Texas Department of Aging and Disability Services
Case Manager Community Based Alternatives Handbook
Revision: 14-1
Effective: April 3, 2014

Section 3000

Case Management Responsibilities

3100  Overview

Revision 13-1; Effective March 1, 2013

This section describes the case management function for the Community Based Alternatives (CBA) program. The Department of Aging and Disability Services (DADS) case manager is responsible for coordinating the case management process with the CBA applicant or individual, the various CBA providers, DADS staff from other programs, Health and Human Services Commission Medicaid staff, the Texas Medicaid & Healthcare Partnership (TMHP) and the interdisciplinary team (IDT).

3110  Case Management

Revision 13-1; Effective March 1, 2013

Case management for the Community Based Alternatives (CBA) program will be provided by Department of Aging and Disability Services (DADS) staff working directly with the applicant or individual and his responsible party in:

  • determining eligibility;
  • assessing and re-assessing needs;
  • developing the individual service plan (ISP) for waiver and non-waiver services;
  • authorizing waiver services;
  • participating in utilization review activities, as needed;
  • monitoring the appropriateness and quality of services;
  • providing crisis intervention and advocacy;
  • safeguarding individual rights;
  • keeping records;
  • coordinating and consulting with service providers; and
  • locating available resources and informal networks in the community.

The timely performance of these functions by the case manager is intended to promote the overall goal of the waiver, which is to provide an individual with meaningful choices regarding long term care services. This goal will be accomplished primarily by facilitating the development and utilization of services that will divert an individual from premature nursing facility placement and provide an individual in a nursing facility an opportunity to return to the community.

The Case Manager Community Based Alternatives Handbook is organized by sections to address required case management functions beginning with enrollment and continuing through denial or termination. Sections include:

  • Intake and Interest List Procedures
  • Assessment and Eligibility Determination
  • Development of the Individual Service Plan
  • Financial Eligibility
  • Ongoing Case Management
  • Service Monitoring
  • Suspensions, Notifications, Denials and Terminations

While some handbook sections are applicable only to a particular action, others are applicable to more than one action. Example: Authorization of payment for the pre-enrollment assessment is applicable for initial enrollment; however, many of the steps required by the Home and Community Support Services Agency (HCSSA) to complete the pre-enrollment assessment and annual assessment are the same. Developing the ISP for enrollment and reassessment are similar. The case manager should be familiar with all processes and requirements of the CBA program to ensure that appropriate actions are taken to meet the individual's needs as well as waiver requirements.

3200  Intake and Interest List Procedures

Revision 10-4; Effective September 1, 2010

3210  Initial Requests

Revision 13-3; Effective September 3, 2013

The initial request for services may be made by an individual, his responsible party or other interested parties on the individual's behalf to the Department of Aging and Disability Services (DADS). The intake screener receiving an initial request is required to complete Form 2110, Community Care Intake, or make an entry in the automated Long Term Care Intake (NTK) system. Every intake must be screened for a nursing facility (NF) diversion slot. Refer to Section 3310.4, Nursing Facility Diversion Procedures for People at Imminent Risk of Nursing Facility Placement, for intake and referral procedures for a NF diversion slot.

The intake screener must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock. The intake screener must be aware of PACE service areas and referral procedures. Additional information on PACE can be found at http://www.dads.state.tx.us/services/faqs-fact/pace.html.

Based on legislative appropriations, enrollment of individuals into the Community Based Alternatives (CBA) program may be restricted and it may be necessary to maintain a list of individuals interested in CBA services. Allocation of available slots, corresponding to the number of individuals who can be enrolled, will be made to each region. The maximum number of available slots is the regional CBA slot allocation.

Each region must manage its CBA interest list by monitoring the number of referrals for pre-enrollment home health assessments, pending applications, and additions and deletions due to denials, terminations or enrollments into the CBA program to ensure that it does not exceed its CBA slot allocation. All eligible applicants may be enrolled up to the regional CBA slot allocation. Once a region has reached its CBA slot allocation for the fiscal year, additional individuals may be enrolled only as slots become available through attrition.

Note: A person who may complete or sign an application for an applicant or individual may not be on the list of people to whom DADS can release the applicant's or individual's individually identifiable health information. See Section 1854, Personal Representatives, for persons who may receive or authorize the release of an applicant's or individual's individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

3210.1  Screening for Referral to CBA Versus Other CCAD Services

Revision 13-1; Effective March 1, 2013

The staff accepting the initial request for service must determine if it is appropriate to refer the intake to the CBA program or other services, such as Primary Home Care (PHC), Family Care (FC), or both, if there is immediate need for services. Every caller should be informed of the services available through all programs and the current availability of specific programs, including interest list procedures, if applicable.

If a person requests a referral to CBA after being informed of the eligibility criteria, whether or not he appears eligible, he is to be placed on the CBA Interest List.

If the person requests services that only CBA can address, such as skilled nursing services, therapy services, home modifications, etc., he is to be placed on the CBA Interest List.

Every caller should be advised of the eligibility criteria for the CBA program.

3210.2  Referral Criteria Summary

Revision 13-1; Effective March 1, 2013

The following chart summarizes the criteria for distinguishing between referrals to CBA services and referrals to PHC or FC.

CBA Primary Home Care Family Care
21+ No age limitation 18+

Receives Medicaid (not QMB or SLMB); or

Appears potentially eligible for MAO TP 14.

Receives Medicaid (not QMB or SLMB); or

Appears potentially eligible for Community Attendant Services (1929(b))

Does not receive Medicaid; and

Appears potentially eligible for CCAD as an income eligible.

Is requesting a service that only CBA can provide; and

Appears likely to meet medical necessity based on a need for skilled nursing tasks on an ongoing basis.

Is requesting assistance with ADL's or household tasks (must include a personal care task based on a medical need);

Is not requesting a service that only CBA can provide;

or

Does not appear likely to meet medical necessity.

Is requesting assistance with ADL's or household tasks.

Note: The person must be referred for CBA services if he specifically requests CBA services.

3210.3  Rural Addresses

Revision 13-1; Effective March 1, 2013

The U.S. Postal Service (USPS) is phasing out rural route addresses as a result of local 9-1-1 systems converting business and residential rural routes to street-style addresses. Mail carriers will continue to deliver mail showing either address to allow time for changing to the Coding Accuracy Support System (CASS) standardized address. Since this address change is not the result of a residential move, a change of address form is not required.

In July 2008, official USPS notices were sent to affected rural route addresses notifying residents of the address change. In August 2008, the new addresses were introduced in the USPS address database. At some time in the future, mail addressed to rural routes not showing the new CASS address will be returned to the sender with the notice "Undeliverable as Addressed."

Case Manager Procedures

The case manager must ask an individual with a rural route address for an updated address. A rural route address may contain any of the following to denote a rural route:

RR (Rural Route)
RT (Route)
Rural
Route
RD (Rural Delivery)
RFD (Rural Free Delivery)
RUTA RURAL
BUZON
BZN

If the individual states he does not have a new address, continue to use the address provided. Take no action if the street-style address is not provided. Ask the individual to update his information with the Department of Aging and Disability Services if he is notified by USPS of a new address.

3210.4  Caregiver Support Assessment Initiative

Revision 11-2; Effective June 1, 2011

This policy applies to all intakes processed by regional staff for community service programs.

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Department of Aging and Disability Services (DADS) staff to:

  • raise awareness of services available to caregivers;
  • perform outreach functions to informal caregivers;
  • gather information about the needs of caregivers, including the collection of profile data on informal caregivers;
  • provide referral to support services, when appropriate; and
  • implement the use of a standardized caregiver assessment tool to evaluate the needs of caregivers.

SB 271 requires DADS to use the information collected to refer informal caregivers to available support services and to:

  • evaluate the needs of assessed informal caregivers;
  • measure the effectiveness of certain informal caregiver support interventions;
  • improve existing programs;
  • develop new services as necessary to sustain informal caregivers; and
  • determine the effect of informal caregiving on employment and employers.

Form 1027, Caregiver Status Questionnaire (CSQ), is designed to meet the requirements of SB 271. The information collected will be analyzed and included in DADS' report to the governor and the Legislative Budget Board. DADS is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

When possible, the CSQ will be completed at the time of the intake contact. If not feasible, one additional contact with the caregiver must be attempted within five business days. (In situations where it is necessary to go beyond the five-business-day period, document the reason in the comments section of the CSQ.) When a follow-up contact is made, enter the date on the top right corner of the CSQ, just under the NTK menu bar. Check the appropriate box to indicate if the attempt to contact failed or if the caregiver declined to participate.

The purpose of the CSQ is to collect the information described above. This information is not being used to determine unmet need criteria, and is not forwarded to the case manager.

Question Sensitivity

Some staff may find it awkward to ask some of the questions on the CSQ. While understandable, all the questions must be asked and a response recorded for each. It is not acceptable to skip a question. If an individual seems resistant to answer any of the questions, do not insist on a response. Simply document the individual refuses to answer and continue to the next question.

Caregiver Employment

Check boxes have been provided as a means to record the ways caregiving responsibilities have affected the caregiver's employment. After asking the open-ended question, listen to the caregiver's comments and check all of the boxes that apply. Staff are not expected to read aloud each possible response to the employment question; however, the list can be used as a prompt if the responder is unsure how to answer. If the individual seems uncertain, read aloud the response category headings. For example, "Has caregiving affected your employment schedule, pay, leave, performance or work relationships?" If further clarification is necessary, staff may ask, "For example, have you had to take extra leave or change your work schedule to meet your caregiver responsibilities?"

Referral to the Area Agency on Aging (AAA)

If the individual meets one of the following criteria, he may qualify for services from AAA. If so, and if the individual indicates he would like assistance, make the referral according to regional procedures.

AAA Eligibility Screening Criteria

The individual may qualify for services from AAA if he is:

  • 60 years of age or older and is caring for an individual of any age;
  • 55 years of age or older and is caring for a grandchild under the age of 18 in his/her home because:
    • the biological or adoptive parents are unable or unwilling; or
    • he has legal custody or guardianship; or
    • he is raising the child informally; or
    • he is caring for an individual age 19-59 with severe disabilities; or
  • a caregiver for an individual of any age who has Alzheimer's or dementia.

Accessing the CSQ

A copy of Form 1027 should be used when the automated system is unavailable; however, all information must be entered in the automated system as soon as possible. The CSQ, which includes a script and instructions on recording responses, may be useful for staff completing the CSQ for the first few times. Follow the instructions below to complete the CSQ.

  1. Conduct intake per usual procedures using the NTK system.
  2. At the Client Information screen, document whether the individual requesting services has a caregiver. If there is a caregiver, the CSQ must be completed at the end of the intake process if the caregiver is available. If the caregiver is not available, document the caregiver contact information. At least one follow-up attempt must be made to contact the caregiver at a later date.
  3. Select the "Caregiver" tab on the NTK section selection menu.
  4. Enter the information on the Caregiver screens, as requested.
  5. If, at the end of the CSQ, it appears the individual requesting services may qualify for services from AAA, make a referral following regional procedures.

It is possible that staff could conduct multiple assessments in situations where DADS staff receive more than one request for services for an individual. Staff should always assume there is no assessment and proceed as usual. If the caller states he has completed the caregiver assessment in the past, staff should not ask him to complete the assessment again. Staff may exit the caregiver screen by selecting "yes" at the top of the page to the question: "Caregiver declined to answer?" In the comments section at the bottom of the page, document that an assessment has already been conducted for that caregiver.

3210.5  Referrals from Midland Document Processing Center

Revision 13-1; Effective March 1, 2013

When the Document Processing Center (DPC) receives an application in which a request is made for a Department of Aging and Disability Services (DADS) program or service, the DPC will fax the first three pages of the application and a cover sheet to the DADS local office. The first three pages will provide local DADS offices with additional information about the individual for whom program or service information is requested, including contact information for a responsible party and the person helping complete the form. DADS staff will review each of the referrals and contact the individual to determine if he is interested in a DADS program or service.

If it is determined the individual is interested in a DADS program or service without an interest list, DADS staff will complete an intake for the program or service requested and access the Health and Human Services Commission (HHSC) Benefits Portal to print a complete copy of the application.

To print the application, DADS staff must access the HHSC Benefits Portal and select the PT Inquiry tab. Once the PT Inquiry is open, select Inbound Correspondence Image Repository Search and search for the application. Select the appropriate document and click View. When the document opens, click on the printing icon to print the application.

If the individual is interested in a program or service with an interest list, he will be placed on the interest list and DADS staff will not need to print a copy of the application.

If the individual is not interested in a DADS program or service or one with an interest list, DADS staff must file the fax from DPC following local office procedures.

3211  Eligibility Criteria

Revision 12-2; Effective June 1, 2012

The eligibility of the CBA applicant and individual receiving services will be determined by the DADS case manager.

3211.1  Basic Eligibility Criteria

Revision 13-2; Effective June 3, 2013

§48.6003 — Eligibility Criteria.

(a)
In this section, the term "individual" means a person applying for or enrolled in the Community Based Alternatives (CBA) Program, unless the context clearly indicates otherwise.
(b)
To be determined eligible by the Department of Aging and Disability Services (DADS) for the CBA Program, an individual must:
(1)
be 21 years of age or older;
(2)
meet the level-of-care criteria for medical necessity for nursing facility care in accordance with §19.2401 of this title (relating to General Qualifications for Medical Necessity Determinations);
(3)
choose the CBA Program as an alternative to nursing facility services, as described in the Code of Federal Regulations, Title 42, §441.302(d);
(4)
not be enrolled in another Medicaid waiver program approved by the Centers for Medicare and Medicaid Services (CMS) pursuant to §1915(c) of the Social Security Act and operated by DADS;
(5)
live in a county not included in a Medicaid managed care area;
(6)
have an individual service plan (ISP) with a cost for CBA Program services at or below 200 percent of the reimbursement rate that would have been paid for that same individual to receive nursing facility services, as of August 31, 2010, considering all other resources, including resources described in §40.1 of this title (relating to Use of General Revenue for Services Exceeding the Individual Cost Limit of a Waiver Program);
(7)
have been determined by the Texas Health and Human Services Commission to be financially eligible for Medicaid;
(8)
have ongoing needs for CBA Program services with projected costs, as indicated on the ISP, that do not exceed the following maximum service ceilings:
(A)
adaptive aids and medical supplies service category must not exceed $10,000 per individual per ISP year without approval by DADS;
(B)
minor home modifications service category must not exceed a lifetime maximum of $7,500 per individual without approval by DADS, and a maximum of $300 per ISP year for repair and maintenance of a minor home modification; and
(C)
respite care must not exceed 30 days per individual per ISP year without approval by DADS;
(9)
receive CBA Program services within 30 days after eligibility is established;
(10)
reside in:
(A)
the individual's own home;
(B)
a licensed assisted living facility contracted with DADS to provide CBA Program services; or
(C)
an adult foster care home contracted with DADS to provide CBA Program services;
(11)
not reside in an institutional setting, including a hospital, a nursing facility, an intermediate care facility for persons with mental retardation, or a facility required to be licensed as an assisted living facility but is not licensed; and
(12)
meet two or more of the criteria specified in the Nursing Facility Risk Criteria Scoring Form as follows:
(A)
needs assistance with one or more of the activities of dressing, personal hygiene, eating, toilet use, or bathing;
(B)
has a functional decline in the past 90 days;
(C)
has a history of a fall two or more times in past 180 days;
(D)
has a neurological diagnosis of Alzheimer's disease, head trauma, multiple sclerosis, parkinsonism, or dementia;
(E)
has a history of nursing facility placement within the last five years;
(F)
has multiple episodes of urine incontinence daily; or
(G)
goes out of one's residence one or fewer days a week.
(c)
Enrollment in the CBA Program is limited to the number of individuals approved by CMS or the availability of state funding.
(1)
An individual is enrolled from the CBA Program interest list on a "first-come, first-served" basis, except for the following:
(A)
an individual who is 21 years of age and:
(i)
has been receiving Medically Dependent Children Program (MDCP) services and is no longer eligible for MDCP; or
(ii)
has been receiving nursing services through the Texas Health Steps Program and is no longer eligible for Texas Health Steps Program services; or
(B)
an individual described in paragraph (3) of this subsection.
(2)
Except for an individual described in paragraph (1)(A) and (B) of this subsection, DADS suspends enrollment of individuals whose names are on the CBA Program interest list into the CBA Program while the census of enrolled individuals exceeds funded limits.
(3)
An individual receiving services reimbursed through the Texas Medicaid Nursing Facility Program will be approved for the CBA Program if the individual requests services while residing in the nursing facility and meets all eligibility criteria for the CBA Program. If the individual is discharged from the nursing facility for a community setting before being determined eligible for Medicaid nursing facility services and the CBA Program, the individual will be denied immediate enrollment in the CBA Program.
(d)
An individual transferring from a nursing facility or from MDCP is exempt from subsection (b)(12) of this section.

The Texas Administrative Code (TAC) rule identified above lists the eligibility criteria that an applicant must meet for initial enrollment and an individual at the annual reassessment for CBA services.

If an individual has had his CBA eligibility terminated, reapplies and is determined eligible for CBA, the individual is treated as an applicant.

On Nov. 28, 2012, DADS rescinded the nursing facility risk criteria as an eligibility requirement for the CBA program.

3211.2  Criteria to Bypass the Interest List and Money Follows the Person Option Criteria

Revision 08-14; Effective December 18, 2008
(c)
Enrollment in the CBA Program is limited to the number of individuals approved by CMS or the availability of state funding.
(1)
An individual is enrolled from the CBA Program interest list on a "first-come, first-served" basis, except for the following:
(A)
an individual who is 21 years of age and:
(i)
has been receiving Medically Dependent Children Program (MDCP) services and is no longer eligible for MDCP; or
(ii)
has been receiving nursing services through the Texas Health Steps Program and is no longer eligible for Texas Health Steps Program services; or
(B)
an individual described in paragraph (3) of this subsection.
(2)
Except for an individual described in paragraph (1)(A) and (B) of this subsection, DADS suspends enrollment of individuals whose names are on the CBA Program interest list into the CBA Program while the census of enrolled individuals exceeds funded limits.
(3)
An individual receiving services reimbursed through the Texas Medicaid Nursing Facility Program will be approved for the CBA Program if the individual requests services while residing in the nursing facility and meets all eligibility criteria for the CBA Program. If the individual is discharged from the nursing facility for a community setting before being determined eligible for Medicaid nursing facility services and the CBA Program, the individual will be denied immediate enrollment in the CBA Program.

3211.3  Applicants Residing in a Nursing Facility

Revision 07-2; Effective February 1, 2007

Any individual residing in a Texas nursing facility (NF) (or designated hospital swing bed) who is enrolled in Medicaid for their nursing facility stay may request community care services in the community. Money Follows the Person option allows Medicaid funds used to pay for the individual's care in an NF to be transferred to pay for CBA services.

An individual must reside in the NF until a final determination is made indicating approval of CBA services. When the individual goes directly into CBA services the NF funds are transferred from the NF to pay for the community services. The NF individual who requests CBA services and transitions into the community will receive services and be registered on the CBA interest list for tracking purposes only. Clients identified as using Money Follows the Person option funded services will not use regional CBA slots allocated to each region.

3211.4  Medically Dependent Children Program and Texas Health Steps Program

Revision 12-2; Effective June 1, 2012

The Medically Dependent Children Program (MDCP) and the Texas Health Steps Comprehensive Care Program (THS-CCP) provide nursing and other related services to children. Both programs end on the individual's 21st birthday. Most individuals will be transitioning to other programs, including Community Based Alternatives (CBA). Children transitioning from these programs are not placed on the Community Services Interest List (CSIL) and may complete an application for other waiver services before the birth date, including the CBA program.

Case managers must follow the transition procedures in Section 3423.5, Special Procedures for MDCP or THS-CCP Transitioning to CBA. It is important that the MDCP case manager and CBA case manager work together to assure a successful transition from one program to the other.

Some individuals requesting CBA services will have needs that cause the estimated annual individual service plan (ISP) cost to exceed the cost limit based on the Medical Necessity and Level of Care (MN/LOC) Assessment. The Texas Legislature prohibits the Department of Aging and Disability Services from providing Medicaid waiver services to an individual when the cost of the CBA services exceeds the cost limit. Special procedures must be implemented when an applicant’s ISP approaches the assessed cost limit.

Individuals in MDCP have MN and the Home and Community Support Services Agency (HCSSA) is not required to complete a new MN/LOC Assessment. CBA case managers will verify the MN in the Service Authorization System (SAS) or Long Term Care (LTC) online portal. At the time of initial enrollment, the case manager will make two changes in SAS:

  • Level of Service record — "Value" entry is changed from MD to CT.
  • MN record — The end date is extended to the end of the ISP.

Due to the nature of MDCP, the procedures for individuals with high needs will be applicable in developing the ISP and addressing issues and concerns that may arise given the special needs of the population while transitioning from one program to another.

3212  Placement on the Community Services Interest List (CSIL)

Revision 13-3; Effective September 3, 2013

An individual who requests Community Based Alternatives (CBA) services must be registered on the CSIL application regardless of the CBA enrollment status, including an individual who requests CBA services through Money Follows the Person (MFP) procedures. The date and time of the expressed interest is recorded in CSIL. If the individual is first on the list and the region is releasing and enrolling for CBA, the individual may be immediately released and assigned for the enrollment process.

An initial request for services is documented using Form 2110, Community Care Intake, or the Long Term Care Intake (NTK) system. Staff add an individual’s information to the interest list by using the interface on the NTK system or by entering the information in CSIL. Staff may choose to use Form 2113, Community Services Interest List Registration and Follow-Up, to manually record information to be data-entered. Staff must also follow regional procedures for maintaining documentation of CSIL requests. Refer to Section 3310.4, Nursing Facility Diversion Procedures for People at Imminent Risk of Nursing Facility Placement, for intake and referral procedures for a NF diversion slot.

Within five working days of the intake and request for CBA services, staff will enter new requests for CBA services into the CSIL. A copy of the CSIL print screen should be printed and placed in the case record.

An individual who requests CBA services is placed on the interest list based on the date of the request for services. An individual may be placed on multiple interest lists but may only be enrolled in one waiver program at a time. An individual whose needs are met by other programs (such as Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), non-waiver programs) may request his name be removed from an interest list, or may choose to remain on interest list(s) while receiving other services.

An individual who requests to be on an interest list for Department of Aging and Disability Services community services must be Texas residents. Information provided by the individual must include a Texas address as the contact location for the individual requesting services. An exception may be made for an individual who is temporarily out of the state because of a military assignment.

An eligible individual is enrolled from the CBA interest list on a first-come, first-served basis, except for an applicant who was:

  • residing in a nursing facility (NF) and enrolled in CBA following MFP procedures;
  • at risk of NF placement and enrolled in CBA using an NF diversion slot;
  • receiving Medically Dependent Children Program (MDCP) services and became ineligible due to aging out; or
  • receiving nursing services through the Texas Health Steps/Comprehensive Care Program (THSteps/CCP) and became ineligible due to aging out.

CSIL must reflect the above criteria when the individual is registered and released.

An individual who resides in a Texas NF and is enrolled in Medicaid may apply for CBA services, following MFP procedures, without waiting on the interest list. To access CBA services using MFP procedures, an individual must request services while residing in a Texas NF, meet all eligibility criteria for CBA services and remain in the NF until CBA eligibility is determined. An individual residing in an NF may choose to remain on the interest list with his original request date instead of using MFP procedures. Refer to Section 3212.1, Additional Procedures for Money Follows the Person, for requirements related to release and assignment of an MFP applicant.

Staff complete and send Form 2111, Interest List Notification, to an individual placed on the CBA interest list. Form 2111 is not sent to an individual who applies for CBA services through MFP provisions and is immediately assigned to a case manager, although the individual's name must still be entered on the CBA interest list.

Form 2111 is to be completed and mailed to the individual within five working days of his request to be placed on the interest list. If the case manager makes a home visit and assesses the individual for other services, Form 2111 may be completed and a copy given to the individual during the home visit.

Form 2121, Long Term Services and Supports, provides an individual with a comprehensive list of Department of Aging and Disability Services (DADS) programs. Form 2121 lists programs administered by Community Services and Program Operations, the Area Agency on Aging (AAA) and the Local Authority (LA) to serve:

  • an adult or child who requires assistance due to a medical condition;
  • an older adult age 60+ and his caregiver; and
  • an adult or child with an intellectual or developmental disability.

Additional programs such as relocation assistance and Texas Health Steps are also listed.

A contact list of telephone numbers by county for Community Services and Program Operations, AAA and LA is found at: www.dads.state.tx.us/services/contact.cfm.

Form 2121 and the applicable contact information for the individual's service area are either mailed or given to the individual, along with Form 2111.

Example: An individual living in Gregg County calls requesting services with an interest list. The staff member handling the request completes Form 2111 by checking the services requested by the individual. The completed Form 2111, Form 2121 and the contact information for Gregg County is mailed to the individual within five working days of the date of the request for services. Form 2111 and Form 2121 are available electronically on the DADS forms and instructions website.

An individual may live in one region but prefer to move to another region if services are available in that region. This individual may request placement on the CSIL in more than one region. In this circumstance, the case manager or designated CSIL staff in the region where the individual currently resides must advise the designated CSIL staff in the other region and request that the individual be added to the CSIL in that region. The designated CSIL staff in the newly requested region must then add the individual to that region's CSIL on the date of the request, if this is a new request for the interest list. An individual may request to transfer his information on an interest list in one region to another region. Refer to Section 3212.4, Transfer to Other Regions for Individuals on the Community Services Interest List (CSIL).

Earliest Date for Adding an Individual Back to the CSIL after Denial

The earliest date an individual may be added back to the CSIL for the same program the individual is denied is the date he was determined to be ineligible for the program.

Example: The individual's information is released from the CBA CSIL on Aug. 2, 2012. The case manager determines the individual is not eligible for CBA on Aug. 28, 2012 and sends notification of ineligibility. The first date the individual may be added back to the CBA interest list is Aug. 28, 2012.

The earliest date an individual may be added back to the CSIL for the same program the individual is terminated is the first date he is no longer eligible for the program.

If the individual's name is added back to the interest list prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System (SAS) will cause the name to be removed from the interest list for that program.

Example 1: An individual's CBA eligibility is terminated due to medical necessity and end on July 31, 2012. The first date the individual can be added back to the CBA interest list is Aug. 1, 2012.

Example 2: An individual's Family Care (FC) is terminated and will end on Aug. 13, 2012. The first date the individual can be added back to the FC interest list is Aug. 14, 2012. If the individual is already on the Home-Delivered Meals (HDM) interest list, the termination date for FC would not impact the individual's original date on the HDM interest list.

3212.1  Additional Procedures for Money Follows the Person

Revision 09-8; Effective September 1, 2009

Information in the Community Services Interest List (CSIL) must be accurately documented for individuals who apply for Community Based Alternatives services through Money Follows the Person (MFP) provisions. This information will provide a record of the number of persons using MFP provisions and the reasons for the success or failure of the individual to transition from a nursing facility to a community setting.

An individual who requests services using the MFP initiative is placed on CSIL for the requested service with the date of the request and a bypass code of "residing in a nursing facility." If the individual is already on CSIL for that service at the time of the request to use the MFP initiative, the bypass code "residing in a nursing facility" is added to the current CSIL record for that service. Any individual who requests a service using the MFP initiative and is recorded in CSIL with a bypass code of "residing in a nursing facility" will be released and assigned to a case manager for the eligibility determination. The release and assignment must be completed as soon as possible, but no later than two workdays following the request.

If an individual withdraws from the MFP process during the MFP enrollment/eligibility process, the individual may remain on CSIL. Staff will remove the bypass code from the CSIL record and place the individual's name back into an "open" status with the MFP request date or the original interest list date, whichever is the earliest. Staff will date and initial an explanation in the comment field of CSIL indicating the person withdrew from the MFP process, but requests to remain on the interest list. The individual will receive a new offer of services when the individual's name reaches the top of the interest list and services are available.

3212.2  Updates and Dispositions

Revision 11-1; Effective March 1, 2011

The Community Services Interest List (CSIL) must be updated to reflect accurate information.

The time frame for data entry of Community Based Alternatives (CBA) actions to CSIL is five business days. Regional staff must complete data entry to CSIL within five business days of the date:

  • an individual first requests CBA services;
  • the case manager signs Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, certifying or denying applications, except Money Follows the Person (MFP) certifications; and
  • the request for other CSIL actions (updating information, transferring an individual to another region's interest list or removing an individual from the interest list upon request by the individual).

For MFP certifications, CSIL is updated when the Service Authorization System (SAS) wizard is completed to register the initial individual service plan. Delaying data entry of the disposition status into CSIL for an applicant certified through MFP provisions avoids removing the individual from the interest list before the actual discharge from the nursing facility is verified. Refer to Section 3440.1, Registration of the Individual Service Plan (ISP), for SAS data entry time frames.

Staff must ensure CSIL closures are recorded accurately. The CSIL Closure Code User's Guide is available at http://dadsview.dads.state.tx.us/handbooks/csil.

CSIL Automated System Information

The CSIL system allows automated updates to occur whenever an individual's name is on more than one interest list at the same time. This allows personal information and contact due dates to be updated simultaneously on every interest list where the same person is listed. Therefore, when an individual is contacted to determine his continued interest in one of DADS programs, staff must also ask about the individual's continued interest in all other programs where the individual's name is listed in CSIL in "open" status. When staff update the personal information or record a contact in any program, all open records will update the next contact due date as 365 calendar days from the date of contact. When an individual indicates he is no longer interested in a program, staff should close that interest list record. Closures for specific programs do not automatically update any other interest list records, so it is necessary to manually close the record when an individual notifies DADS he is no longer interested in a program. If a person is deceased, staff should update the personal information section by checking the box labeled "deceased." When this box is checked, all CSIL records will automatically be closed.

3212.3  Monitoring

Revision 11-1; Effective March 1, 2011

To ensure the integrity and accuracy of the Community Based Alternatives (CBA) interest list, all individuals registered on the list must be contacted regularly.

Individuals on the CBA Community Services Interest List (CSIL) are contacted by telephone every 365 calendar days.

Documentation of the date, telephone number and the results of each call must be maintained. Staff completing CSIL monitoring contacts must make and document two attempts to contact the individual by telephone on two different dates, no less than one week apart. If contact is not made, Form 2247, Interest List Contact Letter, is sent to the individual requesting a response to validate continuing interest in the CBA program. The individual's name is removed from the CSIL as "unable to locate" if the individual fails to respond within 30 calendar days from the date on Form 2247. The inability to locate and closure of records at the annual monitoring contact must be documented in the CSIL record comments section.

Individuals contacting the Department of Aging and Disability Services (DADS) within 90 calendar days of the date the CSIL records were closed may have the CSIL records reopened with the original request date. Individuals contacting DADS after 90 calendar days of the date the CSIL records were closed must be registered on CSIL as a new request with the current date. These individuals are placed on the interest list effective the date of the new request. Any requests for exceptions must be submitted to the state office Program Enrollment manager.

When the closure of a consumer on the CSIL occurred during the "release" or "assigned" status, and the individual is added back to the CSIL interest list, the individual's name may be released for eligibility determination as needed to ensure the region is fully utilizing the regional slot allocation.

During routine interest list contacts, individuals who do not have a Texas address should be removed from the list and informed that they must be Texas residents to be on an interest list. Exceptions may be made for individuals who are temporarily out of the state because of military assignments.

3212.4  Transfer to Other Regions for Individuals on the Community Services Interest List (CSIL)

Revision 08-12; Effective September 30, 2008

When an individual on the CSIL requests a transfer from one region to another region, follow these guidelines.

  • An individual on an interest list who transfers to another region must be added to the new region's interest list using the original date of the request, as documented by the original region. The original request date is only transferable to the interest list for the same services or programs as originally requested.
  • The individual's interest list date and the program enrollment status in the receiving region will determine if the individual will be immediately released for eligibility determination or released at a later date.
  • The case manager or person designated to oversee the CSIL in the original region must close the CSIL entry for that region and send any relevant information to the new region's CSIL contact. The new region must update the information on the CSIL and assign the required monitoring to a staff person.
  • For consumers currently receiving Community Care for Aged and Disabled (CCAD) services and who transfer those services to another region, the new CCAD case manager must ensure the transfer of current CSIL interest lists registrations to the new region.

3212.5  Transfers Between Waiver Program Interest Lists

Revision 12-2; Effective June 1, 2012

If applicants are denied enrollment into a Department of Aging and Disability Services (DADS) waiver program based on diagnosis, medical necessity or other functional eligibility requirements, case managers will inform them that they may be placed on an interest list for an alternate program using the original Community Based Alternatives (CBA) request date. The Community Services Interest List (CSIL) state office and designated staff in the regions will have the authority to transfer applicants who are denied enrollment to any waiver list, except Home and Community-based Services (HCS). DADS staff must contact the Local Authority (LA) serving the applicant’s county of residence for applicants seeking a transfer of the interest list date to the HCS interest list.

Regional Sequence of Activities

DADS Regional staff will provide Form 2121, Long Term Services and Supports, and explain alternate service options to applicants. If applicants request placement on another program’s interest list, case managers must contact state office CSIL unit staff or the designated regional interest list staff for placement on the requested program’s interest list, as applicable. If applicants request placement on the HCS interest list, case managers must contact the LA serving the applicant's county of residence for placement on the HCS interest list.

Placement of a Person on the Interest List

When regional or state office CSIL unit staff are contacted by case managers regarding a DADS applicant who has been denied CBA, interest list staff may enter the applicant's name on an alternate program interest list using the original CBA request date. Interest list staff will confirm the original interest list date through CSIL or Client Assignment and Registration Entry (CARE) System. Staff will verify that the applicant has been denied the CBA based on diagnosis, medical necessity or functional needs. Interest list staff will use the designated code to justify the date the applicant is placed on the new interest list and notify program staff of the applicant's placement on the alternate program interest list. The interest list date and the program's enrollment status will determine if the applicant will be immediately released for eligibility determination or released at a later date.

Since the HCS interest list is not maintained in CSIL, case managers must contact the LA for applicants who were denied eligibility for CBA and requested placement on the HCS interest list. Because the LA has limited ability to back date the HCS request date, the applicant will be registered on the HCS interest list with the current date. The LA will send a written request to the LA section in DADS state office to request the HCS interest list date be changed to the original waiver request date. State office LA staff will review documentation submitted and complete the date change in the CARE System, if warranted.

3213  Conflict of Interest

Revision 13-2; Effective June 3, 2013

Department of Aging and Disability Services (DADS) staff have an obligation to report any relationship in which a conflict of interest may exist that could result in an unethical or biased business relationship. This applies to all staff involved in awarding benefits and determining eligibility for the Community Based Alternatives (CBA) program.

DADS staff must not work on or review an ongoing CBA case record, nor assist an applicant, individual or his responsible party to receive CBA services, if the applicant or individual is a relative (by blood or marriage), roommate, dating companion, supervisor or someone being supervised. DADS staff may not determine eligibility, the need for CBA services or the amount of services authorized to an individual in which the relationship may result in a conflict of interest.

DADS staff may provide anyone with an application for CBA services and information on how and where to apply. DADS staff may help anyone gather any documents the individual needs to verify eligibility and need for services, but must not take any other role in determining eligibility for CBA for an individual with whom a relationship may result in a conflict of interest.

DADS staff must consult with a supervisor if the applicant or individual is a friend or acquaintance. Generally, case managers should not work with these applicants or individuals, but the degree and nature of the relationship must be reviewed by the supervisor to determine if a conflict of interest exists.

If DADS staff have relatives (by blood or marriage), roommates, dating companions or close friends who are contracted with DADS to provide CBA services or who own or are employed by a provider that contracts with DADS to provide CBA services, staff must not demonstrate any special consideration toward that provider. Referrals to a provider must be based strictly on the applicant's or individual's preference and his need for the service the provider offers. In addition, instructions (or lack of instructions) to the provider concerning the delivery of service must be based solely on the applicant's or individual's needs and DADS policy.

If DADS staff know or suspect that a relationship may result in a conflict of interest, staff must complete Form 2115, Conflict of Interest Notification, to inform the supervisor of the relationship. The first-level supervisor must complete the supervisory response section of the form outlining what action, if any, may be necessary and return the signed/dated form to the DADS staff person who initiated the form.

Form 2115 must be completed even if no conflict of interest exists when:

  • a new employee is hired,
  • employee or supervisor transfers occur, and
  • employee evaluations are completed annually.

Staff must complete Form 2115 anytime a potential conflict of interest exists.

3300  Assessment and Eligibility Determination

Revision 11-3; Effective September 1, 2011

3310  Assignment to the Case Manager

Revision 10-1; Effective March 11, 2010

All individuals who request Community Based Alternatives (CBA) services are registered on the CBA interest list. Individuals applying for CBA using Money Follows the Person provisions will be released and assigned to a case manager at the time of intake. Individuals who have been on the CBA interest list will be assigned to a case manager upon release of their name. All releases from the CBA interest list are considered routine referrals.

During times of open enrollment, the immediate or expedited priorities apply.

Staff must provide the brochure, Consumer Directed Services Option, It's Your Choice, to individuals when their names are released from an interest list. The Consumer Directed Services brochure is located at www.dads.state.tx.us/news_info/publications/brochures/cds-itsyourchoice.pdf.

3310.1  Criteria for Determining Immediate or Expedited Response

Revision 05-5; Effective April 29, 2005

The following criteria will apply:

  • immediate — the case manager must make a face-to-face contact with the applicant within 24 hours of the request for services;
  • expedited — the case manager must make a face-to-face contact with the applicant within five calendar days of the date of the request for services;
  • routine — the case manager must make a face-to-face contact with the applicant within 14 calendar days of the date of the request for services.

The response level is assigned at the time of the intake or the service request based on the following criteria:

An applicant requires an immediate response to his service request if he has no available care giver, he has nursing or personal care needs which are not now being met, and he is unable to do without nursing or personal care services for a full day.

The following examples of situations requiring immediate response are just that – examples. This list, and other lists within this section, are not intended to be all inclusive.

If the applicant:

  • is totally bedridden or is unable to transfer from bed to chair without help,
  • cannot manage toileting tasks without personal assistance,
  • is in danger of not receiving daily nourishment because of his need for total assistance in meal preparation or feeding, or
  • is in need of nursing tasks that must be delivered on a daily basis.

An applicant requires an expedited response to his service request if he needs nursing or personal care, he has no available care giver, and his need for services has increased during the five days prior to the service request, or will increase during the five days following the service request. For example, the applicant

  • is being or has been released from a hospital or nursing home within five calendar days of the request, and has no available care giver to provide necessary care,
  • is experiencing or recovering from a major illness and has no available care giver, or
  • loses his care giver within five days of the request and has no available substitute.

Note: If the individual is being removed from the interest list and does not meet the exception criteria for bypassing the interest list, the referral is considered a routine referral.

Routine referrals are those that do not meet the criteria for immediate or expedited response.

3310.2  Releases/Assignments from the Community Services Interest List (CSIL)

Revision 08-10; Effective September 1, 2008

When funding is available, individuals are released from the Community Based Alternatives (CBA) interest list and assigned to case managers. The individual is assigned as a routine referral.

The CSIL must be updated to reflect that a case manager has been assigned to the case by entering the case manager’s budgeted job number (BJN) and the date assigned in the CSIL.

Confirmation of Choice to Apply or Not to Apply for CBA Services

Individuals assigned from the CBA interest list must have the opportunity to confirm their decision to apply or not to apply for CBA services. Individuals must make a choice within 30 calendar days of the assignment of their names to a case manager. Form 3675, Application Acknowledgment, is used to document the individual's choice.

Department of Aging and Disability Services (DADS) case managers will complete current enrollment processes, including responding to the initial request for services within 14 calendar days, per program policy found in Section 3311, CBA Enrollment Process – Initial Assessment.

The following must be completed along with the current enrollment process:

  • On the date an individual on a CBA interest list is assigned to a case manager, Form 3675 is mailed to the individual. Form 3675 provides the individual with three choices:
    • Yes, I would like to apply for CBA services. Please contact me to schedule an appointment to determine eligibility.
    • No, I am no longer interested in CBA services. Please remove my name from the interest list.
    • I am not interested in CBA at this time, but would like my name to be returned to the bottom of the CBA interest list so that I may be contacted again in the future.
  • Form 3675 instructs the individual to return the form with his selected choice by the date provided on the form, which is 30 calendar days from the date the individual is assigned to a case manager. The notification informs the individual that if Form 3675 is not returned by the date provided, the individual's name will be removed from the CBA interest list and no further action taken. If Form 3675 is received after the 30-day time frame, but the individual's signature on the form is dated on or before the 30-day time frame expires, the return of the form may be considered timely.
  • The case manager obtains a copy of Form 3675, signed by the individual during the home visit or by mail, and files a copy in the case record.

The case manager must discuss Form 3675 with the individual when calling to schedule the initial contact or request that the form be completed as the initial step during the home visit. Once the eligibility determination process is initiated, the individual is entitled to notification of the right to appeal. The following scenarios provide direction:

  • The completed Form 3675 is received from the individual before the initial contact or is obtained during the initial home visit. The form is marked, "Yes, I would like to apply for CBA services." The case manager proceeds with the enrollment process. Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is sent notifying the individual of the eligibility decision and the right to appeal.
  • The completed Form 3675 is received from the individual before the initial contact or is obtained during the initial home visit before initiation of the eligibility determination process. The form is marked, "No, I am no longer interested in CBA services" or "I am not interested in CBA services at this time, but would like my name to be returned to the bottom of the interest list so that I may be contacted again in the future." If requested, the case manager returns the individual to the CBA interest list with the new date of request. No further action is taken and the enrollment process stops; Form 2065-C is not required.
  • Form 3675 is obtained during the initial home visit. The form is marked, "Yes, I would like to apply for CBA services." The case manager initiates the enrollment process (completing eligibility forms) but later in the process, the individual decides not to continue with eligibility determination. The case manager follows procedures to deny the application based on the individual's request to withdraw. Form 2065-C is sent notifying the individual of the eligibility decision and the right to appeal.
  • Form 3675 cannot be completed during the initial home visit because the individual requests to discuss CBA services with a responsible party before signing the form. The case manager continues with the enrollment process and eligibility determination at the initial home visit. If the individual does not respond or complete Form 3675 by the 30-day time frame noted on the form, the case manager follows procedures to deny the application based on the individual's refusal to provide information. Form 2065-C is sent notifying the individual of the eligibility decision and the right to appeal.
  • Form 3675 is sent on the date the individual is assigned from a CBA interest list to a case manager. The case manager is unable to contact the individual by telephone or home visit. The individual does not respond or submit the completed form by the 30-day time frame noted on the form. No further action is taken and Form 2065-C is not required.
  • Form 3675 is received before the 30-day time frame marked, "Yes, I would like to apply for CBA services." The case manager has previously been unable to contact the individual. The case manager contacts the individual and proceeds with the enrollment process. Form 2065-B or Form 2065-C is sent to notify the individual of the eligibility decision and the right to appeal.
  • Form 3675 is sent on the date the individual is assigned from a CBA interest list to a case manager. The case manager is unable to contact the individual by telephone or home visit. Form 3675 is received after the 30-day time frame. The case manager determines if the signature date on the form is on or before the 30-day time frame. If so, the case manager proceeds with the enrollment process. Form 2065-B or Form 2065-C is sent notifying the individual of the eligibility decision and the right to appeal. If the signature date on Form 3675 is after the 30-day time frame or missing, the case manager offers the individual the opportunity to be placed at the bottom of a CBA interest list. No further action is taken and Form 2065-C is not required.

Staff must ensure the CSIL is updated to reflect the disposition status of all individuals assigned from the CBA interest list. The case manager should follow up by telephone and document reasonable attempts to obtain a signed copy of Form 3675 when the form cannot be obtained at the initial face-to-face contact or when the consumer withdraws during the telephone call to set up the initial home visit.

3310.2.1  Release/Assignment of an Individual from the Community Services Interest List (CSIL) Who Requests Services in Another Region

Revision 08-1; Effective January 18, 2007

It is imperative that both regions coordinate appropriate actions when an individual is released from the interest list in a service area where he does not live. The individual must move to or live in the region where his name is released from the interest list to be eligible for services. To accomplish this, the following steps must be taken.

  1. The designated CSIL staff in the releasing region will provide notification of release to the designated CSIL staff in the region where the individual resides and is also on the CSIL.
  2. The application is assigned to a case manager in the region where the individual lives to begin assessment procedures as outlined in Section 3300, Assessment and Eligibility Determination.
  3. The case manager in the region where the applicant lives will assist the applicant in selecting a provider to perform the pre-enrollment assessment.
  4. The case manager in the new region forwards a provider choice list to the case manager in the region where the applicant lives for the applicant to select a provider for ongoing services.
  5. The case manager in the region where the applicant lives receives the pre-enrollment assessment, develops a draft individual service plan (ISP), sends the ISP to the provider in the new region for acceptance, and coordinates and develops the final ISP.
  6. Once the ISP is finalized, both case managers coordinate a start of care date to coincide with the applicant's move.
  7. The case manager in the region where the applicant lives completes all Service Authorization System (SAS) entries and sends Form 2065-B, Notification of Waiver Services, to the applicant and providers in the gaining region.
  8. The case manager in the region where the applicant lives forwards the case folder to the new case manager within three workdays of completion of the case in SAS.
  9. The new case manager contacts the consumer upon arrival in the new location and makes any other necessary changes in the SAS system.
  10. The new case manager completes the 30-day contact.
  11. The case manager in the region where the consumer lived updates that region's CSIL with the case disposition.
  12. The new case manager checks and updates that region's CSIL.

It is the responsibility of both the new case manager and the case manager where the individual lived to assist with the resolution of questions or changes requested by the provider.

3310.3  CBA Referrals for Applicants Temporarily Out of County of Residence

Revision 11-1; Effective March 1, 2011

Usually, the case manager responsible for the county in which the applicant resides handles the Community Based Alternatives (CBA) application for that individual. If the applicant is temporarily not in the county of residence, the processing of the application may be initiated by a case manager responsible for the area where the applicant is temporarily located. Staff in the applicant's county of residence may ask staff in the county where the applicant is temporarily located to initiate the processing of the application and to forward the information obtained to the case manager in the applicant's county of residence.

Activities that might be expected of the case manager in the county where the applicant is temporarily located include, but are not limited to:

  • interviewing the applicant or responsible party;
  • assisting the applicant/responsible party in completing applications and obtaining verifications or records available in the temporary area;
  • arranging for assessment by a Home and Community Support Services Agency (HCSSA) registered nurse, if possible, or obtaining the information on the applicant's medical necessity and service needs from other sources such as the hospital or nursing facility where the applicant is temporarily located;
  • informing and forwarding information obtained to the case manager in the receiving county of the work completed on the applicant's request for CBA services; and
  • performing activities the two case managers have mutually agreed upon.

The case manager for the applicant's county of residence is responsible for the overall determination if the applicant meets the eligibility criteria and is responsible for initiating services following the development and approval of an individual service plan for CBA services. The case manager in the applicant's county of residence may choose, based on regional administrative decision, to handle the entire processing of the CBA application without involving staff in the area where the counties disagree about their respective roles. The program managers for the areas involved must be informed of the situation and must resolve the disagreements.

Note: An individual who may complete or sign an application for a consumer may not be on the list of people to whom the Department of Aging and Disability Services can release the consumer's individually identifiable health information. See Section 1819, Personal Representatives, for individuals who may receive or authorize the release of a consumer's individually identifiable health information under Health Insurance Portability and Accountability Act privacy regulations.

3310.4  Nursing Facility Diversion Procedures for People at Imminent Risk of Nursing Facility Placement

Revision 13-3; Effective September 3, 2013

As a new Promoting Independence initiative to divert people in a crisis situation from entry into a nursing facility (NF) and as part of the Department of Aging and Disability Services (DADS) Legislative Appropriations Request for Promoting Independence in the 82nd Legislative Session, the Community Based Alternatives (CBA) program was allotted 100 NF diversion slots for the Fiscal Year (FY) 2012 and FY 2013 biennium. The slots are to be allocated throughout the year at 50 slots per year over the two fiscal years.

The purpose of the initiative is to prevent institutionalization of people who are at imminent risk of entering an NF. The slots are available for any individual requesting services who has a catastrophic episode that precipitates consideration of immediate placement in an NF. The following are examples of a catastrophic episode:

  • An individual is significantly dependent on a caregiver to remain in the community and the caregiver passes away or is suddenly no longer able to provide care.
  • An individual has a community support system, but must suddenly move where there is no support system.
  • Any situation where an individual has a sudden occurrence that would cause imminent placement in an NF because he cannot care for himself.
  • An individual identified by Adult Protective Services as being at imminent risk of NF placement.

Identifying People at Imminent Risk of NF Placement

Every call for an individual requesting services must be screened for an NF diversion slot. In order to identify whether someone is at imminent risk of NF placement, the intake screener follows current procedures for Intake (NTK) data entry. If the individual requesting services requires skilled nursing or administration of medication, the intake screener must ask, "If the individual cannot get the help he needs at home, is there a chance he would have to move to a facility?" If the answer is "No," the intake screener continues with the intake. If the answer to the question is "Yes," then the intake screener proceeds to the NF Diversion tab.

  • On the NF Diversion tab in NTK:
    • if the individual answers "Yes" to the first two screening questions, then the individual meets the initial screening criteria for an NF diversion slot.
    • if the individual answers "No" to any of the first two questions, then the individual is not referred for an NF diversion slot.
  • The NTK intake is completed and appropriate referrals to other resources and services must be made.
  • The individual is placed on the CBA interest list whether he meets the criteria for an NF diversion slot or not.

The intake screener must determine if a referral to Adult Protective Services (APS) is appropriate for this crisis situation and make the referral, if necessary. The intake screener also makes any other appropriate referrals at this time for other DADS services or resources outside of DADS.

