Texas Medicaid: Changes made to STAR+PLUS billing codes and modifiers

Avoid claim denials by using the correct codes and modifiers from the state when each member’s ISP renews.

Starting immediately, when an individual service plan (ISP) renews for a STAR+PLUS member, long-term care providers must use new HCPCS procedure codes and modifiers to bill for certain respite care and assisted living services. This change is to align with the new payment methodology applied by Texas for nursing facilities and home- and community-based services (HCBS). Claims submitted with the codes used before the change will be denied.

New payment methodology

To prepare for an upcoming change in payment methodologies, the Texas Health and Human Services Commission (HHSC) updated the billing matrix in August 2025 for long-term services and supports (LTSS) care provided through STAR+PLUS home- and community-based services (HCBS) programs.

As of Sept. 1, 2025, HHSC transitioned the methodology from the resource utilization group (RUG-III) model to the patient-driven payment model (PDPM). Care providers and nursing facilities will find the new PDPM methodology:

• Focuses on the patient’s characteristics and needs rather than the volume of services provided
• Helps improve payment accuracy and appropriateness
• Aims to enhance care quality in long-term stay nursing facilities

Next steps

The change from RUG-III to PDPM will happen gradually as each member’s ISP is evaluated and renewed. If you care for multiple members in a nursing or community-based facility, the transition from RUG-III to PDPM may take place over the course of a year or until all members’ ISP have renewed. Here’s what to expect during the transition:  

• Between now and when a member’s ISP renews, you’ll continue to use the current procedure codes and modifiers for RUG-III billing
• When a member’s ISP renews, we’ll send you prior authorizations based on the member’s updated plan. You’ll receive the approvals either through the UnitedHealthcare Provider Portal or by fax from a service coordinator.
• Starting with the member’s next transaction, use the updated procedure codes and modifiers to: 
  • Submit claims for STAR+PLUS LTSS using the following procedure codes:  
    • T2031 for assisted living services
    • S5151 for respite care services
      You can find the appropriate modifiers to use with the procedure codes on the state’s site: Payment Rate Information.

• Request prior authorizations
• Continue to report home health care services using an electronic visit verification system
  
  

Please note: You must use the updated codes for reimbursement under the PDPM methodology. If you use the discontinued codes, your claims will be denied, and you’ll need to submit a corrected claim.

How to prepare

Between now and your first renewal, please do the following:

• Visit HHSC for the most recent STAR+PLUS payment rates
• Review these sections of our Long-Term Services and Supports (LTSS) STAR+PLUS and MMP and STAR Kids (including MDCP) Codes and Modifiers Guide
  • STAR+PLUS HCBS PAS and Respite > Date of Service on or after Sept. 1, 2025 (PDPM LTC)
  • Assisted Living > Date of Service on or after Sept. 1, 2025 (PDPM LTC)
• Train your billing and claims staff on the new LTSS billing matrix procedure codes and modifiers

Questions? We’re here to help.

Call the Service Coordination Hotline at 800-349-0550.