1 Tex. Admin. Code § 353.603

Current through Register Vol. 49, No. 48, November 29, 2024

Section 353.603 - Member Participation

(a) Enrollment in the STAR+PLUS program is mandatory for Medicaid recipients who meet one or more of the following criteria:

(1) have a physical or mental disability and qualify for Supplemental Security Income (SSI) benefits or for Medicaid due to low income;

(2) qualify for STAR+PLUS Home and Community-Based Waiver Services;

(3) are age 21 or older and receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for STAR+PLUS Home and Community-Based Services Program;

(4) are age 21 or older and reside in a nursing facility;

(5) are over 18 and under 65 and qualify for Medicaid for Breast and Cervical Cancer as described in Chapter 366, Subchapter D, of this title (relating to Medicaid for Breast and Cervical Cancer); or

(6) FFCC members age 21 through the month of his or her 26th birthday who meet the criteria in subsections (b) or (e) of this section.

(b) In addition to the Medicaid recipients who must enroll in the STAR+PLUS program under subsection (a) of this section, recipients age 21 or older residing in a community-based ICF-IID or receiving services under the following Medicaid 1915(c) waivers and not enrolled in Medicare must enroll in STAR+PLUS to receive acute care services:

(1) Home and Community-based Services (HCS);

(2) Community Living Assistance and Support Services (CLASS);

(3) Texas Home Living (TxHmL); and

(4) Deaf Blind with Multiple Disabilities (DBMD).

(c) Medicaid recipients will have a choice among at least two MCOs.

(d) The following Medicaid recipients cannot participate in the STAR+PLUS program:

(1) persons under age 21;

(2) residents of state supported living centers;

(3) persons not eligible for full Medicaid benefits; and

(4) persons enrolled in Programs of All-Inclusive Care for Elderly (PACE).

(e) Dual eligible individuals.

(1) Enrollment in Medicare does not affect eligibility for the STAR+PLUS program, except as specified in subsection (b) of this section.

(2) Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, and STAR+PLUS Home and Community-Based Services Program through the STAR+PLUS MCO. Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, but may receive additional services through their STAR+PLUS MCO. The STAR+PLUS program does not change the way dual eligibles receive Medicare services.

1 Tex. Admin. Code § 353.603

The provisions of this §353.603 adopted to be effective December 1, 1997, 22 TexReg 11403; Amended to be effective December 1, 2000, 25 TexReg 11666; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013; Amended to be effective February 1, 2011, 36 Tex Reg 231; Amended to be effective March 1, 2012, 37 TexReg 1283; Amended to be effective September 1, 2014, 39 TexReg 5880; Amended by Texas Register, Volume 41, Number 43, October 21, 2016, TexReg 8270, eff. 11/1/2016; Amended by Texas Register, Volume 42, Number 34, August 25, 2017, TexReg 4274, eff. 9/1/2017