For an individual currently receiving DADS services other than CBA who has a crisis situation, the case manager or person identifying the crisis situation refers the individual to the intake screener for the initial NF diversion slot screening.

Form 2110-A, Community Care Intake Nursing Facility Diversion Slot Screening, may be printed off of NTK when the intake is completed. Form 2110-A must be attached to Form 2110, Community Care Intake.

Process for Checking Slot Availability

Once the individual requesting services is determined to meet the criteria for a diversion slot, the intake screener calls the Community Services Interest List (CSIL) unit at state office (1-877-438-5658) to request the individual be placed in the Nursing Facility Diversion (NFD) queue for a slot. Due to the limited number of NF diversion slots, the slots will be allocated on a first come, first served basis and all names are placed in the queue. The CSIL unit staff locate the CBA CSIL record, verify the interest list (IL) number and add the individual to the NFD queue. The CSIL system will be used for tracking NF diversion slots. After all slots are filled, they will be tracked and reused through attrition.

If an NF diversion slot is available, the CSIL unit staff contacts the regional director or designee to advise him of the slot availability and the individual is assigned to a case manager. The regional designee must contact the CSIL unit and provide the case manager assignment by name and budgeted job number (BJN) within the same day. The CSIL unit staff enter the case manager assignment and the individual is placed in assigned status in the NFD queue.

If an NF diversion slot is not available when an individual meets the screening criteria, the individual’s name will be placed in the NFD queue and will remain in the queue for 60 days. As a slot becomes available, the next individual in the NFD queue will be assigned the slot. At the end of the 60th day, the individual’s name will be removed from the queue on the assumption that the crisis situation has been resolved. The individual’s name will remain on the CBA interest list.

Process for Assignment of the Immediate Intake

When the regional director or designee is advised a slot is available and an individual is released from the NFD queue, a case manager will immediately be assigned for an immediate intake. See Section 3310.1, Criteria for Determining Immediate or Expedited Response, for procedures to follow for an immediate response to an intake. The case manager must conduct a face-to-face contact within 24 hours of the time of the assignment.

Case Manager Procedures During the Face-to-Face Contact

The case manager must be prepared to use his assessment skills and be sensitive to the crisis situation the applicant may be experiencing. The case manager must also be alert to assessing the applicant’s current situation and whether immediate action may be required for the applicant’s health and safety.

During the face-to-face contact, the case manager completes Page 2 of Form 2110-A to assure the applicant continues to meet the criteria for an NF diversion slot. If the case manager determines the applicant meets the criteria, he proceeds with the assessment for CBA services following the procedures in Section 3311, CBA Enrollment Process — Initial Assessment.

Additionally, the case manager must discuss with the applicant:

  • the amount of time it will take to complete the CBA enrollment process, which may depend upon the applicant's Medicaid status;
  • whether the applicant has informal supports, resources for assistance or temporary arrangements to meet his needs until CBA services begin; and
  • if there are circumstances or conditions that require a referral to APS. If so, the referral must be made. APS may be able to temporarily provide assistance to the applicant allowing him to remain at home while CBA eligibility is determined.

If the case manager determines the applicant no longer meets the criteria for an NF diversion slot, the case manager makes appropriate referrals for other services and notifies the regional designee and the CSIL unit by telephone within the same day that the NF diversion slot will not be used.

Financial Determination for Applicants Who Do Not Have Medicaid

The Medicaid for the Elderly and People with Disabilities (MEPD) Program has agreed to assist in expediting the NF diversion slot applications for applicants who do not have Medicaid. The process for these applications is streamlined and does not follow the normal procedures for sending an application to MEPD as outlined in Section 3313, Referral for Medicaid Eligibility Determination. The case manager completes a manual Form H1746-A, MEPD Referral Cover Sheet (not the automated version), and enters, "NF Diversion Crisis Slot" at the top of Form H1746-A and Form H1200, Application for assistance — Your Texas Benefits.

On Form H1746-A, the case manager must mark "Application" and enter "Expedited Application- NF Diversion Crisis Slot." In additional comments, the case manager may enter any additional information relevant for the MEPD specialist. All verifications the MEPD specialist may need to determine financial eligibility must be attached.

Form H1746-A and Form H1200 will not be sent to the Document Processing Center in Midland. The case manager will hand deliver or fax the forms to the regional MEPD program manager. If faxed, the case manager calls the MEPD program manager to advise the expedited application has been faxed. The MEPD program manager assigns the case to an MEPD specialist as an expedited application. The MEPD program manager or the specialist assigned will contact the case manager to tell him who the MEPD specialist is that will be completing the financial application.

Due to the expedited nature of the application, the case manager will assist the MEPD specialist, if requested, in obtaining any missing documentation for the applicant.

The case manager must advise the MEPD specialist by telephone or email as soon as medical necessity (MN) is determined and available in the Texas Medicaid & Healthcare Partnership (TMHP) online portal. The case manager must also follow up by entering the information in the Eligibility Data Exchange and Notification (EDEN) system. Refer to Section 3432.3, Procedures for Texas Integrated Eligibility Redesign System (TIERS) Applicants, for EDEN procedures to transmit MN and ISP information to MEPD. As soon as all the information is complete, the MEPD specialist and case manager coordinate to establish a medical effective date (MED) and the case manager can authorize CBA services to begin.

Disability Determinations

If the applicant is under 65 years of age and needs a disability determination, the case manager must complete Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, obtain all of the medical records possible, and follow procedures in Section 3545, Disability Determination for Applicants Under Age 65 Applying for Services. The case manager must write in bold letters, "NF Diversion Crisis Slot" at the top of Form H3034 and Form H3035. Form H3034, Form H3035 and the medical records will be sent to the assigned MEPD specialist and the MEPD specialist will forward to the Disability Determination Unit (DDU). The case manager will assist in gathering additional information required by the DDU to expedite the process. The MEPD program manager will be tracking the progress of the MEPD application and expediting the process for a quick financial eligibility determination.

Expedited Referral to the HCSSA for the Pre-enrollment Assessment and Start of Services

Within 24 hours of the face-to-face contact, the case manager must initiate an expedited referral to the Home and Community Support Services Agency (HCSSA) for the pre-enrollment assessment. The NF diversion slot applicant is designated as a priority status applicant. See the procedures in Section 3312, Referral for Pre-Enrollment Home Health Assessment. According to procedures, the case manager negotiates an assessment completion date. The case manager must explain the referral is for an NF diversion slot and the applicant is in a crisis situation. The negotiated date must be as short a time frame as possible. The case manager completes Section A of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, and writes, "NF Diversion Crisis Slot" at the top of the form. Form 3676 is faxed to the selected HCSSA.

As soon as the pre-enrollment assessment packet is received and all other eligibility requirements are met, including MN and financial eligibility determination, the case manager must negotiate a start-of-care date with the HCSSA to begin services as soon as possible. The case manager must use enrollment code, 17 – COMMUNITY – Diversion Slot, from the Service Authorization System (SAS) drop down list in the Enrollment record "Enrolled From" field.

Tracking of the NF Diversion Slots in CSIL

The CSIL system will be used to track the allocation of NF diversion slots. Upon return from the face-to-face contact, the case manager must advise the regional designee and the CSIL unit of the status of the intake so the CSIL unit can update the system appropriately. If the case manager determines the applicant does not meet the criteria for an NF diversion slot, the CSIL unit staff will update the NFD queue using the closure reason provided by the case manager.

If at any time after the enrollment process begins, the case manager determines the applicant will not be enrolled in CBA, the case manager or regional designee must notify the CSIL unit on the same day he learns the NF diversion slot will not be used. The CSIL unit will remove the applicant’s name from the NFD queue using the closure reason provided by the case manager and release another name from the queue. Failure to be enrolled using the NF diversion slot will not affect the individual’s position on the CBA interest list, unless the CSIL record is closed due to death. Due to the limited number of NF diversion slots, it is extremely important to coordinate all actions with the CSIL unit staff. Regional staff will close the CSIL record when an individual is enrolled to receive CBA services. The CSIL unit staff will close the NFD queue.

3311  CBA Enrollment Process — Initial Assessment

Revision 13-2; Effective June 3, 2013

When an assignment is received, either through release from the Community Based Alternatives (CBA) interest list or by meeting current criteria for bypassing the interest list, the case manager must begin the assessment process. The case manager reviews and confirms the response level of the intake according to the guidelines in Section 3200, Intake and Interest List Procedures, and changes the response level, if appropriate. The case manager makes a face-to-face contact to complete the initial contact with the applicant according to the appropriate response level.

The case manager also reviews Form 2110, Community Care Intake, for the key information necessary for eligibility determination. The case manager determines if the applicant:

  • has current Medicaid status by viewing the Texas Integrated Eligibility Redesign System (TIERS) status, or appears to be financially eligible for CBA if the applicant is not currently receiving Medicaid;
  • has a current medical necessity (MN); and
  • is currently receiving Home and Community-based Services (HCS), Texas Home Living (TxHmL) or Local Authority general revenue services by viewing the Client Assignment and Registration (CARE) system. See Appendix XXI, Instructions and Access to CARE, for procedures for accessing the CARE system.

The case manager checks the mutually exclusive chart for programs that are not mutually exclusive. See Appendix XII, Mutually Exclusive Services, for the chart.

Within 14 calendar days of assignment of a routine release of an applicant from the CBA interest list or an applicant who meets Money Follows the Person (MFP) provisions, the case manager makes a face-to-face contact.

The following is an overview of the items to be covered by the case manager during the initial assessment. Detailed information of each step is provided in the following handbook items.

  1. Explain to the applicant the basic eligibility requirements.
  2. Explain to the applicant the choice of services available through the CBA program and clarify that some services available through other sources may be mutually exclusive and no longer available while receiving CBA services. Present Form 2121, Long Term Services and Supports. Document in the case record and Form H1746-A, MEPD Referral Cover Sheet, that Form 2121 was presented. Send Form H1746-A to Medicaid for the Elderly and People with Disabilities (MEPD) at the same time the financial application is sent for processing.
  3. Present the possible living arrangement options available to the applicant within the CBA program and the array of services available in each setting. Discuss the applicant's need for services to begin identifying which options will best meet the applicant's needs.
  4. Obtain the applicant’s signature on Form 3675, Application Acknowledgment, confirming the applicant’s choice regarding CBA services.
  5. Complete the functional assessment for personal assistance services (PAS) hours, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, if applicable.
  6. Identify any third-party resources, additional services and informal support systems available to the applicant. Explore the use of those resources and methods of accessing them. Document all available resources on Form 8598, Non-Waiver Services. Obtain informal supports signatures or verbal agreements, as applicable.
  7. Begin the financial eligibility process. If the applicant currently is Medicaid eligible, verify information in TIERS and document Medicaid eligibility in the case record. If the applicant is not Medicaid eligible or requires a program transfer from one Medicaid program to Waiver Medicaid, assist the applicant in completing Form H1200, Application for Assistance – Your Texas Benefits, and obtain all verifications that are available. Send Form H1200 to MEPD for processing.
  8. Present and review the Medicaid Estate Recovery Program (MERP) information. Obtain the applicant's signature on Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgment, and complete other MERP activities.
  9. Discuss the MFP option and requirements, if applicable, including Transition Assistance Services and referral to a relocation specialist. Complete Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, if applicable.
  10. Present the Consumer Directed Services option and obtain the applicant's choice.
  11. Review Form 2307, Rights and Responsibilities, along with Form 2307-C, CBA Eligibility Criteria and Responsibilities, and obtain the applicant's signature on Form 2307. If the applicant has requested Emergency Response Services, also review Form 2307-B, ERS Eligibility Criteria and Responsibilities. If the applicant has requested Adult Foster Care, review Form 2307-F, AFC Rights and Responsibilities.
  12. Obtain the applicant's choice of a Home and Community Support Services Agency (HCSSA). Explain the HCSSA's role in assessing the applicant's needs, which includes completing the medical information to obtain the MN determination required for CBA eligibility.
  13. Provide the applicant the opportunity to register to vote.

The case manager must present Form 2121 at the initial assessment, or upon request.

Note: A person who may complete or sign an application for an applicant may not be on the list of people to whom the Department of Aging and Disability Services can release the applicant's individually identifiable health information. See Section 1854, Personal Representatives, for people who may receive or authorize the release of an applicant's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

3311.1  Applicant Choice Among Services

Revision 13-2; Effective June 3, 2013

The case manager must explain to the applicant that he must choose between particular services considered as mutually exclusive. The applicant cannot receive services from:

  • more than one Medicaid 1915(c) waiver program at a time, including the waiver programs known as Home and Community-based Services (HCS), Community Living Assistance and Support Services (CLASS) or Deaf Blind with Multiple Disabilities (DBMD);
  • a waiver program and a Medicaid institutional program;
  • a waiver program and the Program of All-Inclusive Care for the Elderly (PACE);
  • a waiver program and other Community Care for Aged and Disabled programs (with the exception of Day Activity and Health Services (DAHS), unless the individual receiving Community Based Alternatives (CBA) services resides in a CBA Level III Adult Foster Care (AFC) home); and
  • a waiver program and In-Home and Family Support Program (IHFSP). The individual enrolled in IHFSP must use other available services, including placement on interest lists for services. The individual enrolled in IHFSP must provide a compelling reason why he should not be placed on other services. Failure to comply may result in termination of the IHFSP. Effective Jan. 1, 2007, the Medicaid Estate Recovery Program (MERP) is no longer considered a compelling reason for an individual enrolled in IHFSP to refuse to accept CBA or CLASS. Any individual enrolled in IHFSP who used MERP as a compelling reason before Jan. 1, 2007, may continue to receive IHFSP services as long as he wishes. If the individual enrolled in IHFSP is determined to be eligible for and decides to receive services from a Medicaid waiver program, IHFSP will be terminated. The CBA case manager must coordinate this with the IHFSP case manager.

Within the waiver, some services are mutually exclusive. Example: Personal assistance services are not authorized when the individual resides in an assisted living facility.

DAHS must not be authorized for an individual residing in a Level III AFC home. An individual who resides in an AFC home (other than Level III) may receive up to two units of DAHS per day. An individual who resides in an assisted living facility may receive only one unit of DAHS per day. An individual who resides in his own home may receive up to two units of DAHS per day. To be eligible for DAHS, the individual must meet the medical criteria for the DAHS program, which includes having a medical diagnosis and physician's orders requiring care, monitoring or intervention by a licensed vocational nurse or a registered nurse.

The applicant is given the choice among services he is eligible to receive with the understanding that the mutually exclusive services he is receiving, or could receive, will not be available to him. (See Section 3311.2.4, Mutually Exclusive Community Based Alternatives Services.)

3311.2  Living Arrangement Options

Revision 12-2; Effective June 1, 2012

§48.6003 — Eligibility Criteria.

(b)
To be determined eligible by the Department of Aging and Disability Services (DADS) for the CBA Program, an individual must:
(10)
reside in:
(A)
the individual's own home;
(B)
a licensed assisted living facility contracted with DADS to provide CBA Program services; or
(C)
an adult foster care home contracted with DADS to provide CBA Program services;
(11)
not reside in an institutional setting, including a hospital, a nursing facility, an intermediate care facility for persons with mental retardation, or a facility required to be licensed as an assisted living facility but is not licensed;

As part of the assessment process, case managers are responsible for presenting living arrangement options to the Community Based Alternatives (CBA) applicant and individual and assisting him in exploring those options. The case manager must explain the various residential options available to the applicant or individual in the geographic area. The options may include:

  • Assisted Living (AL) apartment settings;
  • Residential Care apartment or Non-apartment settings;
  • Adult Foster Care (AFC) settings; or
  • the applicant's own home or other independent living arrangements with other people.

Eligibility criteria must clearly be explained to the applicant or individual regarding living arrangements. CBA services may not be provided to people residing in:

  • hospitals,
  • intermediate care facility for persons with intellectual disability,
  • nursing facilities,
  • unlicensed personal care facilities,
  • AFC homes not contracted with DADS to provide CBA services, or
  • licensed personal care facilities not contracted with DADS to provide CBA services.

If an applicant or individual is interested in AL or AFC services, a list of contracted and licensed AL facilities and AFC homes in the area is provided. The applicant or individual chooses an AL facility or AFC home from the list. Personal care facilities contract with DADS for a certain number of beds (apartment, private room, double occupancy room, bed) for CBA services. The contracted facility must have an available CBA bed; if not, the applicant or individual may request that his name be placed on the facility's interest list.

An individual may not privately pay an AL facility or AFC home and receive other CBA services from the Home and Community Support Services Agency. The cost of the AL or AFC services must be covered through the CBA program to access any other CBA services. The individual may receive CBA services in another contracted CBA facility that has a CBA bed or in another CBA living arrangement option until the chosen facility is available to provide CBA services. Contracted facilities may amend their contract to increase the number of CBA beds.

If an applicant or individual is in a personal care facility that is not contracted with DADS to provide CBA AL or AFC services, the case manager must determine if the applicant or individual is in a setting that may be considered the applicant's or individual's own home to meet CBA eligibility criteria. The case manager must determine if the facility is, is not or should be licensed. In general, facilities that only provide room and board to four or more persons do not require a license; facilities that provide personal care assistance do require a license. The case manager may check with the facility regarding licensure, or if unable to verify with the facility, contact Licensing and Certification at state office, telephone 512-438-2630, to determine if a particular home or facility is required to be licensed. If the case manager learns of an unlicensed personal care facility that should be licensed, a complaint should be filed with the Consumer Rights and Services hotline, telephone 1-800-458-9858. Medicaid services may not be delivered in an unlicensed facility that is required to be licensed.

If the facility is licensed or should be licensed, the arrangement cannot be considered the applicant's or individual's own home for meeting CBA eligibility criteria. Facilities that have a license or should be licensed must contract with DADS to deliver CBA services. Once contracted, the facility provides CBA AL or AFC services along with other appropriate CBA services.

If the facility is not and should not be licensed, it may be considered the applicant's or individual's home. CBA AL or AFC services are not provided in these settings. The applicant or individual may privately pay the unlicensed facility and receive CBA services that are provided in an individual's home. The case manager should ensure CBA services authorized do not duplicate any services provided by the facility. For example, some facilities provide housekeeping. The case manager should review the needs of the applicant or individual before authorizing housekeeping tasks as part of personal assistance services on the CBA individual service plan.

Some facilities are licensed by the Department of State Health Services as a Special Care Facility. These facilities may provide extended care or care for the terminally ill in an AL-type setting. If the facility is licensed, it may not be considered the applicant's or individual's home. An applicant or individual may not receive CBA services in the Special Care Facility unless it is contracted with DADS to provide CBA services.

If an individual's needs change and a supervised setting is required, the case manager must explain that CBA services can only be delivered in settings that meet the eligibility criteria. The individual will lose CBA eligibility and Medicaid (if non-Supplemental Security Income) if he moves to a setting that does not meet the criteria.

3311.2.1  Exploring Options

Revision 02-0; Effective April 4, 2002

The case manager must assist the client if they wish to explore the residential options and must offer the applicant a choice of the residential option which are appropriate to his needs and available in his geographical area. It may be necessary to arrange visits to various residential settings that are available so the applicant can make an informed choice. The case manager must explain the room and board charges and copayment requirements for the AL/RC and AFC settings.

The applicant who is planning to remain in his own home or return to his own home from a nursing facility may not need to visit an alternate residence prior to enrollment, but needs to be aware that alternatives are available should his circumstances change.

The applicant's preference for his living location should be determined before the development of the ISP, because the residential setting has a significant impact on the ISP and on eligibility determination.

3311.2.2  Assisted Living/Residential Care (AL/RC) Option

Revision 09-4; Effective March 27, 2009

Community Based Alternatives (CBA) consumers who wish to reside in a personal care facility must reside in a licensed assisted living facility which is contracted with the Department of Aging and Disability Services to provide CBA services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services to four or more persons who are unrelated to the owner. The consumer will be required to pay room and board and possibly a copayment based on income in the assisted living setting. See Section 3500, Financial Eligibility, for detailed information.

3311.2.3  Adult Foster Care (AFC) Option

Revision 02-0; Effective April 4, 2002

Adult Foster Care (AFC) provides a 24-hour living arrangement in a DADS-enrolled foster home for person who, because of physical or mental limitations, are unable to continue independent functioning in their own homes. The CBA AFC participant must reside in the CBA AFC home. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living, supervision and the provision of or arrangement of transportation. There are three levels of AFC and the recommendations of the HCSSA nurse regarding the appropriate level of AFC must be considered. The participant will be required to pay Room and Board and a Copayment based on income. See Section 3500 for detailed information.

3311.2.4  Mutually Exclusive Community Based Alternatives Services

Revision 13-2; Effective June 3, 2013

The following Community Based Alternatives (CBA) services are considered to be mutually exclusive, and are not allowed in the CBA program:

  • An individual may receive only one rate (level) of Adult Foster Care (AFC) for a time period.
  • An individual residing in an Assisted Living (AL) facility may not receive AFC for the same time period.
  • An individual residing in a CBA AL facility may not receive Emergency Response Services (ERS), Respite or Personal Assistance Services (PAS).
  • An individual residing in a CBA AL facility, Type B, may not receive Minor Home Modifications (MHM).
  • An individual residing in an AFC home may not receive Respite, ERS or PAS.
  • An individual receiving out-of-home respite in a nursing facility may not receive any other CBA service except for therapies, adaptive aids that he will take with him when he returns to his own home, and MHM that are being completed at his home.
  • An individual receiving respite in an AFC home or AL facility may not receive PAS.
  • An individual receiving in-home respite may not receive PAS, AFC, AL or any category of out-of-home respite for the same period of time.

3311.3  Reserved for Future Use

Revision 13-2; Effective June 3, 2013

3311.4  Functional Assessment for Personal Assistance Services

Revision 13-2; Effective June 3, 2013

If the individual requests personal assistance services (PAS), Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must be completed. Form 2060 is used to assess the individual's functional limitations and determine the number of minutes for personal care and household PAS tasks needed per week.

Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, is also used to document the individual's need for protective supervision; extension of therapy; delegated nursing tasks, health maintenance activities or non-delegated nursing tasks as identified on Form 3671-C, Nursing Service Plan, or Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs); Consumer Directed Services (CDS); and other delegated nursing to PAS tasks not identified and listed on Form 3671-C or Form 2060. Form 2060-A cannot be completed until Form 3671-C or Form 3671-C-Alternate is received from the Home and Community Support Services Agency (HCSSA).

Form 2060 and Form 2060-A are used at the initial enrollment, annual reassessment and changes for PAS.

Form 2060 includes the mandatory Task/Minute and Subtask Guide that is used to allocate minutes for purchased tasks. The guide provides a uniform approach in the authorization of services. The impairment score for each task has a minimal and maximum time that can be allotted. Times outside the minute range may not be allotted without a documented reason and documented supervisory approval. Subtasks for each task must be checked as a way to document the type of assistance needed and to support the time allocated for the task.

Note: The case manager has the option of checking Form 2060 subtasks in the Service Authorization System (SAS) Functional Wizard until SAS is re-programmed to make the subtasks match Form 2060 subtasks.

The case manager sends Form 2060, including Part C, Task/Minute Subtask Guide (Pages 3 and 4), the SAS Auto Form 2060 and Task/Hour Guide, along with Form 2060-A, to providers. This provides additional information to the provider on the tasks/subtasks the individual has indicated he needs performed and the number of days per week a plan is to be delivered. Subtasks may or may not be reflected on the Auto Task/Hour Guide at the option of the case manager. The forms are sent for every initial enrollment, annual reassessment or change in the PAS authorization.

The case manager must complete the handwritten Form 2060, including Part C, Task/Minute Guide, during the assessment with the applicant or individual and retain all pages in the case record. The handwritten Form 2060 and Task/Hour Guide is the official record of the assessment and tasks to be purchased. File a copy of the SAS Auto Form 2060 in the case record along with the handwritten Form 2060.

See the forms section for detailed instructions for completing Form 2060 and Form 2060-A. Form 2059-W, Summary of Consumer's Need for Service Worksheet, is an optional form that may be used during contact with the individual to record information to be entered into the SAS CBA Wizard.

3311.4.1  Delegated Nursing Tasks

Revision 13-2; Effective June 3, 2013

The Board of Nursing (BON) allows a registered nurse (RN) to delegate the delivery of certain nursing tasks to an unlicensed attendant under her supervision or Adult Foster Care (AFC) provider when the individual’s medical condition is stable and predictable. When appropriate, the delegation of nursing tasks to an attendant or AFC provider can be a cost-effective service delivery alternative that maximizes the resources available to an applicant or individual through the Community Based Alternatives (CBA) program. Section 4100, Home and Community Support Services, includes specific policies and procedures related to delegation. The RN exercising the right to delegate nursing tasks uses professional judgment in evaluating the applicant's or individual's needs and ability to participate in supervision of the tasks, determining the specific tasks to be delegated, the ability of the attendent to perform the delegated tasks, and the frequency of supervision or monitoring of the tasks.

The case manager must:

  • be sensitive to the professional judgment of the RN in her decision regarding delegation; and
  • consider the financial implications of the cost of direct nursing care as opposed to the cost for the provision of these tasks through delegation to an attendant or AFC provider.

The following circumstances are situations in which delegation would not be appropriate:

  • the applicant's or individual's medical condition is not stable and predictable;
  • the criteria for delegation according to the rules promulgated by the BON are not met;
  • the physician assesses and orders tasks to be performed only by licensed nurses due to complexity and circumstances; or
  • the applicant or individual refuses delegation of nursing tasks.

The decision to delegate tasks for an applicant or individual is documented on Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, and in other documentation necessary for the provision of services. The time required for the attendant to perform the delegated tasks is authorized on Form 2060-A as a personal assistance services (PAS) task.

The need for assistance in ambulation may be either a PAS or a nursing task depending on the assessment by the nurse on Form 3671-C or Form 3671-C-Alternate. When doing the functional assessment on Forms 2060 and 2060-A, the case manager must consider the Home and Community Support Services Agency (HCSSA) nurse's assessment on the applicant's or individual's need for ambulation, as documented on the nursing assessment on Form 3671-C or Form 3671-C-Alternate. The case manager should not authorize ambulation as a PAS task on Form 2060 if it is being done as a nursing task. Ambulation, as a delegable nursing task (as identified in Item 10 on Form 3671-C or Form 3671-C-Alternate) requires nursing intervention in response to a specific condition of the applicant or individual. The physician may or may not order specific ambulation orders.

As an example, the physician may order "ambulation or activity as tolerated" for an individual with congestive heart failure. This individual experiences increased shortness of breath when ambulating. The nurse intervenes and delegates how to perform the ambulation, "to walk no more than 10-15 steps without resting 1-2 minutes while taking several deep breaths before starting to walk again. Attendant to support the individual on one side while walking by holding on to his elbow."

Ambulation as a PAS task involves non-skilled assistance with walking or transferring while taking the usual precautions for safety, i.e., standby assistance, gentle support of an elbow for balance or assuring balance of walker. This does not involve nursing intervention. No special precautions are needed other than for safety measures.

As part of the RN's responsibility to supervise the provision of delegated tasks, the RN will periodically assess the attendant’s ability to perform the delegated task and the individual’s overall health status and response to the delegated task. If the RN's assessment is that the attendant is not performing the tasks properly, the delegation to that particular attendant must stop. The HCSSA must continue to meet the nursing needs of the individual. If the unsatisfactory attendant is an HCSSA employee, the HCSSA must assure that the individual does not experience a break in service. The individual’s desire to retain an attendant to whom the RN will not delegate must be considered; however, the case manager should help the individual understand the cost implications of the alternatives he selects on the revised service plan. If the unsatisfactory provider is an AFC provider, the case manager must follow the procedures described in Section 4122.5, Nursing Services in Adult Foster Care Homes, Levels I and II.

3311.4.2  Family Members and Informal Supports

Revision 13-2; Effective June 3, 2013

As part of the functional assessment, the case manager determines the personal assistance services (PAS) tasks the applicant or individual needs and the estimated hours necessary to meet those needs. The determination of need for a particular task is based on the applicant's or individual’s functional impairment to complete that task and if the task will be completed by other sources including unpaid caregivers such as family members or other informal supports. PAS, including protective supervision, cannot be authorized if there is not a need for PAS tasks. Refer to Section 3311.4.4, Authorization of Protective Supervision as a Personal Assistance Service Task.

The individual service plan (ISP) must be developed considering the needs of the applicant or individual and the stated intentions and willingness of the caregiver to provide unpaid care. The ISP will include the purchase of those needed tasks that will not be provided by another source or the caregiver. The caregiver should be asked which tasks he will provide without payment through the Community Based Alternatives (CBA) program.

A family member, except a spouse, may be employed by the Home and Community Support Services Agency (HCSSA) as a paid attendant in the CBA program.

The case manager must decide how many PAS hours to authorize when the caregiver is requesting to be the paid attendant. The case manager documents the applicant's or individual’s preference that the caregiver be hired as the paid attendant on Form 2067, Case Information, sent at the time of the written referral to the HCSSA. The case manager must identify the caregiver on Form 2067 and notify the HCSSA that the caregiver may not provide protective supervision if hired as the paid attendant of the HCSSA.

If a family member or other unpaid informal support provides personal care and certain nursing functions, the cost of an individual's care can be more cost-effective. If the ISP includes such arrangements, the case manager follows the policy below to document the agreements based on the type and importance of support provided by the family member or other unpaid support.

All necessary informal support signatures or verbal agreements are required before initial enrollment or annual reassessment.

The HCSSA and case manager are responsible for ensuring the individual's health and welfare and development of an ISP, which includes all necessary elements to adequately meet the individual's needs. Use of informal supports, third-party resources and other community resources is an integral part of the overall development of the ISP and ensures the most cost-effective use of Medicaid funds.

Informal Support Providing Nursing Tasks

Documenting the informal support agreement to perform nursing tasks is a necessary component in developing the ISP and ensuring the individual's health and welfare. If an informal support is performing any nursing tasks as noted on Form 3671-C, Nursing Service Plan, or Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), the HCSSA nurse obtains the signature on the form.

The case manager is not required to document nursing tasks being provided by informal support or obtain a signature on Form 8598, Non-Waiver Services. Form 3671-C or Form 3671-C-Alternate documentation obtained by the HCSSA nurse is sufficient.

Informal Support Providing Personal Care and Household Tasks Necessary for Daily Functioning

Personal care and household tasks documented on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as necessary for daily functioning include feeding, toileting, transfer and meal preparation. If an informal support is voluntarily performing any of these tasks as noted on Form 2060, the case manager will document on Form 8598 the personal care and household tasks necessary for daily functioning being performed, and obtain the signature of the informal support, if possible. If an informal support is not available at the time of the interview, the case manager must document on Form 8598 a telephone contact in which the informal support has agreed to perform these tasks. The case manager should document verbal agreement on the signature line for the informal support on Form 8598 and enter the date the telephone call was made. A signature or verbal agreement by an informal support is not required on Form 2060-A, Addendum to Form 2060 for Personal Assistance Services.

Informal Support Providing All Other Tasks

Performance of all other personal care and household tasks (all tasks on Form 2060 not designated as necessary for daily functioning) does not require the signature of the informal support. The case manager notes the tasks on Form 2060 and documents the role of the informal support. It is not necessary to document these other tasks on Form 8598. Form 2060 documentation is sufficient.

Informal Support Providing Supervision

An applicant or individual living at home may require an informal support to provide periods of supervision to ensure the individual's health and welfare. Provision of supervision by an informal support must be documented on Form 8598 and signature of the informal support obtained, if possible. If the informal support is not available at the time of the interview, the case manager must document on Form 8598 a telephone contact in which the informal support has agreed to provide supervision. The case manager should document verbal agreement on the signature line for the informal support on Form 8598 and enter the date the telephone contact was made.

Individuals with High Needs

In some situations, HCSSAs have difficulty meeting an individual’s needs within the ISP cost limit. In such instances, informal supports are critical to the development of an ISP that will ensure the health and welfare of the individual. If critical to the individual’s ISP, case managers must obtain additional verbal agreements and signatures of informal supports in accordance with the procedures outlined above.

3311.4.3  24-Hour Supervision for Applicants Living at Home

Revision 13-2; Effective June 3, 2013

The applicant who is living at home and has a need for 24-hour supervision can be enrolled in the Community Based Alternatives (CBA) program if he meets all the other eligibility criteria and his needs for supervision can be adequately met by a combination of CBA services provided by providers and non-waiver services provided by informal supports. There must be a reasonable expectation that the individual service plan is adequate to meet the needs of the individual, as determined by the interdisciplinary team (IDT) members.

3311.4.4  Authorization of Protective Supervision as a Personal Assistance Services Task

Revision 13-2; Effective June 3, 2013

Protective supervision is a task that can be included in the hours allowed for personal assistance services (PAS) to assure the health and welfare of an applicant or individual with a cognitive impairment, memory impairment or physical weakness. It can be authorized by the case manager on Form 2060-A, Addendum to Form 2060 for Personal Assistance Services.

The purpose of protective supervision is to provide relief for the caregiver from the responsibility of supervising the individual. The PAS attendant’s responsibility is to supervise the individual. Protective supervision is authorized when the caregiver is not available to supervise the individual on a routine basis. Protective supervision is not authorized to solely provide company for the individual. Protective supervision is appropriate when it will protect the individual from injury due to his cognitive impairment, memory impairment or physical weakness. If left unattended, for instance, the individual may wander off, turn on the stove and burn himself, or try to walk and then fall. Time authorized for protective supervision does not include the delivery of personal care and household tasks (tasks identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide).

When assessing the applicant or individual for protective supervision, the case manager must determine PAS hours for all assistance with personal care and household tasks. Time for protective supervision may be authorized for the time before, between or after personal care or household tasks are needed. In some situations, time for protective supervision may be appropriate even if no other PAS tasks are authorized. Protective supervision should not be confused with respite, which is the temporary relief of a caregiver on an as-needed basis. (See Section 4400, Respite)

Protective supervision may be used in situations in which the primary caregiver works outside the home and additional time for the PAS attendant to supervise an individual who requires continuous supervision to ensure his health and welfare during the time the caregiver cannot provide supervision.

Example 1: An individual requires assistance with personal care and household tasks Monday through Friday. The caregiver is available in the afternoon to supervise the individual Monday through Thursday but attends a class every Friday afternoon. If left unattended, the individual may try to walk and is at risk of falling due to physical weakness. In this situation, the case manager may include time for protective supervision for Friday afternoon when authorizing PAS.

Example 2: The caregiver works eight hours a day, Monday through Friday. The case manager completes Form 2060 and determines the individual needs five hours for assistance with personal care and household tasks. If left unattended, the individual may wander outside and is at risk of getting lost or injured due to a cognitive impairment. In this situation, the case manager may add time for protective supervision daily in addition to the time for personal care and household tasks to authorize eight hours of PAS per day. The attendant may provide protective supervision, personal care and household tasks intermittingly throughout the eight hours of PAS per day.

The caregiver does not necessarily have to live in the same household with the individual. When the case manager authorizes protective supervision, the case manager must identify the caregiver on Form 8598, Non-Waiver Services, in item 5, Family and Community Supports. When authorizing protective supervision, the case record must have documentation indicating the individual has a cognitive impairment, memory impairment or physical weakness and has a need for protective supervision that cannot be met by the caregiver or other informal supports. If the caregiver is the paid attendant for PAS, protective supervision can be authorized for times when the caregiver is out of the home or is not available. The caregiver paid attendant cannot provide protective supervision.

Appropriate service planning must be used to develop an individual service plan (ISP) that assures the individual’s health and welfare.

If the caregiver makes a planned visit to see her sister every three months instead of every Saturday, the case manager should consider respite for those times.

Refer to Section 4121.1, Description of Personal Assistance Services, for additional information about protective supervision.

3311.5  Utilization of Other Resources

Revision 09-3; Effective February 27, 2009

The case manager has primary responsibility for service planning and assisting the applicant/consumer in applying for and using all other available resources. The individual service plan identifies services to be provided so the applicant/consumer can remain in or return to the community. These services must include those funded by the waiver (documented on Form 3671-1, Individual Service Plan) and non-waiver services (documented on Form 8598, Non-Waiver Services) which are provided by, or funded by, the applicant/family/guardian, a third-party resource or another private or government program. Medicare, Medicaid, private insurance, informal supports, such as family members and friends, and community organizations are examples of other resources. The provision of the waiver and non-waiver services must be a cooperative or collaborative effort between the various providers and is coordinated by the case manager.

Based upon federal regulations and 1915(c) Medicaid waiver assurances, the Community Based Alternatives (CBA) program is the provider of last resort for medical supplies, adaptive aids, minor home modifications and other CBA services. The case manager must ensure all other services available to the CBA applicant/consumer to provide medical supplies, adaptive aids, minor home modifications or other CBA services are considered before the service is authorized on the CBA ISP.

3311.5.1  Non-Waiver Services and Third-Party Resources

Revision 13-2; Effective June 3, 2013

Non-waiver services and third-party resources (TPR) must be considered in the development of the Community Based Alternatives (CBA) individual service plan (ISP) and must not duplicate CBA services. The case manager is responsible for assisting the applicant or individual receiving services in applying for and using all available non-waiver resources and TPR. The case manager ensures all services available through non-waiver services and TPR are documented on Form 8598, Non-Waiver Services, and the ISP attachments:

  • Form 3671-B, Therapy Service Authorization
  • Form 3671-C, Nursing Service Plan
  • Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs)
  • Form 3671-D, Minor Home Modifications
  • Form 3671-E, Adaptive Aids and Medical Supplies
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate documentation
  • Form 3671-H, Dental Services
  • Form 3671-J, Dental Services – Proposed Treatment Plan

Medicare, Medicaid and Third-Party Resources Home Health Services

The use of Medicare (Title XVIII), Medicaid (Title XIX) and TPR (such as private insurance) home health services must be explored to determine if any of the needs of the applicant or individual can be met through these resources. It is the responsibility of the Home and Community Support Services Agency (HCSSA) to access Medicare and Medicaid. For the applicant or individual who is eligible for Medicare or Medicaid home health services, the case manager ensures that eligibility for medical supplies, adaptive aids, nursing and other skilled services through these programs is explored by the HCSSA nurse completing CBA assessments.

Example: If the individual is eligible for Medicare and needs nursing services, the services available through Medicare must be used before nursing services are provided through CBA. The HCSSA nurse must document the use of Medicare or Medicaid nursing services on Form 3671-C or Form 3671-C-Alternate.

Medicare, Medicaid, private insurance or other TPR may provide adaptive aids and medical supplies. The CBA program is the provider of last resort for medical supplies and adaptive aids. The case manager must document the denial of items by Medicare, Medicaid or other private insurance before approving the items through the CBA program. If an item is pending approval by Medicare, Medicaid or other TPR, the case manager may purchase the item through CBA for two months while waiting for a denial or approval by the non-waiver source. Consider short-term rental of one-time purchases, such as adaptive aids, if the item is pending approval by a non-waiver source.

Refer to Section 3311.5.2, Third-Party Information, for more details about how to use TPR insurance benefits and handle reimbursements.

Veterans Affairs Benefits

The case manager must consider Veterans Affairs (VA) benefits such as Aid and Attendance (A&A) and Home-Bound (HB) benefits. The applicant or individual may have available VA funds that can be used to purchase CBA services instead of using CBA funds. The applicant or individual may use VA benefits to purchase services that meet the intent of A&A and HB benefits but are not available through the CBA program. The following is a list (not all inclusive) of items/services that can be purchased using A&A funds.

  • medical supplies
  • medical equipment
  • nursing services
  • therapy
  • skilled services
  • cost of medications

VA benefits used by the applicant or individual to purchase attendant care or home health aide services should be considered when developing the ISP. If the applicant or individual uses VA benefits to purchase personal assistance services (PAS), use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to complete the calculations and determine the tasks/hours of PAS to be purchased through CBA.

Hospice Services

Medicare and Medicaid hospice services may be available to an individual who has been certified by a physician to be terminally ill (six months or less to live). The individual may file an election statement to receive hospice services from a particular hospice agency or the hospice agency may contact the case manager by telephone concerning the start and cancel dates for hospice care. For an individual who is eligible for both Medicare and Medicaid, the coverage is concurrent for the Medicare and Medicaid hospice program. Hospice is also available on a private-pay basis. A Medicaid recipient who elects the Medicaid hospice program waives his rights to other programs with Medicaid services related to the treatment of the terminal illness. The Medicaid recipient does not waive his rights to services offered by the Department of Aging and Disability Services (DADS) that are unrelated to the treatment of the terminal illness. If an individual chooses to receive hospice services and some of his needs will not be met by the hospice agency, CBA services may be assessed and authorized to meet the remaining needs. The case manager must coordinate the service plan with the hospice agency to prevent duplication and to ensure adequate services to the individual. The case manager may consult with the DADS regional nurse regarding duplication of tasks or services.

The case manager must follow up with the individual to determine what hospice will provide and adjust the individual’s ISP to assure no duplication of services. The case manager must respond to a notification of hospice election within the time frames of a change request. Refer to the program handbook for a specific service to determine if there are any restrictions to receiving other services.

If an individual whose Medicaid eligibility is determined by Medicaid for the Elderly and People with Disabilities (MEPD) enters a nursing facility under Medicaid hospice, the case manager notifies the MEPD staff of the hospice nursing facility entry and termination of the individual’s program eligibility by sending Form H1746-A, MEPD Referral Cover Sheet.

Mental Illness and Intellectual and Developmental Disability Programs

Programs for persons with mental illness or persons with intellectual and developmental disabilities must be considered in developing the CBA service plan and to reduce the waiver expenditures. Receipt of these services does not make an applicant or individual ineligible for CBA, with the exception that an individual may not receive services concurrently from two waiver programs, such as the Home and Community-based Services (HCS) waiver. The case manager must determine which services are received through the program for persons with mental illness or persons with intellectual and developmental disabilities and ensure non-duplication with CBA services.

The case manager must not refer an applicant or individual to the local authority for case management or service coordination. The local authority provides service coordination to an individual with intellectual and developmental disability (IDD) in the DADS local authority priority population. Per Title 40, Texas Administrative Code, Chapter 2, Subchapter L, service coordination funded by Medicaid targeted case management (TCM) may not be provided to an individual who is receiving services from the Program for All-Inclusive Care for the Elderly (PACE) or waiver services through any waiver program except the HCS or Texas Home Living (TxHmL) programs. CBA and TCM are mutually exclusive.

Local authority staff data enter service records for TCM in the Service Authorization System (SAS). TCM is identified in SAS as Service Group 14, Service Code 12A or 12C. TCM can be authorized for HCS, TxHmL or as a general revenue service. SAS will allow Service Codes 40 (Community Living Assistance and Support Services service code for case management), 40A (pre-assessment) and 60 (prescriptions) to overlap with a TCM service code for an applicant or individual who receives TCM.

Since CBA provides more comprehensive services to the individual, it will take precedence over TCM services in order to maximize the benefit to the individual. The case manager must contact the local authority to coordinate closing TCM for CBA services to begin.

The case manager may continue to refer an individual in CBA for services not already covered by the waiver program following the local authority referral process. DADS allows each local authority to determine whether an individual enrolled in CBA may receive general revenue services. For this reason, general revenue services available to the individual may vary throughout the state.

Other Non-Waiver Services and Third-Party Resources

Other examples of non-waiver services include meals delivered or provided by a community agency, personal care provided by friends or relatives, or other community services. For an applicant or individual receiving funds from other sources, the case manager must consider whether the intended use of the funds is to pay for a service or item that is within a waiver service category.

The case manager must attempt to obtain copies of documents from the applicant or individual, his family or other agencies providing funds and services to determine which services will be provided through the funds. If a written service plan or other documentation is not available, a summary of the services provided by the other agency, local authority or family, or the applicant's or individual's declaration of what the funds are used for, is sufficient to develop the ISP.

General information on potential non-waiver services for an applicant or individual is included in Appendix V, Services Available from Other State Agencies.

The case manager must review Form 8598, Non-Waiver Services, any time Form 3671-1, Individual Service Plan, is revised and make changes, if appropriate.

3311.5.2  Third-Party Information

Revision 12-4; Effective December 3, 2012

The case manager must coordinate with Community Based Alternatives (CBA) providers to access and use third-party resources (TPR) benefits. Insurance companies will provide coordination of benefits information upon request. If the insurance company is a managed care organization (MCO), the case manager obtains a recertification or prior authorization number to give to the provider who will bill for the non-waiver services. Information on benefits can usually be obtained from the insurance company's Customer Service or Benefits Covered department. The company usually needs the following information to begin the recertification process:

  • policyholder's name and Social Security number;
  • group number/employer's name;
  • diagnosis and prognosis; and
  • beginning and end dates, total days of service and/or type of service requested.

Recertification usually must be done monthly, but normally requires only a post card or telephone call. Information on benefits should be provided to the CBA providers, particularly the Home and Community Support Services Agency (HCSSA). The individual may assign his third-party benefits to the CBA provider to reduce the costs of waiver services.

If the individual receives a reimbursement from a TPR for services already paid for through the waiver, the case manager prepares Form 4100, Money Receipt, and annotates the receipt to identify the check or money order as a "third party reimbursement for CBA services Program Activity Code (PAC) 659 Division 641." The receipt must be legible and include the case manager's name and office phone number. A reimbursement check payable to the individual must be endorsed by the individual and marked "payable to." The case manager must send, on the same workday, the reimbursement and the receipt to:

Department of Aging and Disability Services
Attention: Accounts Receivable, Mail Code E-411
P.O. Box 149030
Austin, Texas 78714-9030

The case manager prepares a memo to the CBA Section Manager, Mail Code W-351, which identifies the specific services and dates of service covered by the third-party reimbursement. The case manager attaches to the memo:

  • a copy of the reimbursement check or money order;
  • a copy of the receipt (Form 4100) prepared by the case manager and given to the individual; and
  • an Explanation of Benefits or similar document from the TPR.

Medicaid for the Elderly and People with Disabilities (MEPD) staff are required to complete Form H1039, Medical Insurance Input, for submittal to the Office of Inspector General TPR unit and will share information that is useful to the case manager in developing the ISP. These resources must be utilized in developing the service plan for the individual. The case manager must notify the MEPD staff via Form H1746-A, MEPD Referral Cover Sheet, if it is discovered that an applicant or individual who does not receive Supplemental Security Income has a third-party insurance resource that may offset some waiver or Medicaid services.

3311.6  Financial Eligibility

Revision 05-4; Effective April 18, 2005

§48.6007 — Financial Eligibility Criteria.

(a)
To be determined financially eligible by the Texas Department of Human Services (DHS) for home and community-based services through this waiver program, an applicant must:
(1)
be eligible for Supplemental Security Income (SSI) benefits;
(2)
have been eligible for and received SSI benefits and continue to be eligible for Medicaid as a result of protective coverage mandated by federal law; or
(3)
be eligible for SSI benefits in the community except for income and the special institutional income limit for Medicaid benefits in Texas without regard to spousal income.

3311.6.1  Medicaid Eligibility

Revision 12-3; Effective September 4, 2012

At the time of the initial intake, the Department of Aging and Disability Services (DADS) case manager must obtain information on the applicant's Medicaid or financial status. The case manager must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program through the Texas Integrated Eligibility Redesign System (TIERS), or initiate the Medicaid financial eligibility determination process. Form H1200, Application for Assistance – Your Texas Benefits, is obtained for new Medicaid eligibility determinations and required program transfers from a Medicaid for the Elderly and People with Disabilities (MEPD) program to Community Based Alternatives (CBA) Medicaid. Refer to Appendix XVII, Medicaid Program Actions, for additional information regarding referrals to MEPD.

Medicaid eligibility may have already been determined and must be used unless there have been changes in the applicant's financial situation. Applicants who currently have Form H1200 on file with MEPD may not need to complete a new Form H1200. The DADS case manager must check with the MEPD specialist regarding the need for a new Form H1200. If there is no Form H1200 on file, it is the case manager's responsibility to assist the applicant in completing the application during the home visit, if needed, and help obtain the necessary verifications to establish eligibility.

If Form H1200 has been mailed to the applicant, the case manager will review the form for accuracy and assist with any incomplete items. The case manager is responsible for ensuring that Form H1200 is completed within 14 calendar days of the assignment of the intake.

If Form H1200 cannot be obtained during the initial home visit or within the initial 14 calendar days, the delay must be documented. Additional attempts must be made to ensure there is no unnecessary delay in the CBA eligibility determination process. Explain the financial determination process and inform the applicant that MEPD staff may be calling for additional information.

To facilitate the financial eligibility process for the applicant or individual requiring a referral to MEPD, it is important that Form H1200 is completed accurately. Missing information on the application referral may cause a delay.

The most common omissions for items checked "Yes" on the application form are reflected in the list below. Ensuring the following items are included will greatly facilitate the financial eligibility process:

  • Bank accounts – bank name, account number, balance and account verification (e.g., a copy of the bank statement);
  • Award letters showing the amount and frequency of income payment;
  • Life insurance policy – company name, policy number, face value or copy of the policy;
  • A signed and dated Form 0003, Authorization to Furnish Information;
  • Confirmation that Medicaid Estate Recovery Program information and Form 2121, Long Term Services and Supports, was shared with the applicant by checking the appropriate boxes on Form H1746-A, MEPD Referral Cover Sheet;
  • Preneed funeral plans – name of company, policy/plan number and a copy of the preneed agreement;
  • Correct, up-to-date phone numbers; and
  • Power of Attorney or Guardianship – copy of the legal document.

While it may not always be possible to obtain everything on the list, whatever is acquired will greatly facilitate the process for applicants or individuals. The case manager must explain to the applicant or individual that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

See Section 3313, Referral for Medicaid Eligibility Determination, and Section 3500, Financial Eligibility, for detailed information.

