SKH, Section 3000, STAR Kids Screening and Assessment and Service Planning

SKH, Section 3000, STAR Kids Screening and Assessment and Service Planning

Revision 1718-31; Effective September March 1, 20172018

3100 STAR Kids Screening and Assessment

Revision 1718-1; Effective June March 1, 20172018

All children and young adults enrolled in a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and Community First Choice (CFC), personal care services and/or Medically Dependent Children Program (MDCP) services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member or legally authorized representative (LAR) should notify the MCO of the intended provider of services and the MCO shall reach out to the provider.

3110 Assessment of Medical Necessity for Community First Choice

Revision 1718-31; Effective September March 1, 20172018

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.Field Z5a must be marked yes (indicated by a "1") to request TMHP review and determination of MN. A physician certification is required for all initial assessments for MN for CFC services.Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Z5a is marked yes for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is on file in the member's case file.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and emergency response services. For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the member's file, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including the PCAM and Section P, but leaves Field Z5a as marked "no" (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative (LAR). If a member meets MN and has a need for CFC services, the MCO prepares a service plan for the member and provides an authorization to the network provider of the member's or LAR’s choice.

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 17-3; Effective September 1, 2017

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC.

Applicants or members coming off the MDCP interest list must be assessed for MN for eligibility for MDCP and the SK-SAI must be completed no later than 30 days following notification from Program Support Unit (PSU) staff, detailed inSection 2220, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered complete when the physician certification is on file. MCOs assessing applicants/members for MDCP services complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate yes on Field Z5a when seeking an MN determination from TMHP. A physician certification is required.Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Z5a is marked yes on initial assessments for MDCP.

If a member comes off the interest list who is receiving Community First Choice (CFC) services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Z5a as a “no” (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative. A physician's certification is not required for a reassessment of MN.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.

3200 Member Reassessment

Revision 1718-1; Effective June March 1, 20172018

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed. Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. Before the end date of the annual SK-SAI, including applicable modules, the MCO must initiate an annual reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the one year anniversary of the member's previous assessment using the SK-SAI. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member or member’s legally authorized representative (LAR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive personal care services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized personal care servicePCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The MCO must also complete the NCAM at any time it determines the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

3210 Reassessment of Medical Necessity or Level of Care

Revision 1718-31; Effective September March 1, 20172018

For members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required.Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment and there has been no change to the member’s health status. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member and/or the member's legally authorized representative (LAR) to schedule a reassessment prior to the expiration of the member's LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure that the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member's ISP is completed annually. PSU staff:

• check the Long Term Care (LTC) Online Portal to determine if the MCO has electronically submittedForm 2604, STAR Kids Individual Service Plan -(ISP) Service Tracking Tool, or through a 278 transaction before the ISP end date;
• verify the case has an approved SK-SAI;
• confirm ongoing Medicaid eligibility;
• verify the ISP is within the cost limit; and
• take a screenshot of the ISP and posts the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART) system.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploadingForm H2067-MC, Managed Care Programs Communication, to TxMedCentral, asking PSU staff to manually generateForm H2065-D, Notification of Managed Care Program Services. This form is not generated in the LTC Online Portal at reassessment. PSU staff send Form H2065-D to the member and post a copy to the appropriate MCO STAR Kids folder in TxMedCentral. See Section 3328, Reassessment Notification Requirements, for additional information.

3300 Member Service Planning and Authorization

Revision 17-3; Effective September 1, 2017

Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. Except as provided below for members receiving Medically Dependent Children Program (MDCP) services, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The ISP must be completed within 60 days of completion of the SK-SAI for all subsequent reassessments. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The ISP must be used to communicate and help align expectations between the member, his legally authorized representative (LAR), the MCO and key service providers. The STAR Kids Individual Service Plan (SK- ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member and his LAR, on the member’s behalf, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The STAR Kids ISP is for:

• documenting findings from the SK-SAI;
• developing a plan for services received through the STAR Kids MCO;
• documenting services received through third party sources, such as 1915(c) waivers operated by the state;
• identifying the member or applicant’s strengths, preferences, support needs and desired outcomes;
• identifying what is important to the member;
• identifying available natural supports available to the member and needed service system supports;
• documenting the individual’s preferences for when and how to receive services;
• identifying any special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
• documenting the member's unmet needs.

For STAR Kids members receiving MDCP services, the ISP must establish an MDCP service plan that falls within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member or his LAR following any significant update and no less than annually within five business days of meeting with the member or LAR. The MCO must provide a copy of the ISP to the member's providers and other individuals specified by the member or LAR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member's current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member's service coordinator, or a representative of the MCO, must review and update each member's ISP with the member and his LAR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

3310 Service Planning

Revision 1718-31; Effective September March 1, 20172018

All STAR Kids narrative individual service plans (ISPs) must be developed using person-centered practices.Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

• A summary document describing the recommended service needs identified through the SK-SAI;
• Covered services currently received;
• Covered services not currently received, but that the member might benefit from;
• A description of non-covered services that could benefit the member;
• Member and family goals and service preferences;
• Natural strengths and supports of the member including helpful family members, community supports or special capabilities;
• A description of roles and responsibilities for the member, his legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the managed care organization (MCO), and the member's school with respect to maintaining and maximizing the health and well-being of the member;
• A plan for coordinating and integrating care between providers and covered and non-covered services;
• Short and long-term goals for the member's health and well-being;
• If applicable, services provided to the member through waiver programs not operated by the MCO or third-party resources, and the sources or providers of those services;
• Plans specifically related to transitioning to adulthood for members age 15 and older; and
• Any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, his family and caretakers, providers and any other individual with knowledge and understanding of the member's strengths and service needs who is identified by the member, the member's LAR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but maymust not require the member, to provide a copy of the member's Individualized Education Plan (IEP).