1. (a) Except as provided in subsections (b) and (d) of this section, enrollment in the STAR+PLUS program is mandatory for Medicaid recipients who meet one or more of the following criteria:

   1. (1) Have a physical or mental disability and qualify for Supplemental Security Income (SSI) benefits or for Medicaid due to low income;
   2. (2) Qualify for STAR+PLUS Home and Community-Based Waiver Services;
   3. (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 Waiver Services;
   4. (4) Are age 21 or older and are receiving SSI; and
   5. (5) Are age 21 or older and reside in a nursing facility. HHSC will enforce mandatory enrollment of this population into STAR+PLUS beginning March 1, 2015.

2. (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. (1) Home and Community-based Services (HCS);
   2. (2) Community Living Assistance and Support Services (CLASS);
   3. (3) Texas Home Living (TxHmL); and
   4. (4) Deaf Blind with Multiple Disabilities (DBMD).

3. (c) Enrollment in the STAR+PLUS program is voluntary for children under age 21 who are not in a nursing facility and who receive SSI.

   1. (1) Children residing in a community-based ICF-IID who are not enrolled in Medicare are eligible to voluntarily enroll in STAR+PLUS for acute care services;

   2. (2) Children enrolled in the following Medicaid 1915(c) waivers who are not enrolled in Medicare are eligible to voluntarily enroll in STAR+PLUS for acute care services:

      1. (A) HCS;
      2. (B) CLASS;
      3. (C) TxHmL; and
      4. (D) DBMD.
4. (d) Medicaid recipients will have a choice among at least two MCOs.

5. (e) The following Medicaid recipients cannot participate in the STAR+PLUS program:

   1. (1) Children residing in nursing facilities;
   2. (2) Residents of state supported living centers;
   3. (3) Persons not eligible for full Medicaid benefits;
   4. (4) Children in the conservatorship of the Texas Department of Family and Protective Services; and
   5. (5) Persons enrolled in Programs of All-Inclusive Care for Elderly (PACE).

6. (f) Dual eligible clients.

   1. (1) Enrollment in Medicare does not affect eligibility for the STAR+PLUS program, except as specified in subsections (b) and (c)(1) and (2) of this section.
   2. (2) Dual eligible clients who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, and STAR+PLUS Home and Community-Based Waiver Services through the STAR+PLUS MCO. The STAR+PLUS program does not change the way dual eligibles receive Medicare services.

7. (g) An individual is eligible for STAR+PLUS Home and Community-Based Waiver Services if the individual:

   1. (1) is 21 years of age or older;
   2. (2) has been determined by HHSC to be financially eligible for Medicaid;
   3. (3) is enrolled in the STAR+PLUS program;
   4. (4) meets the level-of-care/medical necessity criteria for nursing facility placement according to applicable state and federal regulations, and as verified by an annual assessment;
   5. (5) has an approved individual service plan with an estimated annual cost that does not exceed the applicable individual cost ceiling and service limits;
   6. (6) chooses STAR+PLUS Home and Community-Based Waiver Services as an alternative to institutional care as described in the Code of Federal Regulations, Title 42, §441.302(d); and

   7. (7) resides:

      1. (A) in their own home;
      2. (B) in a licensed assisted living facility contracted with the applicant's/member's MCO to provide STAR+PLUS Home and Community-Based Waiver Services; or
      3. (C) in an adult foster care home contracted with the member's MCO to provide STAR+PLUS Home and Community-Based Waiver Services.
8. (h) An individual may apply for STAR+PLUS Home and Community-Based Waiver Services when the individual is in a nursing facility and is seeking a return to the community.

Source Note: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 5873.