Note: A person who may complete or sign an application for an applicant or individual may not be on the list of people to whom DADS can release the applicant's or individual's individually identifiable health information. See Section 1819, Personal Representatives, for people who may receive or authorize the release of an applicant's or individual's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

3311.6.2  Medicaid Estate Recovery Program Requirements

Revision 13-1; Effective March 1, 2013

Medicaid Estate Recovery Program (MERP) information must be shared with every Community Based Alternatives (CBA) applicant and, in some cases, an individual receiving services, regardless of age, unless the applicant or individual is determined to have "grandfathered" status.

MERP information must be shared with every applicant for CBA transferring (directly or after a break in services) to CBA if the applicant is not determined to have "grandfathered" status. For example, an applicant applies for and starts receiving Community Attendant Services (CAS) for the first time in April 2008, and is terminated effective Sept. 30, 2010. The applicant applies for CBA Jan. 1, 2011. Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, must be shared with the applicant when applying for CBA. Another example is a CBA applicant transferring directly from CAS on Jan. 1, 2011, without a gap in services. Form 8001 must be shared with the applicant when applying for CBA.

The case manager can no longer use a previously signed Form 8001 from the CAS case record or from Medicaid for the Elderly and People with Disabilities (MEPD), or any other agency, as documentation that MERP information was shared with the applicant.

Note: MERP information is not required to be shared with an applicant applying for programs/services not subject to MERP. For example, MERP does not apply to an applicant applying for Primary Home Care (PHC). If the applicant is not applying for CBA or CAS, staff must not notify the applicant about MERP.

MERP information is shared at the initial home visit or face-to-face contact. MERP information must be presented in person; not over the phone. Form 8001 must not be mailed with the application packet.

An applicant's estate is not subject to MERP if the applicant applied for one of the following programs/services subject to MERP prior to March 1, 2005. An applicant who meets these criteria is considered to be "grandfathered" (or protected) from MERP. The services are:

  • Nursing Facility (institutional Medicaid)
  • Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), including state supported living centers
  • CAS
  • 1915(c) waiver programs:
    • Community Living Assistance and Support Services (CLASS)
    • Deaf-Blind with Multiple Disabilities (DBMD)
    • Home and Community-based Services (HCS)
    • Texas Home Living (TxHmL)
    • Consolidated Waiver Program (CWP)
    • CBA
  • HCBS STAR+PLUS Waiver (SPW)

The application date used to determine if an applicant has "grandfathered" status is based on specific program/service application dates, and must clearly indicate the application process for the program/service was initiated on that date.

The program application date is the date of:

  • receipt of Form H1200, Application for Assistance – Your Texas Benefits/Form H1010, Texas Works Application for Assistance – Your Texas Benefits; or,
  • the home visit if Form H1200 is not applicable.

The earliest verified and confirmed program or service application date can be used to determine the applicant has "grandfathered" status.

There could be scenarios when Form H1200 was mailed to the applicant requesting CBA but Form H1200 was mailed back to MEPD. The case manager uses the earliest date of receipt, by MEPD or DADS, as the application date. Applying for Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) prior to applying for a MERP service does not automatically constitute an application for a MERP service. The case manager must confirm the application date used to determine if an applicant has "grandfathered" status is clearly related to the initiation of the application process for the MERP service.

The case manager must use Form 1575, Medicaid Estate Recovery Program Worksheet, to document verification of an applicant's or individual's "grandfathered" status. All application dates must be verified, confirmed and documented on Form 1575. If there is no clear verification of the application date, the applicant or individual must not be designated as "grandfathered" status. The case manager completes Form 1575 for an applicant or individual to document whether the applicant or individual is considered to have "grandfathered" status. This form is completed at the initial home visit or at the next annual reassessment if there is no Form 1575 in the case record. The following procedures apply:

  • For an applicant, if the case manager cannot determine whether an applicant has "grandfathered" status, the case manager must present MERP information to the applicant and complete Form 8001 and Form 1575.
  • For an individual receiving services, if the case manager cannot determine whether the individual has "grandfathered" status and there is no Form 8001 in the case record, the case manager must present MERP information to the individual and complete Form 8001 and Form 1575.
  • If it is determined the applicant or individual has "grandfathered" status, the case manager must complete Form 1575.
  • If Form 8001 is in the case record for an individual receiving services but no Form 1575, the case manager must complete Form 1575.
  • If it is determined the applicant or individual does not have "grandfathered" status and there is no Form 8001 in the case record, the case manager must present MERP information to the applicant or individual and complete Form 8001 and Form 1575.

Form 1575 and Form 8001 must be filed and kept in the most current volume of the case record. The information documented on Form 1575 includes the:

  • applicant's or individual's name;
  • program/service the applicant is applying for;
  • grandfathered status, including the application date and/or program/service and dates received that support the applicant's or individual's MERP grandfathered status;
  • source of verification of MERP grandfathered status; and
  • date verified.

The case manager uses Appendix X, Medicaid Estate Recovery Program (MERP) Script and Cover Sheet, to assist in presenting MERP information more accurately and thoroughly. The case manager will follow the script (available in English and Spanish) to present MERP information and request the applicant or individual to sign Form 8001. The script also provides guidance for handling questions or the applicant's or individual's refusal to sign Form 8001. The case manager does not have to follow the script if the applicant or individual chooses to sign Form 8001 after a brief overview of MERP as provided in the script.

During the interview, the case manager will ask if the applicant or individual would like to read Form 8001. If the applicant or individual chooses to read Form 8001, the case manager allows time for the applicant or individual to read the form. The case manager must clearly state that Form 8001 is informational material only. After MERP information and Form 8001 are shared, the case manager asks the applicant or individual to sign Form 8001 to acknowledge MERP information was shared. If the applicant or individual refuses to sign the form, the case manager documents the applicant's or individual's refusal on Form 8001. The case manager explains to the applicant or individual that refusal to sign Form 8001 does not exempt the applicant or individual from estate recovery.

Also during the interview, the case manager must obtain and document executor information. Executor information must be recorded in the Service Authorization System (SAS) by creating an "Executor" address type. If the applicant or individual has already identified an executor and this information has been recorded in SAS, confirm with the applicant or individual that this information is correct. If the applicant or individual does not have a will and executor, the case manager asks for the name of the person whom the state should contact after the applicant's or individual's death to determine whether recovery is appropriate. The order of preference for contacts after the executor is: (1) legal guardian, (2) power of attorney (POA), or (3) other family members who have acted on behalf of the applicant or individual. A space is provided on the MERP script to record two names and addresses of the persons the applicant or individual identifies. If the applicant or individual does not have an executor, the case manager enters the information about the first preferred contact in the SAS "Executor" address record. The case manager files the page from the MERP script that lists the contact information in the case record.

The case manager explains program requirements related to sharing MERP information, but does not make recommendations about MERP or speculate whether MERP will be applicable upon the applicant's or individual's death, if the applicant or individual has this type of question. The case manager provides to the applicant or individual additional sources for MERP information, including:

  • Telephone number or website listed on Form 8001;
  • Consumer Rights and Services hotline at 1-800-458-9858 (listen to menu option #4 or wait for a representative); or
  • Legal hotline for Texans at 1-800-622-2520 (available to persons age 60 and over; Medicare beneficiaries, regardless of age; and low-income victims of violent crime.)

Along with Form 8001, the case manager must share a copy of the MERP brochure, Your Guide to the Medicaid Estate Recovery Program.

In addition, the case manager must provide Form 2061, Notification of Medicaid Estate Recovery Program Status, to an applicant or individual who meets "grandfathered" status to alleviate concerns and to confirm the applicant's or individual's MERP status. Form 2061 must only be provided if the applicant's or individual's "grandfathered" status has been researched, verified and documented on Form 1575. A copy of Form 2061 must be placed in the case record, along with Form 1575.

Additional Information

An applicant, individual or family member with access to the Internet can obtain information about MERP at www.dads.state.tx.us/services/estate_recovery/index.html.

Community Services regional staff can obtain information about MERP procedures and estate recovery policy information at http://dadsview.dads.state.tx.us/merp/communications/index.html.

3311.6.2.1  Documenting Executor Information in the Service Authorization System (SAS)

Revision 11-3; Effective September 1, 2011

Within thirty days of notification of the death of a Medicaid recipient, the Texas Health and Human Services Commission (HHSC) sends notice of intent to file a claim to the executor or other estate representative of the Medicaid recipient. Upon certification of the Community Based Alternatives (CBA) applicant, the case manager enters in SAS the name, address and telephone number of the executor or estate representative if the consumer has one. Information is entered in the Address folder as follows:

  • Address Type:  "EX" for executor
  • Address Line 1:  Name of executor – First Name, Middle, Last
  • Address Line 2:  First line of mailing address (street number or P.O. Box)
  • Address Line 3:  Second line of mailing address (apartment number, block)
  • Address Line 4:  Telephone number of executor (format XXX-XXX-XXXX)

Other information such as directions, comments or the executor's relationship to the consumer must not be entered. The executor information in SAS will assist HHSC in the notification process upon the death of the consumer.

The case manager uses the steps above, including "EX" in the Address Type, when the applicant/consumer does not have an executor but has provided another type of contact preference.

3311.6.3  Citizenship Verification

Revision 12-4; Effective December 3, 2012

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid will be required to provide proof of U.S. citizenship and identity. This requirement will affect all applicants whose financial eligibility is based on a determination from Medicaid for the Elderly and People with Disabilities (MEPD) staff.

An applicant is requested to provide this documentation with the Medicaid application. If the documentation cannot be provided for the initial certification, the applicant is allowed a reasonable opportunity period to provide the documentation. The opportunity period is extended to the first complete recertification of Medicaid eligibility.

Verification of citizenship and identity for eligibility purposes is a one-time activity. Once verification of citizenship is established and documented by MEPD staff, verification is no longer required even after a break in eligibility.

The case manager must be prepared to assist an applicant with this process by informing him of the requirement and helping him identify the documentation needed to prove his citizenship and identity. Information available at the time of the Department of Aging and Disability Services (DADS) face-to-face contact must be collected and submitted with the application for Medicaid. An applicant may choose to obtain his own copy and forward to DADS for transmittal to MEPD staff. MEPD staff will accept copies and faxes only if clear, legible and non-questionable. If the case manager receives an affidavit as verification, ensure the reason the applicant is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form H1746-A, MEPD Referral Cover Sheet, along with the affidavit. The case manager must make sure the applicant knows he is signing the affidavit under penalty of perjury. The following information is provided to assist the case manager with this requirement.

Acceptable Documentation for Both Citizenship and Identity

Applicants Who Receive Supplemental Security Income (SSI) — The State Data Exchange (SDX) contains the needed information to verify citizenship. For any applicant who receives SSI, MEPD staff are able to use the SDX as verification of both citizenship and identity. For any applicant denied SSI, the SDX can be used as a valid verification source of both citizenship and identity when the denial is for any reason other than citizenship. The SDX printout will show action code N13 if the denial is for citizenship.

Applicants Who Receive Medicare — — An applicant who receives Medicare is exempt from the requirement to provide evidence of citizenship and identity. The Social Security Administration (SSA) documents citizenship and identity for Medicare eligibility.

For any applicant entitled to or enrolled in Medicare Part A or B and subsequently denied Medicare, use the State On-Line Query (SOLQ) system or Wire Third Party Query (WTPY) system as documentation of both citizenship and identity when the denial is for any reason other than citizenship. If there is an end date listed for Medicare, the applicant must provide documentation on the loss of Medicare.

All Other Applicants — The following primary documents may be accepted as proof of both identity and citizenship:

  • U.S. passport,
  • Certificate of Naturalization (N-550 or N-570), or
  • Certificate of U.S. Citizenship (N-560 or N-561).

If an applicant does not provide one of these primary documents that establishes both U.S. citizenship and identity, the applicant must provide two documents:

  • one document that establishes U.S. citizenship, and
  • one document that establishes identity.

Evidence of identity documents that are acceptable are defined in the last box below.

Documents that establish citizenship are divided into second, third and fourth levels based on the reliability of the evidence.

Primary Evidence of Citizenship and Identity
  • U.S. passport;
  • Certificate of Naturalization;
  • Certificate of U.S. Citizenship;
  • SDX for an applicant who was denied SSI when the denial reason is for any reason other than citizenship (N13); and
  • SOLQ/WTPY and documentation on reason for Medicare denial.

Begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

Second Level of Evidence of Citizenship
(Use only when primary evidence is not available.)
  • A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain's Island or the Northern Mariana Islands (after Nov. 4, 1986). Contact the Bureau of Vital Statistics (BVS) for an applicant born in Texas. If an applicant's date of birth is earlier than 1903 or if the birth was out of state, accept a legible, non-questionable copy. For a birth out of state, an applicant may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; and usbirthcertificate.net or its toll-free number, 1-888-736-2692;
  • Report of Birth Abroad of a U.S. Citizen (FS-240);
  • Certification of Birth Abroad (FS 545 or DS-1350);
  • U.S. Citizen Identification card (Form I-179 or I-197);
  • Northern Mariana Identification card (I-873);
  • American Indian card (I-872) issued by the Department of Homeland Security with classification code "KIC";
  • Final adoption decree showing the applicant's name and U.S. place of birth;
  • Evidence of U.S. Civil Service employment before June 1, 1976; and
  • U.S. military record showing a U.S. place of birth (Example: DD-214).

Third Level of Evidence of Citizenship
(Use only when primary and second level evidence is not available.)
  • Hospital record of birth showing the U.S. place of birth;
  • Life, health or other insurance record showing the U.S. place of birth;
  • Religious record of birth recorded in the U.S. or its territories within three months of birth, that indicates a U.S. place of birth showing either the date of birth or the applicant's age at the time the record was made; and
  • Early school record showing a U.S. place of birth, name of the applicant, date of admission to the school, date of birth, and the name(s) and place(s) of birth of the applicant's parents.

Fourth Level of Evidence of Citizenship
(Use only when primary, second and third level evidence is not available.)

Any listed documents used must include biographical information including U.S. place of birth.

  • Federal or state census record showing U.S. citizenship or a U.S. place of birth and the applicant's age (generally for an applicant born 1900-1950);
  • Seneca Indian Tribal census record showing a U.S. place of birth;
  • Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth;
  • Bureau of Indian Affairs Roll of Alaska Natives;
  • U.S. state vital statistics official notification of birth registration showing a U.S. place of birth;
  • Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth;
  • Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth;
  • Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth; and
  • Affidavits from two adults regardless of blood relationship to the applicant. (Use only as a last resort when no other evidence is available.)

Evidence of Identity
  • Driver license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color;
  • School identification card with a photograph;
  • U.S. military card or draft record;
  • Identification card issued by the federal, state or local government with the same information that is included on a driver license;
  • Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color;
  • Birth certificate;
  • Hospital record of birth;
  • Military dependent's identification card;
  • Native American Tribal document;
  • U.S. Coast Guard Merchant Mariner card;
  • Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information;
  • Data matches with other state or federal government agencies (Example: Employee Retirement System and Teacher Retirement System);
  • Three or more supporting documents such as a marriage license, divorce decree, high school diploma or employer identification card (use only with second and third level evidence of citizenship);
  • Adoption papers or records;
  • Work identification card with photograph;
  • Signed application for Medicaid (accept signature of an authorized representative or a responsible party acting on the applicant's behalf);
  • Health care admission statement;
  • For children under age 16, school records (may include nursery or day care records);
  • For children under age 16, doctor, clinic or hospital records;
  • For children under age 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship); and
  • For an applicant with a disability who resides in a residential care facility who cannot provide any document on this list, an affidavit signed by the facility director or administrator attesting to the identity of the applicant (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship).

In the hierarchy of approved documentation sources, some documents listed to verify citizenship are also acceptable to verify identity. When using the hierarchy of approved documentation sources, the same document cannot be the source to verify both citizenship and identity.

If an applicant is unable to provide any other documentary evidence of citizenship, an affidavit signed under penalty of perjury will only be accepted as a last resort. MEPD staff are required to document the reason another source is not available to verify citizenship. If the case manager is provided an affidavit, ensure the reason the applicant is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form H1746-A, along with the affidavit. The copies of the affidavit form are to be made available in all Health and Human Services Commission (HHSC) benefits offices. The form is also available online at www.hhs.state.tx.us, or Form H1097, Affidavit for Citizenship/Identity, and Form H1097-S (Spanish), may be used.

Reasonable Opportunity to Provide Verification

The case manager must inform the applicant if MEPD staff do not receive documentation of citizenship and identity by the application due date, certification may be delayed and eventually denied if verification documentation is not provided.

If the applicant is enrolled in Medicaid and is making a good faith effort to provide documentation of citizenship and identity, but cannot provide the required verification(s), eligibility will continue until the next Medicaid recertification. Inform the applicant he will be asked to provide documentation that verifies citizenship and identity at the time of Medicaid recertification. Eligibility will be denied if the individual does not provide the required verification(s) at the time of Medicaid recertification.

Assistance to Applicants in Obtaining Documentary Evidence

To assist an applicant who is unable to provide documentary evidence of citizenship and identity in a timely manner because of incapacity of mind or body or the lack of a representative to assist, the case manager may make referrals to the following entities:

  • Department of Family and Protective Services, Adult Protective Services;
  • Legal Aid;
  • Social Security Administration; and
  • 2-1-1.

For an applicant who is born out of state, sources to obtain a birth certificate include:

When assisting the applicant in providing documentary evidence of citizenship and identity, use any available documents regardless of level of evidence.

3311.7  Rights and Responsibilities, Form 2307

Revision 08-10; Effective September 1, 2008

Notifications regarding consumer rights and responsibilities must be shared in the language preference expressed by the applicant/consumer. In the case record, the case manager must document efforts to obtain an interpreter or requests for information translated into the applicant’s/consumer’s language.

Initial Contact

During the discussion about service planning, review with the applicant Form 2307, Rights and Responsibilities, and discuss the information thoroughly to ensure that the applicant understands it and its significance. Have the applicant or responsible person sign and date the form. Give the applicant the original Form 2307. If it appears the applicant does not fully understand his rights or the complaint process, provide a copy of Form 2307 to the individual's responsible person and briefly discuss the information with the responsible person. A responsible person includes a guardian or any family member or other individual who assists in the development of the care plan and/or who maintains regular communication with the individual or department regarding the individual's well-being.

A copy of the signature page signed and dated by the applicant or responsible person must be filed in the case record.

Review and give the applicant or responsible person Form 2307-C, Eligibility Criteria and Responsibilities. If the applicant requests Emergency Response Services, include Form 2307-B, Emergency Response Services Eligibility Criteria and Responsibilities. Obtain Form 2307-F, AFC Rights and Responsibilities, for Adult Foster Care applicants.

Reassessment

At reassessment, review all rights and responsibilities with the consumer or responsible person, including Form 2307-C, Form 2307-B and Form 2307-F, if applicable. A new Form 2307 and consumer/responsible person signature is not required at the reassessment if the Form 2307 information is still current and there have been no changes that affect the consumer’s services. Telephone number and staff name changes do not constitute a reason for completing a new Form 2307; however, the case manager must ensure that the consumer knows how to reach the case manager. Case documentation must clearly document that all applicable rights and responsibilities were shared at the annual reassessment.

Form 2307-F must be signed by the applicant/consumer before certification or recertification of Community Based Alternatives services.

3311.8  Choice of HCSSA

Revision 08-10; Effective September 1, 2008

STANDARD.  The case manager must assure that providers are selected based on the following priorities for ongoing Community Based Alternatives (CBA) services:

  • applicant/consumer's choice; and
  • on a rotation basis if the applicant/consumer has no choice.

The case manager can obtain information on which providers have contracted with the Department of Aging and Disability Services (DADS) to provide CBA services from the regional contract managers. The applicant must be offered a choice among the service providers contracted to provide CBA services in the area.

At the time of the initial contact with the applicant, the case manager determines if the applicant is receiving Medicare home health services and uses the following procedures:

  • If the applicant is receiving Medicare home health services and the Medicare provider is also a CBA provider, the case manager will inform the applicant that he can choose this agency to conduct the pre-enrollment home health assessment or he can select another agency from the list of contracted CBA providers if he wants CBA services to be provided by another agency;
  • If the applicant is receiving Medicare home health services and his Medicare provider is not a CBA provider, the applicant should be informed that he has the option to change his Medicare provider so both CBA and Medicare services can be coordinated and provided by the same agency. If he chooses not to continue to receive his Medicare services from his current provider, he selects another agency from the list of contracted CBA providers; or
  • If the applicant is not receiving Medicare home health services, he chooses an agency or prioritize his choices of agencies from a list of contracted CBA providers presented by the case manager. If he as no preference, the next agency on the rotation list is authorized to complete the Pre-Enrollment Home Health Assessment.

The case manager must document in the case record the applicant's choice, or lack of choice, regarding providers.

CBA applicants living in the community or who are currently hospitalized may need services before the eligibility determination for CBA services. The applicant may contact the CBA provider of the applicant's choice to attempt to make an individual agreement for services. The agency may be able to provide services through Medicare coverage, private insurance or private pay arrangements with the applicant before the final eligibility determination. The case manager must not convey the impression that the services provided before the final determination of CBA eligibility will be reimbursed by DADS, nor should the case manager guarantee that DADS will pay the provider.

3311.9  Opportunity to Register to Vote

Revision 12-1; March 1, 2012

The National Voter Registration Act (NVRA) of 1993 requires the Department of Aging and Disability Services (DADS) to offer each applicant applying for DADS services, at the annual reassessment for individuals receiving services, and when case managers are notified of a change in the individual's address, the opportunity to register to vote, to record the applicant's or individual's decision on Form 1019, Opportunity to Register to Vote/Declination, and to file it in the case record. DADS staff must provide the same degree of assistance, including bilingual assistance, to help the applicant or individual complete the voter registration forms as is provided with the completion of any DADS forms.

DADS staff may not make a determination about an applicant's or individual's eligibility for voter registration other than a determination of whether the applicant or individual is of voting age, which is 18 years of age, or is a U.S. citizen. An applicant's or individual's age or citizenship may be verified by DADS staff only if the age or citizenship can be readily determined from information filed with DADS for purposes other than voter registration. An applicant or individual must be offered voter registration assistance as provided by the NVRA if the applicant's or individual's age or citizenship cannot be determined.

At the time an applicant applies for services, at the annual reassessment or when notified of a change in the individual's address, he must be given the opportunity to:

  • complete Form 0030, Application for Voter Registration, and mail it to the voter registrar; or
  • complete Form 0030 and provide it to DADS staff to mail to the voter registrar.

If the applicant or individual wishes to complete Form 0030 during the interview, DADS staff must review the form for completeness in the presence of the applicant or individual. If the form does not contain all the required information, including the required signature, DADS staff return it to the applicant or individual for completion. If the applicant or individual requests DADS mail the form, Form 0030 must be sent to the appropriate county voter registrar within five working days of the signature by the applicant or individual.

Declining to Register

If the applicant or individual does not wish to complete Form 0030, he must complete and sign Form 1019, unless DADS staff determine the applicant or individual has previously completed and signed the form. If the applicant or individual refuses to sign Form 1019, DADS staff must document the refusal on the form. DADS staff must keep each declination form for at least 22 months after the date of signing in the case record.

Change of Address

DADS staff must contact the individual by phone within five working days after receiving notification of a change of address and offer the opportunity to register to vote. If the individual does not have a phone, DADS staff must mail Form 0030 and Form 1019 within five working days after being notified of a change in address. If DADS staff do not receive either Form 0030 or Form 1019 within 30 days of mailing the forms to the individual, the DADS staff must complete Form 1019 indicating that the individual failed to return Form 1019.

If the individual wishes to register to vote, DADS staff must mail Form 0030 to the individual within three working days after the date of the phone call. If the individual does not wish register to vote, DADS staff must ask the individual to complete and sign Form 1019. DADS staff must mail Form 1019 to the individual within three working days after the date of the phone call. DADS staff must inform the individual that Form 1019 must be returned within 30 calendar days after the date of the phone call with DADS staff. If the individual refuses to sign the declination form, or DADS staff do not receive the form within 30 days after the date of the phone call with the individual, DADS staff must enter on Form 1019 that the individual refused to sign or failed to return the declination form. DADS staff must retain each declination form for at least 22 months after the date of signing in the individual's case record.

DADS staff must not:

  • influence an applicant's or individual's political party preference;
  • display any political party preference or allegiance; or
  • make any statement or take any action for the purpose or effect of:
    • discouraging the applicant or individual from registering to vote; or
    • leading the applicant or individual to believe that a decision of whether to register has any bearing on the availability of or eligibility for DADS services or benefits.

If the applicant or individual has any questions regarding the voter registration process that DADS staff cannot answer, DADS staff must:

  • advise the applicant or individual to call the Office of the Texas Secretary of State toll-free at 1-800-252-8683; or
  • give the applicant or individual the telephone number of the local county voter registrar.

3312  Referral for Pre-Enrollment Home Health Assessment

Revision 09-3; Effective February 27, 2009

Within two Department of Aging and Disability Services business days after the Community Based Alternatives (CBA) applicant selects a Home and Community Support Services Agency (HCSSA), the case manager prepares and sends Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, to notify the HCSSA to perform the assessment.

This time frame applies regardless of whether the case manager has conducted the initial contact visit within or after the 14-day time frame required.

The case manager completes Section A, Referral/Assessment Authorization, of Form 3676 and makes the referral to the selected HCSSA by fax, agency pickup or mail. Along with Form 3676, the case manager sends the HCSSA:

  • the functional assessment;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form 2060-A, Addendum to Form 2060 for Personal Assistance Services; and
  • Form 8598, Non-Waiver Services.

For a priority status applicant (immediate or expedited referrals) or for an individual eligible to bypass the CBA interest list, the case manager negotiates for an assessment completion date, not to exceed 14 calendar days, with the selected HCSSA. If the selected provider is unable to agree to complete the pre-enrollment home health assessment within an acceptable time frame for the applicant and case manager, the case manager contacts other contracted providers selected from a rotation list of providers. Following the verbal authorization to the HCSSA, the case manager completes Section A of Form 3676 and faxes the authorization to the selected HCSSA. The case manager enters the date negotiated for the completion of the assessment in Item 14 of Form 3676.

For a routine status applicant, the case manager enters "14 days" as the time frame for completion of the assessment in Item 14 of Form 3676. The HCSSA has 14 calendar days to complete the assessment and assure that it is received by the case manager. The case manager completes Section A of Form 3676 and mails it to the HCSSA. The HCSSA date stamps the authorization form on the day of receipt and has 14 calendar days after the date of receipt to complete all components of the assessment and return the assessment packet to the case manager.

During the initial contact with the applicant, the case manager must explore the applicant's status in the nursing facility (NF) and determine whether the applicant is a current Medicaid consumer applying for Medicaid in the NF or is on Medicare. Case managers should make every effort to determine whether the HCSSA should be authorized to complete the medical necessity (MN) process or if the NF MN is sufficient for CBA eligibility determination. Duplication of submittal of the MN Level of Care (MN/LOC) Assessment to the Texas Medicaid & Healthcare Partnership (TMHP) should be avoided. Case managers advise the HCSSA on Form 2067, Case Information, sent with Form 3676, whether or not the MN/LOC Assessment should be completed during the pre-assessment of the applicant. Since the fee for completing the MN/LOC Assessment is included in the pre-assessment, no additional service codes or payment is required.

3313  Referral for Medicaid Eligibility Determination

Revision 12-4; Effective December 3, 2012

At the time of the initial contact, it is the case manager's responsibility to determine if a referral to Medicaid for the Elderly and People with Disabilities (MEPD) is needed. If a referral is needed for Medicaid eligibility determination or a required program transfer, the case manager sends Form H1200, Application for Assistance – Your Texas Benefits, to MEPD.

The date on which the case manager or any Department of Aging and Disability Services employee receives a signed and dated Form H1200 becomes the "Date Form Received." MEPD will determine the application file date based on the date the application is received by MEPD.

The case manager must first perform an inquiry in the Texas Integrated Eligibility Redesign System (TIERS) to determine if the applicant receives Medicaid. If the applicant does not receive Medicaid, a referral must be made to MEPD.

Once the case manager determines the applicant being referred to MEPD for a financial determination does not have Medicaid coverage in TIERS, the case manager uses Form H1746-A, MEPD Referral Cover Sheet, and Form H1746-B, Batch Cover Sheet, to send Form H1200 to the Midland Document Processing Center (DPC). Form H1746-B must be attached to the top of the each batch containing more than one Form H1746-A being shipped to DPC.

The case manager must send Form H1200 to DPC no later than close of business on the second working day from the date of receipt of the completed Form H1200.

Staff must maintain a copy of the successful fax transmittal confirmation in the case record. If unusual circumstances exist in which the original Form H1200 must be mailed to MEPD after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 and sending by electronic mail is prohibited.

Refer to Section 3432.3, Procedures for Texas Integrated Eligibility Redesign System (TIERS) Applicants, for coordination with MEPD.

All available verifications provided by the applicant must be attached to the referral. The case manager keeps a copy of all documents for the case record. Form H1200 must be kept in the case record for three years after the applicant is denied or the individual is terminated from the Community Based Alternatives (CBA) program.

MEPD may use streamlining procedures to determine financial eligibility when the situation warrants. MEPD financial decisions should be made within 45 calendar days of the Form H1200 application date for all CBA applications, except for disability determinations that can take up to 90 calendar days. It is the case manager's responsibility to periodically check TIERS or consult with the MEPD specialist to determine the status of the Medicaid eligibility determination so that a CBA eligibility determination can be made within 30 calendar days of receipt of the pre-enrollment assessment.

Note: Regional MEPD management must determine the appropriateness of allowing a delay in certification for the financial determination, which may result in not meeting the CBA enrollment processing deadline.

Refer to Appendix XVII, Medicaid Program Actions, for additional information regarding referrals to MEPD.

3313.1  Unsigned Applications

Revision 12-4; Effective December 3, 2012

Medicaid for the Elderly and People with Disabilities (MEPD) policy requires unsigned applications to be returned to the sender. The case manager must ensure applications are signed prior to referring to MEPD; if not, the case manager will be required to obtain signatures when unsigned applications are returned.

The application forms are:

  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form H1200-EZ, Application for Assistance – Aged and Disabled (Large Print).

If MEPD receives an unsigned application from the case manager with Form H1746-A, MEPD Referral Cover Sheet, MEPD will return the application to the case manager with an annotation on Form H1746-A that the application is unsigned and must be signed before the agency (Health and Human Services Commission) can establish a file date. Once the case manager receives an unsigned application from MEPD, it is the case manager's responsibility to coordinate with the applicant or individual in getting the application signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and Department of Aging and Disability Services eligibility processes and could adversely affect service delivery to an applicant or individual.

3314  Applicants Currently Residing in a Nursing Facility – Money Follows the Person (MFP) Option

Revision 13-1; Effective March 1, 2013

An individual residing in a nursing facility (NF) must follow the Money Follows the Person (MFP) option procedures in order to transition to the community.

To meet the MFP option requirements for enrollment in Community Based Alternatives (CBA), an applicant must:

  • be in an NF at the time CBA services are requested,
  • be enrolled in Medicaid for his NF stay,
  • meet all eligibility requirements for CBA, and
  • remain in the NF until notified that CBA has been approved.

The case manager must strongly advise the applicant the importance of remaining in the NF until the applicant receives notification of CBA eligibility.

An applicant who chooses to return home before being determined eligible for CBA must be notified of ineligibility. An applicant denied CBA for leaving the NF before being determined eligible will have his name put on the CBA interest list based on the date CBA services were requested.

An applicant who is involuntarily discharged from the NF continues to meet the NF residence requirement if conditions are met. The individual who receives Medicaid:

  • requests community based services (Department of Aging and Disability Services waiver programs or Long-term Services and Supports) while residing in an NF,
  • is involuntarily discharged and removed from the NF before the final decision on the request(s), and
  • files a timely appeal with the NF regarding the discharge.

The NF provides the individual who is involuntarily discharged a notice that includes the staff member's name and how to contact the Medicaid for the Elderly and People with Disabilities (MEPD) staff to request an appeal. The NF administrator or social worker can assist the individual in filing the appeal with MEPD. The appeal must be filed within 10 days of the discharge notice.

The individual is considered to be a resident of the NF only while the appeal is pending. CBA eligibility cannot be approved or denied until a decision is made regarding the involuntary discharge. If the individual does not appeal the involuntary discharge from the NF, deny CBA based on the MFP requirement that an applicant remain in the NF until eligibility is determined.

Involuntary discharge from the NF could occur because of the lack of payment to the NF for care or inappropriate behavior. Discharge from the NF because of medical necessity (MN) or financial eligibility is not considered involuntary.

3314.1  Requests for Services from Nursing Facility Residents

Revision 13-1; Effective March 1, 2013

Anyone currently residing in a nursing facility (NF) may request Community Based Alternatives (CBA) services and be assigned to a case manager to begin the CBA eligibility process.

  • The applicant may apply for CBA and Medicaid in the NF at the same time. The two applications may be worked concurrently.
  • The applicant will be placed on the Community Services Interest List (CSIL) and moved into assigned status with the bypass code, "Residing in Nursing Facility."
  • The CBA assessment process must not be delayed pending a decision on Medicaid eligibility.
  • The case manager has the standard 14 calendar days to respond to the request for services.
  • However, the applicant must be determined eligible for Medicaid in the NF before the case manager can determine eligibility for CBA services following Money Follows the Person (MFP) procedures.

There are various circumstances in which Medicaid may be paying for the NF stay. These circumstances include the following:

  • The applicant is receiving Medicaid and the NF is paid solely by Medicaid (Service Code 1).
  • The applicant is receiving Medicaid in a Title XIX swing bed (Service Code 10).
  • The applicant is receiving Medicaid in an NF for a Medicare convalescent stay and Medicaid pays the copayment.
  • The applicant is receiving Title XIX Medicaid Hospice services in an NF (Service Code 8).

The applicant whose NF stay is not being paid by Medicaid must continue to reside in the NF for 30 days until Medicaid eligibility is determined. The 30-day stay requirement does not apply to an applicant receiving Supplemental Security Income and requests use of the MFP option. The applicant must receive written notification that all CBA eligibility requirements are met before leaving the NF. An applicant who leaves the NF before being determined eligible for CBA must be denied CBA.

3314.2  Referral to Relocation Specialists

Revision 09-4; Effective March 27, 2009

All applicants for Community Based Alternatives (CBA) using the Money Follows the Person (MFP) option must be referred to a relocation contractor.

Form 1579, Referral for Relocation Services, is completed and sent to the relocation contractor at the same time the pre-enrollment assessment referral is made to the Home and Community Support Services Agency (HCSSA). A copy of Form 1579 is filed in the case record under Miscellaneous.

Form 1579 must be completed in its entirety to provide specific details regarding the applicant's needs, resources and plans for relocation. Any information that will be helpful to the relocation contractor in assisting the applicant in the relocation process should be included on the form.

Case managers must verbally inform the applicant of the referral to a relocation contractor and document the date and time of contact with the applicant on Form 1579. This initiative ensures the opportunity for facilitation of the relocation process for all individuals choosing to return to the community.

Form 1579 is also used to refer an ongoing CBA individual who has entered a nursing facility for a Code 35, Temporary Nursing Facility Stay. Form 1579 must be sent to the Relocation Specialist within two workdays of completing the Code 35 action in the Service Authorization System.

3314.3  Money Follows the Person Demonstration

Revision 14-1; Effective April 3, 2014

Effective February 1, 2008, Money Follows the Person Demonstration (MFPD) was implemented for Community Based Alternatives (CBA). MFPD is intended to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities and receive necessary long-term services in the setting of their choice.

CBA services received by the CBA individual who participates in MFPD will be the same as services received by other CBA waiver participants. All participants in MFPD will receive more extensive relocation assistance and follow-up.

To be eligible for MFPD through the CBA program, the applicant must meet current CBA and MFP policy, along with the following eligibility requirements for MFPD:

  • Reside continuously in an institutional setting for at least 90 calendar days prior to the CBA enrollment date and be enrolled from a Medicaid-certified nursing facility;
  • Be Medicaid eligible under Title XIX of the Social Security Act;
  • Transition into a qualified residence:
    • Home owned or leased by the individual or individual's family member;
    • Apartment with an individual lease that includes living, sleeping, bathing and cooking areas in which the individual/family member has domain and control;
    • Assisted Living apartment (Service Code 19);
    • Residential Care apartment (Service Code 19A);
    • Adult Foster Care home (no more than four unrelated individuals living in the home);
  • Have Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, signed by the individual, guardian/legally authorized representative (LAR) and case manager after explanation of MFPD and prior to delivery of CBA services;
  • If a guardian is present, include the guardian/LAR in the actual transition planning.

Participants in MFPD must transition directly from a nursing facility to CBA. However, for MFPD, an institutional setting is defined as a nursing facility, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) facility, hospital or state hospital. The 90-calendar day residency rule may be met by a continuous stay in a combination of the settings. The final residence of the individual prior to transitioning to CBA must be the nursing facility.

Example: An MFP applicant may have resided continuously in a nursing facility for 30 days, in a hospital for 30 days, and then re-entered the nursing facility for another 30 days. This would meet the 90-calendar day residency rule for MFPD.

The continuous 90-calendar day requirement must not include any Medicare paid days in a nursing facility, including full Medicare payment and Medicaid copay. In the Service Authorization System (SAS), a nursing facility Service Authorization record will have a Service Group (SG) 1 and a Service Code (SC) 3A for Part-A full Medicare payments, and a SG 1 and a SC 3 for co-insurance (Medicaid copay) record. A nursing facility Service Authorization record will have SG 1 and a SC 1 for full Medicaid payment record. The SG1, SC 3A record will always appear if the individual meets the 20-day qualifying stay for Medicare. Staff may have to contact the nursing facility to verify the actual Medicare days.

To verify MFPD institutional residency requirements, the case manager may:

  • view SAS institutional records;
  • contact the nursing facility or other institution for admission dates;
  • contact the Home and Community Support Services Agency (HCSSA) for hospital days; or
  • obtain confirmation from the applicant as a last resort.

Check SAS for verification of residence in qualified institutional settings. This may include stays in a combination of settings; applicable settings include:

  • Service Group (SG) 1, Service Code (SC) 1, Nursing Facility – Daily Care;
  • SG5, SC1, State Operated ICF/IID;
  • SG6, SC1, Non-State Operated ICF/IID; and
  • SG4, SC1, State Supported Living Centers.

The case manager must document in the case record the dates of each qualifying institutional stay verified to meet the 90-calendar day continuous stay requirement for MFPD.

When determining the applicability of this policy, a hospice stay affiliated with a nursing facility counts towards the 90-calendar day continuous stay requirement. Hospice services are recorded as Service Group 8 in SAS. The case manager must check the SAS hospice enrollment record "Living Arrangement" field to determine if the individual received hospice in a nursing facility. If the case manager cannot determine from SAS if hospice services were delivered in a nursing facility, the case manager must contact the hospice agency to determine if the applicant received hospice in a nursing facility and to obtain the hospice service dates. The case manager uses this information to determine if the individual met the residency requirement for MFPD.

Form 1580 must be presented to all applicants for CBA services through the MFP option. Appendix IX, Money Follows the Person Demonstration Project Script, provides a script to assist case managers in presenting MFPD information to applicants. Participation in MFPD is voluntary. By signing Form 1580, the applicant agrees to participate in MFPD and accept all conditions of participation outlined in Form 1580, which could include surveys or visits to the individual's home by the contractor secured to evaluate MFPD. Applicant/guardian/LAR signatures must be obtained by the case manager. An individual is enrolled in the CBA MFPD for a 12-month period, which is considered the individual service plan (ISP) period.

If an applicant declines participation in MFPD, the case manager documents the applicant's decision in the case record. An applicant's refusal to participate in MFPD does not affect the applicant's eligibility for Medicaid or CBA services. The CBA applicant/individual may withdraw from MFPD at any time by completing Form 3632, Withdrawal Confirmation. Although MFPD eligibility may end, the individual will continue to receive CBA services if all CBA eligibility criteria are met.

All applicants selecting MFPD will be referred to a relocation contractor by completing Form 1579, Referral for Relocation Services. Intensive pre-transition and post-transition services will be provided by relocation contractors who will be actively involved in identifying individuals interested in relocation, and will coordinate the transition with the nursing facility and the case manager. The relocation contractor must be included in the development of the ISP. Additionally, all CBA individuals who enter the nursing facility on a temporary stay must be referred to relocation services. Form 1579 must be sent to the relocation contractor within two workdays of completing the Code 35, Temporary Nursing Facility Stay, action in SAS. File a copy of Form 1579 in the case record under "Miscellaneous."

Case managers must consider all available resources, including the use of Community Transition Teams (CTT), in the service planning for individuals in MFPD.

Individuals who choose to enroll in and meet the eligibility requirements for MFPD must be designated in SAS using special procedures. Refer to Section 3314.3.1, Money Follows the Person Demonstration and the Service Authorization System, for information related to completing SAS records.

Case records of MFPD participants must be flagged by the case manager. When the MFPD participant is enrolled, the case manager will email the following information to the regionally designated MFPD reporting staff:

  • Name;
  • Medicaid number; and
  • ISP start date.

The regionally designated MFPD reporting staff will maintain a list of all MFPD participants in the region.

3314.3.1  Money Follows the Person Demonstration and the Service Authorization System

Revision 10-1; Effective March 11, 2010

Individuals who choose to enroll in and meet the eligibility requirements for Money Follows the Person Demonstration (MFPD) must be designated in the Service Authorization System (SAS) using special procedures.

  • Enrollment Record-Enrolled From Field: Choose "12-Rider 37/28 (FAC to COMM)."
  • Service Authorizations:
    • Force Box: Check the Force box for each service authorization.
    • Fund Type: Choose "19MFP-Money Follows the Person." This code applies only to MFPD recipients.
    • Force Comment: Enter "MFP Demonstration Consumer" and select "Force."

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD period is over or if the CBA consumer withdraws from MFPD. If a CBA consumer enters a nursing facility and then re-enters the community setting before the MFPD ISP period is over, the MFPD entitlement period will resume until the end of the ISP.

Staff should not use Fund Type 19MFP for:

  • Service Code 40A-Pre-Assessment; and
  • Service Code 60-Prescriptions.

Staff should use:

  • Fund Type 1915(c) Waiver for Service Code 40A; and
  • Default Fund Type for Service Code 60.

Staff must manually force all appropriate service authorizations with 19MFP, except Service Code 60, before submitting the ISP through the SAS wizard. Service Code 60 must be left at Default Fund Type. A manual force action is not required for Service Code 40A when using the SAS wizard as Fund Type 1915(c) Waiver will automatically be entered.

Staff must also use Fund Type 19MFP for Service Code 53-Transition Assistance Services (TAS) and Service Code 53-A, TAS fee.

3314.3.2  Money Follows the Person Demonstration 365-Day Entitlement Period

Revision 10-4; Effective September 1, 2010

Community Based Alternatives (CBA) Money Follows the Person Demonstration (MFPD) consumers are entitled to participate in the demonstration for 365 days, beginning the date that the consumer agreeing to participate in the demonstration is enrolled in CBA.

Example: A CBA applicant chooses to participate in MFPD and is enrolled in CBA effective January 1. If there are no institutional stays during the initial individual service plan (ISP) period, the MFPD period ends on December 31. If the MFPD consumer is institutionalized for 10 days in February, the MFPD period is extended to January 10, following the ISP end date of December 31. If the MFPD consumer is authorized for a new MFPD service during the initial ISP period, the 365-day period would still end on December 31, if there were no institutional stays.

Tracking is required to ensure MFPD consumers receive the full 365-day entitlement period unless the consumer withdraws from MFPD. For tracking purposes, the consumer's date of entry and date of discharge from a hospital, nursing facility or other institutional setting is included in the number of days the consumer is considered to be institutionalized.

Each region has a designated MFPD reporting coordinator who will provide the regional Claims Management Services (CMS) coordinator with a copy of the regional spreadsheet that lists all MFPD consumers. The CMS coordinator will use the spreadsheet to track the 365-day period for each MFPD consumer.

Tracking MFPD consumers is a two-step process for CMS coordinators. The first tracking step begins in the tenth month of the ISP. The CMS coordinator will:

  • check the Service Authorization System (SAS) to determine the number of days the consumer was registered as a Code 35, Temporary Nursing Facility Stay, in the initial ISP period;
  • contact the case manager to determine the number of days the consumer was in a hospital (regular, acute care or state) or other institution (rehabilitation or intermediate care facility for persons with mental retardation or related condition) during the initial ISP period and confirm any Form 2067, Case Information, dates of admission to a nursing facility (NF), including any Medicare NF days;
  • calculate the number of total days the MFPD consumer was in an NF, hospital or other institution (this is Check 1); and
  • instruct the case manager via email to take one of the following actions regarding Fund Type 19MFP-Money Follows the Person when processing the reassessment ISP:
    • If the MFPD consumer has not been in a hospital and/or institution during the initial ISP period or if the number of institutional days plus 365 days is less than the total number of days in the ISP year, process the reassessment according to current procedures using SAS wizards. Fund Type 19MFP is not required in the reassessment ISP.
    • If the total number of hospital and/or institutional days is more than the number of days left in the initial ISP period after day 365, process the reassessment according to current procedures for reassessment using SAS wizards. After generating the reassessment, manually open each service authorization record and change the Fund Type from default setting to Fund Type 19MFP. (This requires force capability.)

The second tracking steps begin at the end of the MFPD consumer's ISP. The CMS coordinator will:

  • check SAS and contact the case manager for any additional hospital and/or institutional stays that occurred in the initial ISP not included in the total from Check 1 (this is Check 2);
  • calculate the total number of hospital and/or institutional stays by adding the number of days of hospital and/or institutional stays from Check 1 and Check 2;
  • review the initial ISP period and determine the MFPD extension period, if applicable, and determine if the total number of hospital and/or institutional days requires an extension beyond the initial ISP period or if Fund Type 19MFP must end on or before the initial ISP expiration date; and
  • instruct the case manager via email of the appropriate actions to take to ensure Fund Type 19MFP is accurately recorded in the SAS service authorization records:
    • If the consumer has not entered a hospital and/or institution during the initial ISP year, manually end each service authorization record in the initial ISP period on the 365th day and manually create new service authorization records using the default fund type effective the 366th day through the end of the initial ISP period. (This requires force capability.)
    • If the consumer entered a hospital and/or institution during the first 365 days of the initial ISP year, but the number of days in the hospital and/or institution does not extend beyond the end date of the initial ISP, add the number of days to the 365th day and manually end date the initial ISP service authorization records effective on that date. Then, manually create new service authorization records using the default fund type effective one day after the end date of the Fund Type 19MFP service authorizations and an end date of the last day of the initial ISP period. (This requires force capability.)
    • If the number of days the consumer was in a hospital and/or institution exceeds the number of days left in the initial ISP period after day 365, adjust the reassessment service authorization records to cover these days. Manually open each service authorization record and end each using the last day the consumer is part of MFPD. Then, create new service authorization records using the default fund type for the remaining days of the reassessment ISP period. (This requires force capability.)

Example 1: The CBA MFPD consumer was in the hospital and/or institution for 20 days during the 365-day initial ISP period. The MFPD period must be extended past the initial ISP for 20 days. At the tenth month check, the CMS coordinator instructed the case manager to enter Fund Type 19MFP with the reassessment ISP. After the CMS coordinator completed the second check at the end of the initial ISP, the case manager was instructed to remove Fund Type 19MFP effective the 21st day of the reassessment ISP period.

Example 2: The CBA MFPD consumer was in the hospital and/or institution for 10 days during the initial ISP period. The initial ISP period is January 15 to January 31 the following year, which is a total of 381 days. Fund Code 19MFP must be removed from the initial ISP beginning on day 376 (the 11th day past day 365).

Example 3: The CBA MFPD consumer was not in the hospital and/or institution any days during the initial ISP period. The initial ISP period is January 1 to December 31. Fund Type 19MFP was entered with the initial ISP. No adjustments are necessary to the initial ISP because there were no hospital and/or institutional days in the initial ISP period and the MFPD consumer participated in MFPD for the entire initial ISP, which was a total of 365 days.

Fund Type 19MFP is not entered in service authorization records for Service Code 40A-Pre-Assessment and Service Code 60-Prescriptions. The total number of authorized units for the ISP period must be prorated between the service authorization with the default fund type and the service authorization with Fund Type 19MFP. (This process is similar to the proration of units when completing Code 35 actions or provider transfers.) To ensure Fund Type 19MFP is recorded in SAS for the entire MFPD ISP period, a re-force of service authorization records may be required when changes occur to services during the ISP period. Fund Type 19MFP must be removed from service authorizations if the MFPD consumer withdraws from MFPD.

3314.3.3  Money Follows the Person Demonstration Overnight Companion Services

Revision 10-5; Effective December 1, 2010

Effective Nov. 1, 2009, Money Follows the Person Demonstration (MFPD) offers Overnight Companion Services (OCS) to some Community Based Alternatives (CBA) MFPD consumers in Region 4 and Region 11. OCS was previously available only to MFPD consumers living in Cameron, Hidalgo and Willacy counties in the Rio Grande Valley area of south Texas. OCS is now expanded to include all Region 11 fee-for-service counties (Cameron, Hidalgo, Willacy, Brooks, Duval, Jim Hogg, Kennedy, Live Oak, McMullen, Starr, Webb and Zapata), and all Region 4 counties.

OCS is available in Region 4 and Region 11 for up to 20 CBA MFPD consumers who have a cognitive impairment or physical disability and meet the criteria below. The combined total of OCS consumers in Region 4 and Region 11 cannot exceed 20.

OCS may eliminate one of the barriers to successful transition to the community for individuals with complex needs who require overnight assistance. OCS provides direct support and assistance in the consumer's home during normal sleep hours (not restricted to nighttime hours) and may include assistance with personal care, including toileting, transferring, ambulation, general orientation and medication reminders.

