Table of Contents
Disability Rights Texas Handout
To request this publication in ASL, Braille, or as an audio file, contact us.
Texas Medicaid Changes Because of COVID-19
Since mid-March, numerous changes to the Texas Medicaid program have been implemented in response to the COVID-19 emergency. Many of these changes are temporary and may evolve as this public health crisis continues. The information below is accurate as of the time it was written, but may change on short notice. Contact Disability Rights Texas if you are told something different by your healthcare provider or Medicaid managed care organization (MCO).
State Plan Services
The term “state plan services” applies to the broad array of health care available to most Medicaid-eligible individuals when medically necessary. Of particular importance to people with disabilities are the state plan services that require prior authorization or recertification such as private duty nursing, personal assistance and care services, Community First Choice (CFC) services, physical, occupational and speech therapies, and home health services including durable medical equipment (DME) and supplies. Temporary changes to certain state plan services are as follows:
Prior Authorization of State Plan Services
On March 30, 2020, Texas Medicaid directed the MCOs to extend authorizations that were scheduled to expire between March 13 and December 31, 2020, for an additional 90 days. More recently, however, Texas Medicaid has clarified that services requiring reauthorization or recertification should be extended 90 days until December 31, 2020, or such time that the national public health emergency declaration expires. Extensions are ending December 31, 2020, after which the 90-day prior authorization will come to an end. However, MCOs are instructed to extend existing state plan prior authorizations and service authorization that require recertification and are set to expire through December 31, 2020 for 90 days. Beginning January 1, 2021, existing prior authorizations will not be extended.
Texas Medicaid had not yet implemented any changes to the prior authorization process for new requests for DME or requests for increased medical supplies.
As a reminder, beginning March 18, 2020, through the end of the public health emergency, state Medicaid programs cannot terminate or reduce access to benefits available to certain beneficiaries. Though Medicaid programs cannot be terminated HHS can now move enrollees into a more appropriate Medicaid eligibility type or managed care program. If eligibility criteria was approved, transition to a new program will take effect on March 01, 2021. Members that transitioned should have received an update in mid-February.
Additionally, beginning March 10, 2021, HHS notified individuals in CLASS, DBMD, HCS or TXHmL of termination of waiver benefits. Termination may have occurred due to an inability to locate the individual or failure to utilize a waiver service monthly. Individuals no longer eligible for the waiver will have waiver services termination, but may continue to receive Medicaid state plan services until the end of the public health emergency. Of course, individuals who believe their waiver benefits were terminated erroneously have the right to appeal the denial. Appealing the denial of waiver services timely, will allow the individual to continue to receive waiver services pending a fair hearing decision.
Home and Community-Based Waiver Programs
Home and community-based services (HCBS) waiver programs, also known as 1915(c) waivers, provide a defined set of services, in addition to the Medicaid state plan services, to eligible participants. These programs are limited in enrollment and are targeted to eligible groups by age, diagnosis, or disability. Eligible individuals must meet certain institutional levels of care to qualify for an HCBS waiver program. Texas operates a number of HCBS waiver programs, i.e. Home and Community Services (HCS), Community Living Assistance and Support Services (CLASS), Texas Home Living (TxHmL), Deaf Blind with Multiple Disabilities (DBMD), and the Medically Dependent Children’s Program (MDCP).
In addition to these 1915(c) waivers, Texas Medicaid has a similar waiver program that is known as STAR+PLUS Waiver. Unlike most HCBS waiver programs in Texas, STAR+PLUS waiver is administered by Medicaid managed care organizations.
Face to face service coordination visits may be suspended for CLASS, TxHmL, DBMD, HCS, and coordinators for CFC services, general revenue services and PASRR habilitation, through June 30, 2021.
Temporary changes to these programs are as follows:
Extension for CLASS and DBMD Participants
Assessments and care plans for participants in the CLASS and DBMD programs will be extended for one year from the CARE system expiration date if the individual’s assessment or care plan expires during the public health emergency period, currently ending on December 30, 2020. Face to face meetings to revise care plans will not be required during this period, either.
Yearly assessment extensions will end on December 30, 2020. For plans that are set to expire on December 31, 2020, yearly SPT meetings must be completed before January 1, 2021. The ID/RC assessments can be completed by telehealth or IPCS by phone or telehealth.
