Common use of For Medical Assistance Only Clause in Contracts

For Medical Assistance Only. (MAO) Non-Member Applicants Non-member persons who are not eligible for Medicaid in the community may apply for participation in the 1915(c) STAR+PLUS Waiver (SPW) program under the financial and functional eligibility requirements for MAO. HHSC will inform the non-member applicant that services are provided through an MCO and allow the applicant to select the MCO. HHSC will provide the selected MCO an authorization form to initiate pre-enrollment assessment services required under the SPW for the applicant. The MCO’s initial home visit with the applicant must occur within 14 days of the receipt of the referral. To be eligible for SPW, the applicant must meet financial eligibility, risk criteria, Medical Necessity/Level of Care, the cost of the Individual Service Plan (ISP) cannot exceed 202% of cost of providing the same services in a nursing facility, and the MCO must be able to demonstrate that the applicant has a minimum of one (1) unmet need for at least one (1) SPW service. The HMO must apply risk criteria as illustrated in Section 3242.3 of the STAR+PLUS Handbook, “Risk Assessment.” If the MCO determines that the applicant does not meet the risk criteria for SPW eligibility, the MCO must notify HHSC’s Administrative Services Contractor. The Administrative Services Contractor will notify the applicant that he or she did not meet the eligibility criteria for the SPW, and the right to Appeal the Adverse Determination. If the MCO determined that the applicant meets risk criteria for SPW eligibility, the MCO must complete the Community Medical Necessity and Level of Care Assessment Instrument for Medical Necessity/Level of Care determination, and submit the form to HHSC’s Administrative Services Contractor. The MCO is also responsible for completing the assessment documentation, and preparing a 1915(c) STAR+PLUS ISP for identifying the needed SPW services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% cost ceiling. The MCO must complete these activities within 45 days of receiving the State’s authorization form for eligibility testing. HHSC will notify the applicant and the MCO of the results of its eligibility determination. If the applicant is eligible, HHSC will notify the applicant and the MCO will be notified of the effective date of eligibility, which will be the first day of the month following the determination of eligibility. The MCO must initiate the Individual Service Plan (ISP) on the date of enrollment. If the applicant is not eligible, the HHSC notice will provide information on the applicant’s right to Appeal the Adverse Determination. HHSC will also send notice to the MCO if the applicant is not eligible for 1915(c) Nursing Facility Waiver services. The MCO is responsible for preparing any requested documentation regarding its assessments and service plans, and if requested by HHSC, attending the Fair Hearing.

For Medical Assistance Only. (MAO) Non-Member Applicants Non-member Member persons who are not eligible for Medicaid in the community may apply for participation in the 1915(c) STAR+PLUS Waiver (SPW) program under the financial and functional eligibility requirements for MAO. HHSC will inform the non-member applicant that services are provided through an MCO HMO and allow the applicant to select the MCOHMO. HHSC will provide the selected MCO HMO an authorization form to initiate pre-enrollment assessment services required under the SPW for the applicant. The MCOHMO’s initial home visit with the applicant must occur within 14 days of the receipt of the referral. To be eligible for SPW, the applicant must meet financial eligibility, risk criteria, Medical Necessity/Level of Care, the cost of the Individual Service Plan (ISP) cannot exceed 202% of cost of providing the same services in a nursing facility, and the MCO HMO must be able to demonstrate that the applicant has a minimum of one (1) unmet need for at least one (1) SPW service. The HMO must apply risk criteria as illustrated in Section 3242.3 of the STAR+PLUS Handbook, “Risk Assessment.” If the MCO HMO determines that the applicant does not meet the risk criteria for SPW eligibility, the MCO HMO must notify HHSC’s Administrative Services Contractor. The Administrative Services Contractor will notify the applicant that he or she did not meet the eligibility criteria for the SPW, and the right to Appeal the Adverse Determination. If the MCO HMO determined that the applicant meets risk criteria for SPW eligibility, the MCO HMO must complete the Community Medical Necessity and Level of Care Assessment Instrument for Medical Necessity/Level of Care determination, and submit the form to HHSC’s Administrative Services Contractor. The MCO HMO is also responsible for completing the assessment documentation, and preparing a 1915(c) STAR+PLUS ISP for identifying the needed SPW services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% cost ceiling. The MCO HMO must complete these activities within 45 days of receiving the State’s authorization form for eligibility testing. HHSC will notify the applicant and the MCO HMO of the results of its eligibility determination. If the applicant is eligible, HHSC will notify the applicant and the MCO HMO will be notified of the effective date of eligibility, which will be the first day of the month following the determination of eligibility. The MCO HMO must initiate the Individual Service Plan (ISP) on the date of enrollment. If the applicant is not eligible, the HHSC notice will provide information on the applicant’s right to Appeal the Adverse Determination. HHSC will also send notice to the MCO HMO if the applicant is not eligible for 1915(c) Nursing Facility Waiver services. The MCO is responsible for preparing any requested documentation regarding its assessments and service plans, and if requested by HHSC, attending the Fair Hearing.