Home and Community Support Services Agency (HCSSA) may contract with the Department of Aging and Disability Services (DADS) to provide OCS. The HCSSA that delivers OCS may be different from the HCSSA that delivers CBA services listed on the individual service plan (ISP). Contracted OCS providers will deliver OCS to a CBA MFPD consumer who, as determined by the DADS case manager and interdisciplinary team:

  • has a cognitive impairment or physical disability;
  • is eligible for and chooses to participate in MFPD;
  • has a medical need for specific tasks to be performed during normal sleeping hours;
  • does not have someone currently available to meet these needs;
  • is willing to seek informal supports to meet these needs;
  • understands and agrees that the service is limited to a 365-day demonstration period; and
  • has the ability to notify and wake the companion during normal sleeping hours should a need occur.

The MFPD requires an OCS companion to meet the same qualifications as the Texas 1915(c) waiver Personal Attendant Services (PAS) program. In addition, the OCS provider must meet the MFPD qualifications of an OCS companion. The OCS companion must:

  • be an employee of the HCSSA (unless the MFPD consumer uses the Consumer Directed Services (CDS) option);
  • be 18 years of age or older;
  • pass all registry checks; and
  • not be the spouse or guardian of a consumer who receives OCS.

The interdisciplinary team may consider the use of technological devices (pagers, child monitoring systems, etc.) to enable the consumer to notify/wake the companion. If technological devices are used, the OCS provider must document competency in the use of the devices by both the CBA consumer and companion before OCS is implemented. Technological items may be considered for purchase through the CBA ISP as an adaptive aid. The HCSSA should submit requests for technological devices on Form 3671-E, Adaptive Aids and Medical Supplies.

Requests for Overnight Companion Services

During the initial assessment of the CBA MFPD applicant, the case manager reviews OCS criteria to determine if the applicant meets the criteria and if the service is needed. If the applicant meets OCS criteria and the service is needed, the case manager must send an email to the Community Services Interest List (CSIL) manager to request one of the available OCS slots. The CSIL manager will respond via email and approve or disapprove an OCS slot for the requested applicant. If approval for a slot is given, the case manager authorizes OCS. The case manager presents a list of contracted OCS providers and obtains the applicant's choice of OCS provider.

The case manager submits Form 2067, Case Information, to the selected OCS provider. Form 2067 must document the:

  • applicant's identifying information;
  • authorization of OCS;
  • ISP period;
  • county of residence;
  • cognitive impairment or physical disability requiring OCS;
  • ability to notify and wake a companion during normal sleeping hours; and
  • estimate of the number of hours (per 24-hour period) needed for OCS. Example: Authorized units: 8-12 hours, 5 nights per week.

The case manager notifies the MFPD applicant of eligibility for OCS using the comments section of Form 2065-B, Notification of Waiver Services. If a slot is not available, the case manager uses the comments section of Form 2065-B to notify the consumer that all available slots for OCS are filled and OCS will not be available. If the CBA MFPD applicant requests the service but does not meet the criteria, the case manager includes on Form 2065-B (in comments) the specific OCS criteria the applicant does not meet. The CSIL manager must be notified if an OCS slot is not used by the applicant once the slot has been approved by the CSIL manager. Once all OCS slots are filled, the CSIL manager will maintain an interest list of names submitted for OCS.

OCS may be beneficial in developing an ISP to meet the needs of a CBA MFPD applicant who requires extensive care, or when there is difficulty in securing an HCSSA to accept the applicant due to no informal supports. The availability of an OCS slot may affect whether the HCSSA will accept an applicant. The case manager must ensure the HCSSA has an accurate ISP when negotiating and requesting acceptance of an ISP with the HCSSA for high needs applicants.

Due to changes in condition or circumstances, a CBA MFPD consumer may develop a need for OCS during the ISP year. A request for OCS may be initiated by the case manager or by the HCSSA submitting Form 2067 documenting that the individual now meets OCS criteria. The case manager reviews the criteria and follows procedures to authorize OCS if a slot is available. The CBA MFPD consumer may be authorized OCS for the remainder of the MFPD 365-day eligibility period. Refer to Section 3314.3.2, Money Follows the Person Demonstration 365-Day Entitlement Period, to determine the MFPD 365-day eligibility period.

Authorization of Overnight Companion Services

If approval is given for the CBA MFPD applicant to receive an OCS slot, the case manager authorizes OCS for the ISP period. The service code is 65. The case manager:

  • sends Form 2067 to the OCS provider authorizing OCS, which must include the ISP period and the units authorized;
  • authorizes OCS in the Service Authorization System (SAS). Service Code 65 must be authorized by manual completion of the SAS service authorization record using the following:
    • Unit Type: Daily
    • Units: 1
    • Begin and End Dates: ISP Begin Date (if OCS is authorized at initial certification of CBA) and ISP End date
    • Provider: Selected OCS provider contract number
    • Fund Type: 19MFP-Money Follows the Person
    • Force Box: Force selected
    • Force Comment: MFP Demonstration Consumer

The case manager also notifies the consumer of authorization of OCS on Form 2065-B in the comments section.

Note: If OCS is authorized to begin on a date other the first day of the ISP period, the Begin Date of the SAS record is the date OCS is effective. The End Date is the ISP End date.

The authorized amount of OCS is not included in the total value of the ISP. The case manager documents the use of OCS on Form 8598, Non-Waiver Services. OCS providers bill for Service Code 65 using the appropriate bill code. A unit of service is defined as 8-12 consecutive hours within a 24-hour period.

Monitoring of Overnight Companion Services

At the routine CBA six month contact, the case manager must review OCS with the consumer and determine if OCS should continue or not. If the OCS consumer has secured informal supports to assist with overnight needs or the consumer feels his health status has improved and OCS is no longer necessary, OCS must be terminated. Ninety days prior to the end of the MFPD period, the case manager must begin working with the OCS consumer to seek informal supports to meet the needs of the consumer when OCS is terminated.

Termination of Overnight Companion Services

The CBA MFPD consumer is entitled to receive OCS for the MFPD 365-day eligibility period until the consumer is able to secure informal supports necessary to meet his overnight needs or until it is determined the consumer no longer needs OCS. To terminate OCS, the case manager:

  • sends Form 2067 to the OCS provider terminating OCS, which must include the termination date of OCS;
  • terminates the OCS service authorization manually in SAS;
  • notifies the consumer of termination of OCS on Form 2065-B providing 12 days advance notice; and
  • notifies the CSIL manager via email of the termination. The email must contain the:
    • consumer's name;
    • effective date of termination; and
    • reason for termination.

The CBA MFPD consumer will continue to receive all CBA services as long as eligibility requirements are met without regard to whether the consumer continues to receive OCS. The MFPD and additional services available through the initiative are designed to provide enhanced services to CBA consumers transitioning from institutional settings to the community.

Consumer Directed Services (CDS) Option in Overnight Companion Services

The CDS option is also available for OCS for MFPD consumers in Region 4 and Region 11. The OCS CDS option will allow the CBA MFPD OCS consumer in the OCS service area to recruit and hire the individual that will provide OCS.

The case manager follows the same OCS assessment, authorization and monitoring process as outlined for non-CDS consumers. During the initial visit, the case manager will review the CDS option and inform the applicant that OCS, as well as PAS, respite, nursing and therapies, are offered through the CDS option. If the applicant chooses OCS through the CDS option, Form 2067 and Form 1584, Consumer Participation Choice, are sent to the selected CDS agency (CDSA) to authorize services. Other CDS procedures found in Section 5000, Consumer Directed Services, must be followed. OCS CDS services are documented on Form 8598.

The OCS CDS unit of service is also defined as 8-12 consecutive hours within a 24-hour period. The OCS CDS service code is 65V. Service Code 65V must be authorized by manual completion of an SAS service authorization record using the following:

  • Unit Type: Per Authorization
  • Units: Annualized Dollar Amount (weeks in ISP year x units per week x OCS CDS rate)
  • Begin and End Dates: ISP Begin Date (or Date OCS CDS begins if not the first day of the ISP period) and ISP End Date
  • Provider: Selected CDSA provider contract number
  • Fund Type: 19MFP-Money Follows the Person
  • Force Box: Force selected
  • Force Comment: MPF Demonstration Consumer

Example for calculating annualized dollar amount: The consumer needs three units of OCS CDS per week. There are 53 weeks in the ISP year. The calculation of annualized dollar amount is: 53 x 3 = 159 x $43.17 = $6,864.03.

The CDSA is entitled to a monthly CDS Financial Management Services (FMS) fee. The FMS service code 63V is authorized by manually creating an SAS service authorization record using:

  • Unit Type: 2-Month
  • Units: 1.00

Refer to Section 2400, Reimbursement Rates, and the Health and Human Services Commission Rate Analysis site for current OCS and OCS CDS rates.

3315  Home and Community Support Services Agency (HCSSA) Responsibility for Pre-Enrollment

Revision 13-2; Effective June 3, 2013

Within 14 calendar days of receipt of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, or by an earlier negotiated date, the HCSSA nurse conducts a face-to-face contact with the applicant. The HCSSA nurse is required to:

  • complete and electronically transmit the Medical Necessity and Level of Care (MN/LOC) Assessment to Texas Medicaid & Healthcare Partnership (TMHP). The HCSSA must obtain the physician's signature prior to submitting MN/LOC Assessment in the Long Term Care Portal;
  • assess the need for services available through Community Based Alternatives (CBA) to support the documentation of need on the MN/LOC Assessment and include all identified medically necessary services and rationales on the individual service plan (ISP), Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan, for therapies, skilled nursing, minor home modifications, dental services, medical supplies and adaptive aids;
  • document the conclusion regarding medically necessary services on Form 3671-2, Individual Service Plan, by checking the appropriate boxes and indicating which attachments are included in the assessment packet;
  • review Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, and notify the case manager using Form 2067, Case Information, of any changes needed in personal assistance services (PAS);
  • discuss third-party resources (TPR), non-waiver services and informal supports with the applicant, and document on Form 8598, Non-Waiver Services, or on the appropriate Form 3671 attachment if the TPR relates to the services listed on the attachment;
  • sign Form 3671-2, documenting the assessment of services for the proposed service plan;
  • obtain the applicant's signature on Form 3671-2, in the Freedom of Choice and Acknowledgement and Acceptance of the ISP sections of the form;
  • obtain the signature of the HCSSA representative on Form 3671-2, accepting the applicant or refusing to serve the applicant based on licensure limitations, with the provision that, if accepted, the plan proposed in the pre-enrollment assessment will be implemented, unless the case manager contacts the HCSSA to arrange for changes to the proposed plan; and
  • complete Section B of Form 3676.

Note: After receipt of the developed plan by the case manager, the HCSSA may accept or refuse the consumer and may negotiate plan changes before signing the form.

The HCSSA nurse sends the case manager:

  • the Document Locator Number (DLN) of the completed and transmitted MN/LOC Assessment, with a copy of the signed Physician’s Signature page;
  • Form 3676;
  • Form 3671-2;
  • Form 8598;
  • Form 2060-A and Form 2067, if changes are recommended for PAS;
  • Form 3671-B, Form 3671-C, Form 3671-C-Alternate, Form 3671-D, Form 3671-E, Form 3671-F, Form 3671-H and Form 3671-J, as noted on Form 3671-2; and
  • the appropriate attachments.

Boxes for medically necessary services not checked by the HCSSA nurse on Form 3671-2 indicate that the individual does not need that particular service.

If a pre-enrollment packet is sent back by the case manager because it is incomplete, the HCSSA must complete and return the packet within three working days.

The DLN is a unique number assigned to each MN/LOC Assessment submitted to the Long Term Care Portal. When the DLN is received, the case manager (or designee) must log on to the portal to access and print the MN/LOC Assessment or at a minimum, must document in the applicant’s case record the DLN, the resource utilization group (RUG) value and whether the MN determination was approved or denied. This information may be printed from the TMHP Long Term Care Online Portal or written in the case narrative form for the case record. A copy of the MN/LOC Assessment or the DLN, RUG and result of the MN determination must be filed in the case record. At the time of the Initial Pre-Enrollment Assessment, the HCSSA must supply the case manager with the DLN and a copy of the signed Physician's Signature page. At the time of the Annual Assessment or Significant Change in Status Assessment, the HCSSA is only required to supply the case manager with the DLN. A physician's signature is required on the Physician Signature page when the type of assessment (field A0310 on the MN/LOC Assessment) is marked Initial Assessment. By signing the Physician Signature page, the physician is certifying the applicant requires nursing facility services or alternative community based services under the supervision of a Medical Doctor/Doctor of Osteopathy (MD/DO). There is no requirement for a physician to attest to the accuracy of the MN/LOC Assessment.

Refer to Section 3411, Documentation of Waiver Requirements, for policy regarding obtaining signatures on the ISP.

3315.1  Delay in Completion of the Pre-Enrollment Assessment

Revision 11-3; Effective September 1, 2011

The time frame allowed for the pre-enrollment assessment will be extended if:

  • the decision to initiate Medicare home health services is pending; or
  • there is a delay in getting the Medical Necessity and Level of Care (MN/LOC) Assessment signed by the physician.

The Home and Community Support Services Agency (HCSSA) nurse must notify the case manager verbally within 24 hours of the negotiated completion date for priority applicants, or before the 14 day completion time frame for routine applicants, that the assessment will not be completed. The HCSSA nurse must send the case manager written verification of the delay via Form 2067, Case Information, within two Department of Aging and Disability Services (DADS) working days of the verbal notification of the delay. All required assessment forms must be received by the case manager within two DADS working days after the HCSSA has received the physician's signature on the MN/LOC Assessment or made the decision regarding Medicare home health service initiation.

If the HCSSA cannot meet the time frame for the pre-enrollment home health assessment, the HCSSA must notify the case manager using the procedures described in Section 4442.3, Pre-Enrollment Home Health Assessment, of the Community Based Alternatives Provider Manual. If the case manager does not receive the complete packet of forms within the time frame identified in Item 14 of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, and the HCSSA does not follow the procedure for a delay in the process, the case manager must verbally contact the HCSSA within two DADS working days after the due date of the assessment to determine the status of the assessment. After obtaining the reason for the delay from the HCSSA, the case manager confers with the applicant to decide if the referral should be canceled and a referral made to another HCSSA or if the applicant will wait until the HCSSA can complete the assessment.

If the applicant decides to cancel the referral to the first HCSSA, the case manager must call the HCSSA to cancel the referral by the next DADS working day and send Form 2067 to the HCSSA within five DADS working days of the telephone call. The case manager must not authorize payment for the pre-enrollment home health assessment to the first HCSSA if the applicant chooses to cancel the referral because of the delay in the completion of the assessment.

If the completed assessment is not received by the case manager by the due date, the case manager should file a complaint with the Consumer Rights and Services hotline. Refer to Section 3680, Reporting Service Delivery Issues to Consumer Rights and Services. The case manager may also inform regional contract staff, especially if a pattern of late assessments is detected.

3316  Review and Authorization for Payment of Pre-Enrollment Assessment

Revision 13-3; Effective September 3, 2013

The case manager must review the pre-enrollment assessment for completeness upon receipt. The case manager reviews Form 3671-2, Individual Service Plan, to ensure the attachments (Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan, and Form 3671-K, Service Backup Plan) noted on Form 3671-2 are included in the assessment packet. The case manager should not require the submittal of attachments for services the Home and Community Support Services Agency (HCSSA) nurse has concluded are not medically necessary.

The case manager must review the assessment packet for completeness and inconsistencies at the initial enrollment. Additional information should be requested from the HCSSA nurse when there are inconsistencies in the assessment information.

Complete Pre-Enrollment Assessment

The pre-enrollment assessment is considered complete when the case manager has received:

  • the Document Locator Number (DLN) of the completed and transmitted Medical Necessity and Level of Care (MN/LOC) Assessment, with a copy of the signed Physician's Signature page;
  • Form 2067, Case Information, if applicable, indicating if any changes are needed in personal assistance services (PAS), as identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services;
  • the individual service plan (ISP) attachments, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J and Form 3671-K, including sufficient documentation on Form 3671-F, or other documentation that identifies each adaptive aid, medical supply, dental service, or minor home modification, why it is necessary, and how it is related to the applicant's disability or medical condition, including signatures by informal support providing nursing tasks on Form 3671-C;
  • Form 3676, Pre-Enrollment Home Health Assessment Authorization, with Section B completed;
  • Form 8598, Non-Waiver Services, signed by any third party who has agreed to provide services or protective supervision; and
  • Form 3671-2, with the applicant's signature in the Freedom of Choice and Acknowledgement and Acceptance of the service plan sections, the HCSSA nurse's signature confirming the assessment of medically necessary services, and the HCSSA representative's signature agreeing with the service plan and accepting the applicant with the proposed service plan.

Note: The HCSSA may wait until receipt of the case manager's developed plan before accepting or refusing the applicant.

The case manager should question the HCSSA nurse before approving payment for the assessment if there are inconsistencies in the assessment. For example, if Form 3676 indicates the applicant is receiving Medicare home health services, but the nursing assessment on Form 3671-C does not indicate the applicant is receiving any nursing services through Medicare, the case manager should ask the HCSSA nurse to explain the inconsistency. Discrepancies in medication administration or reminders should be cleared. If the assessment does not include sufficient documentation to support the necessity for each identified adaptive aid, medical supply, dental service, or minor home modification listed on Form 3671-D, Form 3671-E, Form 3671-H or Form 3671-J, the case manager should request the additional documentation. The case manager ensures that the HCSSA nurse obtains the required informal support signatures on Form 3671-C.

If the case manager believes the documentation regarding the medical necessity of the proposed minor home modifications, dental services, adaptive aids or medical supplies on Form 3671-F or other format is inadequate, the case manager should consult with the Department of Aging and Disability Services (DADS) regional nurse.

The service backup plan, Form 3671-K, is used when normal service delivery is interrupted, in the absence of the scheduled service provider, or in an emergency. Form 3671-K identifies the backup plan for the CBA service(s) and indicates who the individual contacts when there is an absence of service delivery. Form 3671-K includes the name and telephone number of the person the individual contacts and a designated resource, who is the person or entity that will provide the backup in the absence of the scheduled service provider. The backup plan enhances the state’s assurance of ensuring the individual’s health and welfare. The individual will continue to have the option of accepting a special attendant, using informal support or forgoing assistance during the absence of the scheduled service provider. During the completion of the pre-enrollment home health assessment, the HCSSA nurse will complete Form 3671-K with the applicant or his responsible party. The case manager will review Form 3671-K for completion and file it in the case record with the ISP.

Additional information on the assessment and special circumstances related to the MN determination is described in detail in Section 3431, Verifying Level of Care/Medical Necessity Determination, and Section 3431.2, Medical Necessity Determination for Applicants Residing in Nursing Facilities.

The case manager may approve payment for the pre-enrollment assessment when the applicant's physician has refused to sign the MN/LOC Assessment if the HCSSA submits documentation that a good faith effort has been made to obtain the physician's signature. Documentation should include the number of attempts made, when and how the attempts were made (by telephone or office contact) and efforts to communicate with the applicant about the impact of not having the physician sign the necessary forms.

Incomplete Pre-Enrollment Assessment

If the pre-enrollment assessment packet is not complete, the case manager must send Form 2067 to the HCSSA within three working days to request additional information or items needed to complete the assessment packet.

Authorization of Payment for Pre-Enrollment Assessments

Within five working days of receiving the completed pre-enrollment assessment, the case manager:

  • completes Section C of Form 3676 to authorize payment to the HCSSA;
  • sends a signed copy of Form 3676 to the HCSSA; and
  • registers the authorization on the Service Authorization System (SAS).

Note: See the instructions for Form 3676 for information about completing Sections A and C. Refer to Section 3411, Documentation of Waiver Requirements, for policy regarding obtaining signatures on the ISP.

3316.1  Physician Signature for Nursing Facility Residents

Revision 10-3; Effective June 1, 2010

The Home and Community Support Services Agency (HCSSA)'s role regarding a physician's signature for nursing facility (NF) residents applying for Community Based Alternatives (CBA) differs from the role required for other CBA applicants. Policy allows the medical necessity (MN) established for an NF resident to be used to determine eligibility for CBA. The case manager instructs the HCSSA not to complete the Medical Necessity and Level of Care (MN/LOC) Assessment as part of the pre-enrollment assessment. The HCSSA may request a copy of the NF Minimal Data Set (MDS) assessment, but the NF is not obligated to provide one. If a copy of the MDS is provided and there is no signature on the form, the HCSSA is not required to obtain a physician's signature. The HCSSA must obtain a physician's signature on the HCSSA's Plan of Care if nursing services are ordered.

3316.2  Licensed Physicians Practicing at Military or Veterans Affairs Facilities

Revision 11-4; Effective December 1, 2011

Licensed physicians currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities can sign orders for Community Based Alternatives (CBA) services even when they do not have a Texas license. This includes signatures on the following forms:

  • Medical Necessity and Level of Care (MN/LOC) Assessment
  • Any other documentation requiring a physician's or practitioner's signature

Licensed physicians practicing in military facilities, including VA hospitals and medical facilities, must practice in accordance with federal law, which supersedes state law. U.S. Code, Section 10 USCA §1094(d) (1) provides: "that notwithstanding any law about licensure of health care providers, a health-care professional who is a member of the armed forces who has a license may practice in any state regardless of whether the practice occurs in a health care facility of the Department of Defense, a civilian facility affiliated with the Department of Defense or any other location authorized by the Secretary of Defense."

Therefore, a physician licensed in any state (including a U.S. territory or District of Columbia) may practice at a military/VA facility. If the licensed physician at a military/VA facility evaluates the applicant or consumer at the facility and signs the documentation, the signature is acceptable.

3317  Authorization for Second Pre-Enrollment Home Health Assessment

Revision 13-2; Effective June 3, 2013

The case manager may authorize a second pre-enrollment assessment before an applicant's enrollment in the Community Based Alternatives (CBA) program if the applicant's condition and need for services has changed significantly since the first assessment and the individual service plan (ISP) does not adequately address the applicant’s current needs.

If a second pre-enrollment assessment is authorized, the case manager must send a copy of the following to the Home and Community Support Services Agency (HCSSA):

  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2060-A, Addendum to Form 2060 for Personal Assistance Services.

The HCSSA is expected to complete the assessment components and return the following to the case manager:

  • the Document Locator Number (DLN) of the transmitted Medical Necessity and Level of Care (MN/LOC) Assessment;
  • the individual service plan (ISP) attachments (Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan — Nursing Services Paln for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, as appropriate, including documentation of Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or similar documentation to justify adaptive aids, medical supplies, minor home modifications and dental services, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan);
  • Section B of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, unless directed otherwise by the case manager on Form 2067, Case Information, attached to the authorization; and
  • Form 2067, indicating changes in personal assistance services, if applicable.

If a second assessment is authorized, the case manager must contact the applicant and review the previous functional assessment, discuss changes with the applicant and review the information developed regarding non-waiver services before sending the ISP for coordination with the CBA providers.

Within five working days after the second completed assessment has been received, the case manager must write "FOR SECOND ASSESSMENT" next to the words "C. PAYMENT AUTHORIZATION" when completing Form 3676. A copy of Form 3676 is sent to the HCSSA to authorize the payment for the assessment.

If an initial ISP has not been entered in the Service Authorization System (SAS), the case manager may use the SAS CBA wizard to enter both pre-enrollment assessment service authorization records (Service Code 40A). The pre-enrollment assessments must be entered in chronological order. For example, a pre-enrollment assessment dated August 10 must be entered before one dated September 1. If the pre-enrollment assessments cannot be entered into the SAS CBA wizard in order by date because the second pre-enrollment assessment was entered first, then the pre-enrollment assessments must be entered in SAS manually. If the initial ISP has already been entered in SAS, the pre-enrollment assessment records must be entered in SAS manually.

The case manager should not authorize a second assessment to obtain a second MN determination because the first MN expired before the applicant was enrolled in the CBA program. The Department of Aging and Disability Services (DADS) regional nurse completes a new MN/LOC Assessment to update the MN determination if the applicant's MN has expired or will expire before CBA eligibility is established. The MN/LOC Assessment completed by the DADS regional nurse is attached to the Physician's Signature page from the initial MN determination documentation.

The DADS regional nurse sends the MN/LOC Assessment to the case manager for force entry into the Service Authorization System (SAS) MN record. The case manager follows regional procedures to complete the force entry into SAS.

See Section 3317.1, Additional Assessments for Applicants with High Needs, for procedures to authorize an additional assessment for an applicant when HCSSAs refuse to accept the applicant because of licensure.

3317.1  Additional Assessments for Applicants with High Needs

Revision 13-2; Effective June 3, 2013

The case manager may authorize the Home and Community Support Services Agency (HCSSA) to conduct a new assessment for an applicant with high needs. Additional assessments may be authorized when several HCSSAs refuse to accept the applicant. When a new assessment is authorized, the HCSSA performing that assessment is not provided copies of prior assessments by other HCSSAs. The HCSSA must complete a new full assessment.

The case manager may authorize additional assessments as requested by the applicant who has been refused by an HCSSA. Once the case manager receives the assessment packet back from an additional HCSSA indicating refusal to serve, the case manager may authorize a different HCSSA to perform a new complete assessment.

The case manager requests the applicant to select a different agency to perform the new assessment and authorizes the HCSSA to complete the assessment by completing and sending Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, to the selected HCSSA.

Additional new assessments may be authorized as determined by the high needs interdisciplinary team (IDT).

Authorization for payment of an additional new assessment must be entered in the Service Authorization System (SAS) upon receipt of the completed assessment and Form 3676 from the HCSSA. Payment should not be authorized if the HCSSA does not complete and submit a new full assessment packet. Refer to Section 3317, Authorization for Second Pre-Enrollment Home Health Assessment, for required documents.

3400  Development of the Individual Service Plan

Revision 11-3; Effective September 1, 2011

3410  Waiver Requirements

Revision 10-3; Effective June 1, 2010

STANDARD.  The case manager, in cooperation with the interdisciplinary team (IDT), is required to develop and document a written individual service plan (ISP) on Form 3671-1, Individual Service Plan, for each consumer and to revise that plan at least annually. Other documentation, such as staffing reports or entries in the case narrative, may be necessary to record the deliberations of the IDT. The IDT must certify in writing that the waiver services are necessary as an alternative to institutionalization and appropriate to meet the needs of the individual in the community.

STANDARD.  The case manager must verify all aspects of eligibility before determining initial or ongoing eligibility for the Community Based Alternatives (CBA) program.

STANDARD.  The case manager must complete the eligibility determination for CBA applications within 30 calendar days after the receipt of a complete pre-enrollment home health assessment from the Home and Community Support Services Agency (HCSSA) with the following exceptions.

If the medical necessity (MN) decision is not available to the case manager by 30 calendar days after receipt of the complete pre-enrollment assessment or the decision on the Medical Assistance Only (MAO) application cannot be made by 30 calendar days after receipt of the pre-enrollment assessment, the program standard is that the case manager must complete the decision on a CBA application within 14 calendar days from the date of notification that the outstanding MN or Medicaid decision is complete.

Service planning requires the synthesis of assessment results, the identification of any goals and preferences of the applicant/consumer and the deliberations by the IDT into a comprehensive plan that uses waiver and non-waiver services to adequately serve the consumer in the community. Key purposes of the service plan are to summarize the services that will meet the needs identified during the assessment process and to document that the services provided under the waiver are feasible and cost-effective. There must be a reasonable expectation that the waiver and non-waiver services on the service plan are adequate to meet the needs of the individual in the community.

The initial and ongoing ISP is developed before the applicant's/consumer's enrollment or re-enrollment into waiver services. By signing Form 3671-2, the applicant or consumer, case manager and any other members of the IDT are certifying that the waiver services proposed on the ISP are necessary to avoid nursing facility (NF) care and are adequate and appropriate to meet the needs of the individual in the community, based on their assessment of the applicant's/consumer's needs.

The case manager is responsible for the completion of the multiple steps required for the development of an ISP. Section 3420, Case Manager Procedures for the Individual Service Plan, identifies the basic sequence of steps required to complete the development of an initial ISP after the case manager has received a complete pre-enrollment home health assessment from the HCSSA. The Department of Aging and Disability Services has the final authority for the ISP.

3411  Documentation of Waiver Requirements

Revision 09-9; Effective December 1, 2009

The Department of Aging and Disability Services (DADS) case manager is responsible for documenting Community Based Alternatives (CBA) waiver assurances outlined in Section 3410, Waiver Requirements.

Obtaining signatures on the following individual service plan (ISP) forms for the initial enrollment and reassessment process, as required by the policy below, provides documentation support for waiver assurances.

Form 3671-2, Individual Service Plan

Home and Community Support Services Agency (HCSSA) Nurse Assessment — The HCSSA nurse assessor signs the form to certify that the applicant/consumer was assessed for the need for CBA services potentially available on Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E and Form 3671-H, and that medical need was found for services on the forms attached to the assessment packet, as noted by the checked boxes on Form 3671-2. The HCSSA nurse assessor's signature is required at initial application and at annual redetermination upon completion of the nurse's assessment.

Freedom of Choice — The applicant/consumer signs the Freedom of Choice section of the form choosing between nursing facility and Home and Community-based Services. The HCSSA nurse assessor obtains the applicant's/consumer's signature in the Freedom of Choice section during the initial application and annual redetermination assessment visit.

Acknowledgement and Acceptance of the ISP — The applicant/consumer signs to acknowledge review of the waiver services identified on the proposed service plan and acceptance of the plan as appropriate to meet the needs assessed. For initial application and annual redetermination, the HCSSA nurse assessor obtains the applicant's/consumer's signature on the "Approval" line, acknowledging acceptance of the proposed service plan during the assessment visit. For initial application, the case manager obtains the applicant's written or verbal approval on the "Final Approval" line after receipt of the pre-enrollment packet from the HCSSA and development of the ISP, which includes personal assistance services (PAS) and documented third-party resources (TPR). For annual redetermination, the case manager obtains the consumer's approval signature on the "Final Approval" line during the annual contact after review of the proposed service plan is submitted by the HCSSA nurse assessor and the development of PAS and TPR.

The case manager must obtain and document the applicant's/consumer's verbal agreement for any changes made in the proposed service plan once the applicant/consumer provides the required approvals in the acknowledgement section, but before certification or recertification. Verbal agreement and the date obtained for changes may be documented on Form 3671-2 in the Acknowledgement and Acceptance of the ISP section, along with the other required signatures and approval documentation.

HCSSA Referral Acceptance — The HCSSA representative signs the form to accept or refuse the referral at initial application and annual redetermination. The HCSSA representative may sign to accept or refuse the referral upon receipt and based on the pre-enrollment or annual assessment completed by the HCSSA nurse assessor, or may wait until the completed ISP packet is sent after development by the case manager. If the HCSSA representative requests changes to the proposed service plan after signing to accept the applicant/consumer, but before certification or recertification, the case manager must obtain and document the verbal agreement and the date obtained by the HCSSA representative for changes made in the proposed service plan before certification or recertification of CBA waiver services.

Adult Foster Care (AFC) or Assisted Living/Residential Care (AL/RC) Referral Acceptance — The AFC provider or AL/RC representative signs to accept or refuse the referral at initial application and annual redetermination.

Interdisciplinary Team (IDT) Certification — The case manager signs the form to certify that the proposed ISP was reviewed, developed and approved by the IDT before implementation. The case manager signs this section after all ISP forms (Form 8598, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J, Dental Services – Proposed Treatment Plan, attachments) are signed by appropriate team members and informal support, and after all other Form 3671-2 signatures/approvals are obtained at initial application and annual redetermination.

Form 8598, Non-Waiver Services

Certification by IDT Members — The case manager coordinates, reviews and documents all non-waiver services at initial application and annual redetermination, and obtains required informal support signatures/verbal agreements. The case manager signs Form 8598 to certify the development of TPR after all non-waiver services are reviewed and documented, and the required signatures/agreements are obtained.

The applicant/consumer and HCSSA representative are not required to sign Form 8598 at initial application or annual redetermination because the signatures and participation in the development of the ISP are documented on Form 3671-2.

The signature line for "Other IDT Member" is used to document required signatures/verbal agreements for informal support or other IDT members at initial application and annual redetermination.

Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, and Form 3671-H, Dental Services

Certification by IDT Members — The HCSSA nurse assessor signs the form to verify the assessed needs at initial application and annual redetermination.

The case manager signs the form to approve or disapprove the services as assessed by the HCSSA nurse assessor at initial application and annual redetermination.

The HCSSA must obtain informal support signatures on Form 3671-C. When applicable, the therapist must sign Form 3671-B or attach a signed treatment plan to Form 3671-B.

The applicant/consumer and HCSSA representative are not required to sign Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E or Form 3671-H at initial application or annual redetermination because the signatures and participation in the development of the ISP are documented on Form 3671-2.

Form 2060-A, Addendum to Form 2060 for Personal Assistance Services

Certification by IDT Members — The case manager signs the form to certify the services developed on Form 2060-A at initial application and annual redetermination.

Informal support signatures/verbal agreements related to Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, are obtained as required and documented on Form 8598 at initial application and annual redetermination.

The applicant/consumer and HCSSA representative are not required to sign Form 2060-A at initial application or annual redetermination because the signatures and participation in the development of the ISP are documented on Form 3671-2.

3420  Case Manager Procedures for the Individual Service Plan

Revision 12-3; Effective September 4, 2012

The case manager has primary responsibility for reviewing the applicant's or individual's need for services, developing the service plan, utilizing non-waiver resources and authorizing Community Based Alternatives (CBA) services at initial enrollment and annual reassessment.

The case manager must:

  • Complete the individual service plan (ISP) attachments to develop estimated costs on Form 3671-1, Individual Service Plan, including:
    • Personal Assistance Services (PAS) hours from Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services; incorporating delegated nursing tasks identified on Form 3671-C, Nursing Service Plan; any protective supervision; and any other adjustments needed for the PAS hours.

    • Use the highest participant rate for PAS hours to compute the ISP, unless doing so will result in exceeding the ISP cost limit. In that situation, the actual PAS rate participant level used by the Home and Community Support Services Agency (HCSSA) should be checked and that rate used in completing the calculation.
    • Form 3671-B, Therapy Service Authorization, to authorize four hours for each category of therapy identified in the pre-enrollment assessment, if any, for the assessment and service initiation.
    • Form 3671-C, to total nursing hours required for direct service, delegation activities and program required hours, including four hours annually to perform semiannual nursing assessments.
    • Form 3671-D, Minor Home Modifications, to total estimated costs identified for minor home modifications. Case managers should consider the needs of applicants who were in nursing facilities or hospitals at the time of the pre-enrollment assessment or individuals whose needs have changed since the assessment.
    • Form 3671-E, Adaptive Aids and Medical Supplies, to total costs identified for adaptive aids and medical supplies and to include additional needs identified since the assessment.
    • Form 3671-H, Dental Services, to determine the total cost that can be approved for dental services. Form 3671-J, Dental Services – Proposed Treatment Plan, is also reviewed for appropriate treatment plans and allowable dental services.
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, if applicable, to total costs identified for items necessary to transition from the nursing facility to the community.

Note: The case manager must evaluate if the documentation provided by the HCSSA on Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or alternate forms of documentation are adequate. Form 3671-J must be submitted along with Form 3671-H. If the documentation of medical need for dental services is adequate on Form 3671-J, Form 3671-F for dental services is not necessary. The documentation should provide the relationship of the proposed item to the individual's medical condition or disability and should be adequate to justify the item. The case manager may consult with the Department of Aging and Disability Services regional nurse if there are questions regarding the adequacy of the documentation or the necessity for the item.

  • Develop Form 8598, Non-Waiver Services, including ongoing services that will be provided by third-party resources (TPR), family members, informal supports and other sources.
  • Develop cost figures for the proposed ISP on Form 3671-1, including information for all services requested on Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J and Form 8604, and for other applicable services such as Emergency Response Services (ERS), Adult Foster Care (AFC), Assisted Living (AL), Home-Delivered Meals (HDM), Respite and the Consumer Directed Services (CDS) option.
  • Determine if the potential ISP is within the cost limit.
  • Determine feasibility of the waiver and discuss the waiver with the applicant or individual.
  • Contact the applicant or individual to:
    • review the results of the pre-enrollment or annual home health assessment and functional assessments;
    • determine the applicant's or individual's goals, needs and preferences for CBA services and the appropriateness of the proposed ISP;
    • discuss any changes that may be needed for the feasibility of the plan to meet the applicant's or individual's needs. If changes to the service plan are needed, the case manager will contact the HCSSA and come to an agreement with the applicant or individual and HCSSA nurse or representative regarding the changes; and
    • finalize the applicant's or individual's choices of services and the applicant's or individual's agreement with the proposed ISP.
  • Obtain any needed signatures for the interdisciplinary team (IDT) certification and sign and date the ISP on all appropriate forms.

Refer to Section 3411, Documentation of Waiver Requirements, for information about obtaining signatures to document waiver assurances. Refer to Section 7000, Case Management Procedures for Utilization Review, for information on determining if the initial ISP requires a prospective utilization review and procedures for processing the prospective review.

3421  Determining Cost Effectiveness

Revision 09-9; Effective December 1, 2009

The costs of the waiver services necessary for the year are based on the estimated service needs included on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and the costs for Adult Foster Care (AFC), Assisted Living/Residential Care (AL/RC), Emergency Response Services (ERS) and Respite Care, included on Form 3671-1, Individual Service Plan.

If the individual service plan (ISP) effective period begins on the first day of the month, the end date of the ISP effective period will be the previous day in the next year. Services should be authorized for 365 days. For an ISP that begins on a date other than the first day of the month, the ISP effective period will end the last day of the month in the next year, and the cost of services that will be delivered through the end of the month must be included in the ISP estimate. Example: An ISP effective period beginning 4-16-XX ends on 4-30-XX of the next year. The service estimates included in the ISP for AFC services must be sufficient for 380 days, rather than just 365 days. ERS services must be authorized for 13 units for an ISP beginning on a day other than the first day of the month.

The Community Based Alternatives (CBA) applicant's/consumer's ISP cost limit is established by the information submitted on the Medical Necessity and Level of Care (MN/LOC) Assessment. If the total estimated cost of the ISP for waiver services exceeds the applicant's/consumer's established cost limit, the applicant/consumer may not be served in the CBA program. The case manager may request that a new assessment be submitted if the applicant's/consumer's condition justifies a review of the cost limit.

Applicants/consumers who are ventilator dependent may be eligible for a higher cost limit for CBA services. This is similar to the supplemental payment to nursing facilities for ventilator dependent residents. The higher cost limit is established by the MN/LOC Assessment.

Applicants/consumers requiring ventilator use from six to 23 hours daily, as identified with a "6" on the MN/LOC Assessment for ventilator/respiratory care, are eligible for a partial ventilator supplement payment. Other applicants/consumers requiring 24 hour continuous ventilator use, identified with a "7" for ventilator/respiratory care, are eligible for the continuous ventilator supplement payment. Applicants/consumers using ventilators less than six hours per day are not eligible for the increased cost limits.

Other case information that may indicate a ventilator dependent applicant/consumer include Section B of Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, and Form 2067, Case Information.

The automated medical necessity process will create a field showing Tracheostomy-Partial (TP) or Tracheostomy-Full (TF) ventilator use in the Service Authorization System (SAS) Level of Service (LOS) record. This allows the CBA wizards to automatically assign the correct Resource Utilization Groups (RUGs) for partial or full ventilator use and to apply the correct cost limit to the ISP.

The case manager must ensure the appropriate ventilator cost limit, as established by the MN/LOC Assessment, is documented in the appropriate service plan records in the SAS.

Refer to Appendix VII, CBA ISP Cost Limits, and the instructions to Form 3671-1 for additional information.

3421.1  Income Diversion Trust

Revision 09-4; Effective March 27, 2009

An individual who has a qualified income trust (QIT) may be determined eligible for Community Based Alternatives (CBA) services even though the individual's income is greater than the special institutional income limit, if the individual also meets all other CBA eligibility criteria. Income converted to the trust does not count for purposes of determining financial eligibility; however, the total income (including income diverted to the trust) is considered for the calculation of copayment for CBA services. An individual may be eligible for CBA services if all other CBA eligibility criteria are met, even if the amount the individual has available for copayment equals or exceeds the total cost of his individual service plan (ISP).

Financial eligibility for an individual with a QIT is determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff. The individual is informed that any funds deposited into the trust must be used as copayment for the cost of services delivered. The MEPD specialist calculates the amount of income available from the trust for copayment and provides the amount to the case manager.

For an individual who is financially eligible based on a QIT, the eligibility based on the ISP cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment will be used to purchase waiver services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of waiver eligibility. A consumer with a QIT copayment that covers all waiver costs receives the benefit of contracted rates as opposed to private pay rates.

First, a plan of care is developed without consideration of the trust. Then, if the individual is eligible for the waiver based on the cost limit, the excess funds from the trust (the monthly income in excess of the institutional income limit and allowable deductions for a spouse's needs and medical expenses) are allocated to pay for services that are identified on Form 3671-1, Individual Service Plan, as waiver services. The ISP total, and therefore the amount of the authorizations to the CBA providers, is reduced by the amount of the excess funds. The CBA consumer must pay the provider directly for the amount of the services equivalent to the amount of the excess funds. Use of the trust fund is documented on Form 8598, Non-Waiver Services. Continuing Medicaid eligibility through the waiver is contingent upon payment of the QIT copayment to the provider(s).

Refer to Section 3550, Copayment and Room and Board, and Section 3550.4, Qualified Income Trust, for specific case manager procedures related to QIT copayments.

3421.2  Denial or Termination When Proposed ISP Exceeds the Cost Limit

Revision 13-1; Effective March 1, 2013

STANDARD.  An applicant who is denied Community Based Alternatives (CBA) services or an individual who is terminated from the program must be referred to appropriate non-waiver services within one working day of the determination, if appropriate.

The case manager must consider all available support systems in determining if the waiver is a feasible alternative that will ensure the needs of the applicant or individual receiving CBA services is adequately met. If the waiver is not a feasible alternative, the case manager must deny the applicant or terminate the individual and maintain appropriate documentation to support the denial or termination. The case manager's documentation of this type of denial or termination is based on the inadequacy of the individual service plan (ISP), including both waiver and non-waiver services, to meet the needs of the applicant or individual within the cost limit.

Based on the information available to the case manager from the Home and Community Support Services Agency (HCSSA) nurse and the applicant or individual, the case manager finalizes the costs of the ISP. In reviewing the ISP to bring it within the cost limit, the case manager should consider:

  • removing adaptive aid ($1,000), medical supplies ($1,000) and dental ($400) buffers;
  • using the actual Personal Assistance Services (PAS) participant rate level applicable to the HCSSA that will deliver PAS;
  • reviewing delivered services records to determine if a specific service is not being fully utilized and, if not, consider a reduction for that service; and
  • removing any authorized minor home modification (MHM) amounts that were not actually utilized in the completion of an authorized MHM.

If the cost of the ISP exceeds the cost limit, the following documentation is required:

  • identify all services determined to be necessary by the HCSSA nurse, the case manager and the applicant or individual;
  • identify waiver services and non-waiver resources needed to meet those needs, including services provided by family members;
  • calculate of the costs of the service plan on Form 3671-1, Individual Service Plan, to show that the service plan exceeds the cost limit;
  • obtain interdisciplinary team (IDT) meeting notes; and
  • obtain a copy of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, with appropriate rule reference documented.

If the case manager and the IDT determine that the proposed ISP is not adequate to meet the needs of the applicant or individual, and CBA is not a feasible alternative, the applicant is denied or the individual is terminated. The case manager must refer the applicant or individual to appropriate services, such as nursing facility care, a hospital or other protected setting, or in-home services for which the applicant or individual may be eligible if there is a need for more intensive care on a sustained basis than can be provided cost effectively in CBA.

The HCSSA may consider the use of an Individual Responsibility Agreement (IRA) when an applicant or individual expresses a desire to take responsibility for certain needs or to leave certain needs unmet, rather than have the HCSSA meet all needs. The HCSSA considers the IRA agreement when assessing the CBA applicant or individual and developing the service plan. An IRA must clearly advise the applicant or individual as to what services will and will not be provided by the HCSSA. The HCSSA and DADS must continue to protect the health and safety of an individual based on regulatory and waiver requirements. The HCSSA should provide the case manager with a copy of the IRA for consideration when developing the ISP. Refer to Section 4115, Individual Agreement for Services, and Section 4116, Refusal to Serve an Applicant or Individual.

If the applicant or individual has high needs, it is extremely important that DADS staff ensure that all options are explored before issuing a denial or termination notice. Applicable CBA policy must be followed in all of these situations. Refer to Appendix XIII, Resources for Handling High Needs Applicants. Refer to Section 3421.3, Requesting General Revenue Funds for Services Not Covered Within the Waiver Cost Limit, to determine if consideration of General Revenue funds is appropriate.

3421.3  Requesting General Revenue Funds for Services Not Covered Within the Waiver Cost Limit

Revision 09-8; Effective September 1, 2009

Effective Sept. 1, 2007, the individual service plan (ISP) cost limit for the Community Based Alternatives (CBA) program changed from 100 percent to 200 percent of the nursing facility rate for each Resource Utilization Group (RUG).

The Texas Legislature requires that the Department of Aging and Disability Services (DADS) set the cost limit for the CBA Medicaid waiver at 200 percent of the reimbursement rate that would have been paid for an individual to receive services in a nursing facility. DADS is prohibited from providing Medicaid waiver services to a consumer when the cost of the CBA services exceeds the cost limit. DADS is authorized to use General Revenue funds to pay for the cost of services on the CBA ISP that exceed the CBA cost limit if DADS determines that:

  • the consumer's health and safety cannot be protected by the services provided within the cost limit; and
  • there is no other available living arrangement in which the consumer's health and safety can be protected, as evidenced by:
    • an assessment conducted by DADS clinical staff; and
    • supporting documentation, including the consumer's medical and service records.

For CBA consumers who were receiving CBA services on Sept. 1, 2005, at a cost that exceeded the cost limit (Rider 7 and 7(b)(2) grandfathered consumers), General Revenue funds must be used to pay for cost of services on the CBA ISP that exceed CBA cost limit, if the services are necessary for consumers to live in the most integrated setting appropriate to meet their needs. No tracking will be required for consumers with this grandfathered status. These consumers will retain this status as long as they receive uninterrupted services in the program. Code 35 suspensions do not constitute a break in service.

The cost limit policy is applied at initial certification of CBA applicants, including individuals transitioning to CBA from the Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (THSteps/CCP), and at the annual reassessment of ongoing CBA consumers. Tracking of the ISP cost limit is required for ongoing CBA consumers when the ISP cost limit is exceeded during the ISP year. Cost limit policy must be followed at initial certification and annual reassessment to determine if General Revenue funds may be used to cover the cost of services on the CBA ISP that exceed the cost limit.

To ensure CBA consumers have an ISP at a cost within the cost limit and the use of General Revenue funds is appropriate, special procedures must be implemented when an applicant's/consumer's ISP approaches the cost limit and when an ongoing CBA consumer's ISP exceeds the cost limit due to a change during the ISP year. Special procedures apply when the average ISP cost exceeds the cost limit for the 12-month period of the ISP year.

3421.3.1  Procedures for Applicants and Individuals Receiving Services

Revision 13-2; Effective June 3, 2013

Designation of an Applicant or Individual with High Needs

The case manager designates an applicant or individual with high needs if the applicant's or individual’s estimated costs of waiver services approach or exceed the individual service plan (ISP) cost limit. The case manager follows the procedures in Section 3423, Applicants and Individuals with High Needs.

The Department of Aging and Disability Services (DADS) case manager must:

  • convene a meeting of the interdisciplinary team (IDT) within five working days after the high needs designation as outlined in the high needs procedures;
  • at the IDT meeting, discuss utilization of third-party resources and informal support systems;
  • ask IDT members to explore all alternative resources for meeting the applicant's or individual’s needs within the cost limit and document all efforts made;
  • send the applicant or individual a letter within two working days after the IDT meeting advising the applicant or individual of the discussions and actions proposed during the IDT. Refer to Appendix XIII-E, Sample Letter – ISP Cost Limit; and
  • continue to work with the IDT to develop an ISP that will bring the total cost of wavier services within the ISP cost limit. All options for reducing costs must be explored and documented.

Exploration of Alternative Resources and Ensuring Health and Safety

DADS must explore alternatives to ensure the applicant's or individual’s health and safety by:

  • accessing additional assistance of family or local community organizations or other natural supports; and/or
  • seeking funding through non-waiver resources such as Medicaid State Plan services or local community agencies.

If the above efforts are not successful and it is determined that the absence of sufficient service(s) prevents DADS from ensuring the applicant's or individual's health and safety in the community, he is:

  • given an opportunity to request services through another existing home and community-based service for which the applicant or individual may be eligible;
  • assisted in seeking admission to a nursing facility, if appropriate; or
  • assisted in seeking admission to a different living arrangement, such as an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), a state supported living center or an Assisted Living (AL) facility.

Request for Use of General Revenue Funds

If all efforts to secure other alternatives or to ensure the health and safety of the applicant or individual are unsuccessful, the region requests a staffing with state office to determine if a request to use General Revenue funds is appropriate. The region completes and sends the High Needs Chronology and Form 1024, Individual Status Summary, to the Community Services and Program Operations assigned policy specialist, W-351.

The region continues to review all options for reducing costs and proceeds with additional high needs procedures.

3421.3.2  Additional Procedures for Individuals Receiving Services

Revision 12-2; Effective June 1, 2012

Change Requests

If the Department of Aging and Disability Services (DADS) case manager receives a request for services that would cause the estimated individual service plan (ISP) cost for needed services to exceed the cost limit, the case manager:

  • considers a re-evaluation to determine whether another Resource Utilization Group (RUG) is more appropriate to the individual's needs;
  • calculates the estimated costs for all Community Based Alternatives (CBA) services, including minor home modifications, adaptive aids, and the $1,000 add-on amounts for adaptive aids and medical supplies;
  • considers the request for a change in the ISP if there is a change in the:
    • individual's medical condition, functional needs or environment;
    • caregiver support or third-party resources that have been providing service to the individual; or
    • need for a service to adequately support the individual living in the most integrated setting appropriate to his needs;
  • makes the determination to approve or deny the request in consultation with the DADS regional nurse, as needed; and
  • begins tracking procedures if the change is approved and the ISP exceeds the cost limit by completing Form 2108, Cost Limit Tracking.

