Common use of For Members Clause in Contracts

For Members. Members can request to be tested for eligibility into the HCBS STAR+PLUS Waiver. The MCO can also initiate HCBS STAR+PLUS Waiver eligibility testing on a STAR+PLUS Member if the MCO determines that the Member would benefit from the HCBS STAR+PLUS Waiver services. To be eligible for the HCBS STAR+PLUS Waiver, the Member must meet Medical Necessity/Level of Care and the cost of the Individual Service Plan (ISP) cannot exceed 202% of cost of providing the same services in a nursing facility. The MCO must be able to demonstrate that that Member has a minimum of one (1) unmet need for at least one (1) HCBS STAR+PLUS Waiver service. 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 HCBS STAR+PLUS ISP for identifying the needed HCBS STAR+PLUS Waiver services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% cost limit. The MCO must complete these activities within 45 days of receiving the State's authorization form for eligibility testing. HHSC will notify the Member and the MCO of the eligibility determination, which will be based on results of the assessments and the information provided by the MCO. If the STAR+PLUS Member is eligible for HCBS STAR+PLUS Waiver services, HHSC will notify the Member of the effective date of eligibility. If the Member is not eligible for HCBS STAR+PLUS Waiver services, HHSC will provide the Member information on right to Appeal the Adverse Determination. The MCO is responsible for preparing any requested documentation regarding its assessments and ISPs, and if requested by HHSC, attending the Fair Hearing. Regardless of the HCBS STAR+PLUS Waiver eligibility determination, HHSC will send a copy of the Member notice to the MCO.

For Members. Members can request to be tested for eligibility into the HCBS 1915(c) STAR+PLUS WaiverWaiver (SPW). The MCO can also initiate HCBS STAR+PLUS Waiver SPW eligibility testing on a STAR+PLUS Member if the MCO determines that the Member would benefit from the HCBS STAR+PLUS Waiver SPW services. To be eligible for the HCBS STAR+PLUS WaiverSPW, the Member must meet risk criteria, Medical Necessity/Level of Care and Care, the cost of the Individual Service Plan (ISP) cannot exceed 202% of cost of providing the same services in a nursing facility. The , and the MCO must be able to demonstrate that that Member has a minimum of one (1) unmet need for at least one (1) HCBS STAR+PLUS Waiver SPW service. The MCO must apply risk criteria as illustrated in Section 3242.3 of the STAR+PLUS Handbook, “Risk Assessment.” If the MCO determines that a Member 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 Member 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 Member 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 ’s Administrative Services Contractor. The MCO is also responsible for completing the assessment documentation, and preparing a HCBS 1915(c) STAR+PLUS Waiver ISP for identifying the needed HCBS STAR+PLUS Waiver SPW services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% cost limit. The MCO must complete these activities within 45 days of receiving the State's ’s authorization form for eligibility testing. HHSC will notify the Member and the MCO of the eligibility determination, which will be based on results of the assessments and the information provided by the MCO. If the STAR+PLUS Member is eligible for HCBS STAR+PLUS Waiver SPW services, HHSC will notify the Member of the effective date of eligibility. If the Member is not eligible for HCBS STAR+PLUS Waiver SPW services, HHSC will provide the Member information on right to Appeal the Adverse Determination. The MCO is responsible for preparing any requested documentation regarding its assessments and ISPs, and if requested by HHSC, attending the Fair Hearing. Regardless of the HCBS STAR+PLUS Waiver SPW eligibility determination, HHSC will send a copy of the Member notice to the MCO.

For Members. Members can request to be tested for eligibility into the HCBS 1915(c) STAR+PLUS WaiverWaiver (SPW). The MCO HMO can also initiate HCBS STAR+PLUS Waiver SPW eligibility testing on a STAR+PLUS Member Member, if the MCO HMO determines that the Member would benefit from the HCBS STAR+PLUS Waiver SPW services. To be eligible for the HCBS STAR+PLUS WaiverSPW, the Member must meet risk criteria, Medical Necessity/Level of Care and Care, the cost of the Individual Service Plan (ISP) cannot exceed 202% of cost of providing the same services in a nursing facility. The MCO , and the HMO must be able to demonstrate that that Member has a minimum of one (1) unmet need for at least one (1) HCBS STAR+PLUS Waiver SPW service. The MCO HMO must apply risk criteria as illustrated in Section 3242.3 of the STAR+PLUS Handbook, “Risk Assessment.” If the HMO determines that a Member does not meet the risk criteria for SPW eligibility, the HMO must notify HHSC’s Administrative Services Contractor. The Administrative Services Contractor will notify the Member that he or she did not meet the eligibility criteria for the SPW, and the right to Appeal the Adverse Determination. If the HMO determined that the Member meets risk criteria for SPW eligibility, the 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 ’s Administrative Services Contractor. The MCO HMO is also responsible for completing the assessment documentation, and preparing a HCBS 1915(c) STAR+PLUS Waiver ISP for identifying the needed HCBS STAR+PLUS Waiver SPW services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% cost limit. The MCO HMO must complete these activities within 45 days of receiving the State's ’s authorization form for eligibility testing. HHSC will notify the Member and the MCO HMO of the eligibility determination, which will be based on results of the assessments and the information provided by the MCOHMO. If the STAR+PLUS Member is eligible for HCBS STAR+PLUS Waiver SPW services, HHSC will notify the Member of the effective date of eligibility. If the Member is not eligible for HCBS STAR+PLUS Waiver SPW services, HHSC will provide the Member information on right to Appeal the Adverse Determination. The MCO is responsible for preparing any requested documentation regarding its assessments and ISPs, and if requested by HHSC, attending the Fair Hearing. Regardless of the HCBS STAR+PLUS Waiver SPW eligibility determination, HHSC will send a copy of the Member notice to the MCOHMO.