Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Note: The Health and Human Services Commission (HHSC) has requested that TMHP publish the following information:
HHSC is reminding nursing facility (NF) providers of the essential role of Medicaid managed care organization (MCO) service coordinators. As the option for in-person MCO service coordination visits resume, and as the public health emergency continues, there is a critical need for regular and timely communication between NF providers and MCO service coordinators. This communication is required in the Uniform Managed Care Manual Chapter 8.6, State Mandated Requirements for STAR+PLUS Nursing Facility Providers.
Role of MCO Service Coordinator
The MCO service coordinator is responsible for working with the member who resides in a NF to ensure all of their medically and functionally necessary needs are met. This includes, but is not limited to, referring and assisting the member in obtaining appointments with specialists, participating in discharge planning for members leaving a hospital or NF, and referring members to community organizations for services and assistance not covered by Medicaid. Refer to the STAR+PLUS Handbook, Sections 1200 and 1210.
MCOs are contractually required to make quarterly visits to most members residing in a NF; with the exception that NF residents receiving hospice or in a NF outside of the MCO’s service area receive two telephonic service coordination outreach contacts each year. Refer to the STAR+PLUS Expansion Contract, Section 126.96.36.199 “Service Coordinator Plan Requirements” for more information.
MCO Service Coordinator as a Provider of Essential Services
MCOs are permitted to resume the option for in-person assessments and service coordination visits, effective September 1, 2021. Details can be found in a provider notice titled, “Nursing Facility and Assisted Living Facility Providers: Resumption of Option for In-Person MCO Service Coordination Visits,” from August 9, 2021. MCO service coordinators are considered “providers of essential services,” specifically “health care professionals,” as defined in the COVID-19 emergency rule, 26 Texas Administrative Code §554.2803. According to subsection (e) of that rule, NF providers must allow these individuals to enter the NF if they pass the NF’s COVID-19 screening. See Provider Letter 2021-33 for details on the authority to enter long-term care facilities.
Informing MCO Service Coordinator of Changes
NF providers have a contractual requirement to inform a member’s MCO service coordinator if the member has any of these changes:
- Has had a significant, adverse change in condition, including a positive COVID-19 diagnosis; a positive COVID-19 diagnosis is considered to be a significant change in condition described in the Uniform Managed Care Manual Chapter 8.6, State Mandated Requirements for STAR+PLUS Nursing Facility Providers, Section 2.22;
- Has had an admission or discharge from the NF;
- Has had an emergency room visit; or
- Is requesting to return to the community.
The NF is responsible for notifying the service coordinator within one business day of receiving this information. Notification can be done via phone, email, or other electronic means. NF providers are also required to submit Form 3618 or Form 3619, as applicable, to HHSC no later than 72 hours after a member’s admission or discharge from the NF.
Refer to the Uniform Managed Care Manual Chapter 8.6, State Mandated Requirements for STAR+PLUS Nursing Facility Providers, Sections 2.22 and 2.23; and the STAR+PLUS Handbook Section 1210 for more information.
Providing MCO Reasonable Notice in Care Planning Discussions
NF providers have a contractual requirement to provide the MCO with reasonable notice of and the opportunity to participate in care planning discussions and activities. Refer to Uniform Managed Care Manual Chapter 8.6, State Mandated Requirements for STAR+PLUS Nursing Facility Providers, Section 2.1.3.
If a NF provider needs to reach the member’s designated service coordinator, they can contact their MCO’s care coordinator team, listed below.
- Amerigroup Member Services: 800-600-4441 (TTY 711)
- Cigna-HealthSpring Service Coordinator: 877-725-2688
- Molina Healthcare Member Services: 866-449-6849
- Superior Health Plan Service Coordination: 877-277-9772
- UnitedHealthcare Member Services: 888-887-9003 (TTY 711)
Contact Managed_Care_Initiatives@hhs.texas.gov for questions about this notice.