Upon approving a change that causes the individual to exceed the ISP cost limit, the case manager sends Form 2065-B, Notification of Waiver Services, to notify the individual of the change.

Tracking of Costs for the 12-Month Period

For tracking purposes, the ISP year is considered the 12 full months included in the ISP coverage period. Dollar amounts on the ISP are converted to percentages for tracking purposes. Any increase during a calendar month is counted as the ISP amount for that full month. The case manager records the new ISP total. If the total ISP cost is at or exceeds the cost limit, the case manager tracks the cost for services and the percentage the ISP exceeds the ISP cost limit for the full 12-month ISP period.

Example: The individual's ISP year begins on Oct. 1. In the third month of the ISP, the individual's condition changes and the case manager approves a change to exceed the ISP cost limit. The case manager goes back and tracks the cost and percentage beginning with Month 1, October, of the ISP and tracks the cost on a monthly basis for the full 12-month period. Refer to the instructions for Form 2108, Cost Limit Tracking, for information on tracking and example.

Designation of an Individual with High Needs

In the month that the individual's estimated ISP cost exceeds the ISP cost limit, high need procedures are implemented.

Additionally, the case manager must complete the following steps:

  • Request that the Home and Community Support Services Agency (HCSSA) complete a Significant Change in Status Assessment (SCSA) to reset the RUG for the individual, if appropriate. Consult with the individual, his responsible party, or both, the HCSSA nurse and the DADS regional nurse regarding the changes in the individual's condition that would warrant a RUG reset. Contact the HCSSA by telephone to begin the RUG reset process and follow up the request with Form 2067, Case Information.
  • Explain to the individual that funds to pay for CBA services may not be available if the cost of care averaged for a 12-month period exceeds the ISP cost limit.

In the ninth month of the ISP period, the case manager determines if the projected average for the 12-month period will exceed the cost limit. If options for reducing the costs have been found and the projected 12-month average is below the cost limit, then CBA services may continue to be authorized on the ISP at the annual reassessment.

If it appears the projected average for the 12-month period will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the case manager initiates a request for a staffing with state office staff to determine whether a request for the use of General Revenue funds is appropriate.

3421.3.3  State Office Review and Process to Request General Revenue Funds

Revision 13-1; Effective March 1, 2013

State Office Staffing

An interdisciplinary team (IDT) meeting is held by state office staff with regional staff upon receipt and review of an applicant's or individual's chronology and Form 1024, Individual Status Summary, prepared by regional staff. The purpose of the staffing is to:

  • review and evaluate the applicant's or individual's needs;
  • discuss any other possible resources or service options to meet the applicant's or individual's needs within the cost limit; and
  • determine if the use of General Revenue funds is appropriate for the individual service plan (ISP) cost that exceeds the cost limit.

State office staff:

  • compile pertinent records and applicable rules and information for review;
  • consult with all appropriate staff;
  • assemble a team of subject matter experts for the completion of the staffing and case review;
  • contact regional staff to review the issues and deliberations that occurred at any past interdisciplinary or service planning team meetings or conferences with an applicant or individual, his family, or both;
  • collaborate with regional staff to identify additional resources;
  • investigate other community service alternatives; and
  • determine whether the needs of the applicant or individual can be managed within the cost limit.

State office staff recommend that regional staff follow up and implement any identified resources or options.

Before a request for approval to use General Revenue funds is initiated, all attempts must be made to arrange for services to the applicant or individual within the cost limit, and it must be determined that the absence of sufficient service(s) prevents the Department of Aging and Disability Services (DADS) from protecting the individual's health and welfare in the community.

If the identified options are implemented and the applicant's or individual's ISP is adjusted to an ISP cost that does not exceed the cost limit, then he may receive services. The case manager notifies the applicant or individual by Form 2065-B, Notification of Waiver Services, of service eligibility and level.

If it is determined that a request for the use of General Revenue funds to pay for the ISP cost over the cost limit is not appropriate, state office staff advise the region to notify the applicant or individual of the decision. See Form 2065 notification procedures below.

If it is determined that a request for the use of General Revenue funds to pay for the ISP cost over the cost limit is appropriate, state office staff begin the process of requesting the use of General Revenue funds.

Process for Approval to Use General Revenue Funds

If state office staff determine a request to use General Revenue funds is appropriate, the assigned state office staff coordinate with:

  • DADS clinical staff to conduct a review as required by the Texas Legislature; and
  • regional staff to obtain medical documentation required for the clinical review.

If the DADS clinical staff determine that the applicant or individual can be served in an alternate living arrangement (such as a nursing facility or state supported living center), the case manager, in coordination with the Community Services and Program Operations assigned program specialist, attempts to locate an appropriate institutional living arrangement. Community Based Alternatives (CBA) will be denied or terminated if an alternative living arrangement can be found. If the DADS clinical staff determine that the applicant or individual cannot be served in an alternate living arrangement, the assigned state office policy specialist:

  • updates Form 1024, Individual Status Summary, with all new information to summarize the applicant's or individual's current needs and services;
  • completes Form 1023, Request for Services Funded by General Revenue; and
  • forwards the forms through the approval process and to the DADS commissioner's office for final decision regarding approval or denial of the request.

Form 2065 Notification Procedures

If the use of General Revenue funds for the ISP cost above the cost limit is approved, the case manager notifies the applicant or individual by Form 2065-B of eligibility and service level.

If the use of General Revenue funds is not appropriate or not approved, the applicant is denied CBA or the individual is terminated. The applicant or individual is given the right to a fair hearing regarding the DADS action. The case manager sends the applicant or individual Form 2065-C, Notice of Ineligibility or Suspension of Waiver Services, denying or terminating services. The decision is based on Texas Administrative Code, §48.6003(b)(6). The applicant or individual must have an ISP with a cost for CBA program services at or below 200 percent of the reimbursement rate that would have been paid for that same individual to receive nursing facility services considering all other resources. If the use of General Revenue funds is not appropriate or not approved, the case manager also contacts the designated Community Services and Program Operations program specialist to obtain a copy of a denial letter to send with Form 2065-C.

If an individual requests a timely appeal regarding the decision, services may continue at the current level until the end of the current ISP year regardless of when the hearing decision is made. The case manager follows the hearings officer's instructions on further case actions.

3421.3.4  Authorizations in Service Authorization System (SAS)

Revision 09-8; Effective September 1, 2009

The Department of Aging and Disability Services (DADS) case manager authorizes the individual service plan (ISP) services using the Service Authorization System (SAS) Community Based Alternatives (CBA) wizard. Before the initial or reassessment ISP is authorized in SAS, the case manager must ensure cost limit procedures were followed and have a copy of Form 1023, Request for Services Funded by General Revenue, documenting approval for the use of General Revenue funds for the ISP costs that exceed the cost limit. SAS may generate a pop-up box to document type of approval. Use the "State Office Approval" option for cost limit procedures.

At the end of the ISP year, the separation of waiver funds and General Revenue funds in relation to billing is reconciled through Claims Management System processes. DADS also employs utilization review practices to ensure cost effectiveness.

3421.4  New Service Limits and Exception Criteria

Revision 12-2; Effective June 1, 2012

§48.6084

(a)
Service limits.
(1)
The limits to an individual's services listed in paragraph (2) of this subsection are in effect through August 31, 2013.
(2)
Subject to an exception granted by DADS in accordance with §48.6085 of this subchapter (relating to Exception to Service Limit), the following limits apply to an individual's services:
(A)
An individual may receive, during an ISP year, adaptive aids having a maximum cost of $2,050.
(B)
An individual may receive, during an ISP year, general dentistry services and the services of an oral and maxillofacial surgeon having a maximum combined cost of $4,675.
(C)
An individual may receive, during an ISP year, medical supplies having a maximum cost of $1,736.
(D)
During the time period an individual is enrolled in the CBA Program, an individual may receive minor home modifications that have a maximum cost of $6,550, which may be paid in one or more ISP years.
(E)
An individual may receive a maximum of 24 days of respite during an ISP year.
(F)
The maximum number of hours of a specialized therapy that an individual may receive during an ISP year is as follows:
(i)
for occupational therapy, 61 hours;
(ii)
for physical therapy, 86 hours; and
(iii)
for speech, hearing, and language therapy, 69 hours.
(G)
An individual may receive a maximum of 2,135 hours of PAS during an ISP year.
(3)
Not subject to an exception granted by DADS, an individual may receive, during an ISP year, a maximum of $300 for repair and maintenance of a minor home modification.
(4)
In accordance with §62.5(c) and (d) of this title (relating to Service Description), an individual may receive a maximum of $2,500 of transition assistance services.
(5)
Effective September 1, 2013, the following limits apply to an individual:
(A)
For adaptive aids and medical supplies, minor home modifications, and respite during an ISP year, the maximum service ceilings described in §48.6003(b)(8)(A) – (C) of this subchapter (relating to Eligibility Criteria);
(B)
For dental services during an ISP year, a maximum combined cost of $5,000 for general dentistry and the services of an oral and maxillofacial surgeon and an additional maximum cost of $5,000 for the services of an oral and maxillofacial surgeon.

§48.6085

(a)
If a DADS case manager receives information demonstrating that exceeding a limit to an individual's service described in §48.6084(a)(2)(A) – (G) of this subchapter (relating to Service Limits and Claim Limits) is necessary to meet an individual's needs, the DADS case manager determines whether providing the service in excess of the limit is necessary for the ISP to meet the criteria described in §48.6006(d)(1) – (5) of this subchapter (relating to Individual Service Plan).
(b)
The DADS case manager grants an exception to a limit if, after a review of the information received as described in subsection (a) of this section, the DADS case manager determines that providing the service in excess of the limit is necessary for the ISP to meet the criteria described in §48.6006(d)(1) – (5) of this subchapter.
(c)
An exception granted under subsection (b) of this section is subject to:
(1)
for adaptive aids and medical supplies, minor home modifications, and respite during an ISP year, the maximum service ceilings described in §48.6003(b)(8)(A) – (C) of this subchapter (relating to Eligibility Criteria);
(2)
for dental services during an ISP year, a maximum combined cost of $5,000 for general dentistry and the services of an oral and maxillofacial surgeon and an additional maximum cost of $5,000 for the services of an oral and maxillofacial surgeon; and
(3)
the ISP cost as described in §48.6003(b)(6) of this subchapter.

The Department of Aging and Disability Services (DADS) implemented new service limits in the Community Based Alternatives (CBA) program as part of DADS cost savings initiative. The new service limits are time limited through Aug. 31, 2013, at which time DADS may keep, retract or change the new service limits.

The following CBA services have new service limits:

  • Personal Assistance Services
  • Adaptive Aids
  • Medical Supplies
  • Minor Home Modifications
  • Respite
  • Dental
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

The new service limits also apply to services delivered through the Consumer Directed Services (CDS) option. See Appendix XX, Community Based Alternatives Program Service Limits, for a table with the new and existing service limits for use as a reference to assist case managers when following this policy.

Exception Criteria

For applicants or individuals receiving services whose needs exceed the new service limits, case managers must determine if an exception to the new service limits may be granted. Case managers must review the five questions below with applicants or individuals to determine if an exception may be granted. The applicant or individual must meet all the exception criteria below to be eligible for an exception to the new service limits.

  • Is the amount of services above the service limit necessary to protect the individual's health and welfare in the community?
  • Does the amount of services above the service limit supplement rather than replace the individual's natural supports and other non-waiver services and supports for which the individual may be eligible?
  • Will the amount of services above the service limit prevent the individual's admission to an institution?
  • Is the request to exceed the service limit the most appropriate type and amount of services to meet the individual's needs?
  • Is the amount of services above the service limit cost effective?

Case managers determine if an exception will be granted and may accept verbal statements from applicants or individuals. Case managers must use Form 3669, New Service Limit Exception Criteria, to record decisions to grant or deny exceptions to the new service limits. Form 3669 is filed with Form 3671-1, Individual Service Plan, in the case record.

Service-Specific Procedures For Case Actions and Exceptions

Adaptive Aids

If the applicant or individual requests multiple adaptive aids, case managers apply exception procedures to the total cost for adaptive aids. Case managers must not apply the exception process on single items if two or more items are requested. The adaptive aid buffer and specification fees are not subject to the new service limit and do not require an exception. Case managers must not apply the buffer or specification fees to the cost of adaptive aids when determining if the request for adaptive aids is over the new service limit. If the buffer causes the cost for adaptive aids to go over the new service limit, case managers document the finding on Form 3669 and no further action is required.

Medical Supplies

If the applicant or individual requests multiple medical supplies, case managers apply exception procedures to the total cost for medical supplies. Case managers must not apply the exception process on single items if two or more items are requested. The medical supply buffer is not subject to the new service limit and does not require an exception. Case managers must not apply the buffer to the cost of medical supplies when determining if the request for medical supplies is over the new service limit. If the buffer causes the cost for medical supplies to go over the new service limit, case managers document the finding on Form 3669 and no further action is required.

Minor Home Modifications and Dental

Case managers must not apply buffers or specification fees to the cost of minor home modifications or dental services, if applicable, when determining if requests for minor home modifications or dental services are over the new service limits. If the dental buffer placed the cost of dental services over the new service limit, case managers document the findings in the case record and no further action is required.

Notes:

  • Requests for repair and maintenance of minor home modifications costing $300 or less are not subject to the new service limit and do not require an exception.
  • The new service limit for dental applies to requests for general dentistry, oral surgery or both.
  • The dental buffer is not subject to the new service limit and does not require an exception.

Personal Assistance Services (PAS)

The new service limit for PAS includes all PAS tasks identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services.

Initial Applications and Annual Reassessments

For initial applications and annual reassessments, case managers and Home and Community Support Services Agencies (HCSSAs) will continue to assess applicants' and individuals' needs for the ISP year. Case managers must discuss the new service limits with applicants and individuals and follow exception procedures for applicants and individuals with needs for services over the new service limit.

ISP Changes for Services Exceeding the New Service Limit

Case managers must apply exception procedures for all service requests above the new service limits. This includes any new requests for services/items exceeding the new service limit, as well as requests for additional services/items in which case managers have already granted an exception. If service requests exceed existing service limits, such as $5,000 for dental, $7,500 for minor home modifications, and $10,000 for adaptive aids and medical supplies, case managers must follow current procedures in Section 3610.2.1, Requests Sent to Regional Nurse for Review, and Section 4173, Case Manager Responsibilities Pertaining to Dental Services.

Exception Procedures for Individuals Who Are Temporarily Residing in Nursing Facilities

Upon notification that individuals will be or are released from a nursing facility and will resume CBA services, case managers must follow current policy to reopen the case record and apply the exception criteria for services over the new service limit. Case managers must contact individuals and review Form 3669 to determine if an exception may be granted. If an exception is granted, case managers document the finding on Form 3669 and no further action is required.

Exceptions Not Granted By Case Managers Upon Reviewing Requests to Exceed the New Service Limit

If an exception is not granted, case managers must obtain regional management approval when reducing or denying services due to the new service limits.

Regional management must conduct a second level review of a case prior to case managers reducing or denying a service due to the new service limits. The review must be conducted by the manager of the case manager’s supervisor. The second level review is required when services are being denied due to the individual not meeting the exception criteria. The regional management review must occur after case managers have determined an individual did not meet the exception criteria.

Regional Management Review Procedures

Case managers must send case information for regional management review to determine agreement with the decision not to grant an exception to the new service limit. If the regional management reviewer disagrees with the determination, the case manager grants the exception. Case managers must document on Form 3669 indicating the regional management reviewer’s name, job position and date of disagreement of the denial.

If the regional management reviewer agrees with the determination, case managers will deny the service and send the appropriate notification to the individual. Case managers must document on Form 3669 indicating the regional management reviewer’s name, job position and date of agreement of the reduction or denial.

3422  Interdisciplinary Team

Revision 11-1; Effective March 1, 2011

The case manager convenes and leads the interdisciplinary team (IDT). The minimum composition of the IDT is the case manager and the applicant/consumer or his designated representative. Other team members may include the applicant's/consumer's friends or family members, physician, Adult Foster Care (AFC) providers, Assisted Living/Residential Care (AL/RC) providers, Home and Community Support Services Agency (HCSSA) or anyone the applicant/consumer wants to include.

The IDT is involved in service planning through the deliberation and assessment of the applicant's/consumer's needs during the development of the ISP. The IDT is responsible for:

  • considering all available assessment information in its deliberations;
  • estimating the costs for the types and amounts of services identified as necessary to meet the applicant's/consumer's needs;
  • determining that the applicant/consumer can be served safely in the community;
  • identifying the waiver and non-waiver service to be used to meet the applicant's/consumer's needs;
  • documenting the service plan on Form 3671-1, Individual Service Plan, and Form 8598, Non-Waiver Services, the ISP attachments and other supporting documentation;
  • determining that the services identified on the ISP developed are necessary as an alternative to institutional care and appropriate to meet the needs of the applicant/consumer; and
  • determining if an applicant/consumer residing in, or intending to live in, an AFC home can be left alone for up to three hours.

The IDT must make all of the determinations listed above for the initial and each subsequent development of the ISP.

If the case manager or other professional member of the IDT has doubts about the adequacy or appropriateness of the proposed ISP to meet the needs of the applicant/consumer in the community, these concerns should be expressed and documented on the appropriate ISP form or in the IDT meeting notes, if applicable.

The case manager may involve other professional staff, such as provider staff, the Department of Aging and Disability Services regional nurse or administrative staff in developing the ISP for applicants/consumers with ongoing needs for life-sustaining care or those in questionable living situations. Refusals of members of the IDT to sign the ISP should be documented.

The case manager provides copies of IDT notes, ISP attachments and notification forms to all members of the IDT.

Refer to Section 3411, Documentation of Waiver Requirements, for policy regarding obtaining IDT member signatures and agreements.

3422.1  Freedom of Choice

Revision 08-10; Effective September 1, 2008

The applicant/consumer is given the opportunity to make a free choice between institutional care and the services of the waiver. The applicant's/consumer's choice of Community Based Alternatives (CBA) services instead of nursing facility (NF) care is documented on Form 3671-2, Individual Service Plan.

If the applicant/consumer chooses institutional services, the case manager assists by providing the information on medical necessity and Medicaid eligibility status to the applicant/consumer to take to the NF of his choice. If the applicant/consumer chooses services through the CBA waiver and signs Form 3671-2, the case manager develops the individual service plan (ISP), determines eligibility and authorizes services if the applicant/consumer meets all eligibility criteria.

The applicant/consumer must sign the Freedom of Choice section of Form 3671-2 at initial enrollment, annual reassessment, when provider changes occur and when Assisted Living/Residential Care (AL/RC) or Adult Foster Care (AFC) services are added.

See Section 3411, Documentation of Waiver Requirements, for policy regarding the signature of the consumer on the ISP.

3422.2  Applicant Choices in Development of the ISP

Revision 08-10; Effective September 1, 2008

The case manager must consult with the applicant/consumer during the development of the individual service plan (ISP) to provide the applicant/consumer the opportunity to:

  • make choices regarding the ISP;
  • review the assessment completed by the Home and Community Support Services Agency (HCSSA) and the proposed ISP; and
  • provide acceptance and approval.

Within the constraints of the ISP cost limit and the types of providers available in the area, the applicant/consumer has choices about the types of and location for delivery of services proposed under the waiver. The applicant/consumer may choose to receive services in his own home or in an Adult Foster Care (AFC) or Assisted Living/Residential Care (AL/RC) setting. The applicant/consumer has choices about the types of adaptive aids and minor home modifications and the timing of purchases. He also has choices among providers of services and may select a particular HCSSA to deliver services, or may choose to receive particular nursing tasks from a licensed nurse rather than from a non-licensed person who has received training and authority to perform the tasks through delegation from a registered nurse (RN).

The case manager must inform the applicant/consumer of the feasibility and consequences of the choices, including the ISP cost limit implications. Example: If the applicant/consumer chooses only licensed nursing care, the cost of nursing care may cause him to be ineligible for the waiver because his ISP costs exceed the overall cost limit. Extensive use of licensed nursing care could reduce the amount of adaptive aids or other Community Based Alternatives (CBA) services that can be purchased within the waiver cost limit. The applicant/consumer may choose to stay at home as long as possible with a family member providing the nursing care, under the supervision of an RN.

In cases where the costs of all the waiver services identified by the HCSSA nurse would cause the applicant/consumer to be ineligible for the waiver because the waiver costs exceed the applicant's/consumer's assessed cost limit, the applicant/consumer may choose to reduce or delay some services that are not critical for health or safety. Example: The applicant/consumer may choose to postpone doing minor home modifications or use informal supports to deliver personal assistance or nursing services instead of CBA-purchased nursing or personal assistance services. The applicant/consumer may choose to use emergency response systems instead of direct supervision.

The combined waiver and non-waiver services may not be reduced below a level that is adequate to meet the applicant's/consumer's needs as determined by the interdisciplinary team (IDT). If there are disagreements between the applicant/consumer, the case manager and the service providers regarding the type or amount of CBA services necessary, the case manager must involve the Department of Aging and Disability Services (DADS) regional nurse and/or the applicant's/consumer's physician. The decision reached by the DADS staff involved in this consultation is final.

The input of the applicant/consumer will be included in the ISP that is developed and shared with the providers. The case manager must note any changes from the pre-enrollment assessment completed by the HCSSA nurse on Form 2067, Case Information, which is sent to the potential HCSSA at the time of the coordination of the ISP. Refer to Section 3433, Coordination of ISP with HCSS, AFC and AL/RC Providers.

See Section 3411, Documentation of Waiver Requirements, for obtaining the applicant's/consumer's acknowledgement and acceptance of the ISP.

3422.3  Regional Nurse Consultation and Approval

Revision 10-4; Effective September 1, 2010

Department of Aging and Disability Services (DADS) regional nurses provide consultation and required approvals for certain case actions to case managers. The case manager must submit Form 1547, Regional Nurse/Dental Consultant Request Worksheet, to the regional nurse to request assistance or approval for the following:

  • regional nurse approval for items not on the approved Adaptive Aids/Medical Supplies/Minor Home Modifications (AA/MS/MHM) list;
  • regional nurse approval to exceed the service limit for AA/MS/MHM;
  • regional nurse determination of medical need for requested item(s); and
  • consultation with the regional nurse to obtain professional judgment regarding requested item(s) or documentation submitted by the Home and Community Support Services Agency (HCSSA) in order to assist the case manager in making the authorization determination.

The case manager submits Form 1547 for requests for AA/MS/MHM, or other services. Other services include Therapy, Nursing Services, Respite, Emergency Response Services (ERS) and Personal Assistance Services (PAS). A separate worksheet must be completed for each type of request. For example, if the HCSSA submits a request for a MHM and AA, the case manager must complete two forms, one for the MHM and one for the AA. However, if the HCSSA submits a request for three different medical supplies, all three medical supplies may be listed on one form.

The case manager completes Form 1547 and submits it to the regional nurse with the appropriate individual service plan (ISP) documents. Refer to Form 1547 instructions (17. Supporting Information) and handbook sections related to regional nurse approvals for documents required for specific requests. If there are other supporting documents (for example, product information or a physician's order submitted by the HCSSA or information researched by the case manager), these must also be submitted to the regional nurse with Form 1547.

The regional nurse reviews the information submitted, provides professional consultation, approves or denies requests, as appropriate, and includes a short rationale for the determination and consultation on the form. The regional nurse may refer the request to state office staff for review. The regional nurse decision is submitted to the case manager.

3422.4  Review of Nursing Plans and Administration of Medication Documentation

Revision 13-2; Effective June 3, 2013

The case manager must review nursing plans submitted by the Home and Community Support Services Agency (HCSSA) to ensure the nursing plans related to assistance with medications documented on Form 3671-C, Nursing Service Plan, or Form 3671-C-Alternate, CBA Individual Services Plan — Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activites (HMSs), appear to be consistent with documentation on the Medical Necessity and Level of Care (MN/LOC) Assessment, information obtained during case manager assessment of the applicant or individual or other case documentation, such as documentation of informal supports on Form 8598, Non-Waiver Services. The case manager may view the MN/LOC Assessment on the Texas Medicaid & Healthcare Partnership (TMHP) online portal or by printing a copy. Some discrepancies may occur due to variances in the interpretation of the term "administration of medications," as defined by the Board of Nursing or other licensing rules.

The case manager should review all documentation in the case record and use his observation and interviewing skills to determine if any discrepancy exists between the documentation and what his observation or interview reveals. For example, is the documentation consistent with the individual’s functional ability to handle and manage his own medications? Is the documentation consistent with the need for nursing, informal support or other resources to assist with medication needs?

If the case manager determines a discrepancy exists, the case manager should contact the HCSSA nurse to determine how the nursing tasks documented on Form 3671-C or Form 3671-C-Alternate address the medication needs of the individual, or if any additional nursing tasks are required. The case manager must document this conversation in the case record.

If the HCSSA nurse concurs that additional nursing tasks are needed to provide assistance with medications to the applicant or individual, the case manager requests the HCSSA nurse to update Form 3671-C or Form 3671-C-Alternate to accurately reflect the medication needs of the applicant or individual and resubmit the form to the case manager. The case manager sends Form 2067, Case Information, to the HCSSA to document the request for a new Form 3671-C or Form 3671-C-Alternate to address the additional nursing hours needed. If the HCSSA nurse states assistance with medications is covered under Section II, Nursing Tasks, the case manager documents the HCSSA nurse's explanation on Form 3671-C or Form 3671-C-Alternate. The case manager does not request the HCSSA to resubmit Form 3671-C or Form 3671-C-Alternate.

Example 1: The documentation from the MN/LOC Assessment indicates the individual cannot self-medicate. Form 3671-C, Section II, Nursing Tasks, shows minimal direct nursing hours to provide assistance with medication administration. The case manager observes the informal support is not capable of pre-filling the medications. There is no documentation of who pre-fills the medications on Form 3671-C. The case manager contacts the HCSSA nurse to ask about the discrepancy. The HCSSA nurse explains to the case manager that the HCSSA nurse pre-fills the medication; the HCSSA nurse documented the hours on Form 3671-C but did not clearly specify the time was for pre-filling the medication. The case manager documents this on Form 3671-C but does not request the HCSSA nurse to submit a new form.

Example 2: The documentation from the MN/LOC Assessment indicates the individual cannot self-medicate. Form 3671-C shows minimal hours for the HCSSA nurse to pre-fill medications. The case manager knows through his assessment that the informal support assists with medication administration, but is unsure if the informal support is capable of assisting adequately. The case manager calls the HCSSA nurse and discusses the informal support's role in assistance with medications. The HCSSA nurse realizes Form 3671-C does not accurately address the individual's medication needs. The case manager requests the HCSSA to submit a new Form 3671-C and sends Form 2067 as a follow-up to document the request.

3423  Applicants and Individuals with High Needs

Revision 13-2; Effective June 3, 2013

An applicant or individual who meets the high needs criteria is immediately designated as an individual with high needs. Special procedures apply for working with an applicant or individual with high needs to assist the case manager in identifying and managing the special needs of the individual. It is possible that routine procedures will be sufficient to meet the needs of an individual with high needs. An individual may be at risk of being designated as an individual with high needs at a later time due to declining health, service interruptions, inability of providers to continue services, or other health and safety issues.

3423.1  Identification and Designation of an Applicant or Individual with High Needs

Revision 13-2; Effective June 3, 2013

Identification of an Applicant with High Needs

As part of the total assessment procedure, it is the case manager's responsibility, in consultation with the supervisor and Department of Aging and Disability Services (DADS) regional nurse, to identify and designate any applicant that has high needs. Following are some examples of situations where an applicant could be identified as having high needs.

  • The individual receiving services from the Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (THS-CCP) is turning age 21 and applying for Community Based Alternatives (CBA) services. Designation is not optional.
  • The applicant is on ventilator care.
  • The applicant has high-skilled nursing needs, such as tracheotomy care, wound care, suctioning or feeding tubes.
  • The applicant is seeking community placement and currently is in a nursing facility, state mental health facility or hospital, and community support resources to meet all his needs have not been identified.
  • The applicant will exceed the individual service plan (ISP) cost limit and has needs that will require special services or service delivery, and community support resources have not been identified.
  • The individual has a need for Personal Assistance Services (PAS) in excess of the ISP cost limit due to lack of caregivers or a diagnosis indicating he cannot be left alone.

This list is not all-inclusive.

Identification of an Individual with High Needs Who is Receiving Services

It is the responsibility of the case manager to be alert to changes in the situation of an individual who may require designation as high needs. These situations may include:

  • The individual’s medical condition severely deteriorates, requiring a significant increase in skilled nursing.
  • The individual loses third-party resources (TPR) or informal support(s) that is critical to his plan of care.
  • The individual has made requests for services that exceed the ISP cost limit.
  • The Home and Community Support Services Agency (HCSSA) is having difficulty keeping staff to deliver services to the individual and meeting his needs.
  • The HCSSA is citing health and safety issues and has notified the case manager that it cannot meet the individual’s needs.

Documentation and Designation of an Applicant or Individual with High Needs

Designation as high needs should take place as early as possible, either in the assessment process of the applicant or as soon as a high needs situation is identified for an individual receiving services.

The case manager designates the applicant or individual has high needs after consulting with the DADS regional nurse, supervisor and other regional management. The decision is documented in the case record and the case manager begins a chronology of events. It is imperative that detailed documentation be kept outlining all options and considerations for determining whether CBA services are feasible for the applicant or individual. Narratives should record all contacts and case actions in chronological order. If issues cannot be resolved, a full chronology of events may be required for submittal to regional management or state office. See Appendix XIII-A, Sample Chronology for High Needs.

Once the designation is made, a DADS regional nurse is assigned to work with the case manager and applicant or individual with high needs.

3423.2  Staff Responsibilities

Revision 13-2; Effective June 3, 2013

Responsibilities of the DADS Case Manager

The case manager will take the following actions in high needs situations.

  • Send the Department of Aging and Disability Services (DADS) regional nurse the applicant's pre-enrollment packet and individual service plan (ISP). For an individual, send the reassessment packet and ISP, or the most recent ISP if the situation arises between annual reassessments.
  • In consultation with the designated DADS nurse, explore and document all possible third-party resources (TPR). Explore Assisted Living (AL), Adult Foster Care (AFC), Day Activities and Health Services (DAHS), Nursing Facility (NF) and Community Living Assistance and Support Services (CLASS) programs or services. Determine if services are available through Medicare, Medicaid, home health, local community agencies and private insurance. Consider other Health and Human Services Commission (HHSC) enterprise agencies, such as the Department of Assistive and Rehabilitative Services (DARS) and the Department of State Health Services (DSHS). Identify local community support services, such as independent living centers and Area Agencies on Aging (AAA).
  • Determine if the applicant or individual will exceed the ISP cost limit and review cost-out procedures if the applicant or individual is being discharged from an NF. Refer to Section 3423.4, Procedures for Applicants and Individuals Residing in a Nursing Facility and the ISP Exceeds the Cost Limit.
  • Convene a meeting with the interdisciplinary team (IDT) to explore options for meeting the applicant's or individual’s needs. The IDT must consist of the:
    • case manager;
    • applicant or individual;
    • applicant's or individual's responsible party (if applicable);
    • Home and Community Support Services Agency (HCSSA) nurse or representative;
    • relocation specialist (if applicable); and
    • designated DADS regional nurse.
  • Regional staff may identify additional IDT participants. Other people who should participate, as needed, might include:
    • all identified informal supports;
    • any identified community resources;
    • the DADS Long Term Care Regulatory (LTC-R) licensing nurse;
    • contract managers;
    • interested advocates; and
    • any other interested relatives or friends of the individual.

If an individual in an NF requests community placement, contact the contracted relocation specialist. If there is an issue regarding provider licensure, the DADS LTC-R licensing nurse should also participate. If travel restrictions apply, staffings or consultations may be completed through a conference call.

  • Document in the chronology the results of the IDT. Specifically outline the agreements made and the needs and issues that were resolved. Document the needs and issues that will continue to be unmet and the actions planned.
  • Send a follow-up letter outlining the IDT discussions and agreements made by all parties involved and file a copy in the case record. Specifically outline in the letter the needs and issues resolved and not resolved, and the actions planned.

Responsibilities of the Designated DADS Nurse

In each region, at least two DADS regional nurses (a primary and a backup) will be designated by the regional director to handle and coordinate high needs designations. The designated nurse will be involved in:

  • assessment,
  • support planning,
  • coordination of services, and
  • advocacy.

The DADS regional nurse will assist the applicant or individual who is in transition and assist the case manager with the assessment and decision process.

The responsibilities of the designated DADS regional nurse are to:

  • carefully review the pre-enrollment assessment and determine if it is accurate and complete. It is the DADS nurse's discretion if a home visit is necessary to make a decision. If, in the DADS regional nurse's judgment, the pre-enrollment assessment is not appropriate, the nurse must either:
    • complete a new Medical Necessity and Level of Care (MN/LOC) Assessment; or
    • authorize additional pre-enrollment home health assessments by another HCSSA, as applicable;
  • determine whether the proposed ISP is reasonable and appropriate to meet the needs of the applicant or individual;
  • verify that Medicare and Medicaid are being accessed to the fullest possible extent;
  • contact and work with the HCSSA nurse to explore and discuss if nurse delegation can be used or is appropriate, and review the ISP to determine if the applicant or individual will exceed the ISP cost limit;
  • contact the Board of Nursing for questions regarding nursing care limitations;
  • advise the HCSSA nurse of required documentation if the HCSSA has refused to serve the applicant or individual due to inability to meet the individual's needs. The HCSSA must:
    • develop a care plan based upon its assessment of what is appropriate to meet the needs of the applicant or individual and the costs; and
    • document the specific licensing rule(s) used to refuse the applicant or individual and document in detail, according to the rule(s), why it cannot meet the needs of the applicant or individual in the community;
  • review licensing documentation, in consultation with the regional DADS licensing nurse, to ensure that the HCSSA has followed appropriate procedures and the reason for refusal is within licensing guidelines;
  • advise and work with the HCSSA and contract manager if the above procedures are not within guidelines, and seek a resolution for development of an appropriate ISP for the applicant or individual;
  • participate in the IDT and provide information regarding TPR, licensing issues and any other relevant findings to the case manager for documentation in the case record; and
  • conduct a home visit, if necessary, before an IDT meeting with state office staff.

3423.3  Responsibilities of Complex Needs Coordinators

Revision 10-4; Effective September 1, 2010

Each region has a designated complex needs coordinator. The complex needs coordinator has primary responsibility for the coordination of high needs consumers transitioning from children's programs to adult programs. The complex needs coordinator will also assist with other high needs consumer situations that require the expertise of the coordinator.

The duties of the complex needs coordinator are outlined below. Regional directors may assign additional staff to assist with these duties, but the designated coordinator will be the point of contact for issues and questions.

Quarterly Comprehensive Care Program (CCP) Transition Report

The designated complex needs coordinator will be responsible for:

  • completing the quarterly CCP Transition Report for the region and submitting it to the state office special initiatives coordinator by the designated due date. The report includes all transitioning individuals;
  • being the point of contact for any questions on the quarterly CCP Transition Report;
  • ensuring the 12-month visit and contacts are made and reporting to the state office Community Services and Program Operations contact any consumers who may potentially be over the cost limit based on current services;
  • identifying the high needs consumers and ensuring all aging-out assessments are started on time and remain on track; and
  • submitting frequent progress reports to the state office Community Services and Program Operations contact on the consumers who have been identified as high needs.

Identification and Tracking of High Needs Aging-Out Consumers

The complex needs coordinator will be responsible for:

  • identifying the aging-out consumers who may be close to the cost limit or have other issues that may complicate the development of an acceptable individual service plan (ISP);
  • coordinating the regional interdisciplinary team (IDT) meetings as needed;
  • being the regional contact person for state office staff for questions on pending applications or ongoing consumers with high needs;
  • requesting and participating in the state office IDT, including ensuring the chronology and other required documentation are submitted; and
  • assisting with collecting and submitting the required medical and service documentation if a physician's clinical visit is required for the General Revenue (GR) process.

Providing Assistance and Overview of High Needs Assessments

The complex needs coordinator will be responsible for:

  • working with the assigned case manager and other regional staff on all high needs assessments;
  • reviewing the draft ISP packet to check for the following:
    • Are the Medical Necessity/Level of Care (MN/LOC) and Resource Utilization Group (RUG) level set correctly? Is the consumer a ventilator patient and, if so, is the RUG coded correctly for the 6-23 hour or 24-hour vent care?
    • Are the nursing hours on Form 3671-C, Nursing Service Plan, calculated correctly? Are the registered nurse (RN) required hours included? Has the type of nursing (specialized or non-specialized) been discussed and set up correctly?
    • Does Form 3671-C reflect the informal support hours the family has agreed to, and is this information reflected the same on Form 8598, Non-Waiver Services? Is the family in agreement with the plan and is Form 8598 signed in agreement with the overall plan?
  • assisting regional staff in working with provider agencies and contract management to develop a cost-effective ISP that ensures health and safety and is ready to be implemented on the age-out date; and
  • working with state office staff if the General Revenue process is initiated.

3423.4  Procedures for Applicants and Individuals Residing in a Nursing Facility and the ISP Exceeds the Cost Limit

Revision 13-2; Effective June 3, 2013

If an applicant or individual is being discharged from a nursing facility and will exceed the cost limit, follow these guidelines along with other high needs procedures.

  • Refer the applicant to a minimum of three additional Home and Community Support Services Agencies (HCSSAs) to determine if a more cost-effective plan can be developed. Referrals can be made one at a time after the first referral comes back indicating the applicant's individual service plan (ISP) exceeds the cost limit amount, or can be sent to different providers at the same time.
  • The case manager and the Department of Aging and Disability Services (DADS) regional nurse compare the pre-enrollment home health assessments to determine if there are any significant areas of discrepancy.
  • The region holds an interdisciplinary team meeting (IDT) with the applicant or individual, informal supports, advocates, Area Agencies on Aging, HCSSA, independent living centers, sister agencies and other resources to determine if the information on the assessment(s) accurately reflects the needs of the applicant or individual and if there are other alternatives.
  • Once the IDT has been held, if other informal supports or resources are identified that could reduce the cost of care, refer the applicant to one of the original HCSSAs of his choice for another assessment.
  • If the ISP remains above the cost limit after the assessment and the IDT, forward all documentation to state office for review.
  • If state office staff identify other resources or other possible changes to the ISP, the information is shared with the region so the applicant can be referred to one of the original HCSSAs of his choice for another assessment.
  • If the ISP still remains above the cost limit and state office identifies no other resources, the case is referred to the region to follow normal procedures for denial of eligibility.

Regional staff must authorize payment to any HCSSAs conducting pre-enrollment home health assessments. Refer to Section 3317.1, Additional Assessments for Applicants with High Needs.

3423.5  Special Procedures for MDCP or THS-CCP Transitioning to CBA

Revision 13-1; Effective March 1, 2013

A Community Based Alternatives (CBA) applicant who is aging out (turning 21) of the Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (THS-CCP) Private Duty Nursing (PDN) is identified prior to his 20th birthday so that plans for transitioning to CBA services can begin. A report is generated and sent to the regional directors every three months with a list of the applicants who will turn 21 within the next 18 months and require contacts.

Department of Aging and Disability Services (DADS) staff will assist a CBA applicant who is transitioning out of MDCP services. Department of State Health Services staff will assist a CBA applicant who is transitioning out of CCP-PDN.

It is very important to explain the aging out process to the applicant, his responsible party or both, so they understand that current services will no longer be available and to introduce the options available at age 21.

Upon receipt, a CBA case manager and DADS regional nurse are assigned to the CBA applicant. DADS staff must send the Initial Age-out Letter found in Appendix XIII-C, Age-out Transition Letters, prior to the 12-month home visit. The Initial Age-out Letter serves as an introduction to the process and advises the applicant, responsible party, or both, to expect contact from DADS staff to schedule the 12-month visit. The CBA case manager coordinates with the DADS regional nurse and arranges to make an overview visit to the applicant (or responsible party) within 14 days of the assignment. For an individual receiving MDCP services, the CBA case manager coordinates the visit with the MDCP case manager.

Overview Home Visit for a CBA Applicant Who is Receiving MDCP or CCP-PDN

During the home visit to the CBA applicant who is receiving MDCP or CCP-PDN, the CBA case manager and DADS regional nurse present an overview of the CBA program and identify some of the differences between CBA and MDCP or CCP-PDN. If there are high needs that may be difficult to meet through the CBA program, those needs are identified and efforts are initiated to locate alternative resources to meet the applicant's needs. The CBA case manager provides the following information:

  • The CBA program contracts with a Home and Community Support Services Agency (HCSSA); nursing services are delivered through the HCSSAs and not independently enrolled nurses.
  • The pay rate for HCSSA nurses is less than MDCP or CCP-PDN and should be considered in locating nursing services.
  • HCSSAs do not typically have nurses available for daily nursing care and the applicant or responsible party may need to be instrumental in identifying nurses who are willing to work.
  • The individual service plan (ISP) is developed using the applicant's assessed cost limit.
  • To be eligible for CBA services, an ISP must be developed that can meet the needs and assure the health and safety of the applicant.
  • Contracted service providers may refuse to accept the referral based on licensure, and DADS cannot guarantee providers to be available to meet the applicant's needs.

The CBA case manager also shares:

  • the array of services available within the CBA program; and
  • Form 2307, Rights and Responsibilities, and Form 2307-C, CBA Eligibility Criteria and Responsibilities, which identify the applicant's rights and responsibilities in the CBA program.

The CBA case manager explains the intake process to the applicant or responsible party and advises the intake process will begin six months before the applicant's 21st birthday. Advise the applicant or responsible party to expect to be contacted at that time and to be exploring the availability of service providers and other resources that can meet the applicant's needs.

Monitoring Procedures for a CBA Applicant Who is Receiving MDCP or THS-CCP

The MDCP case manager monitors the service planning with the CBA applicant who is receiving MDCP services or responsible party every 90 days during the time before the applicant turns 21. If there are any problems or concerns, the MDCP case manager contacts the CBA case manager and the DADS regional nurse to discuss these issues.

The monitor may be made by telephone and will include:

  • contacting the applicant or responsible party to review services being considered and progress in locating resources to meet the applicant's needs;
  • contacting the THS-CCP medical case manager for additional information, if needed; and
  • documenting the contact and information on Form 2314, Satisfaction and Service Monitoring, Form 2058, Case Activity Record, or other case narratives as determined by the region.

Intake Procedures for a CBA Applicant Who is Receiving MDCP or CCP-PDN Transitioning to CBA

Based on the quarterly CCP Transition Report, the complex needs coordinator and regional staff assign a CBA case manager to a CBA applicant aging out of MDCP or CCP-PDN. The assigned CBA case manager is alerted to start the pre-enrollment and service development planning to ensure that a feasible ISP is in place before other services end.

Service Planning

Due to the complexity of a CBA applicant with high needs transitioning from children's programs to adult programs, the regional complex needs coordinator assists in the coordination of the transition to CBA. Refer to Section 3423.3, Responsibilities of Complex Needs Coordinators.

The regional complex needs coordinator, the DADS regional nurse and the CBA case manager must complete the required steps and time frames:

  • Identify every applicant on the Aging Out reports prior to his 20th birthday, send the Initial Age-out Letter and schedule the initial home visit.
  • Assess whether the applicant may be potentially over the cost limit based on the MDCP assessment or the number of nursing hours through CCP. If the CBA applicant's plan is at 150% or over the cost limit, notify state office.
  • Advise the applicant or responsible party that the intake process will begin six months prior to the applicant's 21st birthday.
  • Notify the Community Services and Program Operations unit manager at state office by email if the service plan may potentially be over the cost limit and designate as an applicant with high needs.
  • Send nine months prior to the applicant’s 21st birthday, the Follow-up Letter in Appendix XIII-C, to an applicant who has 50 or more hours of skilled nursing services weekly as a reminder that the aging out application process will begin six months prior to his 21st birthday. The letter will be sent by the assigned CBA case manager.
  • Complete the CBA intake pre-assessment and service development process six months prior to the applicant's 21st birthday to determine if resources have been identified to develop an ISP within the cost limit.
  • Convene a regional interdisciplinary team (IDT) meeting to explore all possible resources for developing an ISP that will meet the applicant's needs within the cost limit.
  • Advise state office of the results and recommendations of the IDT. If the applicant has high needs and a plan has not been developed within the cost limit, request a state office IDT meeting within 10 calendar days.
  • Send the High Needs Chronology and Form 1024, Individual Status Summary, to state office.
  • Convene the IDT with state office staff and explore all possibilities for developing a plan within the cost limit. If a plan cannot be developed, then a decision will be made to determine whether it is appropriate to request General Revenue (GR) funds.
  • If a GR request is not appropriate, send Form 2065-C, Notification of Ineligibility or Suspension of Waivers Services, according to the procedures in Section 3421.3, Requesting General Revenue Funds for Services Not Covered Within the Waiver Cost Limit.
  • If a GR request is appropriate, obtain additional medical documentation required for the clinical review and send to state office. State office staff will contact the Center for Policy Innovation (CPI) to arrange for the clinical staff to conduct a review. This review can take up to 60 days.
  • If the clinical staff determine that GR funds are not appropriate, state office staff send the Preliminary Report letter informing the applicant of the decision and allowing the applicant 10 working days to submit additional medical information. If additional information is received, the clinical staff will review the information to determine whether GR funds will be approved.
  • If the clinical staff determine that GR funds are not appropriate, state office will send a Final Report letter denying GR funds, along with a termination notice regarding MDCP services, if appropriate. Regional staff will send Form 2065-C to the applicant denying CBA services according to state office instructions. The MDCP termination notice must be sent 30 calendar days prior to the applicant's 21st birthday to allow time to arrange for alternate placement.
  • If the clinical staff determine that GR funds are appropriate, proceed with developing an ISP to begin on the applicant's 21st birthday.

High needs procedures include identifying all third-party resources and convening the IDT as part of the service planning process. The IDT consists of the CBA applicant or responsible party, CBA case manager, regional complex needs coordinator, designated DADS regional nurse, MDCP case manager and/or THS-CCP medical case manager, HCSSA staff, other current service providers, family and informal supports, advocates and anyone else the applicant or responsible party wishes to have present. The IDT explores all available resources for developing an ISP that will meet the applicant's needs.

Procedures if Service Providers Cannot be Found for a CBA Applicant Who is Receiving MDCP or CCP-PDN

If, after all resources are explored and all options considered, a CBA provider cannot be found to accept the CBA applicant transitioning from the MCDP or CCP-PDN, the applicant is not denied CBA.

The enrollment process remains open and efforts continue to locate a suitable CBA provider that is able to meet the applicant's needs. Send the applicant a letter stating efforts will continue to locate a provider that can meet his needs, and services will start as soon as a provider is found. Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, must not be used for this notification, as the applicant remains eligible for services. Use the sample letter in Appendix XIII-D, Sample Letter – Provider Refusal.

Continue to contact additional CBA providers and explore other resources. Any HCSSA refusing to serve the applicant must document the specific licensure reasons why it will not accept the applicant. All referrals to providers and the responses are documented in the case narrative in chronological order.

If, at the end of 120 calendar days after the letter is sent to the applicant, no resources have been located to serve the applicant, begin denial procedures as outlined in the high needs procedures. State office must be notified of the pending denial. Follow the guidelines for notifying state office with an updated chronology of all options explored.

3423.6  Notification of Refusal to Serve an Applicant or Individual with High Needs

Revision 13-1; Effective March 1, 2013

Immediately upon receipt of a notice from the Home and Community Support Services Agency (HCSSA) of refusal to serve an applicant or individual with high needs, the case manager must advise the supervisor, Department of Aging and Disability Services (DADS) designated regional nurse, and other appropriate regional management and interdisciplinary team (IDT) members. The case manager will complete the following steps:

  • Consult with the DADS regional nurse and the DADS contract manager concerning the licensure reasons and any contract related issues.
  • Request the DADS regional nurse to identify the specific skilled needs the HCSSA is unable to meet under its licensure and verify that the refusal is valid.
  • Convene an IDT in person or by telephone as soon as possible to address alternative resources for meeting the skilled needs. Along with the DADS regional nurse and the applicant or individual, include the licensing nurse, contract manager, the HCSSA nurse and other appropriate IDT members. If the ISP is expiring soon for an individual receiving services, determine if the current HCSSA will complete a reassessment packet and submit the Medical Necessity and Level of Care (MN/LOC) Assessment for the medical necessity determination.
  • Explore and document all possible options for meeting the identified needs, including Medicare, Medicaid, or both, change in homebound status, informal supports, other community resources, private insurance and services from other agencies. The case manager must also discuss other service options, including Day Activity and Health Services (DAHS), Community Living Assistance and Support Services (CLASS), Assisted Living (AL), Adult Foster Care (AFC) and nursing facility (NF) placement.
  • Make a referral to the Department of Family and Protective Services if the applicant or individual lives alone or has health and safety issues.
  • For an individual, if a resource is located to meet the needs, revise the individual service plan (ISP) and resolve the issue with the current HCSSA. Determine if the provider is willing to continue serving the individual.
  • If the issue cannot be resolved for an applicant or individual and the current HCSSA is not willing to accept or serve him, refer the applicant or individual to a minimum of three other HCSSAs. Authorize payment to each HCSSA to complete a new assessment. The case manager may negotiate the date of response from the HCSSAs to avoid a service gap or to expedite service approval. As soon as an HCSSA agrees to accept the applicant or individual, negotiate a start of care date. Transfer the individual to the new HCSSA. Any HCSSA refusing to serve an applicant or individual must document the specific licensure reason(s) why it will not accept the applicant or individual. It is the region's discretion to decide if referrals to additional HCSSAs are necessary.
  • Document all referrals to HCSSAs and their responses in the case chronology. Document all options explored.
  • For an individual, if a new HCSSA cannot be located before the current HCSSA stops service, the case manager will discuss with the individual:
    • provision of care by family or friends, either in the individual's home or their home; or
    • respite services in an NF, AL, AFC or other temporary locations.
  • If no other alternative can be found, request the current HCSSA to continue serving the individual unless a suspension is necessary due to imminent danger.

