opposed to the proposed rules.

Summaries of each comment and HHSC's response follow:

Comment: One commenter noted that in §353.2(45) "based on the individual's person-centered service plan" is omitted from the definition of "habilitation."

Response: HHSC agrees with the comment and has amended the definition as suggested.

Comment: One commenter noted that §353.2(52) provided a citation for 42 CFR 431.923, but the commenter could not locate this reference.

Response: HHSC agrees and has corrected the citation to reflect the correct reference of 42 CFR 435.923.

Comment: Regarding §353.2(65)(B)(iv), one commenter questioned whether or not the individual's functional need is assessed to determine medical need.

Response: HHSC thanks the commenter for this feedback. HHSC believes the definition of functional necessity in §353.2(44) addresses the commenter's concern, and no changes were made as a result of this comment.

Comment: One commenter noted that in §353.2(80) "significant level of care" is vague in the definition of "significant traditional provider."

Response: HHSC thanks the commenter for this feedback. HHSC declines to make a change to this definition at this time, because the definition of "significant level of care" is specific to each program and cannot be generalized here. HHSC will consider addressing this comment in future rule projects, as the definition applies to all managed care programs and has impact beyond the primary reason for this rule change, implementation of STAR Kids.

Comment: One commenter noted that that §353.2(83) "long-term services and supports" is vague in the definition of "STAR Kids."

Response: HHSC thanks the commenter for this feedback. The type of long-term service and support provided by the managed care organization (MCO) varies considerably depending on the child or young adult, their enrollment in a waiver program, their residence in an institution, and a number of other factors. The definition as written is meant to be broad enough to account for all of the different scenarios and factors. Therefore, HHSC declines to make a change to this definition at this time.

Comment: One commenter requested a definition for "person centered care services."

Response: HHSC declines to make the suggested change at this time. HHSC will address the requested definition in a future rule project to ensure the public has the opportunity to comment on the proposed definition.

Comment: One commenter requested that the definition of "STAR+PLUS Home and Community-Based Services Program" in §353.2(85) only state the program is for individuals over 21 years old.

Response: HHSC agrees with the comment and, therefore, deleted "who are age 65 or over" and "are blind or have a disability" from the definition and added "Medicaid eligible." The individual over the age of 21 will still have to be otherwise qualified for the program.

Comment: One commenter noted that §353.603(e)(2) uses the term "client," but "individual" and "member" are used elsewhere.

Response: HHSC agrees with the comment and has changed the term "clients" to "individuals" to reduce the number of terms used to describe individuals. Member is used to describe an individual who is enrolled with a managed care organization.

Comment: One commenter noted that that §353.1153(a) is missing a subsection (G)(1).

Response: HHSC disagrees with this comment. Paragraph (2) is not a subpart of subparagraph (G). Rather, subparagraph (G) is a subpart of paragraph (1). Therefore, HHSC declines to make a change to the rule at this time.

Comment: One commenter noted that §353.1153(b)(1)(A) and §353.1155(c)(1)(A) did not note that calls are toll-free or provide a phone number.

Response: HHSC agrees with the comment and has corrected §353.1153(b)(1)(A) and §353.1155(c)(1)(A) to note the toll-free numbers.

Comment: One commenter requested that §353.1153(c)(1)(F) and corresponding §353.1155(d)(1)(F) reflect that service plans may be reviewed and revised at the request of the individual or legally authorized representative.

Response: HHSC agrees with the comment and updated §353.1153(c)(1)(F) and §353.1155(d)(1)(F) to reflect that a service plan may be reviewed and revised at the request of an individual or their legally authorized representative.

Comment: One commenter requested clarity about the terms "residing" and "immediate" in §353.1155(b)(2).

Response: HHSC thanks the commenter for this feedback. HHSC declines to define these terms at this time, as the terms are sufficiently clear in their current context. HHSC will consider addressing this in future rule projects to ensure the public has the opportunity to comment on the proposed language.

Comment: One commenter requested clarity about whether the term "provider" in §353.1155(f) referred to in-network providers.

Response: HHSC thanks the commenter for this feedback. The term "provider" in §353.1155(f) refers to a provider as defined in §353.2(74) who has a contract with the managed care organization. Therefore, HHSC declines to make a change to the rule based on this comment.

Comment: One commenter requested clarity about whether §353.1155(h) refers to HHSC conducting utilization reviews of providers or MCOs.

Response: HHSC thanks the commenter for this feedback. This section of rule pertains to utilization reviews of MCOs. Rules pertaining to HHSC utilization reviews of providers can be found in Texas Administrative Code Title 1, Part 15, Chapter 371, Subchapter C.

STATUTORY AUTHORITY

The new rules are adopted under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; and Texas Government Code §531.00253, which directs HHSC to create the STAR Kids managed care program.