Provider Alert! Medically Dependent Children Program Waiver (MDCP) Eligibility Process and Peer-to-Peer Review

Attention: Primary Care Providers and Sub Specialists 

Effective Date: December 1, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Per Texas Health and Human Services Commission (HHSC) contract changes effective December 1, 2020, Texas Children’s Health Plan (TCHP) would like to inform network providers about a new offering for children applying for the Medically Dependent Children Program (MDCP) waiver.  Individuals, who may or may not be a member of Texas Children’s Health Plan, can request a peer-to-peer review for potential MDCP waiver denials. The MDCP peer-to-peer review occurs between the individual’s treating physician of choice and a TCHP Medical Director to share additional medical information about the individual that may aid in eligibility determination for the MDCP waiver.

Here are the steps in the review process:

1. TCHP will contact the individual or individual’s Legally Authorized Representative (LAR) to determine if they would like to initiate a MDCP peer-to-peer review.
2. If they wish to proceed, outreach will be made to the individual’s physician of choice to schedule the MDCP peer-to-peer review with TCHP’s Medical Director.
3. TCHP Medical Director will contact the individual’s physician of choice for the MDCP peer-to-peer case discussion.
4. TCHP Medical Director will document potentially helpful additional clinical information to submit to Texas Medicaid & Healthcare Partnership (TMHP) for consideration. The individual’s physician of choice may also submit a letter of medical necessity or clinical notes to document additional relevant clinical information to TMHP at 512-514-4223.
5. TMHP will issue a decision. If a denial is issued, the individual or LAR has an opportunity to request a State Fair Hearing.

Important reminders:

• Eligibility is determined by Texas Medicaid & Healthcare Partnership (TMHP) based on information gathered from the individual and individual’s LAR using the Screening and Assessment Instrument (SAI) by the Managed Care Organization’s (MCO) Service Coordination team.
• TMHP must receive any additional medical information within 14 business days of initial MDCP denial. The MDCP Peer to Peer review must occur within sufficient time to meet the 14 business day requirement by TMHP.
• Election to use or participation in the MDCP Peer to Peer process does not interfere with the individual’s ability to utilize the State’s Fair Hearing process.

References: For additional information on Texas Medicaid waivers, including MDCP, please click on the following link:  https://www.txhealthsteps.com/static/courses/waivers/sections/section-1-2.html

How this impacts providers: No action required until physicians are called upon to participate in the peer-to-peer discussion.

Next steps for providers: Providers should notify their staff of this new process.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.