If no HCSSA will accept the applicant or individual and no other resources have been found to meet his needs, begin denial or termination procedures.

3423.7  Disposition of an Applicant or Individual with High Needs

Revision 13-1; Effective March 1, 2013

The purpose of high needs procedures is to identify additional resources to develop an individual service plan (ISP) that will meet the applicant's or individual's needs and assure health and welfare.

If additional resources are found, document all third-party resources (TPR) and informal supports on Form 8598, Non-Waiver Services. Obtain the commitment and signature of informal support that will assure health and welfare.

Once the applicant meets all eligibility criteria, an ISP has been developed to meet the needs of the applicant, and the Home and Community Support Services Agency (HCSSA) and applicant have agreed to the plan by signing Form 3671-2, Individual Service Plan, the applicant may be enrolled in CBA.

Continue services to an individual receiving services when an ISP has been developed to meet the needs of the individual, and the HCSSA and the individual have agreed to the plan by signing Form 3671-2.

Notifying State Office of an Applicant or Individual with High Needs

Regional management will make the decision to notify state office of an applicant or individual with high needs when:

  • regional staff have completed the applicable high needs procedures and there is no resolution for services for the applicant or individual; or
  • other parties such as state or local media, legislators or advocates become involved on behalf of the applicant or individual.

Once the decision is made to notify state office, the information is relayed by electronic mail message to the Community Services Policy and Curriculum Development (CSPCD) unit manager. CSPCD staff will coordinate with other appropriate state office entities, which could include the Center for Policy and Innovation, Regulatory, Center for Consumer and External Affairs or Legal Services. The CSPCD staff will set up the staffing as necessary and distribute case information to the participants.

The case information distributed must include:

  • identifying information, including the applicant's or individual's name, Medicaid number and region;
  • summary of the situation and the current status; and
  • chronology of the case actions detailing the efforts made to resolve service issues, including all interdisciplinary team (IDT) staffings, referrals to additional agencies and other service options explored. The chronology may be faxed rather than mailed electronically, if it is legible.

If state office staff identify other resources or other possible changes that would facilitate serving the applicant or individual, the information will be shared with regional staff. CSPCD staff will coordinate any necessary follow-up meetings.

Procedures for Denial or Termination of an Applicant or Individual with High Needs

After all appropriate steps outlined above have been completed and state office staff identify no other resolution to meet the applicant's or individual's needs through the Community Based Alternatives (CBA) program, CSPCD staff will direct regional staff to follow procedures for denial or termination. These procedures include:

  • confirming approval to deny the applicant or terminate the individual from regional management, as designated by the regional director;
  • sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the applicant or individual with the reason for denial or termination clearly stated and the appropriate Department of Aging and Disability Services (DADS) rule referenced;
  • submitting all relevant information to the hearings officer in the event of a hearing; and
  • referring the applicant or individual to any other programs that may assist in meeting his needs, including Community Care for Aged and Disabled (CCAD), Texas Aging Services and all other state and community resources that have been identified as available for the applicant or individual.

3423.8  Contacts from External Sources

Revision 12-4; Effective December 3, 2012

Contacts from external sources, such as a legislator's office, attorney or legal representative, advocacy group or media, require consultation and follow up by regional and state office management.

Procedures, as outlined by the Center for Consumer and External Affairs, will be used when working with an applicant or individual with complex needs who has a legislative or external inquiry.

Designated regional management is mandated to participate in the interdisciplinary team (IDT) and provide guidance and direction to the case manager to ensure guidelines are followed.

3430  Finalizing Enrollment

Revision 13-3; Effective September 3, 2013

Within 30 calendar days of receiving the completed pre-enrollment assessment packet from the Home and Community Support Services Agency (HCSSA), the case manager determines eligibility and authorizes Community Based Alternatives (CBA) services.

All of the following must be completed by the case manager within 30 calendar days:

  • Verify medical necessity (MN) through the Service Authorization System (SAS) or the Long Term Care (LTC) online portal.
  • Verify financial eligibility for applicants with Supplemental Security Income (SSI) or a determination from Medicaid for the Elderly and People with Disabilities (MEPD) through the Texas Integrated Eligibility Redesign System (TIERS).
  • Through the Eligibility Data Exchange and Notification (EDEN) system, provide the MEPD specialist with the date the case manager has an accepted and approved individual service plan (ISP) and valid MN for CBA.
  • Coordinate with MEPD to establish the medical effective date (MED), if appropriate.
  • Verify that the ISP has been signed appropriately by all applicable parties.
  • Complete Form 3671-1, Individual Service Plan, listing all authorized services and ensuring the service plan is below the cost limit.
  • Send the ISP, Form 3671-1, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, and Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, to the potential providers, except for Emergency Response Services (ERS) providers, for acceptance of the referral or negotiation of any necessary changes to the ISP. If changes are made to the ISP, the case manager must obtain the individual's signature or document his verbal agreement to the changes on the ISP.
  • Negotiate a service initiation date with the CBA provider if the applicant or individual cannot be without services, such as a nursing facility (NF) resident. The negotiated date should ensure there is no interruption of needed services for the applicant or individual.
  • Send Form 2065-B, Notification of Waiver Services, along with Form 3671-1 and the ISP attachments to the applicant or individual, all appropriate CBA service providers and all members of the interdisciplinary team (IDT), including MEPD with Form H1746-A, MEPD Referral Cover Sheet, if appropriate. This notification must be sent no later than 30 days from receipt of the completed pre-enrollment packet.
  • Enter the authorized the services in the SAS according to data entry time frames.
  • Remove the applicant's name from the Community Services Interest List (CSIL).

    Note: The authorized services must be entered in SAS. The provider cannot be paid until the ISP is in SAS. Entering the authorized services in the ISP in SAS is a requirement to meet the CBA processing time frames for initial enrollment, annual reassessment and changes. See Section 3440, Service Authorization System (SAS) Online Overview, for data entry requirements.

If at any time during the initial enrollment or annual reassessment process the case manager receives information indicating the applicant or individual is not eligible (due to MN, Medicaid eligibility or other factors), then within two working days of making the eligibility decision, the case manager must:

  • send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the applicant or individual offering the right to appeal, with copies to all appropriate CBA service providers and members of the IDT, including MEPD with Form H1746-A, if appropriate;
  • screen and refer the applicant or individual for non-waiver services, as appropriate; and
  • for an applicant, remove his name from the CSIL, entering the reason for denial.

Refer to Section 3411, Documentation of Waiver Requirements, for information on obtaining signatures for the above process.

3430.1  Additional Procedures for Medical Necessity Denials

Revision 13-1; Effective March 1, 2013

When medical necessity (MN) is initially denied by Texas Medicaid & Healthcare Partnership (TMHP), TMHP sends a letter to the Community Based Alternatives (CBA) applicant or the individual receiving CBA services, his physician and the Home and Community Support Services Agency (HCSSA), which includes the phone number for the TMHP Help Desk, 1-800-626-4117, Option 2. The physician or HCSSA can call this number, select Option 2 and submit additional medical information to TMHP.

The case manager must follow this process when the Medical Necessity and Level of Care (MN/LOC) Assessment status in the Long Term Care (LTC) Portal is "MN Denied" for an applicant or individual. The MN/LOC Assessment status of "MN Denied" is the period when the applicant's or individual's physician has 14 working days to submit additional information. Once an MN/LOC Assessment status is in "MN Denied" status, several actions may occur:

  • MN Approved: The status changes to "MN Approved" if the TMHP doctor overturns the denial because additional information is received;
  • Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14 working day period for the TMHP doctor to overturn the denied MN has expired. No additional information was submitted for the doctor to review. The denied MN remains in this status unless a fair hearing is requested; or
  • Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

The case manager sends Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, when "Overturn Doctor Review Expired" or "Doctor Overturn Denied" appears on the LTC Portal and the MN denial is final. At this point, the TMHP Help Desk phone number is of no assistance to the applicant or individual. Option 5, to request a fair hearing, is available at the above TMHP number; however, option 5 is only for a person in a nursing facility to call to request a fair hearing.

The case manager must not mail Form 2065-C to deny or terminate CBA eligibility until after 14 working days from the date the "MN Denied" status appears in the LTC Portal. TMHP phone numbers must not be included on Form 2065-C for MN denials. The applicant or individual should request a fair hearing by contacting the case manager. The case manager must meet initial enrollment and annual reassessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented.

3431  Verifying Level of Care/Medical Necessity Determination

Revision 02-0; Effective April 4, 2002

§48.6005 — Level of Care Criteria.

(a)
Waiver participants must meet the level of care/medical necessity criteria for nursing facility placement according to applicable state and federal regulations, and as verified by a current assessment.
(b)
A preadmission level of care and medical necessity determination expires 120 days from its issuance.
(c)
Level of care assessments/medical necessity determinations must be performed annually for all waiver clients.

3431.1  Medical Necessity Determination

Revision 12-4; Effective December 3, 2012

An applicant or individual must have a valid medical necessity (MN) determination for initial enrollment into the Community Based Alternative (CBA) program or annual reassessment. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant's or individual's individual service plan (ISP) cost limit is calculated based on the Resource Utilization Group (RUG) that resulted from the MN/LOC Assessment information.

The Home and Community Support Services Agency (HCSSA) completes and submits an MN/LOC Assessment to Texas Medicaid & Healthcare Partnership (TMHP) for an applicant or individual. TMHP will process the MN/LOC Assessment for an applicant or individual to determine MN and calculate a RUG value. The RUG value is a measure of nursing facility staffing intensity and is used in CBA to:

  • categorize an applicant's or individual's needs;
  • establish the ISP cost limit; and
  • identify provider reimbursement rates.

When TMHP processes an MN/LOC Assessment, a three-alphanumeric digit RUG will appear in the Level of Service record in the Service Authorization System (SAS) and in the TMHP Long Term Care (LTC) online portal.

For an applicant or individual who requires Medicaid eligibility financial decision, the case manager must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the applicant or individual meets MN. See procedures in Section 3432.3, Procedures for Texas Integrated Eligibility Redesign System (TIERS) Applicants, for sending MN determination information to MEPD. The MEPD specialist may view the SAS or the LTC online portal to confirm that the applicant or individual has met the MN criteria.

3431.2  Medical Necessity Determination for Applicants Residing in Nursing Facilities

Revision 13-1; Effective March 1, 2013

During the initial contact with the applicant, the case manager must explore the applicant's status in the nursing facility (NF) and determine whether the applicant is currently receiving Medicaid, applying for Medicaid in the NF or is on Medicare. If the applicant is currently on Medicare, the case manager needs to know the length of the Medicare stay. This information helps determine whether the case manager should authorize the Home and Community Support Services Agency (HCSSA) to complete the Medical Necessity and Level of Care (MN/LOC) Assessment. Communication with the NF regarding plans for submittal of the MN/LOC Assessment may be necessary.

The case manager should make every effort to determine if authorizing the HCSSA to complete the MN/LOC Assessment is necessary and to avoid duplication of submittal to Texas Medicaid & Healthcare Partnership (TMHP) for MN. The case manager advises the HCSSA on Form 2067, Case Information, sent with Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization, whether the MN/LOC Assessment should be completed during the pre-enrollment assessment of the applicant. Since the fee for completing the MN/LOC Assessment is included in the pre-enrollment assessment, no additional service codes or payment are required.

MN may be verified through the Service Authorization System (SAS) for a Community Based Alternatives (CBA) applicant residing in an NF who is already approved for Medicaid if the MN is already in the SAS. In this situation, the HCSSA should not complete a new MN/LOC Assessment. The MN on record will be accepted as a valid MN. The HCSSA should ask the NF for a courtesy copy of the MN assessment completed by the NF. If the NF refuses, it will not be mandatory for the HCSSA to have a copy.

If an applicant is applying for Medicaid as a resident in the NF and is concurrently applying for CBA, the NF should complete the MN Assessment. The HCSSA is instructed not to complete a new MN/LOC Assessment with the pre-enrollment assessment. If the NF refuses to complete the MN Assessment in a timely manner, the case manager may authorize the HCSSA to complete the MN/LOC Assessment for the applicant. If a temporary NF MN is on file, the case manager should determine the length of stay of the applicant in the NF and if the NF MN will be permanent before authorizing the HCSSA to complete and submit the MN/LOC Assessment.

A different situation exists when a person enters the NF on Medicare. Medicare provides 100% beginning on the 21st day. Medicare pays 80% and the resident must arrange for the 20% copayment. If the resident has Medicaid, Medicaid will pay the 20% copayment. Medicare coverage can extend to the 100th day. The NF is under no obligation to complete the MN process during the time Medicare pays for the NF, even if the resident plans to stay until he becomes eligible for full Medicaid. The NF can wait even longer than the 100th day to complete an MN assessment and coverage will be retroactive to the Medicaid start date. In this situation, the case manager may authorize the HCSSA to complete the MN/LOC Assessment to expedite receiving an MN and avoid a delay for the CBA applicant returning to the community.

An applicant from an NF requires a CBA pre-enrollment home health assessment by the HCSSA nurse before enrollment in the CBA program in order to develop the individual service plan (ISP), but the HCSSA nurse is instructed not to complete or transmit the MN/LOC Assessment to TMHP if not applicable. The case manager accesses the SAS or the Long Term Care (LTC) Online Portal to verify that the applicant has a valid MN determination.

If the applicant has a valid MN determination, the case manager proceeds with the CBA eligibility determination.

For an applicant who satisfies the CBA MN requirement based on the MN determination made while in an NF, a copy of the SAS or LTC online portal screen or a TMHP status report showing the applicant has approved MN must be filed in the case record. A denied MN decision resulting from an Admission MN/LOC Assessment submitted by the HCSSA will not be used to deny a CBA applicant who has a current valid NF MN. The NF MN and resource utilization group will be used in the CBA eligibility determination.

An MN record must be located in the SAS so the ISP registration will not suspend because of a lack of MN information. The SAS MN record must match the ISP effective period.

For billing purposes, providers may be required to submit ICD-9 Diagnosis Codes found in the MN/LOC Assessment. The diagnosis codes also may appear in the SAS Diagnosis screen once MN is approved. The diagnosis code is required for all CBA claims except meals, Emergency Response Services (ERS) and atypical services such as Financial Management Services (FMS). In most cases, the HCSSA will have the diagnosis codes, except when the HCSSA does not complete the MN/LOC Assessment. Assisted Living (AL), Adult Foster Care (AFC) and out-of-home respite providers do not have access to the MN/LOC Assessment. The case manager must send a copy of the current MN/LOC Assessment to AL, AFC and out-of-home respite providers when the applicant is enrolled in CBA and when the annual reassessment is completed. The case manager should provide the ICD-9 Diagnosis Codes to the HCSSA when the provider does not have access to the MN/LOC Assessment information.

A denied MN decision resulting from a Significant Change in Status Assessment (SCSA) will not be used to terminate CBA in the current ISP year. The MN denial resulting from an SCSA submitted after the Annual MN/LOC Assessment by the HCSSA will result in termination of CBA services at the end of the ISP period.

3431.3  Medical Necessity Determination for Applicants Not Residing in Nursing Facilities

Revision 13-2; Effective June 3, 2013

For most Community Based Alternatives (CBA) applicants not living in nursing facilities, the medical necessity (MN) determination will be made by Texas Medicaid & Healthcare Partnership (TMHP) based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the Home and Community Support Services Agency (HCSSA) nurse doing the pre-enrollment home health assessment. The MN determination is handled differently, except if the applicant had a valid MN determination prior to discharge from a nursing facility (NF) and will begin receiving CBA services within 60 days of the discharge.

For CBA applicants recently discharged from an NF, if services will begin within 60 days of the discharge, the case manager follows the procedures identified in Section 3431.2, Medical Necessity Determination for Applicants Residing in Nursing Facilities, to verify the applicant has a valid MN determination. If the applicant does not have a valid MN or services will not begin within 60 days, a new MN determination will be necessary.

The HCSSA must electronically submit the MN/LOC Assessment to the TMHP Long Term Care Portal after it has been signed by the physician. The HCSSA sends the case manager the Document Locator Number (DLN) of the transmitted MN/LOC Assessment. The case manager may access the TMHP Long Term Care Portal to print the MN/LOC Assessment or at a minimum, must document in the case record the DLN, the resource utilization group (RUG) value and whether the MN determination was approved or denied. This information may be printed from the TMHP Long Term Care Online Portal or written in the case narrative form for the case record. A copy of the MN/LOC Assessment or the DLN, RUG and result of the MN determination must be filed in the case record.

3431.4  Special Procedures for Individuals Whose Medical Necessity Was Determined by a DADS Nurse (Second MN)

Revision 13-2; Effective June 3, 2013

For applicants whose medical necessity (MN) determination has expired or will exceed the 120-day expiration standard before Community Based Alternatives (CBA) eligibility is established, the MN determination must be updated by a Department of Aging and Disability Services (DADS) regional nurse. Although the Service Authorization System (SAS) may reflect a one-year MN determination resulting from the enrollment assessment submitted by the Home and Community Support Services Agency (HCSSA), a Medical Necessity and Level of Care (MN/LOC) Assessment must be completed by the DADS regional nurse to confirm continued MN after 120 days.

The DADS regional nurse should complete a new MN/LOC Assessment to confirm the original MN determination. The updated form, completed and signed by the DADS regional nurse to validate continued MN, is attached to the Physician's Signature page from the initial MN determination documentation (a copy of the initial MN/LOC Assessment or document locator number (DLN)/MN determination documentation) and filed in the case record. The MN determination is sent to the case manager and filed in the case record. The existing MN and level of service record on file in SAS will be used in the enrollment process.

If the review completed by the DADS regional nurse results in information that the applicant may not meet continued MN, the DADS regional nurse informs the case manager to authorize the HCSSA to complete a second MN/LOC Assessment and submit as a Significant Change in Status Assessment (SCSA). The SCSA submittal of the MN/LOC Assessment will process the MN determination and possibly reset the applicant's Resource Utilization Group (RUG) based on the MN/LOC Assessment information submitted. The case manager will use the SCSA information in the LTC online portal to determine the appropriate case action based on the MN determination and the new RUG, if applicable. If the second assessment results in a favorable change in the calculated cost limit for the individual, the case manager is responsible for ensuring the new cost limit is appropriately recorded in SAS.

3431.5  Long Term Care Portal

Revision 13-2; Effective June 3, 2013

Home and Community Support Services Agency (HCSSA) staff must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal to process a determination of MN and reimbursement rates. HCSSA staff submit the MN/LOC Assessment as:

  • Admission Assessment — submitted at enrollment when authorized on Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization;
  • Annual Assessment submitted for the annual reassessment; or
  • Significant Change in Status Assessment (SCSA) submitted when authorized by the case manager due to changes in the individual's medical condition.

TMHP retains an electronic copy of each MN/LOC Assessment for seven years. TMHP assigns a Document Locator Number (DLN) to each electronic copy of an MN/LOC Assessment that allows the case manager, regional nurse, case analyst, utilization review (UR) nurse or HCSSA that completed the assessment, as applicable, access to the information from the MN/LOC Assessment.

The HCSSA has the ability to correct or inactivate an assessment submitted within a specific time frame. A correction is completed when data submitted incorrectly is corrected; inactivation is completed when data needs to be removed from the LTC Online Portal system. If the HCSSA submits an SCSA without case manager approval, the case manager should request the HCSSA inactivate the SCSA.

The case manager is given access to the LTC Online Portal to:

  • check and verify MN status and Resource Utilization Groups (RUG);
  • review actions placed in a "workflow" status that result from the submittal of the MN/LOC Assessment at initial enrollment, annual assessment and SCSA; and
  • manage and take action in response to "workflow" messages.

Other Department of Aging and Disability Services (DADS) staff with access and responsibilities to manage workflows related to their job duties include Claims Management System (CMS) coordinators, Provider Claims Services (PCS) coordinators and UR nurses.

Submittal of the MN/LOC Assessment through the LTC Online Portal creates MN, Level of Service (LOS) and Diagnosis (DIA) records in the Service Authorization System (SAS). The LOS record is also referred to as the LVL record in status messages. A Community Based Alternatives (CBA) RUG will be noted as CR.

Status messages appear in the LTC Online Portal workflow folder when an MN/LOC Assessment is submitted and certain requirements in TMHP processing cannot be completed. Status messages may be generated when:

  • assessments have missing information;
  • the system cannot match the assessment to an applicant's or individual's SAS records;
  • the applicant or individual is enrolled in another program;
  • assessments are out of sequence;
  • corrections are made to submitted assessments after SAS records have already been generated based on the previously submitted assessment;
  • changes occur in MN or LOS status that affect the individual’s services; or
  • SAS records were manually changed within the current individual service plan period.

This list is not all inclusive.

Messages will appear in the workflow folder to indicate whether or not the LTC Online Portal action was processed as complete. In some situations, MN, LOS and DIA records will not be generated to SAS; in other situations, SAS records will be generated but messages may still appear in the case manager workflow for required action.

The case manager may filter the workflow messages by choosing specific criteria, such as the individual’s name or type of MN/LOC Assessment. Workflow items may require the case manager to update SAS records or take specific case actions based on the MN and RUG information found in the LTC Online Portal. The case manager must document responses to workflow messages appearing for an individual receiving services by clicking on applicable buttons related to the messages. The case manager is required to check the LTC Online Portal workflow items to process case actions per CBA policy.

Note: Refer also to Appendix XI, Common Scenarios and Workflow.

3432  Verifying Financial Eligibility and Coordination of Enrollment with Medicaid Eligibility

Revision 13-3; Effective September 3, 2013

The case manager will determine that the applicant has met all eligibility criteria, including:

  • Medicaid eligibility, as verified through the Texas Integrated Eligibility Redesign System (TIERS);
  • a valid medical necessity (MN), as shown in the Service Authorization System (SAS) or Long Term Care (LTC) online portal or by other acceptable MN documentation;
  • an individual service plan (ISP) that is adequate to meet the applicant's needs, as confirmed by the signatures on Form 3671-2, Individual Service Plan, and other applicable ISP attachments; and
  • the ISP is cost effective and within the ISP cost limit.

The initial ISP is developed prior to the enrollment of the applicant into the waiver program. It identifies services to be provided after approval and enrollment of the applicant. Other eligibility factors, such as the financial eligibility determination, may be outstanding, so it is important that the case manager not communicate to providers the impression that services delivered prior to the applicant being approved by the Department of Aging and Disability Services (DADS) will be guaranteed DADS payment.

The case manager must coordinate enrollment with Medicaid for the Elderly and People with Disabilities (MEPD) staff when the applicant's Medicaid eligibility is determined by MEPD. After the case manager determines the applicant meets all other eligibility requirements, the case manager notifies MEPD staff:

  • the applicant meets medical necessity;
  • an ISP has been developed;
  • the individual has chosen Community Based Alternatives (CBA) services rather than nursing facility services; and
  • there is a service begin date no later than 30 days from CBA eligibility certification.

This notification is made through the Eligibility Data Exchange and Notification (EDEN) system. The case manager must obtain information from MEPD staff about the status of the Medicaid determination. When the Medicaid eligibility determination is ready for completion, the case manager and the MEPD staff coordinate to establish the Medical Effective Date (MED) for Medicaid coverage. Once MEPD has processed the financial application and is ready to establish the MED, MEPD sends an MEPD to DADS Communication Tool to the Outlook resource mailbox requesting a start date for waiver services from the case manager. The case manager or regional designee reviews the MEPD to DADS Communication Tool for this notification. The case manager emails the MEPD specialist indicating the date CBA services will begin. The MEPD specialist will set the MED to be the first day of the month in which waiver services begin if the individual is not currently on Community Attendant Services (CAS). The case manager must check TIERS to determine if the financial documentation has been made so the eligibility determination can be made within the 30-day certification time frame. The MED cannot be after the CBA eligibility date. CBA services must begin within 30 calendar days of the date of the determination that the applicant is eligible for the CBA program. The case manager should inform the applicant, his representative, or both, and potential providers of any delay in CBA enrollment due to the Medicaid eligibility determination. The case manager should refer the applicant to other services, including non-waiver services, as necessary to meet the applicant's needs.

If the applicant is receiving CAS, the case manager submits information to MEPD on Form H1746-A, MEPD Referral Cover Sheet, to request a program transfer from CAS to CBA and explains in the additional comments section of Form H1746-A the applicant currently receives CAS and is transferring to CBA. The case manager must also request in the additional comments section of Form H1746-A to end CAS financial eligibility the day before CBA services are to begin. The MED will be the same as the ISP begin date.

If the applicant is already on a full Medicaid program, such as Supplemental Security Income (SSI) or Medical Assistance Only (MAO) Type Programs (TP) 03, 12, 18 or 22, the MED was established when eligibility was granted for that program.

The MED established for a "new" application cannot precede the MN effective date or the date the ISP is signed by the applicant.

3432.1  Procedures for Money Follows the Person Option Applicants

Revision 12-3; Effective September 4, 2012

The case manager must verify the applicant has been approved for Medicaid through the Texas Integrated Eligibility Redesign System (TIERS) or verification through the Service Authorization screen in the Service Authorization System (SAS) that Medicaid payments have been authorized to the nursing facility (Group Code 1, 8 or 10). After the case manager has verified Medicaid eligibility and all other Community Based Alternatives (CBA) eligibility criteria have been met, the applicant must be notified in writing on Form 2065-B, Notification of Waiver Services, that CBA services have been certified. Once the applicant has been notified in writing, the applicant may consider transferring from the nursing facility. An applicant is not considered for the Money Follows the Person option until all CBA eligibility requirements (including enrollment for Medicaid in the nursing facility) have been met and the applicant has been certified for CBA services.

3432.2  Procedures for Interest List Individuals Referred for Financial Eligibility

Revision 12-3; Effective September 4, 2012

In anticipation of slot availability, the case manager makes referrals to Medicaid for the Elderly and People with Disabilities (MEPD) to begin the financial determination process for the Community Based Alternatives (CBA) program.

This course of action allows the Department of Aging and Disability Services to minimize the amount of time applicants must wait for service delivery. This process applies only to applicants who do not have current Medicaid eligibility or an active Community Attendant Services (CAS) eligibility through MEPD. For individuals receiving CAS, the case manager follows procedures in Appendix XVII, Medicaid Program Actions, for requesting a program transfer.

If MEPD completes the financial determination for CBA before a slot for services becomes available, the case manager and MEPD take the following actions:

  1. On the 30th day from the date the case manager receives the completed pre-enrollment assessment packet from the Home and Community Support Services Agency, the case manager sends Form H1746-A, MEPD Referral Cover Sheet, to MEPD to:
    1. inform MEPD a CBA service slot is still unavailable; and
    2. ask MEPD to place the case on delay of certification if CBA has not been certified by the MEPD deadline for processing an application.

    This allows the application to remain open for an additional 90 calendar days.
  2. Once the case manager is able to authorize services, staff notify MEPD by sending Form H1746-A to MEPD. MEPD returns provides the notification of the certification effective date through the MEPD to DADS Communication Tool.

If MEPD staff do not receive notification from DADS that CBA services are ready to be authorized before the end of the delay in certification period, MEPD will deny the application. If MEPD staff deny the application, the case manager must begin the entire enrollment process again.

If at any point in the process the applicant withdraws his request for services, the case manager must notify MEPD immediately so MEPD can terminate the Medicaid application by completing and sending Form H1746-A to the Midland Data Processing Center. MEPD continues to notify DADS of eligibility status using established MEPD – DADS processes.

3432.3  Procedures for Texas Integrated Eligibility Redesign System (TIERS) Applicants

Revision 12-3; Effective September 4, 2012

Referral of Applicants

The Department of Aging and Disability Services (DADS) case manager will use Form H1746-A, MEPD Referral Cover Sheet, and Form H1746-B, Batch Cover Sheet, to send the Medicaid application to Medicaid for the Elderly and People with Disabilities (MEPD). Form H1746-A, a referral form, will cover Form H1200, Application for Assistance – Your Texas Benefits, sent to the Midland Document Processing Center (DPC). MEPD staff may contact the DADS staff member listed on Form H1746-A to obtain information needed to determine financial eligibility. Form H1746-B must be attached to the top of each batch containing more than one Form H1746-A being shipped to the DPC.

When requesting a program transfer, consult Appendix XVII, Medicaid Program Actions, to determine what information must be transmitted along with Form H1746-A. The gaining case manager will send Form H1746-A to DPC with the end date of the losing program and the begin date of the gaining program documented in the Comments section.

Form H1746-A should also be sent to DPC when services are denied. Include the end date, service group, service code and termination reason in the Comments section.

Information related to functional eligibility is communicated through the Eligibility Data Exchange and Notification (EDEN) system.

Coordinating Functional Information with Medicaid Eligibility

The EDEN system is a web-based program that allows DADS and the Health and Human Services Commission to exchange information on TIERS-related waiver cases. The EDEN system is accessed through the Health and Human Services (HHS) Enterprise Portal and DADS Work Center. Refer to EDEN Permissions below.

Once all functional eligibility requirements for the Community Based Alternatives (CBA) program (an approved individual service plan (ISP) and approved medical necessity) are ready, the information must be transmitted to MEPD using the following steps:

  1. Once in EDEN, right click on Client Number.
  2. Select Initial Functional Assessment.
  3. Enter the Client Number and click on Load Client.
  4. View the Initial Functional Assessment Screen.

The Initial Functional Assessment Screen is used to provide data to MEPD on initial applications. The following information will be provided to MEPD:

  1. Approved ISP
  2. Approved Medical Necessity (MN)

On the Initial Functional Assessment Screen, some of the individual’s personal information will be populated. Continue with the following steps:

  1. In the Begin Date (MM/DD/YY) box, enter the date the case manager has an accepted ISP and valid MN.
  2. In the Service Group box, select 3-CBA from the drop down menu. The Service Code and the Functional boxes are not applicable.
  3. In the ISP/IPC box, select Approved or Denied from the drop down menu.
  4. In the Medical Necessity/LOC box, select Approved or Denied from the drop down menu.
  5. Check the Information Complete box and click on Send to TIERS. A message will appear on the screen if the send is successful.
  6. Print a copy of this screen for the case record.

Receiving Notifications from MEPD

The MEPD to DADS Communication Tool is an automated system that sends notification from MEPD staff when financial eligibility or ineligibility is determined or when MEPD staff need DADS assistance in obtaining pending information. The notifications that are submitted through the MEPD to DADS Communication Tool arrive in a DADS regional-specific resource mailbox.

EDEN Permissions

EDEN is accessed through the HHS Enterprise Portal and DADS Work Center at https://hhsportal.hhs.state.tx.us/wps/portal. New users must sign up for an account.

3433  Coordination of ISP with HCSSA, AFC and AL/RC Providers

Revision 08-10; Effective September 1, 2008

If a Community Based Alternatives (CBA) provider indicates the applicant/consumer cannot be adequately served by the provider, the case manager must send the individual service plan (ISP) and related information to a second CBA provider of the same category (Home and Community Support Services Agency (HCSSA), Assisted Living/Residential Care (AL/RC) or Adult Foster Care (AFC) provider). The second HCSSA cannot bill for a pre-enrollment assessment unless authorized by the case manager, but may conduct a home visit and complete its own home health assessment of the applicant/consumer.

If changes are made to the ISP signed by the applicant/consumer, the case manager must obtain the applicant's/consumer's signature on the revised plan or document the applicant's/consumer's verbal agreement to the changes on the ISP.

3433.1  Restrictions Regarding HCSSA Attendants

Revision 13-2; Effective June 3, 2013

An applicant’s, individual’s or Home and Community Support Services Agency's (HCSSA's) choice of an attendant is not limited unless the:

  • case manager has specified that a particular person should not be employed by the HCSSA; or
  • supervisor, case manager, or regional nurse has determined that the attendant is not providing adequate care.

The case manager must inform the HCSSA that a particular person may not be employed as the attendant if that person:

  • has abused, neglected, or exploited the applicant, individual or others; or
  • is the spouse of the applicant or individual.

The case manager communicates restrictions regarding the employment of a particular person as the attendant for an applicant or individual to the HCSSA. The case manager should also identify the unpaid caregiver and indicate that this person may not deliver the protective supervision as a Personal Assistance Services paid attendant of the HCSSA. This is included on Form 2067, Case Information, sent to the HCSSA at the time the ISP is sent for referral acceptance or with the written authorization to the HCSSA. The suggestions or recommendations of the individual to hire a particular person, including the caregiver, may be included on Form 2067, which is sent at the time of the coordination of the ISP with the HCSSA, or at the time of the written referral for the HCSSA, with the specific notation that this person was suggested by the individual. The individual should be encouraged to discuss his request that a particular person be hired as the attendant with HCSSA staff.

3434  Establishment of the Eligibility Date and Effective Date on Form 2065-B

Revision 13-2; Effective June 3, 2013

The case manager authorizes program eligibility and services by completing Form 2065-B, Notification of Waiver Services, and registering the individual service plan (ISP) in the Service Authorization System (SAS).

Three important dates must be established for an initial enrollment:

  • eligibility date;
  • effective date; and
  • Medicaid medical effective date (MED) determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff.

The eligibility date and effective date are entered on Form 2065-B.

Eligibility Date

The eligibility date is used only for the initial enrollment. The case manager signs Form 2065-B confirming all eligibility criteria is met, valid and effective, including:

  • medical necessity (MN); and
  • ISP acceptance signed by the applicant and all parties.

The case manager enters the eligibility date on Form 2065-B and signs and mails the form on the same day.

Effective Date

The effective date is the first date Community Based Alternatives (CBA) services on the ISP are authorized. It is either the:

  • Form 2065-B date (top right corner); or
  • negotiated date determined by the case manager and CBA Home and Community Support Services Agency (HCSSA).

Start dates must be negotiated:

  • when an applicant is on another program or service and the transfer must be coordinated;
  • if an applicant is leaving a nursing facility under Money Follows the Person (MFP) option; or
  • if the applicant will move to an Adult Foster Care (AFC) home or Assisted Living (AL) facility on a designated date.

The effective date on Form 2065-B, Provider Authorization block effective date, and effective date on Form 3671-1, Individual Service Plan, must be the same date. The effective date can be the same as the eligibility date, but the effective date cannot be before the eligibility date.

For an MFP applicant, the eligibility date cannot be after the effective date. When the case manager gives the MFP applicant verbal or written approval of eligibility, Form 2065-B providing the eligibility date must be signed and mailed or given to the applicant the same date. The applicant's nursing facility discharge date may not be known at the time Form 2065-B is sent notifying the applicant of eligibility, and a second Form 2065-B with the effective date must be mailed. The ISP effective date cannot be before the applicant's signature date on Form 3671-2, Individual Service Plan, or the effective date of the MN or the Medicaid MED.

For an applicant transferring from the Medically Dependent Children Program or Texas Health Steps Comprehensive Care Program, the eligibility and effective date cannot be before the applicant’s 21st birthday.

Medical Effective Date

The MED is important for an initial enrollment in determining the eligibility and effective dates. It is not entered on Form 2065-B.

The MED cannot be after the case manager's signature date on Form 2065-B, the eligibility date or the effective date.

At the annual reassessment, the eligibility date is not required on Form 2065-B. The case manager determines eligibility, signs Form 2065-B and enters the effective date, which is the first day after the previous ISP expiration date.

If denying the application or terminating CBA at the annual reassessment, Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is signed and mailed or given to the applicant or individual on the same date.

Department of Aging and Disability Services staff must send each applicant Form 0401, HIPAA – Privacy Notice, upon enrollment.

3434.1  Notification of Eligibility for CBA Applicants Using Money Follows the Person Option

Revision 08-10; Effective September 1, 2008

To meet Money Follows the Person (MFP) option requirements, the date of Community Based Alternatives (CBA) eligibility and the date of release from the nursing facility (NF) must be clearly established and documented in the case record.

Notification of CBA eligibility must be in writing on Form 2065-B, Notification of Waiver Services. If the applicant/consumer is given verbal approval, the case manager must sign Form 2065-B on the same day and provide a copy to the applicant/consumer. If the consumer leaves the NF before receipt of Form 2065-B confirming eligibility, the case manager must send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, notifying the applicant of ineligibility for CBA services and placement back on the CBA Community Services Interest List (CSIL).

In most cases, discharge plans will be in place and a date negotiated with the Home and Community Support Services Agency (HCSSA) for the start of care. In rare extenuating circumstances, the case manager may need to notify the consumer of the eligibility determination before plans for returning to the community are finalized. In this situation, the case manager sends Form 2065-B notifying the consumer of eligibility and later sends a second Form 2065-B to the consumer and the providers with the effective date of CBA services.

The case manager must verify and document the applicant's/consumer's release date from the NF. This may be done with a copy of Form 3619, Medicare/SNF Patient Transaction Notice, or Form 3618, Resident Transaction Notice, from the MEPD specialist or a documented telephone call to the NF verifying the discharge date from the facility.

The enrollment record in the Service Authorization System (SAS) must reflect code "12 Rider 28 (Fac to Comm)" in the Service Group.

For MFP certified applicants, the CSIL is updated when the SAS wizard is completed to register the initial individual service plan. For denied MFP applicants, the CSIL is updated within five business days of the decision to deny the application.

Correct procedures and coding are extremely important for the MFP option to be implemented and the NF funding transferred to CBA appropriately. Case managers must ensure that all requirements are met before designating a case as an MFP option and that data entry is completed timely and correctly for proper tracking of these cases.

3434.2  Pending Money Follows the Person Option Applications Due to Delay in Nursing Facility Discharge

Revision 08-10; Effective September 1, 2008

In keeping with the Promoting Independence initiative, case managers assist the nursing facility (NF) applicant/consumer who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, the case manager has the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A 120 calendar day time frame is the guideline for use in determining pending or denying requests for services.

Examples:

  • A Community Based Alternatives (CBA) applicant has a definite date of discharge within 120 calendar days from the date services were requested. Pend the application until the date of discharge and coordinate the transfer to the community.
  • A CBA applicant is in the process of making living arrangements that will allow him to leave the NF within 120 calendar days from the date services were requested. Pend the application.

Case managers use their judgment and work with applicants who have arrangements pending, but are not finalized. If the applicant has an estimated date of discharge that may or may not go beyond the 120 calendar day period, the case manager should keep the request for services open.

CBA applicants who have not made any living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community should be denied. Deny the request for services by sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, within two Department of Aging and Disability Services business days after the end of the 120 calendar day pending period.

If an assisted living applicant meets eligibility criteria, but is on a waiting list for a contracted CBA assisted living facility, the case manager will verify the applicant is on the list and may leave the service request pending until the slot opens.

Section 48.6003 of the Texas Administrative Code, which is found in Section 3211.1, Basic Eligibility Criteria, should be used as the rule reference on Form 2065-C. The specific eligibility criteria that the applicant/consumer does not meet must be indicated. The applicant is advised in writing on Form 2065-C of his right to reapply for services under the Money Follows the Person option. The applicant also is advised the provision requires that an individual meets all eligibility criteria while residing in a Texas NF.

3435  Provider Authorization and Initiation of Services

Revision 11-1; Effective March 1, 2011

3435.1  Verbal Negotiation with CBA Providers Regarding Service Initiation Date for Applicants

Revision 12-2; Effective June 1, 2012

§48.6092 — Initiation of Community Based Alternatives (CBA) Home and Community Support Services Agency.

In order to initiate CBA HCSS services, the provider agency must:

(1)
negotiate a start date with the Department of Aging and Disability (DADS) case manager for:
(A)
priority status applicants; or
(B)
routine status applicants needing a specific start date as determined by the (DADS) case manager;
(2)
initiate waiver services:
(A)
on or before any negotiated start date;
(B)
within seven calendar days from the effective date on the DADS Notification of CBA Services form for routine status applicants, if no earlier start date has been negotiated;
(C)
within seven DADS workdays of the initiation of personal assistance services (PAS) and send a Case Information form to the case manager with the:
(i)
service initiation date; and
(ii)
name of the attendant performing PAS; and
(3)
for non-delegated PAS provided under the PAS licensure category and in accordance with §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services), ensure that the HCSSA provides the training specified in subparagraphs (A) — (C) of this paragraph to the attendant in the participant's home, on or before the date of initiation of PAS:
(A)
tasks to be performed;
(B)
work schedule; and
(C)
emergency procedures.
(4)
for PAS provided under the home health licensure category and in accordance with §97.401 of this title (relating to Standards Specific to Licensed Home Health Services), ensure that the HCSSA licensed vocational nurse or registered nurse (RN) provides the training specified in subparagraphs (A) - (C) of this paragraph to the attendant in the participant's home, on or before the date of initiation of PAS:
(A)
information about the participant's health condition and how it may affect the performance of tasks;
(B)
tasks to be performed, and safety emergency procedures; and
(C)
symptoms or changes in the participant's health status about which the unlicensed person should notify either the RN or the attending physician.

For priority applicants determined to be eligible for Community Based Alternatives (CBA) services, the case manager must contact the providers to negotiate a service initiation date and authorize services no later than the next working day after the case manager determines the applicant is eligible for CBA services. Services must begin by the negotiated date that can be no later than seven calendar days after this verbal authorization.

There are other situations when the case manager may negotiate a service initiation date with a provider. Examples include, but are not limited to, situations when:

  • the applicant may not plan on leaving a hospital or nursing facility until a particular date and services need to start on that same day;
  • the termination of Primary Home Care services and the initiation of CBA services must be coordinated to assure there is no gap in services; or
  • the applicant wants to move into an Adult Foster Care or Assisted Living setting on a particular date.

If there is a compelling reason that CBA services begin on a specific date, the service initiation date must be negotiated with the provider and documented on Form 2067, Case Information.

3435.2  Written Authorization to HCSSA

Revision 12-2; Effective June 1, 2012

No later than two DADS business days after determining that the applicant is eligible for CBA services, the case manager must fax to the Home and Community Support Services Agency (HCSSA) a copy of:

  • Form 3671-2, Individual Service Plan; and
  • Form 2065-B, Notification of Waiver Services, which authorizes the HCSSA to deliver the services identified on the ISP.

If the case manager has negotiated a service initiation date with the provider, he must also fax Form 2067, Case Information, documenting the service initiation date negotiated with the provider.

3435.3  Written Authorization to ERS, HDM, AFC and AL/RC Providers

Revision 11-1; Effective March 1, 2011

No later than two DADS business days after determining that the applicant is eligible for Community Based Alternatives services, the case manager must mail to the Emergency Response Services (ERS), Home-Delivered Meals (HDM), Adult Foster Care (AFC) or Assisted Living/Residential Care (AL/RC) provider a copy of:

  • Form 3671-2, Individual Service Plan; and
  • Form 2065-B, Notification of Waiver Services, which authorizes the provider(s) to deliver the services identified on the individual service plan (ISP) and notifies the AFC or AL/RC provider to collect the copayment and room and board amounts indicated.

If the case manager has negotiated a service initiation date with the ERS, AFC or AL/RC provider, he must also send Form 2067, Case Information, documenting the service initiation date negotiated with the provider.

The case manager must send Form 2067 along with the above forms to the HDM provider.

Note: The case manager must also send the ERS provider a copy of Form 3671-1, Individual Service Plan and Form 8598, Non-Waiver Services, at this time.

3435.4  Delay in Initiation of Authorized Services by HCSSA

Revision 02-0; Effective April 4, 2002

§48.6094 — Delay of Community Based Alternatives (CBA) Home and Community Support Services (HCSS) Initiation.

(a)
The HCSS agency must orally notify the case manager by the next Texas Department of Human Services (DHS) workday if services cannot be initiated:
(1)
within seven calendar days of the effective date entered on DHS's Notification of CBA Services form, for cases in which a service initiation date was not negotiated; or
(2)
by the negotiated service initiation date documented on DHS's Case Information form sent to the HCSS agency by the case manager as part of the written authorization.
(b)
The HCSS agency must submit DHS's Case Information form to the case manager confirming verbal agreements by the next DHS workday of having negotiated a new service initiation date with the case manager.

After the verbal notification, the case manager determines if it is appropriate to negotiate a new service initiation date with the HCSSA or cancel the authorization and authorize another agency to provide services. The case manager should contact the participant to determine if negotiating a new initiation date or authorizing a new agency will best meet the needs of the participant. The case manager may not negotiate for a new service initiation date that is more than 30 days after waiver eligibility was established because of the requirement that waiver services be received by the participant within 30 days after waiver eligibility is established. If a new service initiation date is negotiated, the HCSSA will send Form 2067 to the case manager by the next DADS workday to confirm any verbal agreements for service delivery negotiated with the case manager. If a different agency is to be authorized, the case manager must:

  • fax the ISP and attachments to the new provider selected by the participant for referral acceptance;
  • negotiate the service initiation date with the new provider, if appropriate to meet the needs of the participant;
  • prepare and send Form 2065-B, Notification of Waiver Services, to notify
    • the terminated provider of the termination of the authorization,
    • the "new" provider of the effective date of the authorization,
    • the participant of the new provider; and
  • prepare and submit Form 3671-1, to register the provider change.

If the reason for the delay in service initiation is that the participant is not home so the HCSSA cannot initiate services as authorized, the HCSSA must initiate waiver services as soon as the participant returns home. The HCSSA notifies the case manager of the delay, but the case manager does not negotiate a new date nor authorize a new provider when the delay has been caused by the participant's absence.

3436  Coordination of Termination of CCAD Services Upon Community Based Alternatives (CBA) Enrollment

Revision 13-1; Effective March 1, 2013

The Community Based Alternatives (CBA) case manager must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services, such as Primary Home Care (PHC) and Family Care (FC) with the CCAD case manager, so that the CBA applicant does not experience a break in services and does not receive concurrent services through another waiver or CCAD service. The same is true when CBA program eligibility is terminated. The CBA applicant, if eligible to receive CCAD services, should not experience a break in services and should not receive concurrent services. For the individual receiving CCAD Residential Care (RC) or Adult Foster Care (AFC) transferring into CBA Assisted Living (AL) or AFC, the day of the transfer should be planned for a future date which is mutually agreeable to the CBA AL or AFC provider and the Home and Community Support Services Agency (HCSSA). In such situations, the case manager should negotiate the date of service initiation and enter this date on Form 2067, Case Information, to send to the providers.

CCAD services are terminated no later than the same day CBA services start. An individual may receive PHC in the morning and transfer to a CBA AL facility in the afternoon. An individual may not receive PHC and CBA HCSSA services on the same day. A CBA applicant may choose to continue to receive Day Activity and Health Services (DAHS) as a non-waiver service.

The adverse action advance notice requirement does not apply to an individual who transfers from CCAD to CBA. The case manager must consider the date the applicant is determined eligible for CBA and must assure that CBA services begin within 30 calendar days after waiver eligibility is established.

Any person, including an individual who receives Title XX-funded DAHS, who is determined eligible for CBA, is eligible for Title XIX DAHS. If an individual who receives Title XX DAHS becomes eligible for CBA, the CCAD case manager must transfer the individual to Title XIX DAHS. The CCAD case manager completes and submits Form 2101, Authorization for Community Care Services, following the instructions for authorizing Title XIX DAHS. This notifies the provider to bill correctly in the Service Authorization System (SAS).

3436.1  Continuation of Community Attendant Services Pending Initiation of Community Based Alternatives Services

Revision 10-1; Effective March 11, 2010

The Medicaid eligibility status changes from 1929(b) to full Medicaid coverage when a Community Based Alternatives (CBA) applicant receiving attendant care through Community Attendant Services (CAS) under 1929(b) eligibility status becomes eligible for CBA services. The applicant is then entitled to all Medicaid services, including Primary Home Care (PHC) under Fund Type 19 (non-1929(b) eligibility status). Since the date the applicant is eligible for CBA may not be the date CBA services start, the applicant can continue to receive attendant care services until CBA services start. To prevent billing rejections, the Community Care for Aged and Disabled case manager must complete Form 2101, Authorization for Community Care Services, to notify the provider the billing code will change from CAS to full Medicaid PHC attendant services. The Service Authorization System will not allow the provider to be paid if billing under the incorrect billing code/fund type.

3436.2  Transferring an Individual Who Receives QMB or SLMB to Community Based Alternatives

Revision 12-4; Effective December 3, 2012

When transferring an individual who receives Qualified Medicare Beneficiary (QMB) or Specified Low-income Medicare Beneficiary (SLMB) recipients to Community Based Alternatives (CBA), the Medicaid for the Elderly and People with Disabilities (MEPD) staff must change the Type Program (TP) 23 or 24 on Form H1000-B, Record of Case Action, to TP 14/Base Plan (BP) 10. When Form H1000-B is processed, it is changed to TP 14/BP 13. The status in group (SIG) codes "Q" for QMB and "B" for SLMB are entered in Item 40 on Form H1000-B. The medical effective date (MED) will be available in the Texas Integrated Eligibility Redesign System (TIERS). The MEPD specialist must submit Form H1270, Data Integrity SAVERR Notification, to correct the MED to the date of the financial certification for the CBA enrollment.

Note: Due to a large amount of force change requests, Data Control may run a backlog completing the force change to the MED. When the "From" date on the individual service plan (ISP) effective period on the Service Authorization System (SAS) screen is different from the effective date entered on Form 2065-B, Notification of Waiver Services, the case manager must request a force change of the ISP effective period to the appropriate time period to coincide with Form 2065-B notification and the MED change request. Changes to both the MED and ISP effective period are necessary to avoid provider billing rejections. Refer to Section 3440.2, Force Change Requests.

3440  Service Authorization System (SAS) Online Overview

Revision 13-1; Effective March 1, 2013

SAS is the primary repository of service authorization information for an individual enrolled in a Department of Aging and Disability Services (DADS) program. SAS accepts and maintains information relevant to services authorized for the individual. Authorized services must be registered in SAS before the payment for services is provided to an individual.

