Texas Medicaid Updates STAR+PLUS Billing Codes and Modifiers
Avoid denials by using the state-required codes and modifiers whenever a member’s ISP renews.
Effective immediately, when a STAR+PLUS member’s individual service plan (ISP) renews, long-term care providers must bill certain respite and assisted living services with the updated HCPCS procedure codes and modifiers. This aligns with Texas’s new payment approach for nursing facilities and HCBS. Claims filed with the old codes will be denied.
New payment methodology
To prepare for the payment transition, HHSC updated the LTSS billing matrix in August 2025 for STAR+PLUS HCBS services.
Beginning September 1, 2025, HHSC shifted from the RUG-III model to the Patient-Driven Payment Model (PDPM). Under PDPM, providers and nursing facilities can expect a system that:
- Emphasizes each patient’s characteristics and needs rather than service volume
- Improves payment accuracy and appropriateness
- Seeks to enhance the quality of care in long-stay nursing facilities
Next steps
The shift from RUG-III to PDPM will roll out as each member’s ISP is reviewed and renewed. If you serve multiple members in facility or community settings, your transition may span up to a year, finishing as soon as all ISPs are renewed. During this period:
Before an ISP renews: Continue billing under RUG-III using the current procedure codes and modifiers.
At renewal: You’ll receive prior authorization tied to the updated ISP, delivered via the UnitedHealthcare Provider Portal or by fax from the service coordinator.
After renewal (next transaction): Switch to the updated codes and modifiers:
STAR+PLUS LTSS claims:
- T2031 for assisted living services
- S5151 for respite care services
Use the correct state-required modifiers listed on the state’s Payment Rate Information page.
- Submit prior authorization requests as usual.
- Continue EVV reporting for home health services.
Important: Reimbursement under PDPM requires the updated codes. Claims with discontinued codes will be denied and must be resubmitted as corrected claims.
Here’s How You Can Prepare
Before your first renewal, make sure to:
Check HHSC for the latest STAR+PLUS payment rates.
Review LTSS Codes & Modifiers Guide, focusing on:
- STAR+PLUS HCBS PAS & Respite: Dates of Service on/after Sept. 1, 2025 (PDPM LTC)
- Assisted Living: Dates of Service on/after Sept. 1, 2025 (PDPM LTC)
- Train billing and claims teams on the updated LTSS billing matrix, including the new procedure codes and modifiers.
