Full Benefit Dual Eligibles (FBDE)
An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community- based waivers, but who does not meet the income or resource criteria for QMB or SLMB. Obligations may effectively be covered by the state Medicaid benefit, but certain conditions must be met including:
- The service is also covered by Medicaid;
- The provider is a Medicaid provider; and
- The Medicaid fee schedule amount is greater than the Medicare amount paid.
Qualified Medicare Beneficiary (QMB Only)
A “QMB” is an individual who is entitled to Medicare Part A, has income that does not exceed 100% of the Federal Poverty Level (FPL), and whose resources do not exceed twice the Supplemental Security Income (SSI) limit. A QMB is eligible for Medicaid payment of Medicare premiums, deductibles, coinsurance, and copayments (except for Part D). QMBs who do not qualify for any additional Medicaid benefits are called “QMB Only”. Providers may not assess a QMB for Cigna-HealthSpring deductibles, copayments, or coinsurances.
Qualified Medicare Beneficiary Plus (QMB+)
A “QMB+” is an individual who meets standards for QMB eligibility and also meets criteria for full Medicaid benefits in the state. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or through spending down excess income to the Medically Needy level.
Specified Low-Income Medicare Beneficiary (SLMB Only)
An “SLMB” is an individual who is entitled to Medicare Part A, has income that exceeds 100% FPL but is less than 120% FPL, and whose resources do not exceed twice the SSI limit. The only Medicaid benefit for which a SLMB is eligible is payment of Medicare Part B premiums. SLMBs who do not qualify for any additional Medicaid benefits are called “SLMB Only.”
Specified Low-Income Medicare Beneficiary Plus (SLMB+)
A “SLMB+” is an individual who meets the standards for SLMB eligibility, but who also meets the criteria for full state Medicaid benefits. Such individuals are entitled to payment of the Medicare Part B premium, as well as full state Medicaid benefits. These individuals often qualify for Medicaid by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.
Qualifying Individual (QI)
A “QI” is an individual who is entitled to Part A, has income that is at least 120% FPL but less than 135% FPL, resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid. A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for QIs are 100% federally funded and the total expenditures are limited by statute.
Other Full Benefit Dual Eligibles (FBDE)
An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community-based waivers, but who does not meet the income or resource criteria for QMB or SLMB.
Qualified Disabled and Working Individual (QDWI)
A “QDWI” is an individual who lost Medicare Part A benefits due to returning to work, but who is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. QDWIs are eligible only for Medicaid payment of Part A premium.
COORDINATION OF CARE WITH STAR+PLUS MEDICAID
The state of Texas’ goal for managed Medicaid services is to integrate acute care and Long Term Services and Supports, including services provided through Medicare Advantage Dual Special Needs Plans (MA-
Dual SNP); provide continuity of care; and ensure timely access to quality care through an adequate provider network that includes behavioral health services and disease management services.
The term “dual eligible” refers to someone who is enrolled in both Medicaid and Medicare. Some dual eligible clients are eligible for STAR+PLUS. Dual eligible clients must choose a STAR+PLUS MCO, but do not choose a PCP because they receive acute care services from their Medicare providers. The STAR+PLUS MCO covers only Long-Term Services and Supports (LTSS) for dual eligible customers.
Certain Medicaid clients are excluded from enrolling in STAR+PLUS. This includes:
- Clients of Medicaid 1915(c) waiver services other than Community-Based Alternatives services.
- Clients not eligible for full Medicaid benefits, such as Frail Elderly program customers, Qualified Medicare Beneficiaries, Specified Low-IncomeMedicare Beneficiaries, Qualified Disabled Working Individuals and undocumented aliens.
- Children in state foster care.
- People not eligible for Medicaid.
- Undocumented immigrants.
In service areas where STAR+PLUS is available, customers are eligible for Community-Based Long-Term Care Services and Supportsthrough their STAR+PLUS MCO.
Long-term Care Services available to all STAR+PLUS customers include:
- Providers offering Personal Attendant Services (PAS) assist customers with the performance of activities of daily living and household chores necessary to maintain the home in a clean, sanitary, and safe environment. The level of assistance provided is determined by the customer’s needs and plan of care. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing, and protective supervision provided solely to ensure the health and welfare of a customer with cognitive/ memory impairment and/or physical weakness.
- Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitation services, nutrition services, transportation services, and other supportive services.
These services are offered by facilities licensed by the Texas Department of Human Services and certified by Texas Department of Aging and Disability Services. Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.
Long-term Care Services Available to STAR+PLUS customers who qualify under the HCBS STAR+PLUS Waiver (SPW) (previously known as 1915 (c) Nursing Facility Waiver program):
Adaptive aids and medical equipment include devices, controls, or medically necessary supplies that enable customers with functional impairments to perform activities of daily living or to perceive, control, or communicate with the environment in which they live. A complete listing of covered adaptive aids and medical equipment is available in the STAR+PLUS Handbook which is available at www.dads.state.tx.us/handbooks/sph.
Adult Foster Care
Adult foster care is a 24-hour living arrangement in a Department of Human Services (DHS) foster home for people who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with activities of daily living, supervision, and the provision or arrangement of transportation.