The SAS online application is designed using a hierarchical tree structure of directories, folders and records. The SAS online application directories contain records that are used to perform the SAS functions and to store information. The history of each record completed for a service authorization is stored in the folders located on the tree directory.

SAS is designed using an online process model. The model is used with SAS business rules; both general rules and rules specific to programs utilizing SAS direct entry capabilities. SAS online has a force capability that can be used to override business rules to allow certain procedures to be completed.

Detailed instructions for using the SAS wizards are contained in Section 9000, Service Authorization System Help File.

Requirement to Use SAS Wizards

Regional management must ensure the use of SAS wizards to:

  • enhance the accuracy of eligibility determinations, service plans, service authorizations and data;
  • improve documentation of an individual's satisfaction;
  • provide a database for provider monitoring and case reading sample selection; and
  • ensure compliance with federal regulations for program delivery.

The SAS wizards must be used to document the following case actions:

  • service authorizations, including initials, annual reassessments and changes to the individual service plan (ISP); and
  • terminations.

The SAS Monitoring wizard must be used to document all required monitoring contacts, including the 30-day, 60-day, 90-day, six-month and annual.

At regional discretion, the SAS monitoring wizard may be used to document other contacts with the individual, including requests for changes in the ISP or complaints regarding service delivery. The SAS monitoring wizard may be used to document:

  • complaints received from an individual regarding his ISP;
  • provider changes;
  • calls received from an individual that require case manager action (for example, requests for ISP changes);
  • Day Activity and Health Services provider changes; and
  • other scheduled monitoring or follow-up contacts, as appropriate.

See Section 3716.1, Service Authorization System (SAS) Monitoring Documentation, for additional information about documentation of the above actions.

3440.1  Registration of the Individual Service Plan (ISP)

Revision 13-1; Effective March 1, 2013

The case manager must register ISP information in the Service Authorization System (SAS) by appropriate time frames and then ensure accuracy of the information submitted.

STANDARD.  The case manager must verify the information in SAS matches Form 3671-1, Individual Service Plan, submitted for Community Based Alternatives (CBA) actions. If the SAS information does not match, the case manager must submit an ISP change to correct the mistake and ensure that the ISP is accurately registered within 30 calendar days from the effective date on Form 3671-1. The case manager should research the error message in SAS, make appropriate corrections and resubmit the ISP for processing.

SAS Wizard Time Frames

The CBA SAS wizard must be completed at the same time Form 2065-B, Notification of Waiver Services, is completed authorizing an initial enrollment, annual reassessment or ISP change, or when Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is completed for termination of CBA program eligibility. When the action cannot be completed using the CBA SAS wizard at the same time Form 2065-B or 2065-C is completed, the delay must be documented in the case record. There is an exception to this for an initial enrollment following Money Follows the Person (MFP) procedures.

Completion of Form 2065-B or Form 2065-C and entry into the SAS wizard must meet the following time frames that are concurrent with the time frames for completing the specific case actions.

  • Non-MFP Initial Enrollments — Form 2065-B and the SAS wizard must be completed within the 30-calendar day time frame for an initial enrollment of an application or within 14 calendar days of receipt of pending information if the application is pended.
  • Annual Reassessments — Form 2065-B and the SAS wizard must be completed by the end of the ISP.
  • Changes — Form 2065-B and the SAS wizard must be completed within the 14-calendar day time frame for completing the change.

MFP Initial Enrollments

The case manager notifies the MFP applicant of CBA eligibility and the negotiated nursing facility (NF) discharge date, which is the effective date of CBA services on Form 2065-B. When an MFP applicant is unsure of his NF discharge date, the case manager completes and sends Form 2065-B to notify the MFP applicant of CBA eligibility. At a later date, the case manager negotiates the NF discharge date and sends a second Form 2065-B providing the CBA effective date. The case manager is not required to enter the CBA authorization into SAS the same date the initial Form 2065-B is sent to the MFP applicant if Form 2065-B does not include an effective date for CBA.

Within 14 calendar days of the negotiated NF discharge date as established on Form 2065-B as the effective date, the case manager must verify the NF discharge date and the SAS wizard must be completed.

If the SAS wizard cannot be completed at the same time as Form 2065-B or Form 2065-C, the delay must be documented in the case record. The case manager must then register the ISP in SAS within the time frame for the action being taken. If the SAS data entry cannot be completed within the initial time frame, the case manager must document the delay and register the ISP in SAS as soon as the system will allow for entry. The registration of the ISP in SAS must be completed accurately within 30 calendar days of the ISP effective date to meet the accuracy standard above. All delays must be documented in the case record.

Note: The SAS wizard action generates the ISP required to be mailed to the individual and the CBA providers. The CBA provider cannot be paid until the ISP is registered in SAS. Registering the ISP in SAS is a requirement in order to meet the CBA processing time frames for an initial enrollment, annual reassessment and ISP change. See Section 3440, Service Authorization System (SAS) Online Overview, for additional SAS requirements.

The application date on the SAS screen is the date of:

  • receipt of Form H1200, Application for Assistance – Your Texas Benefits; or
  • the initial home visit if Form H1200 is not applicable.

3440.1.1  Nursing Facility Consumers Transitioning to the Community

Revision 10-3; Effective June 1, 2010

Closure of nursing facility (NF) records may be necessary when registering an individual service plan (ISP) in the Service Authorization System (SAS) for an applicant transitioning from an NF to the community.

The case manager must call the Provider Claims Services hotline to close the NF authorization. The hotline number is: 512-438-2200. Select Option 1.

The case manager should call the hotline directly to request the nursing facility record in SAS be closed so Community Based Alternatives (CBA) services can be authorized. The case manager must confirm the consumer has been discharged from the NF and CBA services are negotiated to begin on or after the date of discharge.

When calling the hotline, the case manager must identify himself as a Department of Aging and Disability Services (DADS) employee and report that the consumer has discharged from the NF and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SAS, including the Service Code 60. The case manager documents the contact in the case record.

3440.2  Force Change Requests

Revision 11-1; Effective March 1, 2011

Certain capabilities to modify the Community Based Alternatives (CBA) database and individual service plan (ISP) registrations by force changes will be retained by designated regional staff.

Follow regional procedures for submitting force changes. The case manager should submit force change requests only after obtaining approvals required in the local unit or region.

Refer to the Service Authorization System (SAS) Help files for more information on force changes.

3450  Case Record Contents

Revision 13-2; Effective June 3, 2013

The case record for an applicant or individual maintained by the case manager should contain all assessment and eligibility information.

STANDARD.  The case record will be considered deficient if it does not contain the following information, at a minimum:

  • A copy or original Form 2110, Community Care Intake, Form 2059, Summary of Client's Need for Service, or other intake forms designated by regional procedures.
  • A copy or original Form H1200, Application for Assistance – Your Texas Benefits, if applicable.
  • Copies of Form H1746-A, MEPD Referral Cover Sheet, if applicable.
  • Copies of Form 2067, Case Information.
  • Copies of Form 1547, Regional Nurse/Dental Consultant Request Worksheet.
  • A copy or original Form 3676, CBA Pre-Enrollment Home Health Assessment Authorization.
  • Medical necessity (MN) documentation:
    • A copy of the Medical Necessity and Level of Care (MN/LOC) Assessment submitted to Texas Medicaid & Healthcare Partnership (TMHP) by the Home and Community Support Services Agency (HCSSA) (or signed by a Department of Aging and Disability Services (DADS) nurse) with a copy of a TMHP status report;
    • documentation of the Long Term Care Online Portal or Service Authorization System (SAS) MN record; or
    • the document locator number (DLN), resource utilization group (RUG) value and whether the MN determination was approved or denied.
  • A verification of informed choice documenting that the applicant or individual chooses to participate in the Community Based Alternatives (CBA) program over nursing facility placement. This is documented on Form 3671-2, Individual Service Plan.
  • Documentation of financial eligibility information obtained through the Texas Integrated Eligibility Redesign System (TIERS).
  • Documentation of eligibility for Supplemental Security Income (SSI), as determined by the Social Security Administration (SSA), with a copy of one of the following:
    • Social Security and Medicaid numbers for an individual who receives SSI; (may be obtained from TIERS);
    • SSA Form 8165, Notice of Decision for Payment, which indicates the
      • amount of the award,
      • retroactive and monthly payment amounts,
      • reason for eligibility,
      • basis for payment such as rent and other expenses, and
      • date of eligibility (usually date of application) for an applicant for SSI benefits; or
    • other SSI eligibility notification forms (many formats are used).
  • The completed individual service plan (ISP) for waiver and non-waiver services (Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, and Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, as applicable) developed or approved by the interdisciplinary team (IDT), along with meeting notes or other documentation regarding the ISP.
  • Documentation of attempts to correct ISP registrations.
  • Documentation of the applicant's or individual's choice of providers.
  • Service reviews and monitoring reports.
  • Assessment of the applicant's or individual's current medical, mental, social, financial, and functional situation and need for services.
  • Names, relationship and contact information on any person providing assistance, available to help, or involved with the applicant or individual.
  • Names and contact information for any agencies or organizations providing, or available to provide, services to the applicant or individual, including private insurance resources.
  • Documentation that validates that third-party resources were utilized, when available, to meet the applicant's or individual's needs.
  • Information on adaptive aids or minor home modifications the applicant or individual is using or needs.
  • Other formal or informal assessments completed by other persons or organizations.
  • Records or summaries of interviews or other contacts with the applicant, individual or his responsible party, including interest list contacts.
  • Copies of Form 2065-B, Notification of Waiver Services, and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services.
  • Case narratives.

Regional staff keep all CBA case records even if the applicant does not meet the eligibility criteria or does not choose the CBA program. The case manager must maintain a separate case record for each individual receiving waiver services. A case record must be maintained for the five-year time period following the termination of services required for medical records.

Wire Third Party Query (WTPY) and State On Line Query (SOLQ)

SSA requires safeguarding information contained on WTPY and SOLQ. Staff must not print or file WTPY or SOLQ printouts in the case record. Staff must document in the case record the:

  • date the information from WTPY, SOLQ, or both, is viewed;
  • income verified; and
  • source (WTPY, SOLQ, or both).

If a WTPY or SOLQ report must be printed, the document must not be filed in the case record or sent to the state vendor for imaging. The document must be stored in a central locked filing cabinet, only accessible by Health and Human Services Commission or DADS authorized staff. DADS staff are advised of confidentiality, the safeguards to protect the information and the civil and criminal sanctions for non-compliance contained in federal and state law. This requirement is met when the DADS employee signs Form 4014, Computer Security Agreement.

3500  Financial Eligibility

Revision 12-4; Effective December 3, 2012

3510  Financial Eligibility Criteria

Revision 02-0; Effective April 4, 2002

§48.6007 — Financial Eligibility Criteria. To be determined financially eligible by the Texas Department of Human Services (DHS) for home and community-based services through this waiver program, an applicant must:

(1)
be eligible for supplemental security income (SSI) benefits;
(2)
have been eligible for and received SSI benefits and continue to be eligible for Medicaid as a result of protective coverage mandated by federal law; or
(3)
be eligible for SSI benefits in the community except for income and meet the special institutional income limit for Medicaid benefits in Texas without regard to spousal income.

3520  Spousal Impoverishment

Revision 02-0; Effective April 4, 2002

§48.6008 — Spousal Impoverishment Provisions.

(a)
For waiver recipients with community spouses, the income and resource eligibility requirements are determined in accordance with the spousal impoverishment provisions in §1924 of the Social Security Act and as specified in the Medicaid state plan and in §48.6007 of this title (relating to Financial Eligibility Criteria).
(b)
After the recipient is determined to be eligible for Medicaid, a determination is made by the Texas Department of Human Services regarding the amount of the recipient's income applicable to payment.

3530  Applicants with Medicaid Eligibility

Revision 12-4; Effective December 3, 2012

At the time of the initial intake, the case manager must obtain information on the applicant's Medicaid or financial status. The case manager must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from Medicaid for the Elderly and People with Disabilities (MEPD) staff or through the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for the Community Based Alternatives (CBA) Program, the applicant must be certified for a full Medicaid Type Program. Additional full Medicaid programs including Health and Human Services Commission Texas Works Medicaid programs, may qualify an applicant financially for CBA. Refer to Appendix XVII, Medicaid Program Actions, for additional information related to Medicaid Type Programs.

An applicant who receives Supplemental Security Income (SSI) is financially eligible for Medicaid and will not require a financial determination; the Social Security Administration (SSA) has already made this determination.

An applicant who receives Community Attendant Services is not automatically eligible for CBA. Form H1200, Application for Assistance – Your Texas Benefits, must be obtained and a referral for a program transfer must be sent to MEPD.

The Medicaid Buy-In (MBI) Program implemented Sept. 1, 2006, allows working Texans with disabilities to purchase health insurance through Medicaid by paying a monthly premium through the MBI Program. Due to an amendment to the CBA waiver, the MBI program is an acceptable "categorically eligible" type Medicaid for eligibility purposes for persons applying for CBA. The case manager can determine if an applicant receives MBI Medicaid by looking in the TIERS database. The MBI program is coded TP 87, ME-Medicaid Buy-In.

3540  An Applicant or Individual Without Medicaid Eligibility

Revision 13-1; Effective March 1, 2013

The Code of Federal Regulations, Section 42 CFR 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas State Plan designates the Health and Human Services Commission (HHSC) as the sole agency with the authority to make an eligibility determination for an individual who receives Medical Assistance Only (MAO).

Financial eligibility for a Community Based Alternatives (CBA) applicant or individual receiving services without an acceptable full Medicaid program is determined exclusively by Medicaid for the Elderly and People with Disabilities (MEPD) staff. Department of Aging and Disability Services staff must not:

  • screen an applicant from referral to MEPD due to apparent financial ineligibility; or
  • deny an application or terminate CBA at the annual reassessment based on financial eligibility criteria unless notified by MEPD of financial ineligibility.

If the applicant's or individual's income exceeds the Supplemental Security Income (SSI) federal benefit rate (FBR) per month, the applicant or individual applies for Medicaid through HHSC by completing Form H1200, Application for Assistance – Your Texas Benefits, for MAO. If the combined income of the applicant or individual and the spouse exceeds the SSI FBR for a couple, the applicant or individual may apply for MAO with HHSC. See Appendix XIV, Monthly Income/Resource Limits, for the current SSI FBRs.

3541  Monthly Income Below the SSI Standard Payment

Revision 10-1; Effective March 11, 2010

An applicant in the community (with no ineligible spouse) that has income less than the Supplemental Security Income (SSI) federal benefit rate (FBR) must apply for SSI through the Social Security Administration. The Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except in cases where the SSI application for disability has been pending for more than 90 days and a decision is made by HHSC Disability Determination Services staff.

If there is a question whether the applicant should apply for SSI or for Medical Assistance Only (MAO), the case manager may consult regional Medicaid for the Elderly and People with Disabilities (MEPD) staff.

3542  Coordination with the MEPD Staff

Revision 12-1; Effective March 1, 2012

The Community Based Alternatives (CBA) case manager must inform the applicant or individual receiving services and his responsible party, if applicable, that Medicaid for the Elderly and People with Disabilities (MEPD) staff will complete a financial eligibility (Medicaid) determination. The case manager should assist the applicant or individual, his responsible party, or both in completing Form H1200, Application for Assistance – Your Texas Benefits, and return the form to the MEPD staff. The case manager should encourage the applicant or individual, his responsible party, or both to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by the case manager should be shared with the MEPD specialist to prevent the applicant or individual from having to provide the information twice.

If an applicant's or individual's application for Supplemental Security Income (SSI) disability has been pending for over 90 days, the Health and Human Services Commission (HHSC) Disability Determination Services (DDS) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDS staff to make a disability determination, DDS staff require Form H3034, Disability Determination Socio-Economic Report (annotated "CBA14" in the "Type Program" box), Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, the case manager or MEPD staff will be notified. See Section 3545, Disability Determination for Individuals Under Age 65 Applying for Services, for procedures when a disability determination is required.

The applicant or individual should be told the transfer of assets policies apply to him and that transfers may make him ineligible for the waiver for the duration of the penalty period.

Applicants or individuals currently residing in nursing facilities under the Medicaid program known as "Mason Manor" (identified as Type Program 14, Base Plan 10 on the computer files with Form H3618-A, Resident Transaction Notice for Designated Vendor Numbers, sent to Provider Claims to block vendor payment) will not be eligible for CBA during the duration of the penalty period.

The case manager should also be aware that there are significant differences in the income and resource eligibility criteria for CBA and other income-eligible Community Care for Aged and Disabled services. The case manager should not advise the applicant or individual or his responsible party on the transfer of resources or other financial areas that may affect Medicaid eligibility.

3543  Applicants Residing in the Community

Revision 10-1; Effective March 11, 2010

The case manager is responsible for assisting applicants, if necessary, in completing applications for Supplemental Security Income (SSI) or Form H1200, Application for Assistance – Your Texas Benefits (for those individuals not already eligible for Medical Assistance Only (MAO) in the community).

See Section 3313, Referral for Medicaid Eligibility Determination, for additional information.

3544  Applicants Residing in Nursing Facilities

Revision 10-1; Effective March 11, 2010

If an individual is eligible for Medicaid in a nursing facility (NF) and not in Mason Manor, (a Type Program 14/Base Plan 10 NF Medicaid program that disallows NF payment), the individual will be eligible for Medicaid when discharged from the NF and entering the Community Based Alternatives (CBA) program. The individual may be eligible either as a Supplemental Security Income recipient or Medical Assistance Only recipient.

The case manager must work closely with the Medicaid for the Elderly and People with Disabilities specialist and with the individual while still in the NF to ensure the individual retains Medicaid eligibility upon discharge to the community.

3544.1  Applicants in Nursing Facilities with Monthly Income Below the SSI Standard Payment

Revision 10-1; Effective March 11, 2010

If an individual is eligible for Supplemental Security Income (SSI) (Type Program 13) or Medical Assistance Only in the nursing facility (Type Program 14) but has a monthly income below the SSI standard payment (see Appendix XIV, Monthly Income/Resource Limits), the case manager should contact and work with the local Social Security Administration (SSA) representative for pre-release planning. Individuals who plan to move into the community should apply for SSI as soon as they know their prospective discharge dates. SSA allows individuals to apply for SSI three months before their release from a facility. SSI payments will not begin until the individual has moved into the community and SSA has been notified. The advance application will increase the likelihood that the individual will receive full SSI benefits more quickly after discharge from the nursing facility.

In these cases, the individual and/or his responsible party must contact a representative from the SSA office and report all the following:

  • The individual's living arrangement. For example, determine if the individual will live alone, with roommates or other family members in Adult Foster Care or in Assisted Living/Residential Care. Support and/or maintenance provided to an individual may affect the SSI benefit amount. Support and/or maintenance includes food, clothing, shelter, and other expenses paid for an individual. An individual who is denied SSI should be referred immediately to the designated Medicaid for the Elderly and People with Disabilities (MEPD) specialist.
  • Who is or who will be the payee for the individual's check? For example, if the nursing facility is currently the representative payee, the payee should now be the individual or a relative.
  • The individual's previous eligibility for SSI.

The SSA will then determine the individual's SSI eligibility, the amount of SSI to be received in the community, who will be the payee, and where the check will be mailed. It may take more than one month before the individual is notified of the decision by SSA.

Because of SSA's policy, the decision will take longer than usual if a Community Based Alternatives program provider applies to be the individual's representative payee for the SSI or Social Security Disability Insurance benefits.

When contacting or visiting the SSA, ask for "Title XVI" when discussing an SSI check, or "Title II" if discussing a Social Security check.

Similar procedures may be necessary to report changes, change payees, or payments for other types of income, such as Veterans Administration benefits, insurance benefits or retirement funds.

3544.2  Applicants in Nursing Facilities with Monthly Income At or Above the SSI Standard Payment

Revision 13-1; Effective March 1, 2013

If an individual who resides in a nursing facility (NF) receives Medical Assistance Only (MAO) (Type Program 14) Medicaid and has monthly income at or above the Supplemental Security Income (SSI) standard payment (see Appendix XIV, Monthly Income/Resource Limits), the case manager should contact the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to inform him of the individual's discharge plans. The MEPD specialist confirms that the individual has entered the Community Based Alternatives (CBA) program when he receives:

  • notification of the development of or a copy of Form 3671-1, Individual Service Plan, from the case manager and is informed that CBA services have started or will start within 60 days of discharge from the nursing facility; or
  • Form 3618, Resident Transaction Notice, for designated vendor numbers from the NF indicating discharge of the individual from an NF.

For an individual who receives SSI, it will take longer for the address on the SSI check to change. The case manager must inform the individual or his responsible party to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System after SSA makes the change.

Whether the individual receives MAO or SSI, the case manager should, on the day of discharge, arrange with staff at the discharging NF to provide the individual or his responsible party with the Your Texas Benefits Medicaid card.

3545  Disability Determination for Applicants Under Age 65 Applying for Services

Revision 12-1; Effective March 1, 2012

Applicants under age 65 without Medicaid eligibility may need assistance to complete the forms required by the Texas Health and Human Services Commission (HHSC) for a disability determination. Applicants age 65 or over may qualify for Medicaid or Medicaid-funded programs without a disability determination.

The case manager must review an applicant's disability status by using the State On-Line Query (SOLQ) or Wire Third Party Query (WTPY) systems. An applicant has a disability established by Social Security if there is a disability onset date on the SOLQ or WTPY systems. If the applicant under age 65 does not have a Social Security established disability, the case manager must assist the applicant in completing Form H1200, Application for Assistance – Your Texas Benefits, Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact when assessing eligibility.

To determine a disability, HHSC must review evidence, signed by the applicant's treating physician (that may include medical reports), detailing the degree and history of the applicant's diagnosis. The case manager must inform the applicant when scheduling the initial face-to-face contact that the case manager will need the required evidence at the initial contact with the applicant. If the case manager schedules the face-to-face contact at least seven calendar days in advance, the case manager must send Form 2423, Request for Medical Evidence, to the applicant on the same day of the telephone contact to advise the applicant of the evidence requirement. If the case manager schedules the face-to-face contact less than seven calendar days in advance, the case manager must present Form 2423 at the face-to-face contact. The case manager must not delay the face-to-face contact for the purpose of allowing the applicant time to obtain the medical evidence.

The case manager should include the completed Form H3034, Form H3035 and any evidence obtained at the initial face-to-face contact with Form H1200 following current transmittal procedures to Medicaid for the Elderly and People with Disabilities (MEPD). If evidence was not available at the initial face-to-face contact, the case manager documents "No evidence was obtained" in Section I, Comments about your disability, on Form H3034 prior to submitting to HHSC for a disability determination. Applicants age 65 or older do not need a disability determination.

3550  Copayment and Room and Board

Revision 12-2; Effective June 1, 2012

§48.6009 — Calculation of Client Copayment.

(a)
Clients who are determined to be financially eligible based on the special institutional income limit may be required to share in the cost of waiver services. The method for determining the client's copayment is described in subsection (b) of this section and documented on the Texas Department of Human Services (DHS) copayment worksheet for 1915 (c) waiver programs. When calculating the copayment amount for clients with incomes that exceed the SSI federal benefit rate (FBR), DHS staff deduct the following:
(1)
the cost of the client's maintenance needs which must be equivalent to:
(A)
the special institutional income limit for waiver recipients residing in their own homes, or
(B)
the SSI federal benefit rate per month for individuals residing in foster homes and personal care facilities;
(2)
the special couple institutional income limit for waiver recipients, which for couples living in adult foster care, [assisted living or] personal care facility settings, must be equivalent to the federal benefit rate for an individual living in other community living arrangements for each member of the couple;
(3)
the cost of the maintenance needs of the client's spouse [if the spouse is the only dependent of the recipient]. This amount is equivalent to the SSI federal benefit rate less the spouse's income;
(4)
the cost of the maintenance needs of the client's dependent children. This amount is equivalent to the aid to families with dependent children (AFDC) basic monthly grant for children, or a spouse with children, using the recognizable needs amounts in the AFDC budgetary allowances chart; and
(5)
the costs incurred for medical or remedial care which are necessary but are not subject to payment by Medicare, Medicaid or any other third party. These include the cost of health insurance premiums, deductibles and co-insurance.
(b)
The copayment amount is the client's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of home and community-based services which are funded through this waiver program and specified on the client's individual [service plan]. The copayment must not exceed the cost of services actually delivered.
(c)
Clients must pay the cost-sharing amount directly to the provider contracted to deliver authorized waiver services.

§48.6015 — Calculation of Room and Board Amounts.

To determine the room and board amounts for clients residing in adult foster care or personal care facilities, the Texas Department of Human Services (DHS) staff apply the following post eligibility calculations:
(1)
for individuals, the room and board amount is the supplemental security income (SSI) federal benefit rate minus the personal needs allowance;
(2)
for SSI couples, the room and board amount is the SSI federal benefit rate [for a couple] minus the personal needs allowance for an individual multiplied by two; or
(3)
for couples with incomes that exceed the SSI federal benefit rate for couples, the room and board amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the room and board amount for an individual.

Some individuals will be responsible for contributing toward the cost of Community Based Alternatives (CBA) services. This is referred to as copayment and/or room and board charges.

The copayment amount is not a factor in determining the individual's eligibility for CBA services.

Texas Integrated Eligibility Redesign System (TIERS) calculates copayments and deducts allowable incurred medical expenses (IMEs) for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a Qualified Income Trust (QIT). Refer to Section 3671, Incurred Medical Expenses. TIERS will not calculate copayment amounts for individuals receiving Retirement, Survivors and Disability Insurance (RSDI) exclusion, such as Type Program (TP) 03, TP 18 or TP 22. Individuals on these TPs have full Medicaid eligibility and are considered categorically eligible for the CBA program. No copayment is required for these individuals and IME policy does not apply.

Individuals receiving Supplemental Security Income (SSI), including those who also receive RSDI, are not required to make a copayment and no copayment calculation is necessary for them.

Individuals who reside in adult foster care (AFC) or assisted living (AL) settings may be required to pay a copayment.

The case manager must clearly explain to the applicant or individual, if it is determined the individual must pay a monthly copayment, that the copayment amount must be paid directly to the AFC or AL provider.

All individuals, including those who receive SSI, are required to pay room and board in AFC and AL settings.

The case manager must explain to the individual that the individual is required to pay the AFC or AL provider a room and board charge. If the individual fails to pay the agreed upon room and board charge, copayment, or both, the individual could be terminated from the CBA program. The Department of Aging and Disability Services (DADS) is not responsible, and will not pay under any circumstances the individual's copayment or room and board charges.

Refer to Appendix VI, Calculation of Copayment and Room and Board, for examples of how to calculate the monthly room and board and monthly amounts available for copayment.

The case managers will notify the individual and the provider of new copayment amounts to be collected on Form 2065-B, Notification of Waiver Services.

Refer to Section 3550.4, Qualified Income Trust, and Section 3550.4.1, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

3550.1  Determining Room and Board Charges

Revision 12-2; Effective June 1, 2012

All individuals must pay the room and board charges to be eligible for Assisted Living (AL). Room and board cannot be waived, but an AL facility may choose to accept an individual for a lower amount. Community Based Alternatives (CBA) policy does not direct the facility to accept or reject the individual.

The room and board charge for an individual is fixed at the amount remaining after subtracting $85 from the Supplemental Security Income (SSI) federal benefit rate (FBR). The FBR current amounts are found in Appendix XIV, Monthly Income/Resource Limits, which is updated when the FBR changes.

For couples where both partners are residing in AL or Adult Foster Care (AFC) settings, $170 is subtracted from the couple's income so each member of the couple keeps $85 a month for personal needs and the remainder is the room and board charge for the couple. Due to the difference in income between couples and individuals, the amount of room and board charge for a couple depends on income.

  • For SSI couples, the room and board charge is the FBR for a couple minus the $170 personal needs allowance.
  • For those couples who are not SSI recipients, but whose income is less than the current FBR for an individual doubled, their room and board charge is their monthly income minus the $170 for personal needs.
  • For couples whose income exceeds twice the SSI FBR for an individual, the full room and board charge for two individuals is required.

An individual residing in an AL or AFC setting will keep $85 a month for personal needs.

Refer to Appendix VI, Calculation of Copayment and Room and Board, for instructions about how to calculate room and board for a partial month.

3550.2  Determining Copayment Amounts

Revision 12-4; Effective December 3, 2012

The Texas Integrated Eligibility Redesign System (TIERS) calculates and documents the monthly ongoing copayment in the copayment record. The case manager will use this information to determine the copayment amount for the initial month of entry to the Adult Foster Care (AFC) home or Assisted Living (AL) facility.

The ongoing copayment amount is the amount available for copayment calculated by TIERS, except in those cases where the amount available exceeds the cost of AFC or AL services. In this case the copayment is set at the actual rate of the Community Based Alternatives (CBA) service, and the individual retains any remaining amount. The ongoing copayment applies to the second and subsequent months of the individual service plan (ISP) effective period and is for complete months of service.

The initial copayment applies to the first month of the ISP effective period. The initial copayment amount is the lower of:

  1. the prorated copayment; or
  2. available funds (cash on hand that will be available from regular income expected to be available by the 10th day of the month, such as Social Security or monthly retirement checks, even if this income is not actually in the possession of the applicant on the date the calculation is completed, and liquid resources such as checking or savings accounts) minus the prorated allowance for personal needs ($85 per month) and room and board.

The case manager calculates the initial copayment by completing two separate calculations and comparing the results, with the smaller amount being the initial copayment registered on the ISP. The case manager determines the prorated copayment by dividing the ongoing copayment amount by the number of days in the month and multiplying that figure by the number of days of AFC or AL services the applicant is expected to receive services. The case manager compares the prorated copayment to the remainder determined by subtracting the prorated allowance divided by number of days in the month multiplied by number of days of AFC or AL services from the available funds. The initial copayment is the smaller of the prorated copayment or the available funds minus the prorated allowance.

The individual is notified of the amount of the initial and ongoing copayment on the ISP and Form 2065-B, Notification of Waiver Services, as described in Section 3821, Notifications. For individuals who will be responsible for copayment in AFC or AL settings, the copayment used in developing the initial ISP may have to be estimated if the copayment amount is not available in TIERS prior to ISP cost calculation. If an estimated copayment is used on the initial ISP, the case manager should explain to the individual that these estimated amounts are subject to change when the actual amount is obtained. The case manager should annotate items pertaining to copayment on Form 3671-1, Individual Service Plan, as "estimates." When the actual amount available for copayment is available in TIERS, the case manager must calculate accurate copayment amounts, register the ISP with the correct copayments, and prepare Form 2065-B. The case manager notifies the AFC or AL provider of the amount of the individual's initial and ongoing copayment, as well as room and board charges, on Form 2065-B. If there is no copayment, the amount on Form 2065-B will be entered as $0 for initial and ongoing copayments. The individual has the right to appeal the copayment determination.

If the Department of Aging and Disability Services (DADS) determines that the individual is responsible for copayment, the amount that DADS pays to the provider will be reduced by the copayment amount. The amount of the individual's copayment or the combined reimbursement from DADS and the individual's copayment cannot exceed the rate authorized for the CBA service. After full payment of the copayment up to the authorized rate for the CBA service, the individual retains any remaining amount. The case manager must send Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist, documenting the individual's copayment amounts within 10 working days after the initiation of AFC or AL services, or a change in copayment.

For individuals in AFC settings, the case manager assists the individual and AFC provider in documenting the room and board and copayment amounts on Form 2327, Individual/Member and Provider Agreement.

For additional information on calculation of copayment, refer to Appendix VI, Calculation of Copayment and Room and Board.

3550.3  Copayment Changes

Revision 12-2; Effective June 1, 2012

An individual's copayment may change during the time he is receiving Community Based Alternatives (CBA) services, typically due to a change in income or medical expenses. Copayment changes must always be effective on the first of the month. If the copayment is increasing, the case manager must send the individual and provider notification on Form 2065-B, Notification of Waiver Services, and the increase will be effective the first of the month after the expiration of the adverse action period. If the first of the month occurs before the end of the adverse action period, the copayment increase must be effective the first of the subsequent month. Decreases in copayment require Form 2065-B notification, but can be effective the first of the month after the notification is sent.

Copayments may also change due to other circumstances. Medicaid for the Elderly and People with Disabilities (MEPD) staff will be responsible for calculating and handling fraud referrals. Notices and letters on these issues will be prepared by MEPD staff with copies to CBA staff. MEPD staff will inform the case manager of fraud referrals and determine whether any corrections are necessary to the individual's copayment based on a change in the amount available for copayment.

Underpayments by the individual that are not part of a fraud referral, such as those based on reconciliation of variable income, will result in the MEPD staff sending a letter to the individual requesting that the individual pay the Department of Aging and Disability Services for the amount of copayment that was underpaid. The case manager is not responsible for determining if the underpayment is made to MEPD. The underpayment is not retroactively considered in the CBA copayment calculation. The MEPD specialist will notify the case manager if the ongoing copayment amount will increase. If the amount does increase, the case manager must complete a copayment change to increase the monthly copayment amount. The increase in copayment will be effective the first of the month after the expiration of the adverse action period indicated on Form 2065-B, notifying the individual of the copayment change.

Refunds due to the individual require a new copayment calculation be completed. The copayment may be calculated to allow the refund to be deducted from the individual's next copayment amount due to the provider or the individual may be given a reimbursement by the Adult Foster Care (AFC) or Assisted Living (AL) provider if there will be no future copayments. The case manager should consult with the regional Claims Management System Coordinator to determine if the AFC or AL provider should submit a negative billing. The effective date of the decrease in copayment is the first of the month after Form 2065-B is sent.

Example: The individual's ongoing copayment is $100 per month. The copayment amount of $75 should have been effective February 1. A refund of $25 per month for the months of February, March, April and May total $100. The case manager finds out about the new amount on May 20. The case manager completes Form 2065-B to notify the individual of the new copayment amounts: June – $0, July – $50, August – $75, ongoing.

Additional information on copayment and room and board payments is included in Appendix VI, Calculation of Copayment and Room and Board; Section 4200, Adult Foster Care; and Section 4300, Residential Care Services.

Information on copayment entered for the annual reassessment of the ISP is included in Section 3644, Reassessment Copayment Procedures.

3550.4  Qualified Income Trust

Revision 12-2; Effective June 1, 2012

Applicants and individuals with a qualified income trust (QIT) are responsible for a copayment in Adult Foster Care (AFC), Assisted Living (AL) settings or the at-home setting. The case manager must clearly explain that the funds from the QIT determined to be available for copayment must be used to purchase waiver services. Payments are made directly to the AFC provider, AL provider or Home and Community Support Services Agency (HCSSA).

For applicants and individuals residing in AFC or AL settings, the copayment amount is usually applied to the cost of AFC or AL services. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other CBA services such as nursing or medical supplies. For applicants or individuals in their home, the copayment is first used to purchase personal assistance services, nursing or medical supplies. The case manager calculates the type and amount of payment the applicant or individual will make directly to the service provider using the following steps:

  • The case manager develops the individual service plan (ISP) showing the total requested services and total cost of the ISP without consideration of the amount of services the QIT copayment will purchase.
  • Once the ISP has been developed, the case manager uses the QIT copayment amount in the Texas Integrated Eligibility Redesign System (TIERS) copayment record to determine the units of service to be purchased from the trust. The units of service are determined by dividing the monthly copayment amount by the unit rate for the service and rounding the result to the next lower half unit. If the provider(s) of service is a participating provider, use the participating rate for calculations. Check with the service provider(s) or the contract manager to determine the participating level. Refer to Section 2400, Reimbursement Rates, for rates.
  • The calculations are entered on Form 1578, Qualified Income Trust (QIT) Copayment Agreement. The case manager documents the amount of services the individual must pay directly to the provider(s) and obtains the applicant's or individual's agreement. Refer to Section 3550.4.1, Qualified Income Trust Copayment Agreement, for specific details about documenting the agreement.
  • The case manager develops a second Form 3671-1, Individual Service Plan, to reflect the amount of services reduced by the QIT copayment amount. The second Form 3671-1 is annotated in the top margin as "Adjusted ISP for QIT Copayment." For the service category where the QIT payment will be applied, the monthly units to be purchased through the copayment are multiplied by 12 to determine an annual amount of services to be purchased. This amount is subtracted from the total authorized amount to determine the new service units to be authorized and the new ISP total. Form 8598, Non-Waiver Services, is used to document the specific services provided through the QIT.
  • The amounts on the adjusted ISP are entered into the Service Authorization System (SAS). The total available QIT copayment amount is not entered on Form 3671-1 in the Copayment section and is not reflected in SAS copayment screens for individuals with a QIT living at home. If the individual lives in an AFC or AL setting, the calculated QIT copayment amount is entered on Form 3671-1 in the Copayment section and will be reflected in the copayment screens in SAS. Refer to the information below if the available QIT copayment amount is sufficient to fully pay for AFC or AL services. The copayment amount for services other than AFC or AL is documented on Form 1578 and Form 2065-B, Notification of Waiver Services.
  • The adjusted ISP and Form 1578 are sent to the CBA service provider(s). The HCSSA will review the adjusted ISP and attachments to determine the acceptance of a referral.
  • Form 2065-B is used to notify the individual and provider(s) of the amount of copayment to be made directly to the provider(s). QIT copayment amounts to the HCSSA are shown on Form 2065-B in the comments section.

Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL

If the available QIT copayment amount exceeds the daily rate for AFC or AL, the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The individual lives in an Assisted Living Apartment – Non-Participating facility. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May). This amount is entered on Form 3671-1 and in the SAS copayment record for the month.

A copayment record based on the number of days in the month must be completed in SAS. Form 2065-B may be completed each month or may be completed with the copayment amount for several months in the future. If the copayment amount changes for any of the months the individual has been notified of in advance, a new Form 2065-B must be sent to reflect the new copayment amounts for each month. SAS copayment records must also be updated.

If any QIT copayment amount remains after the monthly copayment amount is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the HCSSA. In these cases, the individual, AFC or AL provider, HCSSA and trustee must be notified of the amounts to be collected from the individual based on the days in the month.

Example: In the same example above, the individual has a $134.60 copayment remaining in the month of April to pay for services delivered by the HCSSA. In May, the individual has $92.42 remaining to pay for services delivered by the HCSSA.

Failure to pay the required QIT copayment could result in termination of CBA services. Refer to Section 3550.4.2, Refusal to Pay Qualified Income Trust Copayment.

3550.4.1  Qualified Income Trust Copayment Agreement

Revision 13-1; Effective March 1, 2013

The case manager completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

  • service purchased;
  • amount available for copayment;
  • unit rate;
  • units purchased; and
  • monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, then the copayment is applied to a second (or third) service, if necessary. For an individual residing in an Adult Foster Care (AFC) or Assisted Living (AL) setting, the copayment amount is usually applied to the cost of AFC or AL. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other CBA services such as nursing, personal assistance services (PAS) or medical supplies. For an individual who receives services in his home, the copayment is first used to purchase PAS, nursing or medical supplies.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

Calculation Example and Completion of Form 1578

There are 1,400 units (hours) of PAS included in the initial ISP. The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) equals 115.101 units, rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Next, calculate the annual amount of units to be purchased through the QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through the QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form 3671-1, Individual Service Plan. For example, 1,400 units minus 1,380 equals 20 units of PAS to enter on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the case manager discusses the copayment with the applicant or individual and the trustee of the trust. After explaining the requirements, the applicant, individual, his responsible party, if applicable, and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant or individual, his responsible party, if applicable, and the trustee.

CBA services cannot begin until Form 1578 is signed indicating the applicant's or individual's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or individual refuses to sign the adjusted ISP or the copayment agreement, CBA is denied or terminated for failure to pay the required copayment.

3550.4.2  Refusal to Pay Qualified Income Trust Copayment

Revision 12-4; Effective December 3, 2012

The trustee of the Qualified Income Trust (QIT) must pay the QIT copayment directly to the Home and Community Support Services Agency (HCSSA) by the 10th day of the month, or not later than 10 calendar days after Community Based Alternatives (CBA) services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for HCSSA services, the HCSSA is required to notify the case manager via Form 2067, Case Information, within two working days. The case manager must contact the trustee to learn the reason for refusal to pay. The case manager must write a letter to the individual and the trustee explaining the consequences of continued failure to pay. If the copayment is not fully paid within 30 calendar days of the due date, the case manager initiates termination of CBA services. Refer to Section 3811, Circumstances Requiring Termination of CBA Services with Advance Notice, and Section 3821.1, General Information Regarding Notifications, for termination reasons and procedures.

If the HCSSA does not deliver sufficient services to use the copayment amount, the HCSSA must refund any remaining copayment to the trustee and notify the individual and case manager via Form 2067. Example: The HCSSA collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the individual went out of town. The HCSSA must refund the dollar amount difference between 36.5 hours and 15 hours. The case manager must notify Medicaid for the Elderly and People with Disabilities staff of the refund.

Refer to Section 4200, Adult Foster Care, or Section 4300, Residential Care Services, for procedures related to failure to pay copayment for an applicant or individual in Adult Foster Care or Assisted Living settings.

3560  Texas Medicaid Estate Recovery Program

Revision 11-3; Effective September 1, 2011

3561  Introduction

Revision 11-3; Effective September 1, 2011

To comply with federal and state laws, the Texas Health and Human Services Commission implemented the Medicaid Estate Recovery Program (MERP). Under this program, the state may file a claim against the estate of a deceased Medicaid recipient, age 55 and older, who applied for certain long term care services on or after March 1, 2005.

Claims include the cost of services, hospital care, prescription drugs and for dual-eligible with full Medicaid coverage, Medicare cost sharing expenses paid by Medicaid. Claims will not be recovered when certain documented exemptions occur. Hardship waivers, either full or in part, may also be allowed.

The Medicaid long term care services subject to MERP are:

  • nursing facilities (institutional Medicaid);
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID), which include state supported living centers;
  • Community Attendant Services (CAS);
  • Department of Aging and Disability Services 1915(c) waiver programs:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disability (DBMD) Waiver services;
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL);
    • Consolidated Waiver Program (CWP);
    • Community Based Alternatives (CBA); and
  • HCBS STAR+PLUS waiver services.

Estates of individuals who applied for one of the above services before March 1, 2005, are permanently exempt from recovery.

3562  Medicaid Estate Recovery Program Claims

Revision 05-4; Effective April 18, 2005

Medicaid Estate Recovery Program claims will not be filed when it is not cost-effective. Claims that are considered not cost effective are those where the:

  • value of the estate is $10,000 or less;
  • recoverable amount of Medicaid costs is $3,000 or less; or
  • cost of the sale of the property would be equal to or greater than the value of the property.

The acceptance of Medicaid medical assistance provides a basis for a Class 7 probate claim, as defined in §322 of the Texas Probate Code. The Medicaid Estate Recovery Program files claims in accordance with the requirements contained in sections 298 and 301 of the Texas Probate Code. Additionally, a claim may not be filed under the Medicaid Estate Recovery Program if there is:

  • a surviving spouse;
  • a surviving child or children under 21 years of age;
  • a surviving child or children of any age who are blind or permanently and totally disabled under Social Security requirements; and/or
  • an unmarried adult child residing continuously in the Medicaid recipient's homestead for at least one year before the time of the Medicaid recipient's death.

3563  Undue Hardship Waivers

Revision 08-2; Effective February 25, 2008

The Medicaid Estate Recovery Program (MERP) will not recover costs from estates that would result in undue hardship. An undue hardship waiver request form will be provided as part of the MERP notice of intent to file a claim. The state will consider waiving recovery in part, or in full, when:

  • the estate property is:
    • a family business, farm or ranch;
    • the primary income-producing asset of the heirs;
    • produces at least 50 percent of the livelihood for heirs for at least 12 months before the death of the Medicaid recipient; and
    • recovery by the state would affect the property and result in heirs losing their primary source of income;
  • beneficiaries of the estate would become eligible for public or medical assistance if a recovery claim is collected;
  • allowing one or more heirs to receive the estate enables them to discontinue eligibility for public or medical assistance;
  • the Medicaid recipient received medical assistance as the result of being a crime victim;
  • the value assessed by the tax appraisal district is less than $100,000 and heirs have gross family incomes below 300 percent of the federal poverty level;or
  • other compelling reasons exist.

Exemptions and hardships are evaluated at the time of death, not at the time of application for services.

3564  Claim Filing Process

Revision 05-4; Effective April 18, 2005

Medicaid Estate Recovery Program claims are filed in Probate Courts within 70 days after the state receives notice of the death of a Medicaid recipient, age 55 and older, and who after March 1, 2005, applied for and received certain Medicaid long-term care services as previously described. A Medicaid Estate Recovery Program Notice of Intent to File a Claim Form will be sent to the estate representative of a Medicaid recipient within 30 days of notification of the death of a Medicaid recipient. The notice will include a program overview, a questionnaire regarding allowable exemptions and deductions, an undue hardship waiver request form and the date and source from which the state received notice of the Medicaid recipient's death.

Following receipt of a Medicaid Estate Recovery Program Notice of Intent to File a Claim Form, an estate representative has up to 40 days to submit an undue hardship waiver request. Determination of an undue hardship waiver will be evaluated on a case-by-case basis and will be completed within 40 days of receipt of the request and supporting documentation. Should an undue hardship waiver be denied, the estate representative may submit an appeal by writing to the Medicaid Estate Recovery Program. An appeal of denial must be submitted within 40 days following receipt of the denial.

If no exemptions apply, a claim will be filed against the estate of a deceased Medicaid recipient in Probate Court for the cost of covered Medicaid services received after the effective date of the program. Medicaid Estate Recovery Program claims may be filed in accordance with the requirements contained in sections 298 and 301 of the Texas Probate Code. Section 322 of the Texas Probate Code contains the classification and priority of claims from a decedent's estate. The acceptance of certain Medicaid long-term care services provides a basis for a Class 7 claim after:

  • last illness expenses and funeral expenses;
  • estate administration expenses;
  • tax liens;
  • child support;
  • taxes, including penalties and interest; and
  • expenses from cost of penal confinement.

An estate, according to the Texas Probate Code, is the real and personal property of an individual, such as a home or car. It does not include:

  • insurance policy proceeds,
  • retirement accounts such as IRAs,
  • pension plans,
  • financial institution accounts,
  • mutual funds, or
  • deferred compensation plans.

Under the claims procedures in the Texas Probate Code, the recovery amount represents the actual cost of Medicaid services. The Medicaid Estate Recovery Program may compromise, settle or waive any claim upon good cause shown.

3565  Allowable Claim Deductions

Revision 05-4; Effective April 18, 2005

Under the Medicaid Estate Recovery Program, certain deductions from the claim amount may be considered. These include necessary and reasonable expenses for home maintenance, including:

  • real estate taxes;
  • real estate insurance, excluding liability;
  • utility bills;
  • home repairs; and
  • other maintenance expenses such as lawn care.

Additionally, deductions from the claim amount may be considered for necessary and reasonable expenses for the direct payment of the costs of care (including payment of personal attendant care) provided for the Medicaid recipient that enabled the recipient to remain at home, thereby delaying the need for institutionalization.

As previously discussed, a Medicaid Estate Recovery Program Notice of Intent to File a Claim Form will be sent to the estate representative of a Medicaid recipient within 30 days following the death of a Medicaid recipient. The estate representative must provide supporting documentation to support any declared deductions within 60 days following receipt of notice of intent to file a claim to recover Medicaid costs.

3566  Transfer of Assets

Revision 05-4; Effective April 18, 2005

Be aware that giving away assets without compensation may result in nonpayment of nursing facility, ICF/IID and CBA services. Assets transferred up to 36 months before application for long-term care or institutionalization services, and 60 months for certain trusts, may affect an individual's entitlement to payment of services. There is no transfer penalty if a recipient transfers a home to a:

  • spouse living in the home (the transfer penalty applies when the community-based spouse transfers the home without full compensation);
  • child or children under age 21;
  • child or children over age 21 living in the home for at least two years before the client's institutionalization and who provided care to prevent institutionalization;
  • child or children of any age that meet the Supplemental Security Income (SSI) rule for disability/blindness; and
  • brother or sister with equity interest in the home and who lived there for at least one year before the client's institutionalization.

3570  Correcting County Codes in the Service Authorization System (SAS)

Revision 13-1; Effective March 1, 2013

It is essential that the resident code reflected in the Texas Integrated Eligibility Redesign System (TIERS) and Service Authorization System (SAS) reflect the correct resident county code. Incorrect county records in TIERS and SAS can cause enrollment problems, suspension of services and coordination of Community Based Alternatives (CBA) services with managed care services. Incorrect county codes can also affect Title XX budgets. When making a referral to a managed care program for an individual with an incorrect address, the case manager must immediately follow the procedures below to correct the individual's address.

The location record reflects the residence county as recorded in TIERS and is updated through monthly interfaces. If the county code is incorrect in TIERS, it must be changed to ensure the correct code appears in SAS.

Individuals Who Receive Supplemental Security Income (SSI)

If the individual receives SSI Type Medicaid, TIERS derives the county based on the residential zip code provided by the Social Security Administration (SSA). Two potential problems could arise:

  • SSA entered an incorrect ZIP code; or
  • a ZIP code crosses county lines and TIERS assigns the wrong county.

The case manager must inform the individual or his responsible party to contact the SSA to request the residence address change. The address change will be reflected in TIERS after SSA makes the change. The case manager must not send address change requests to Medicaid for the Elderly and People with Disabilities (MEPD) staff or the Midland Document Processing Center. Although MEPD staff are able to make those address changes, the addresses will revert back to the address on the SSI record at the next state cutoff.

Individuals Who Do Not Receive SSI

If the individual receives non-SSI Type Medicaid, TIERS contains the county code entered by the MEPD specialist. Two potential problems could arise:

  • an individual moves without notifying MEPD; or
  • an MEPD specialist entered the county code incorrectly.