Face to face service coordination visits are suspended through June 30, 2021.
A number of the therapies available to CLASS participants can be provided through telehealth effective March 15, 2020, through June 30, 2021. Specified therapies are physical and occupational therapy, speech and language pathology, recreational and music therapy, behavior support, dietary services, and cognitive rehabilitation therapy.
Extension for HCS and TxHmL Participants
Assessments and care plans for participants in the HCS and the TxHmL programs will be extended for one year from the CARE system expiration date if the individual’s assessment or care plan expires during the public health emergency period, currently ending on December 31, 2020.
HCS or TxHmL program providers may provide day habilitation through June 30, 2021, to an individual in the individual’s permanent or temporary residence. Host home/companion care can be provided to an individual at the same time residential support, supervised living or host home companion care is provided.
Community First Choice Services for HCS and TxHmL Participants
Texas Medicaid has temporarily suspended the current policy that prohibits service providers of CFC services (personal assistance services and habilitation) from living in the same home as an HCS or TxHmL participant. This prohibition is also temporarily suspended for providers of respite services to individuals 18 years of age and older. This change does not apply to participants who are under 18 years of age. This is a temporary policy change effective through at least June 30, 2021.
Extension for MDCP Participants
Texas Medicaid extended enrollment in MDCP for participants with individual service plans (ISPs) that expired through December 2020. This extension applied to members’ Screening and Assessment Instruments (SAI) and corresponding individual service plans (ISPs). MDCP is administered through STAR KIDS and STAR Health MCOs.
MCO’s must complete STAR Kids Screening and Assessment Instruments via telehealth for members with ISP expired December 30 and moving forward.
Since Texas Medicaid is no longer extending enrollment for those participants with ISPs that expired after December 30th, Texas Medicaid has begun to issue denial determinations for those enrollees who no longer meet the eligibility requirements.
Extension for STAR+PLUS Waiver Participants
Texas Medicaid is extended enrollment in the STAR+PLUS Home and Community Based Services for members with individual service plans (ISPs) expiring through December 2020. This extension applied to the member’s STAR+PLUS Medical Necessity Level of Care (MNLOC) and corresponding ISPs.
MCO’s must complete MNLOC assessments via telehealth for individuals with ISPs expiring December 30 and moving forward.
For STAR+PLUS members that exited a nursing facility on or after March 18, 2020, due to COVID-19 concerns without HCBS in place, Managed Care Organizations can use the existing STAR+PLUS HCBS upgrade process. The MCO must identify eligible members and inform them of the option to transition away from nursing facility Medicaid to STAR+PLUS HCBS. If this option is chosen, the MCO must conduct the initial HCBS program assessment via telehealth or telephone and develop ISP telephonically.
Additionally, nursing facilities have been reminded of maintaining residents’ Medicaid eligibility, as well as selecting a STAR+PLUS MCO for the purposes of PASRR specialized services.
Since Texas Medicaid is no longer extending enrollment for those participants with ISPs that expired after December 30th, Texas Medicaid has begun to issue denial determinations.
Aging out of Children’s Medicaid — Individuals that Turned 21 during the pandemic
Previously, because of the COVID-19 extensions in place, HHS maintained individuals who turned 21 years old in Children’s Medicaid. However, to ensure compliance with CMS guidance, HHS needs to review the transition of individuals that turned 21 during the pandemic to ensure they are in the appropriate program. Therefore, HHS will begin notifying Managed Care Organizations (MCOs) to begin the transition process. The timing of the transition depends on when the individual turned 21 and the type of program or services they receive. Typical transitions will be to STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS).
1) For STAR Kids members that turned 21 in MARCH 2020
These individuals successfully transitioned to STAR+PLUS or STAR+PLUS HCBS. However, MCO’s were instructed to continue these individuals on the STAR Kids benefits/ level of services.
Beginning April 1, 2021, individuals will no longer be eligible for STAR Kids benefits and/or services. Therefore, they will no longer be eligible for the following TEXAS HEALTH Steps benefits: Private Duty nursing services, Personal Care Services, Eyeglass Program, dental services and Prescribed Pediatric Extended Care Center Services.
MCOs have been instructed they must inform members and providers of the change in services. The MCOs may need to update service plans to update changes, and these changes must take place before April 2021.