Assisted living (AL) is a twenty-four (24) hour living arrangement in a licensed personal care facility in which personal care, home management, escort, social and recreational activities, twenty-four (24) hour supervision, supervision of, assistance with, and direct administration of medications, and the provision or arrangement of transportation are provided. Under the HCBS STAR+PLUS Waiver (SPW), personal care facilities may contract to provide services in two distinct types of living arrangements: (1) assisted living apartments, and (2) assisted living non-apartment settings.
The services provided by a dentist to preserve teeth and meet the medical need of the customer. Allowable services include emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection; preventive procedures required to prevent the imminent loss of teeth; the treatment of injuries to teeth or supporting structures; dentures and the cost of preparation and fitting; and routine procedures necessary to maintain good oral health.
Emergency Response Services
Emergency Response Services (ERS) are electronic monitoring systems for use by functionally impaired individuals who live alone or are isolated in the community. In an emergency, the customer can press a call button to signal for help. The electronic monitoring system, which has a twenty-four (24) hour, seven (7) day per week capability, helps ensure that the appropriate persons or service agency responds to an alarm call from the customer.
Financial Management Services
Assistance to customers with managing funds associated with services elected for self-direction and is provided by the consumer directed services agency. This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
Home Delivered Meals
Home delivered meals are provided to people who are unable to prepare their own meals and for whom there are no other persons available to do so or where the provision of a home delivered meal is the most cost effective method of delivering a nutritionally adequate meal. Modified diets, where appropriate, will be provided to meet the customer’s individual requirements.
Minor home modifications are services that assess the need for, arrange for, and provide modifications and/or improvements to an individual’s residence to enable them to reside in the community and to ensure safety, security and accessibility.
Medical supplies are not available under the 1915(b) Waiver program.
In-home Nursing Services include, but are not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician and/ or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching customers about proper health maintenance.
Respite Services offer temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care (AFC) homes or Assisted Living /Residential Care (AL/RC) facilities. Respite services are provided on an in-home basis and out-of-home basis and are limited to thirty (30) days per year. Room and board is included in the Waiver program payment for out-of-home settings.
Support Consultation is an optional service component that offers practical skills training and assistance to enable an individual to successfully direct those services the individual elects for participantdirection. This service is provided by a certified support advisor, and includes skills training related to recruiting, screening, and hiring workers, preparing job descriptions, verifying employment eligibility and qualifications, completion of documents required to employ an individual, management of workers, and development of effective back-up plans for services considered critical to the individual’s health and welfare in the absence of the regular provider or an emergency situation. Support consultation is provided only by a certified support advisor certified by the Department of Aging and Disability.
- Physical therapy includes specialized techniques for the evaluation and treatment of chronic conditions related to functions of the neuromusculoskeletal systems. Services include the full range of activities provided by a physical therapist or a licensed physical therapy assistant under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
- Occupational therapy includes interventions and procedures for chronic conditions to promote or enhance safety and performance in instrumental activities of daily living, education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
- Speech therapy includes evaluation and treatment of impairments, disorders or deficiencies related to a customer’s speech and language which are chronic conditions. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.
Transition Assistance Services (TAS)
Offers a maximum of $2,500 to enhance the ability of nursing facility residents to transition and receive services in the community. TAS helps defray the costs associated with setting up a household for those customers establishing an independent residence. TAS include, but are not limited to, payment of security deposits to lease an apartment, purchase of essential furnishings (table, eating utensils), payment of moving expenses, etc.
Employment Assistance Services is a service that assists individuals to obtain competitive integrate employment and includes, but are not limited to the following: Identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions; locating prospective employers offering employment compatible with a member’s identified preferences, skills, and requirements; and contacting a prospective employer on behalf of a member and negotiating employment.
Supported Employment Services are assistive services provided in order to sustain paid employment, to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which members without disabilities are employed. Supported Employment includes employment adaptations, supervision, and training related to a member’s diagnosis.
Cognitive Rehabilitation Therapy
Cognitive rehabilitation therapy is a service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
Targeted Case Management
Targeted Case Management (TCM) consists of services designed to assist Members who are diagnosed with Severe and Persistent Mental Illness (SPMI) and Severe Emotional Disturbance (SED) with gaining access to needed medical, social, educational and other services and supports.
Mental Health Rehabilitative Service
Mental Health Rehabilitative Services are those age appropriate services determined by HHSC and Federally approved protocol as medically necessary to reduce a Member’s disability resulting from severe mental illness or serious emotional or behavioral disorders that help to increase the Member’s level of functioning and maintain independence in the home and the community. These services include the following: medication training and support, psychosocial rehabilitative services, skills training and development, crisis intervention, and day programming for acute episodes.
Community First Choice (CFC)
Community First Choice (CFC) allows provider to provide home and community-based attendant services and supports to Medicaid recipients with disabilities. All CFC services will be provided in a home or community based setting, which does not include a nursing facility, hospital providing long-term services, institution for mental disease, a condition, or a setting with the characteristics of an institution. Community First Choice Services include: help with activities of daily living and health-related tasks through hands-on assistance, supervision or cueing; services to help the individual learn how to care for themselves; backup systems or ways to ensure continuity of services and supports; training on how to select, manage and dismiss attendants.