All MCOs, DMOs and MMPs: COVID-19: MCO Appeal Determination Extension Reporting
HHSC is providing guidance to MCOs, Dual Demonstration Medicare-Medicaid Plans (MMPs), and DMOs for reporting member appeals occurring during the COVID-19 emergency.
MCOs, MMPs, and DMOs are normally required to resolve standard appeals within 30 days of the date the member requested the appeal. On March 26, 2020, HHSC provided guidance allowing MCOs, MMPs, and DMOs 60 days to resolve a standard appeal for appeal determinations due through the end of May 2020.
MCOs, MMPs, and DMOs are expected to limit use of this flexibility for additional time to make an appeal determination to when it is absolutely necessary, and not for every case.
Summary of Request:
MCOs, MMPs, and DMOs must report COVID-19 related cases using Uniform Managed Care Manual (UMCM) 5.24.6, Member Appeals Text File Layout, and maintain member appeal supporting documentation
All MCOs, MMPs, and DMOs should follow the guidance below for reporting appeals occurring during the COVID-19 emergency using UMCM 5.24.6. Fields not specified below should be completed with existing instructions.
- Enter “OTH” in the Reason for Denial field (Row 18)
- Enter “COVID-19” in the Other Reason for Denial free text field (Row 19).
- Enter “30” in the Appeal Timeframe field (Row 20)
- Indicate if an extension up to 30-days was required in the Was a 14-Day Extension Needed field (Row 21).
- If an extension was requested or required, specify the requestor in the Extension Requested By field (Row 22). All MCOs, MMPs, and DMOs must maintain all member appeal supporting documentation to provide to HHSC, if requested.
STAR Kids, STAR Health, STAR+PLUS, MMP: Families First Coronavirus Response Act Information for FMSAs and CDS Employers
The United States Department of Labor (DOL) issued a temporary rule implementing the paid sick leave and expanded family medical leave provisions of the federal Families First Coronavirus Response Act (FFCRA), as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The rule is effective from April 2, 2020, through December 31, 2020.
The rule was published in the Federal Register on April 6, 2020, and can be found here: https://www.federalregister.gov/documents/2020/04/…
MCOs should remind Financial Management Services Agencies (FMSAs) and Consumer Directed Services (CDS) employers that they are required to comply with all applicable employment-related laws, including the DOL temporary rule and associated guidance about the FFCRA. MCOs may do so by sharing HHSC Information Letter 2020-22 with FMSAs and CDS employers.
The information contained in the letter is intended only as a high-level summary of paid leave offered through the FFCRA and CARES Act. For further details and questions about the DOL temporary rule or IRS instructions, MCOs, FMSAs and CDS employers should contact the U.S. Department of Labor, Wage and Hour Division, or the IRS.
CDS Policy & Operations team at CDS@hhsc.state.tx.us
STAR+PLUS: Money Follows the Person Process for Nursing Facility Residents
HHSC is reminding STAR+PLUS MCOs of the Money Follows the Person (MFP) process for nursing facility (NF) residents requesting to leave the NF during the COVID-19 emergency.
The existing MFP process is described in the STAR+PLUS Handbook, Section 3500. HHSC allows the current, approved NF Minimum Data Set (MDS) to be used for medical necessity (MN). During the COVID-19 emergency the process will differ to align with suspension of face-to-face visits and to change MCO-HHSC communication processes to ensure people can begin to access community services quickly.
Items in italics show changes to the current process. The process will be as follows:
- The Program Support Unit (PSU) will process for STAR+PLUS HCBS if all eligibility criteria are met: approved medical necessity using MDS, Individual Service Plan (ISP), and active NF Medicaid.
- The MCO will develop the ISP from the NF plan of care and telephonic discussion with the individual and family members.
- The ISP start date will be the NF discharge date.
- The MCO must document information gathered from the telephonic discussions.
- STAR+PLUS HCBS would be authorized for 12 months.
- The MCO will complete Form 2067 including the individual’s new address with phone number, and discharge date.
- The existing NF Resource Utilization Group (RUG) determines the cost ceiling.
- PSU will complete Form 2065D with a start date of care the date of discharge.
- PSU will notify MEPD via 1746 for a program transfer.
You can find the original announcements here.