2) For individuals who turn 21 on or before March 31, 2021, and are not receiving Medically Dependent Children Program, Prescribed Pediatric Extended Care Center, or Private Duty Nursing services, they will transition to STAR Plus or STAR Program effective April 1, 2021.
On April 1, 2021, these individuals will no longer be eligible for STAR Kids benefits and/or services. Therefore, they will no longer be eligible for the following TEXAS HEALTH Steps benefits: Private Duty nursing services, Personal Care Services, Eyeglass Program, dental services and Prescribed Pediatric Extended Care Center Services.
A notice will be issued to member’s mid-February of the change.
3) For individuals who turn 21 in April 2021, they will continue a standard HHS transition processes.
HHS will send a letter to individuals notifying them of the upcoming transition.
4) For individuals who turn 21 and ARE receiving MDCP, PPECC, or PDN services before May 1, 2021
Starting February 2021, Managed Care Organizations will begin completing the Medical Necessity Level of Care (MNLOC) assessments.
The process is different for these individuals because the MNLOC assessment is necessary to determine eligibility for the appropriate STAR+PLUS Program. MCO’s are expected to provide the same level of benefits and services they are receiving prior to May 01, 2021 to continue until the member completes the transition or is determined ineligible.
*If individuals are not eligible for a waiver program, they will not receive waiver program services or start to receive STAR+PLUS HCBS. Rather they will receive Medicaid state plan services on or before May 01, 2021.
However, if determined ineligible individuals will no longer be eligible for STAR Kids benefits and/or services. Therefore, they will no longer be eligible for the following TEXAS HEALTH Steps benefits: Private Duty nursing services, Personal Care Services, Eyeglass Program, dental services and Prescribed Pediatric Extended Care Center Services.
Termination of MDCP or STAR+PLUS HCBS Services
For STAR+PLUS HCBS and MDCP members: Automatic eligibility will begin to terminate. Termination denial notices will be mailed out as soon as February 28, 2021. The individual maintains appeal rights and can request a fair hearing to prove continued eligibility.
Medicaid Plan Appeals and Fair Hearings
Medicaid applicants and recipients must be afforded the opportunity to appeal adverse eligibility determinations, as well as reductions, denials, or terminations of health care services. The following changes to the timelines for MCO plan appeals and fair hearings will be in effect through June 30, 2021:
MCO Plan Appeals
Now, an individual has 90 days from the date of the denial notice to request an MCO Plan Appeal; it was 60 days.
Now through June 30, 2021, an individual has 30 days to request continuation of benefits from the date of the denial notice; it was 10 days. Starting July 01, 2021, individuals will have only the federally required 10 days from the date of the agency action to request continuation of services.
Now, MCOs have 60 days to resolve an internal Plan Appeal; it was 30 days.
Texas Medicaid also now requires all MCOs to accept oral requests for appeals without the member having to provide a written request.
Now, an individual has 150 days to request a fair hearing after the internal MCO Plan Appeal; it was 120 days.
If the timeframe for a member to request a fair hearing would have expired in August 2020, they will have an extra 30 days from that expiration date to request a fair hearing.
Individuals should request that the hearings officer reschedule their hearing to a later date if they are having difficulty getting their case file, the agency’s or MCO’s exhibits, or records or documents from their healthcare providers. According to HHSC’s Appeals Division, hearings officers should continue hearings to a later date under these circumstances.
Hearing officers must continue to issue hearing decisions within 120 days of the date the request for a fair hearing is received, unless the hearing has been continued.
*IMPORTANT* CDS Employee — COVID-19 vaccine
HHSC is aware that many CDS employees have difficulty obtaining the COVID-19 vaccine without proper designation as a healthcare worker. Therefore, HHSC has created a template form for the Financial Management Service Agencies (FMSA)s to fill out and provide to the employee as proof they are classified as a healthcare worker and eligible to receive the COVID-19 vaccine. A sample form is available online.
Created: May 12, 2020
Updated: June 7, 2021
Publication Code: HC11
Disclaimer: Disability Rights Texas strives to update its materials on an annual basis, and this handout is based upon the law at the time it was written. The law changes frequently and is subject to various interpretations by different courts. Future changes in the law may make some information in this handout inaccurate.
The handout is not intended to and does not replace an attorney’s advice or assistance based on your particular situation.Print This Page