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 live in a STAR+PLUS service area and 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; or
   4. (4) Are age 21 or older and are receiving SSI.
2. (b) Enrollment in the STAR+PLUS program is voluntary for children under age 21 receiving SSI.
3. (c) Medicaid recipients will have a choice among at least two managed care organizations (MCOs).

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

   1. (1) Residents of nursing facilities;
   2. (2) STAR+PLUS members who have been in a nursing facility for more than four consecutive months;
   3. (3) Clients receiving Medicaid 1915(c) waiver services, other than Community-Based Alternatives services;
   4. (4) Residents of intermediate care facilities for persons with mental retardation (ICFs/MR);
   5. (5) Persons not eligible for full Medicaid benefits; and
   6. (6) Children in the conservatorship of the Texas Department of Family and Protective Services.

5. (e) Dual eligible clients.

   1. (1) Enrollment in Medicare does not affect eligibility for the STAR+PLUS program.
   2. (2) Individuals who are covered by both Medicare and Medicaid (also known as "dual eligibles") and 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.

6. (f) 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 the Texas Health and Human Services Commission 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.
7. (g) 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.