If the individual does not receive SSI, and the residence county is incorrect, refer to the MEPD specialist for correction of the residential county field. If the residential ZIP code in TIERS is correct but the county is incorrect, send the following information to the Data Integrity Unit, using Form H1270, Data Integrity SAVERR Notification:

  • individual's name as recorded in TIERS;
  • individual's number;
  • residential ZIP code; and
  • residence county as it should be reflected in TIERS.

The Data Integrity Unit can force correct the problem in TIERS. The correction will take place in TIERS during the next TIERS cutoff processing (usually around the 20th day of the month). SAS should reflect the corrected county during the first TIERS-to-SAS reconciliation that occurs after TIERS cutoff (usually the day after cutoff).

If the individual receives Supplemental Nutrition Assistance Program (SNAP), contact the assigned Texas Works advisor and request a correction.

The case manager should contact the Claims Management Services coordinator to determine how to handle issues with county codes that cannot be corrected by following these procedures.

3600  Ongoing Case Management

Revision 13-1; Effective March 1, 2013

Based on the needs of the individual enrolled in the Community Based Alternatives (CBA) program, the case manager's ongoing case management responsibilities could include:

  • revising the individual service plan (ISP) as necessary to meet the needs of the individual, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services, respite or requests for service suspension;
  • coordinating and consulting with CBA providers regarding delivery of services;
  • reassessing the individual annually for continuing eligibility;
  • assisting the individual with issues related to continuing Medicaid eligibility;
  • monitoring services delivered to the individual, evaluating the adequacy and appropriateness of waiver and non-waiver services and documenting monitoring activities;
  • assisting the individual in accessing and using community, Medicare, family and other third-party resources;
  • providing written notification to the individual and CBA providers of approval, denial, termination, service plan changes, provider changes and responding to appeal requests;
  • assisting with crisis intervention; and
  • responding to situations of potential termination of an individual whose ISP costs exceed the individual’s assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of CBA eligibility.

3610  Revising the Individual Service Plan (ISP)

Revision 12-3; Effective September 4, 2012

It may be necessary to revise the individual service plan (ISP) within the authorization period due to changes in the needs of the individual or changes in the services offered. The case manager documents a revision to the ISP on Form 3671-1, Individual Service Plan. Revisions to Community Based Alternatives services must be approved by the interdisciplinary team. Changes must be registered in the Service Authorization System (SAS) for the provider to be paid.

Refer to Section 7000, Case Management Procedures for Utilization Review, for information on determining if the revision to the ISP requires a prospective review and procedures for revisions to the ISP resulting from a prospective or concurrent review.

3610.1  Routine Service Plan Changes to the Individual Service Plan

Revision 09-9; Effective December 1, 2009

For changes in the individual service plan (ISP) which are routine, not emergencies or not due to sudden changes in needs that must be met immediately, the Home and Community Support Services Agency (HCSSA) is required to follow procedures outlined in the rules.

§48.6023 — Routine Service Plan Changes. The Home and Community Support Services agency must submit routine service plan changes, for all services except personal assistance services, within seven Texas Department of Human Services (DHS) workdays of identifying the need for a change in the service plan by submitting the following:

(1)
the Case Information form, containing the rationale for service plan change, the type and amount of additional services needed and the anticipated duration, signed by the home and community support services agency professional;
(2)
the appropriate individual service plan (ISP) attachment page B-E, identifying the service plan change, signed by the provider professional; and
(3)
documentation of necessity from a physician, physician's assistant, registered nurse, nurse practitioner, or therapist for any adaptive aid, medical supply, or minor home modifications identified.

The HCSSA requests the change in the ISP by submitting the following to the case manager within seven workdays of identifying the need for the change:

  • Form 2067, Case Information.
  • The appropriate ISP form (Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan), identifying the service plan change, signed by the provider professional.
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or documentation of necessity from a physician, physician's assistant, registered nurse, nurse practitioner, or therapist for any adaptive aid, medical supply or minor home modification identified, if applicable.

For routine changes, the HCSSA is not required to submit Form 3671-2, Individual Service Plan, signed by the consumer. The case manager is responsible for discussing the requested change with the consumer and obtaining the consumer's signature or documenting the consumer's verbal agreement on Form 3671-2, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H or Form 2060-A, Addendum to Form 2060 for Personal Assistance Services. The case manager approves or disapproves the change and completes all other documentation to process the ISP change request.

If the HCSSA feels additional units of personal assistance services (PAS) are necessary, the provider should submit Form 2067, explaining the need for additional units of service, to the case manager within seven workdays of identifying the need for the additional units. The case manager completes the functional assessment and obtains the consumer’s signature or documents the verbal agreement and the date the change was obtained. The case manager signs to approve or deny the change in PAS hours. Within seven workdays of receipt of the revised ISP, the HCSSA initiates the change in PAS and signs and returns the updated ISP to the case manager. The HCSSA may submit Form 2067 to the case manager if the HCSSA has questions about a change in PAS hours initiated by the case manager or consumer, or determines an additional change in PAS hours is needed.

For ISP changes, the case manager may write "verbally approved" on the Applicant/Consumer/Responsible Party signature line of the ISP form attachment when the applicant's/consumer's or responsible party's agreement with the ISP change is obtained by telephone. If verbal approval for the change is not appropriate, such as the consumer has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone, the case manager makes a home visit to obtain the consumer's approval. The case manager sends notification on Form 2065-B, Notification of Waiver Services, to the consumer and provider along with a copy of the ISP attachment that includes the change. The HCSSA should also request a change in the service plan, including a reduction in services, when there is a significant improvement in the consumer's condition and the ISP does not reflect the consumer's current needs.

It is not appropriate to request a new Medical Necessity and Level of Care (MN/LOC) Assessment be submitted to Texas Medicaid & Healthcare Partnership to "reset" the individual's cost limit if the consumer's condition improves. The service plan should be based on the consumer's needs, not the cost limit.

3610.2  Case Manager Response to Routine Change Requests

Revision 13-1; Effective March 1, 2013

STANDARD.

The case manager must respond to service plan change requests within 14 calendar days of the documented verbal notification or the date of receipt of the written notification.

Service plan change requests include increases, decreases, adding or denying services or terminating Community Based Alternatives (CBA) program eligibility. Service plan changes may be requested directly by the individual or by the Home and Community Support Services Agencies (HCSSAs) after consultation with the individual. A change may be due to the individual's preference, a change in living arrangements, a nursing facility admission or the individual's death. This list is not all inclusive.

Within the 14-calendar-day time frame, the case manager must complete the following activities:

  • determine if an individual service plan (ISP) change is necessary;
  • convene the interdisciplinary team (IDT), if appropriate;
  • obtain regional nurse approval, if required;
  • approve or deny the service plan change request;
  • notify the individual and providers on Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, of the approval, denial or termination;
  • complete Service Authorization System (SAS) entries; and
  • submit any revised ISP forms, as necessary, to the individual and provider – Form 3671-1, Individual Service Plan (pg.1); Form 3671-2, Individual Service Plan (pg. 2); Form 8598, Non-Waiver Services; Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; Form 2060-A, Addendum to Form 2060 for Personal Assistance Services; Form 3671-B, Therapy Service Authorization; Form 3671-C, Nursing Service Plan; Form 3671-D, Minor Home Modifications; Form 3671-E, Adaptive Aids and Medical Supplies; or Form 3671-H, Dental Services.

Form 2065-B and Form 2065-C must be completed according to the specific time frame and requirement related to the type service plan change request being completed (for example, a decrease in hours requires adverse action notice, a termination due to loss of Medicaid requires notification be sent within two working days of notification of loss of Medicaid). Refer to Section 3800, Suspensions, Notifications, Denials and Terminations, for notification time frames. Refer to Section 3440, Service Authorization System (SAS) Online Overview, for additional information regarding SAS requirements.

For ISP changes, the case manager may write "verbally approved" on the Applicant/Individual/Responsible Party signature line of the ISP form attachments when the applicant's, individual's or responsible party's agreement with the ISP change is obtained by telephone. If verbal approval for the change is not appropriate, such as the individual has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone, the case manager makes a home visit to obtain the individual's approval. The case manager sends notification on Form 2065-B to the individual and provider, along with a copy of the ISP attachment that includes the change.

Requests made by the individual that do not require an ISP assessment by the HCSSA must be completed within the 14-calendar-day time frame. For example, a verbal or written request from the individual for a service plan change regarding Personal Assistance Services (PAS), other than delegated nursing tasks, must be processed within 14 calendar days. All other service plan change requests made to the case manager by the individual or responsible party that require an assessment by the HCSSA must be referred to the HCSSA within seven calendar days. Upon receipt of the written response or request from the HCSSA, the case manager must process the request, including the activities listed above, within 14 calendar days. Delays must be documented.

For requested changes to nursing services, the case manager should review new diagnosis and changes in the individual's condition, functional needs, environment, caregivers or third-party resources that may have prompted the need for additional nursing hours. The case manager may need to consult with the individual, HCSSA or the regional nurse or qualified medical professional to obtain additional information before approving or denying the requested change in nursing hours.

The case manager is not required to obtain the HCSSA's signature on Form 2060-A before the authorization of a change in the PAS plan during the ISP year. Within seven calendar days of receipt of the revised ISP, the HCSSA will initiate the change in PAS and sign and return the updated ISP to the case manager. The HCSSA submits Form 2067, Case Information, if the HCSSA does not agree with the change in PAS hours. Provider policy is found in the Community Based Alternatives Provider Manual, Section 4452.2, Requests for Routine Service Plan Changes.

3610.2.1  Requests Sent to Regional Nurse for Review

Revision 10-5; Effective December 1, 2010

When a change request is received that requires regional nurse review, the case manager forwards the request to the regional nurse following established procedures.

The case manager indicates the date the change must be completed on Form 1547, Regional Nurse/Dental Consultant Request Worksheet, sent to the regional nurse. The case manager must monitor the case for the regional nurse's response if the due date is approaching and the case manager has not received a response from the regional nurse. The case manager must contact the regional nurse either by phone or email prior to the 14-calendar day time frame to check the status of the change request, documenting the contact in the case record.

The case manager must contact the regional nurse early enough to allow adequate time for the regional nurse to review the change request and provide a decision to the case manager so the case manager can complete the change request within the 14-calendar day time frame. There should be rare instances when the change cannot be completed by the required time frame due to pending regional nurse review.

If the case manager cannot complete the change request by the required time frame due to pending regional nurse review, the case manager documents regional director (RD) approval and must not take action on the change request until a decision is received from the regional nurse. The case manager must follow local office procedures for obtaining approval from the RD to leave the request open beyond the 14-calendar day time frame. The case manager documents the delay in the case record and continues to coordinate with the regional nurse to receive a decision as quickly as possible. The case manager takes action once the decision is received from the regional nurse.

This policy applies to all change requests sent to the regional nurse for review.

3610.3  Emergency Service Plan Changes to the Individual Service Plan

Revision 08-10; Effective September 1, 2008

If the consumer experiences an emergency or crisis that in the Home and Community Support Services Agency (HCSSA) nurse's judgment requires the provider to deliver additional hours of nursing or personal assistance services (PAS), the HCSSA must provide the care to meet the consumer's needs. The case manager or the case manager's supervisor must be verbally notified by the next Department of Aging and Disability Services (DADS) workday of this change so that the HCSSA can receive authorization for the additional services. Written notification, including Form 2067, Case Information, identifying the rationale for the change and specific changes for PAS, a new Form 3671-C, Nursing Service Plan, signed by the consumer identifying the specific nursing services to be delivered, and Form 3671-2, Individual Service Plan, signed by the consumer, should be submitted to the case manager by the HCSSA within seven calendar days after the verbal notification.

The HCSSA must deliver all the nursing and PAS necessary to meet the needs of waiver consumers experiencing crisis situations, unanticipated medical needs, unexpected or sudden changes in medical condition or health status, or loss of caregiver.

The HCSSA may procure adaptive aids and medical supplies not currently authorized on the individual service plan (ISP) in emergencies that are defined as only situations that place the consumer's health and/or safety at risk. If procuring emergency adaptive aids and medical supplies, the HCSSA must:

  • obtain written agreement from the consumer or caregiver that the item is needed by obtaining his signature on Form 3671-E, Adaptive Aids and Medical Supplies, and Form 3671-2;
  • verbally notify the case manager by the next DADS workday after purchasing the necessary item(s);
  • submit the following documentation to the case manager within seven days of the verbal notification of purchase of the emergency item(s):
    • the revised Form 3671-E and Form 3671-2, with the consumer's signature or caregiver's signature showing that the purchase was needed;
    • Form 2067, explaining why the emergency purchase was necessary; and
    • a physician's statement that the adaptive aid or medical supply was for an emergency.

If the HCSSA follows the notification procedures outlined above, the case manager must submit an ISP change to authorize the emergency services and/or purchases and increase the ISP authorizations in order for the HCSSA to be paid for purchases or services already delivered.

3610.4  Case Manager Response to Emergency Requests

Revision 02-0; Effective April 4, 2002

If the case manager documents the verbal notification by the Home and Community Support Services Agency (HCSSA) of the delivery of emergency services or services determined to be necessary at the time of service initiation, he must respond to the individual service plan (ISP) change request within 14 calendar days of the documented verbal request.

If the provider agency follows the procedures for emergency changes, the case manager must submit an ISP change, if necessary, to cover the purchase of emergency adaptive aids, medical supplies, nursing, or personal assistance hours already delivered with an effective date of the date the increased services were initiated. Any ongoing services the HCSSA has been providing after notification to the case manager must also be authorized for payment on the ISP. Routine changes must be authorized on the ISP before the services are delivered by the HCSSA.

3610.5  Agency Response to Change Requests

Revision 02-0; Effective April 4, 2002

The Home and Community Support Services Agency (HCSSA) has seven calendar days after receipt of the revised individual service plan (ISP) to initiate the changed service, (except for adaptive aids, medical supplies, or minor home modifications) and acknowledge receipt by signing and returning the signed ISP attachment form(s). For adaptive aids, medical supplies, and minor home modifications, the HCSSA will provide the needed items or modifications by the dates required in Section 4400 of the CBA Provider Manual.

3610.6  Agency Flexibility

Revision 03-4; Effective Upon Receipt

The participant and the Home and Community Support Services Agency (HCSSA) staff can modify the initial schedule, days of services, and personal assistance tasks that were included on Forms 2060 and 2060-A to a mutually agreeable schedule and combination of services that will meet the participant's needs. Only personal assistance services (PAS) tasks that are allowed in the community based alternatives (CBA) program can be delivered and billed as CBA services. It is not necessary for the HCSSA to notify the case manager of schedule modification or changes in tasks as long as the units of PAS delivered and billed for a calendar month do not exceed 4.33 times the adjusted weekly hours identified in item IV on Form 2060-A. The HCSSA must notify the case manager if additional units of PAS services are necessary to meet the participant's needs; use the procedures in Section 3610.1 and Section 3610.3, as appropriate to the participant's condition.

The schedule modification can be ongoing; for example, the bathing identified for delivery four days a week can be changed to three days a week if the participant and HCSSA agree; or for particular days, for example, if the participant requires that the services originally scheduled for Tuesday be delivered Wednesday.

The ongoing flexibility allowed the participant and HCSSA in establishing and modifying the schedule of PAS services by mutual agreement is intended to allow the services to meet the participant's needs considering changes in his condition and desires. The flexibility in scheduling is not intended to be for the convenience of the HCSSA or to be applied retroactively to justify an attendant absence or break in services. The schedule for the delivery of delegated nursing tasks can be modified but must meet the participant's needs and comply with the physician's order, nursing practice standards, and licensure requirements.

The participant can choose to receive PAS outside the home up to the number of hours authorized per month. The case manager continues to allocate hours based solely on hours needed, as measured by Form 2060 and Form 2060-A. Hours are based solely on services assumed to be provided within the home environment. The case manager does not authorize additional hours to the service plan if the delivery of services in an alternate location results in the client not having enough hours remaining for the attendant to provide the client's needed tasks.

The provider agency must have a backup system to assure the provision of all PAS services on the schedule agreed to by the participant and the HCSSA without a service break, even if there are unexpected changes in personnel.

If the participant notifies the case manager that the HCSSA has not delivered services as mutually agreed, the case manager must notify the HCSSA of the participant's concerns. The case manager must contact the contract manager if the HCSSA has not adequately prevented service breaks, has other problems which endanger the health and safety of the participant, or has not fulfilled its agreement to provide services.

3610.7  Provider Change Procedures

Revision 10-5; Effective December 1, 2010

Assuming that another Community Based Alternatives (CBA) contracted provider is available and able to serve the CBA consumer, the consumer can change providers with no restrictions.

Case managers must complete the provider change within 14 calendar days of the documented date of the request by the consumer to change providers. Form 2065-B, Notification of Waiver Services, authorizing the provider transfer, must be signed by the 14th calendar day. Acceptable delays, such as mail delays in receiving the consumer's signature on Form 3671-2, Individual Service Plan, or receiving acceptance by the Home and Community Support Services Agency (HCSSA) must be documented. The effective date of the transfer must be within the 14 calendar days unless a delay, such as a negotiated date start date, is documented.

After a CBA consumer or his representative contacts the case manager requesting to change providers, the case manager initiates the provider change process. To process a provider change, the case manager:

  1. Contacts the consumer to confirm that he wants to change providers.
  2. Determines the effect of the provider change on the cost of the individual service plan (ISP) if waiver services are to change (for example, the consumer is requesting a change from Adult Foster Care (AFC) to Assisted Living/Residential Care (AL/RC)).
  3. Asks the consumer to select another provider and selects the new provider in the CBA Wizard.
  4. Faxes or mails the ISP for referral acceptance to the new provider. The case manager sends Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, and attachments:
    • Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan, as appropriate, to AFC providers;
    • Form 3671-B, Form 3671-C, Form 8598, Form 3671-E, Form 3671-H and Form 3671-J, as appropriate, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment, to HCSSAs and AL/RC providers.
    • Note: The case manager should annotate on the applicable attachment(s) sent to the new provider to identify items or services that already have been delivered, or are no longer necessary, to notify the receiving provider not to deliver the item or service.

  5. Mails Form 3671-2 to the consumer for signature to confirm his agreement with the selection of the new provider(s) and any change in the ISP.
  6. Negotiates the effective date of the change with the providers, to assure there is no gap in services.
  7. Prepares and sends Form 2065-B to the:
    • consumer to notify him of the provider change,
    • "old" provider to inform the provider of the termination date of the authorization for services, and
    • "new" provider to notify it of the effective date of the authorization for services.
  8. Registers the provider change and any change in services in the Service Authorization System (SAS).

If another CBA contracted provider is not available in the geographic area of the consumer, for example, the consumer wants to change from one AL/RC provider to another but no other AL/RC providers are available, the case manager must help the consumer determine other alternatives available to him. If the provider selected by the consumer does not accept the referral of the consumer, the case manager should have the consumer select another provider and send the ISP for referral acceptance to that provider. It is not necessary to provide the Emergency Response Service (ERS) providers the opportunity to accept a referral as described in Step 4 above.

The consumer's signature is required on Form 3671-2 in the "Freedom of Choice" and "Acknowledgement of Provider Change" sections to acknowledge the consumer's request to change the CBA waiver service delivery provider.

The new HCSSA representative signs Form 3671-2 in the "HCSSA Referral Acceptance" block to show acceptance or refusal of the consumer. The new AFC provider or AL/RC facility representative must sign in the "AFC/AL/RC Referral Acceptance" block when provider/facility changes occur.

The new provider is not required to sign Form 3671-1, Form 8598, Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-H, Form 3671-J and Form 2060-A for a provider transfer, although the case manager must submit these forms to the new provider as part of the change procedures. The new provider may initiate change requests once the transfer is made. The case manager signs in the "Interdisciplinary Team Certification" section to authorize the provider transfer once all required signatures are obtained and the negotiated transfer date is established.

It may be necessary for the consumer to remain in his current location and go on the desired provider's waiting list.

3610.7.1  Provider Change Authorization

Revision 07-6; Effective May 31, 2007

When completing a provider change, the case manager must ensure the Service Authorization System (SAS) wizard Service Unit/Rate Entry screen reflects service units available for the new provider and utilized units for the previous provider.

Change actions must not be made at the same time the Provider Transfer action is completed in the SAS wizard. If a change is necessary for the previous provider, process the change effective the day before the transfer. If the change affects the new provider, process the change after the Provider Transfer action.

If the previous provider requests additional units/amount added to a cancelled service authorization record after the Provider Transfer action is completed, the case manager must update SAS to add the additional units/amount to the previous provider's service authorization.

Consult the SAS help file for specific steps.

3610.7.2  Assessing Satisfaction When a Provider Change is Requested

Revision 13-1; Effective March 1, 2013

When a request to change providers is made, within the 14-day time frame to complete the change to the service plan for provider transfers, the case manager must contact the individual and the provider to determine:

  • the individual's reason for dissatisfaction; and
  • whether the individual's satisfaction can be accomplished without changing providers.

The case manager must first attempt to resolve any problems the individual may have with the current provider before processing the transfer.

The case manager must consider if the dissatisfaction is due to services not being provided according to the service plan, problems with the attendant, problems with the provider or the individual's failure to comply with the service plan.

The case manager may determine that an interdisciplinary team meeting is appropriate to discuss and find a resolution to service delivery issues, if possible.

Within the 14-day time frame to process the service plan change, the case manager authorizes the transfer if:

  • it is determined that the individual's satisfaction cannot be met without changing providers and services do not have to be terminated based on failure to comply with the service plan; or
  • the individual continues to request a provider transfer and the case manager determines that services do not have to be terminated based on failure to comply with the service plan.

The individual will continue to have the freedom to choose and change providers without restriction. However, the case manager should follow current program procedures to terminate the individual's program eligibility if he repeatedly refuses to comply with the service delivery provisions by repeatedly and directly, or knowingly and passively, condoning unacceptable behavior of someone in his home.

3610.8  Optional Change Procedures for Adaptive Aids and Medical Supplies

Revision 12-3; Effective September 4, 2012

Optional change procedures for adaptive aids and medical supplies allow the Home and Community Support Services Agency (HCSSA) registered nurse (RN) to provide certain adaptive aids and medical supplies without obtaining prior authorization from the case manager. The procedures allow for items to be delivered to the individual quickly and reduce the number of individual service plan (ISP) changes.

HCSSA Procedures for Change Requests Using the Optional Change Procedures

Using the optional change procedures, the HCSSA delivers an adaptive aid or medical supply without prior authorization from the case manager if it meets the following criteria:

  • The item costs $200 or less.
  • The item is listed on the approved list of adaptive aids and medical supplies.
  • There is a medical need for the item as determined and documented by an RN or other health professional.

Within seven calendar days of identifying the individual’s need for an item, the HCSSA sends the case manager:

  • Form 2067, Case Information;
  • Form 3671-E, Adaptive Aids and Medical Supplies;
  • Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications; and
  • other appropriate forms.

The HCSSA must deliver an adaptive aid to the individual within 14 working days and a medical supply within five working days of the HCSSA RN or health professional signature on Form 3671-E and Form 3671-F. Form 2067 submitted to the case manager must identify the item and clearly state that the item meets the adaptive aid or medical supply guidelines and has been delivered to the individual.

Semiannual Nursing Assessments

The HCSSA RN completes the semiannual nursing assessment and identifies additional changes in an individual's condition and initiates appropriate interventions. The HCSSA RN submits Form 2067 to the case manager within seven calendar days of completion of the semiannual nursing assessment, even if no service plan changes are required. Form 2067 must indicate:

  • the date of the semiannual nursing assessment;
  • new requests initiated at the semiannual assessment;
  • all items and requests delivered during the past six months; or
  • no changes requested.

Refer to Section 4143.1, Agency Responsibilities Pertaining to Optional Change Procedures for Adaptive Aids/Medical Supplies.

Case Manager Procedures for Responding to Change Requests

Upon receipt, case managers must review requests for adaptive aids and medical supplies to determine if the item delivered meets the criteria for delivery without prior authorization from a case manager. The case manager responds, based on the following criteria.

  1. Upon receipt of Form 2067, Form 3671-E, Form 3671-F and other appropriate forms advising of the delivery of an item that costs $200 or less, the case manager checks if the item is on the list of approvable items in Section 4141, List of Adaptive Aids and Medical Supplies, and that documentation of medical need is received. If the item is on the list and there is documentation of medical need, the case manager approves the request. If documentation of medical need is not received, the case manager must contact the HCSSA to request documentation of medical need before approving the request. Within 14 calendar days of receipt of the change request, the case manager signs, dates and records the approval of the request on Form 3671-E. Form 3671-E and Form 2065-B, Notification of Waiver Services, are sent to the HCSSA and individual. The ISP change may be entered in the Service Authorization System (SAS) at the time of approval or held and entered when the HCSSA notifies the case manager that the semiannual nursing assessment has been completed. The $1,000 buffer is added into the plan at each update. Note: The case manager must deny the request if all three criteria are not met.
  2. Change requests received at the time of the semiannual nursing assessment are processed within 14 calendar days of receipt. Upon receipt of Form 2067, advising that the HCSSA nurse has completed the semiannual nursing assessment, the case manager approves or denies new requests made by the HCSSA at the semiannual nursing assessment and updates the ISP in SAS to include the new items and all items previously approved and delivered during the past six months, if these changes have not been previously authorized in SAS. Form 3671-E (for new requests) and Form 2065-B are sent to the individual and the HCSSA.
  3. Change requests for an item not on the approved list or an item over $200 are handled as routine requests and must be approved or disapproved by the case manager within 14 calendar days of receipt of the request. Follow the procedures in Section 3610.2, Case Manager Response to Routine Change Requests, and submit the ISP change in SAS. Case managers are not required to consult with the Department of Aging and Disability Services (DADS) regional RN before denying routine change requests, but may do so if unsure about the request. If an item over $200, or not on the approved list, is delivered by the HCSSA before case manager authorization, the item is denied.

The case manager should accept the medical need documentation and authorize payment of an item already delivered using the optional change procedures. However, the case manager must ensure medical need is appropriate for inclusion of the item in the ISP for ongoing months. The case manager may consult with the DADS regional nurse to determine if there is a medical need for ongoing authorization of the item. The case manager must report to the Consumer Rights and Services hotline when an HCSSA repeatedly submits requests with inadequate supporting medical need documentation for change requests obtained through this process.

The ISP effective date is the date the case manager processes the change requests after being notified that a semiannual nursing assessment has been completed. The case manager does not go back to the delivery date for the items. The items are added to the ISP the date of processing and revising Form 3671-1, Individual Service Plan. According to the instructions for Form 2065-B, the effective date on Form 2065-B is the same as the effective date on Form 3671-1, Item 5.

Example: A request comes in for adult diapers at $150 per month. Since the item is under $200, is on the list of approved medical supplies and the HCSSA RN documents a medical need, the optional procedures may be used. The HCSSA RN sends the case manager Form 2067, Form 3671-E and Form 3671-F. The case manager signs, dates and records the approval of the request on Form 3671-E. Form 3671-E and Form 2065-B are sent to the HCSSA and individual. The case manager updates the amount in SAS when notified by the HCSSA that the semiannual nursing assessment has been completed. The ISP is updated by adding the $150 monthly for the remainder of the ISP year. The amount is added to the "Previously authorized this ISP year" amount for the subtotal (Item 15 on Form 3671-E) and then the $1,000 is added to that subtotal.

The HCSSA must check the most recent Form 3671-E for the addition of the $1,000 before delivery of an item under the optional procedures. If the HCSSA's records indicate that funds have been expended during the past six months, the HCSSA must request prior approval from the case manager using the procedures in Section 3610, Revising the Individual Service Plan (ISP), and in the Community Based Alternatives Provider Manual, Section 4452.2, Requests for Routine Service Plan Changes, for additional requests.

To prevent billing rejections, case managers add to the ISP an additional $1,000 for adaptive aids and $1,000 for medical supplies to cover the cost of items delivered by the HCSSA. The additional amounts are added at initial enrollment and annual reassessment unless doing so exceeds the ISP cost limit. The case manager may add a portion of the $1,000 that will keep the ISP within the cost limit, but the case should be flagged for additional procedures for individuals close to the ISP cost limit. The HCSSA is notified on Form 2067 that a reduced amount or no additional amount is added to the ISP. If an individual is approved to exceed the ISP cost limit, the additional amounts may be included in the ISP, as needed.

When the additional amount was not added to the ISP because the ISP was close to the cost limit and Form 3671-E is received, notifying the case manager of the delivery of an item, the case manager processes the request within 14 calendar days of receipt. The case manager adds the additional $1,000 amounts to the ISP and updates SAS using the HCSSA RN's or health professional's signature date on Form 3671-E as the effective date of the change. If the additional amounts have been added and the case manager processes an update after the semiannual nursing assessment, new items will be added on Form 3671-E and subtotaled with the amount shown in "Previously authorized this ISP year" from the preceding Form 3671-E, excluding the $1,000. The change is subtotaled and then the $1,000 is added. The case manager does not track how much is used from the $1,000.

The HCSSA must continue to assure that Medicare, Medicaid and other third-party resources (TPRs) are accessed before providing an adaptive aid or medical supply through the CBA program. If a request is submitted on Form 3671-E and subsequently approved for payment through Medicare, Medicaid or a TPR, the HCSSA advises the case manager by Form 2067 and the item is not included on the ISP update. When applicable, the HCSSA uses the emergency procurement procedures outlined in the Community Based Alternatives Provider Manual, Section 4424.4.2, Emergency Procurement of Adaptive Aids and Medical Supplies.

For requests costing more than $200, the HCSSA RN must follow normal procedures as outlined in the Community Based Alternatives Provider Manual, Section 4424.1, Documentation of Necessity.

For items requested that are not listed in Section 4141, List of Adaptive Aids and Medical Supplies, the HCSSA RN follows the procedures as outlined in Section 4424.1 to document if the item meets medical criteria. The nurse submits Form 3671-E and the appropriate attachments to the case manager.

3610.9  Case Record Transfer to Another Service Area

Revision 13-1; Effective March 1, 2013

When an individual receiving Community Based Alternatives (CBA) services moves from one service area to another, the case must remain open and the existing individual service plan (ISP) remains in effect until a new ISP is implemented. Every effort must be made to minimize gaps in services for the individual, although in some cases services may be temporarily suspended.

Responsibilities of the Original Case Manager

When the individual (or his responsible party) notifies the original case manager that he is moving to another service area, it is the case manager's responsibility to:

  • contact the office in the new service area to obtain the name, address and telephone number of the new case manager and provide the information to the individual;
  • contact the new case manager by telephone or email to provide the individual's Medicaid number and other identifying information;
  • notify the new case manager of the individual's new address and phone number, if available;
  • request that the new case manager fax a provider choice list, if the current provider does not serve the new location;
  • notify the individual that he may elect to remain with the current provider, if available in the new area, or provide the individual with the provider choice list and have the individual select a new provider;
  • communicate the individual's provider choice to the new case manager with a projected date of transfer;
  • fax a copy of the ISP to the new case manager and request that a copy of the ISP be sent to the new provider for review and acceptance;
  • notify the individual that if a provider is not chosen quickly and it is near the end of the ISP period, a gap in services may occur;
  • send Form 2065-B, Notification of Waiver Services, to terminate provider authorization (as appropriate) with the current provider and coordinate the dates with the new case manager;
  • forward the case record to the new case manager within three working days of confirming the move;
  • send Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable, advising of the transfer and new address; and
  • notify other staff and agencies, such as Texas Works staff and a Day Activity and Health Services provider, of the individual’s move.

Responsibilities of the New Case Manager

When the new case manager is notified that an individual is moving or has moved to the new service area, it is the new case manager's responsibility to:

  • contact the original case manager to notify him of the individual's move or intent to move and provide the individual's new address and phone number, if available;
  • request the individual's case record;
  • access the Service Authorization System (SAS) to confirm the current service plan;
  • send a provider choice list to the original case manager if the current provider does not serve the new area, or negotiate which case manager will obtain the individual's choice of provider if the individual has already moved;
  • negotiate a start-of-care date with the new provider and coordinate the end date for the original provider(s) with the original case manager;
  • update all applicable records in SAS, including processing the provider transfer; and
  • send Form 2065-B, authorizing services and notifying the individual of continued eligibility.

3610.10  Case Manager Activities for Individuals Transferring Between CBA and STAR+PLUS Waiver

Revision 12-4; Effective December 3, 2012

Community Based Alternatives (CBA) staff are involved any time an individual moves between CBA and STAR+PLUS Waiver (SPW). Case manager activities are specified in the STAR+PLUS Handbook.

3620  Required Notifications from the HCSSA

Revision 13-1; Effective March 1, 2013

STANDARD

  1. The Home and Community Support Services Agency (HCSSA) must notify the case manager when one or more of the following circumstances occur:
    1. The individual leaves the state for more than 90 days. The Department of Aging and Disability Services (DADS) retains the authority to extend this time in extraordinary circumstances.
    2. The individual has been legally confined or has resided in an institutional setting for longer than 120 days. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). DADS retains the authority to extend this time in extraordinary circumstances.
    3. The individual is not financially eligible for Medicaid benefits.
    4. The individual does not meet the medical necessity (MN) criteria for nursing facility care.
    5. The HCSSA has refused to serve the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in his residence.
    6. The individual or someone in his home refuses to comply with mandatory program requirements, including the determination of eligibility or the monitoring of service delivery.
    7. The individual fails to pay his qualified income trust copayment.
    8. The situation, individual or someone in his home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the service provider.
    9. The individual or someone in his home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider.
    10. The individual requests services end.

If the case manager determines that documentation supports initiation of termination, the case manager provides written notification of the termination to the individual and provider within two working days. The written notification must specify the reason for the termination, the effective date of the termination, the rule or handbook reference and provide written notice of the right to appeal.

If the individual appeals the termination notification within the 12-day adverse action period, the CBA provider continues service delivery until notification of the decision by the Health and Human Services Commission (HHSC) hearings officer. The CBA provider must not reduce the level of service until the outcome of the appeal is known.

  1. The HCSSA must verbally notify the case manager by the next working day of the reason for the termination and follow up with written documentation on Form 2067, Case Information, within two working days of the verbal notification. Refer to Section 3800, Suspensions, Notifications, Denials and Terminations, for further information on the actions that follow these notifications.
  2. If one or both circumstances specified in paragraphs (1) and (2) of this subsection occur, the HCSSA must provide written documentation to DADS to support the reason for the termination of services.
    1. The individual or someone in his home has a substantial and demonstrated pattern of verbal abuse and harassment of service providers, not related to the individual's disability, which results in an inability to provide service(s) to the individual.
    2. The individual or someone in his home has a substantial and demonstrated pattern of discrimination against the service providers on the basis of race, color, national origin, age, sex or disability that has not improved with appropriate intervention and which results in an inability to provide service(s) to the individual.
  3. The case manager must provide advance written notification of termination of services to the individual with written notice of the right to appeal.
  4. If the individual appeals the termination of services within the 12-day adverse action period, the CBA HCSSA must continue CBA services until notification of the decision by the HHSC hearings officer. The CBA provider must not reduce or suspend services until the outcome is known.

Immediate Suspension or Reduction of Services

  1. If the individual or someone in his home exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the case manager and HCSSA are required to make an immediate referral for appropriate crisis intervention services to the Department of Family and Protective Services (DFPS), the police, or both, and suspend services. Suspension of services is defined in §48.6002 of this title (relating to CBA Definitions).
  2. The case manager must immediately provide written notice of temporary suspension to the individual, and the right of appeal to a fair hearing must be explained to the individual. The written notification must specify the reason for the suspension, the effective date, the rule or handbook reference and the right of appeal.
  3. The HCSSA must verbally inform the case manager by the following DADS workday of the reason for the immediate suspension and follow up with written notification to DADS within two working days of verbal notification.
  4. The case manager must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the case manager.
  5. With prior authorization by DADS, the CBA HCSSA may continue providing services to assist in the resolution of the crisis. This service will be reimbursed as an administrative expense.
  6. If the crisis is not satisfactorily resolved, the DADS case manager provides notification of CBA termination and offers the right of appeal. Services do not continue during the appeal process.

Note: The above standards are based on current rule language. Policy allows 180 days suspension, which is greater than the standard requirements and rule language.

3630  Service Breaks

Revision 10-5; Effective December 1, 2010

§48.6096 — Service Breaks. The home and community support services (HCSS) agency must ensure that any authorized or scheduled personal assistance services are delivered in accordance with the Individual Service Plan unless the actions specified in paragraphs (1)-(5) of this section occur:

(1)
services are automatically suspended;
(2)
services are suspended for cause;
(3)
the participant is not at home when services are scheduled to be delivered;
(4)
the participant requests that services not be provided on specific days; or
(5)
the participant agrees to less than the scheduled hours as documented in the record.

§48.6096(1) — pertains to circumstances identified in §48.6100, 48.6098 and 48.6106, found in Texas Administrative Code (TAC), Chapter 48.

§48.6096(2) — pertains to circumstances identified in §48.6102 and 48.6104 found in TAC, Chapter 48.

Service breaks are not permitted except in the circumstances identified above.

Rescheduling is allowed for the provision of delegated nursing tasks, as long as the needs of the participant can be met and the schedule change is consistent with the orders of the physician.

The provider agency must have a backup system to assure the provision of all authorized personal assistance services (PAS) without a service break, even if there are unexpected changes in personnel.

There is no requirement that the provider agency call the participant to determine if there is a service break.

The case manager must contact the contract manager if the Home and Community Support Services Agency (HCSSA) has not adequately prevented service breaks, has other problems which endanger the health and safety of the participants, or has not fulfilled its commitments to provide services.

The case manager must consider the nature of the service breaks and the possible risks to the participant when deciding if there should be a change in the provider or the service plan.

If the participant receives delegated nursing tasks, the agency may temporarily use licensed personnel (RNs or LVNs) to prevent a break in nursing care. The use of licensed personnel to prevent a service break is limited to 10 hours per individual service plan (ISP) waiver year, under the following conditions:

  • there are no attendants available to perform the needed tasks and only licensed personnel can be recruited; and
  • the HCSSA informs the case manager, via Form 2067, Case Information, by the next DADS workday when licensed personnel are used to prevent a service break. Form 2067 must detail what efforts the provider has made to locate an attendant to deliver the personal assistance services.

When an attendant is not available, the HCSSA is responsible for providing the authorized personal assistance services. If the HCSSA licensed nurse directly provides the nursing tasks that previously had been delegated, the nurse may bill at the nursing hourly rate for up to 10 hours per ISP year. If the nurse is providing only personal care tasks, the nurse must bill his time at the attendant hourly rate, not the nursing hourly rate.

The case manager reviews Form 2067 sent by the HCSSA to verify compliance with the notification requirements, and revises, if appropriate, the ISP, Form 3671-1, Individual Service Plan, based on the existing authorizations for attendant and nursing services.

3640  Annual Reassessments

Revision 12-3; Effective September 4, 2012

3641  Annual Reassessment Activities

Revision 12-3; Effective September 4, 2012

The individual service plan (ISP) must be approved by the Department of Aging and Disability Services (DADS) and updated by the interdisciplinary team (IDT) at least annually.

Medical necessity determinations must be performed annually for all individuals in the Community Based Alternatives program.

Refer to Section 7000, Case Management Procedures for Utilization Review, for information on determining if the annual reassessment ISP requires a prospective utilization review and procedures for processing the prospective review.

3642  Annual Medical Necessity Evaluation and Home Health Assessment

Revision 13-3; Effective September 3, 2013

STANDARD.  The case manager assures that the reassessment of medical necessity (MN) is completed within the annual requirement to prevent any gaps in eligibility. The MN expires on the last day of the current individual service plan (ISP) effective period. The Home and Community Support Services Agency (HCSSA) must submit the annual reassessment packet to the case manager according to the time frames listed in Appendix VIII, CBA Reassessment Packet Due Dates.

The HCSSA nurse performs a face-to-face assessment to collect information for the Community Based Alternatives (CBA) annual eligibility determination and to identify needs for care plan development. The HCSSA nurse is required to:

  • complete and electronically transmit the Medical Necessity and Level of Care (MN/LOC) Assessment to Texas Medicaid & Healthcare Partnership (TMHP);
  • assess the need for services available through CBA to support the documentation of need on the MN/LOC Assessment and include all identified medically necessary services and rationales on Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, and Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan;
  • complete Form 3671-K, Service Backup Plan, for each CBA service to document the name and telephone number of the person the individual contacts and a designated resource, who is the person or entity that will provide the backup when normal service delivery is interrupted, in the absence of the scheduled service provider, or in an emergency;
  • document the conclusion regarding medically necessary services on Form 3671-2, Individual Service Plan, by checking the appropriate boxes on Form 3671-2 and indicating which attachments are included in the assessment packet;
  • review Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, and notify the case manager using Form 2067, Case Information, of any changes needed in personal assistance services (PAS);
  • discuss third-party resources (TPR), non-waiver services and informal support with the individual and document on Form 8598, Non-Waiver Services, or the ISP form attachments if the TPR relates to the services listed on the attachment;
  • sign Form 3671-2, documenting the assessment of services for the proposed service plan;
  • obtain the individual's signature in the "Freedom of Choice and Acknowledgement" and "Acceptance of the ISP" sections on Form 3671-2; and
  • obtain the signature of the HCSSA representative on Form 3671-2, accepting the individual or refusing to serve the individual based on licensure limitations with the provision that, if accepted, the plan proposed in the assessment will be implemented, unless the case manager contacts the HCSSA to arrange for changes to the proposed plan.

Note: The HCSSA may wait to accept or refuse the individual after receipt of the developed plan by the case manager and the HCSSA may negotiate plan changes before signing Form 3671-2.

The HCSSA nurse sends to the case manager:

  • the Document Locator Number (DLN) of the completed and transmitted MN/LOC Assessment (the consumer's Physician Signature Page is not required at the annual reassessment);
  • Form 3671-2, with required HCSSA and individual signatures;
  • Form 8598, if applicable;
  • Form 2060-A and Form 2067, if changes are recommended for PAS; and
  • any appropriate attachments noted on Form 3671-2 (Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-F, Form 3671-H, Form 3671-J and Form 3671-K).

Boxes for medically necessary services not checked by the HCSSA nurse on Form 3671-2 indicate that the individual does not need that particular service.

At the time of the Annual MN/LOC Assessment or Significant Change in Status Assessment (SCSA), the HCSSA is only required to supply the case manager with the DLN; the Physician Signature Page is not required.

The case manager must review the annual reassessment packet for completeness upon receipt. Additional information should be requested from the HCSSA nurse when there are inconsistencies in the assessment information or required signatures are missing.

If the annual reassessment packet is not complete, the case manager must send Form 2067 to the HCSSA within three working days requesting additional information or items needed to complete the assessment packet.

If the annual reassessment packet is not received by 60 calendar days before the expiration of the ISP, or subsequently not received by the dates listed in Appendix VIII, the case manager must notify the HCSSA by telephone and via Form 2067 to complete the MN/LOC Assessment, Form 3671-2, and any ISP attachments, if applicable.

The MN decision made by TMHP, based on the MN/LOC Assessment submitted by the HCSSA, will be shown on the Service Authorization System (SAS) MN record or the Long Term Care (LTC) online portal. The case manager is responsible for accessing the MN denial determinations from the SAS MN record or LTC online portal and generating Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, within two working days of determining that MN has been denied. When notifying the individual of an MN denial, the case manager must reference the appropriate rule for termination.

Annual reassessments must be completed timely to avoid gaps in services. The HCSSA is not entitled to payment if the annual reassessment packet is submitted late.

Follow procedures in Section 3411, Documentation of Waiver Requirements, and Section 3315, Home and Community Support Services Agency (HCSSA) Responsibility for Pre-Enrollment, for guidelines to obtain HCSSA signatures.

3642.1  Physician Signature at Annual Reassessment

Revision 10-3; Effective June 1, 2010

A physician's signature is not required on the Medical Necessity and Level of Care (MN/LOC) Assessment for an annual assessment. The Home and Community Support Services Agency's (HCSSA's) requirement to obtain a physician's signature on the HCSSA's Plan of Care is sufficient.

At the initial pre-enrollment assessment, the HCSSA is not required to obtain a physician signature on the nursing facility (NF) Minimal Data Set (MDS) assessment for consumers who entered the Community Based Alternatives (CBA) program from the NF if the MDS assessment does not have a physician's signature. For these consumers, the HCSSA completes and submits the MN/LOC Assessment at the annual reassessment with the "Reason" (AA8a) marked as "Annual" (option 2).

3643  Annual Update of the ISP

Revision 12-4; Effective December 3, 2012

STANDARD.  The case manager must assure that the individual's individual service plan (ISP) is updated at least annually. The case manager must verify all aspects of eligibility before determining ongoing eligibility for the Community Based Alternatives (CBA) program.

The case manager must complete all procedures necessary to develop and approve the new reassessment ISP and enter the authorized services into the Service Authorization System (SAS) before the expiration date of the current ISP. The effective date of the new reassessment ISP is the first day of the new ISP year, which is the day after the last day of the previous ISP. The effective dates are the same on Form 3671-1, Individual Service Plan, and Form 2065-B, Notification of Waiver Services (effective and provider authorization date). The case manager signature date and the date mailed (top right corner) on Form 2065-B must be the same date and must be before the ISP expires.

The case manager should schedule face-to-face interviews with the individual, his family or other knowledgeable responsible party no earlier than 60 calendar days before the expiration of the individual's ISP, but early enough to complete all annual reassessment activities before the ISP expiration date. The case manager may be required to assist the individual in completing the application for Medicaid recertification.

If the individual or provider requests or documents a need for a service on the current ISP prior to the new reassessment ISP implementation date, the case manager should process the request to change the ISP within 14 calendar days of receipt of the request using routine change policy found in Section 3610.2, Case Manager Response to Routine Change Requests. Otherwise, the case manager should process the change as part of the new reassessment ISP.

The case manager must not enter the services from the reassessment ISP in SAS unless the individual meets all eligibility criteria or the reassessment ISP is being submitted due to the individual's timely appeal due to program termination.

To complete the new reassessment ISP, the case manager must complete all of the following activities before the expiration of the current ISP:

  • Verify medical necessity (MN) through SAS or the Long Term Care (LTC) portal.
  • Verify continued financial eligibility.
  • Complete a functional assessment on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-A, Addendum to Form 2060 for Personal Assistance Services (except for individuals residing in assisted living (AL) facilities). Note: Use the highest participant rate for personal assistance services (PAS) to compute the ISP.
  • Calculate the room and board charges and copayment for an individual in an Adult Foster Care (AFC) or AL setting and copayment for any individual whose financial eligibility involved an income diversion trust.
  • Review and complete the ISP attachments (Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, Form 3671-H, Dental Services, and Form 3671-J, Dental Services – Proposed Treatment Plan), as appropriate, and incorporate any delegated tasks or other changes to PAS on Form 2060 and Form 2060-A.
  • Review and document non-waiver services on Form 8598, Non-Waiver Services.
  • Meet with the individual, review the selection of providers and confirm agreement with the completed ISP.
  • Develop cost figures and determine the ISP is within the cost limit. If not, consider additional policy to exceed the cost limit.
  • Send the providers copies of the ISP, Form 3671-1, Form 3671-2, Individual Service Plan, Form 8598, and any attachments (Form 3671-B, Form 3671-C, Form 3671-D, Form 3671-E, Form 3671-F, Form 3671-H, Form 3671-J, Form 2060 and Form 2060-A).
  • Obtain the accepted Form 3671-2 from the AFC, AL and Home and Community Support Services Agency (HCSSA), as appropriate. Providers are required to fax Form 3671-2 back to the case manager within two working days of receipt of the ISP. If changes are made to the ISP, the case manager must obtain the individual's signature or document his verbal agreement to the changes on the ISP.
  • Verify that the ISP has been signed appropriately by all applicable parties.
  • Complete Form 2065-B and send to the individual with copies to the authorized providers.
  • Along with Form 2065-B, send Form 3671-1 and the ISP attachments to the individual, all appropriate CBA service providers and all members of the interdisciplinary team
  • Send Form 2065-B to Medicaid for the Elderly and People with Disabilities (MEPD) staff with Form H1746-A, MEPD Referral Cover Sheet, if appropriate.
  • Data enter the authorized services in SAS according to the time frames.

Note: Send a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment to the AL provider but do not send copies of Form 2060 and Form 2060-A. Send Form 2067, Case Information, to notify the HCSSA of any changes in the ISP developed after the assessment.

If the reassessment Form 3671-1 is submitted and current MN information is not found in SAS, the ISP will suspend. The ISP will also suspend if the Texas Integrated Eligibility Redesign System (TIERS) records do not reflect eligibility for a correct Medicaid type program at the time the ISP reassessment is data entered.

For an individual who appeals a program termination within the 12-day advance notice period, CBA services can be continued into the new reassessment period, if requested by the individual. However, the case manager must complete the new reassessment ISP and it must be registered in SAS. The case manager will notify the providers via Form 2067 to continue services until the outcome of the appeal is determined.

Any gaps in concurrent coverage of the MN or the ISP will cause the loss of payment to the providers and unnecessarily jeopardize the care of the individual.

3643.1  Medical Necessity Denials at the Annual Reassessment

Revision 12-4; Effective December 3, 2012

The case manager must complete an additional process when the Medical Necessity and Level of Care (MN/LOC) Assessment status in the Long Term Care (LTC) Portal for an individual receiving services is "MN Denied." Refer to Section 3430.1, Additional Procedures for Medical Necessity Denials, for the process to use when the status "MN Denied" shows up on the LTC Portal.

3644  Annual Reassessment Copayment Procedures

Revision 12-4; Effective December 3, 2012

For an individual who lives in an adult foster care (AFC) or assisted living (AL) setting, Form 3671-1, Individual Service Plan (ISP), submitted for the reassessment must include copayment entries for the initial and ongoing copayments. For an ISP that begins on the first of a month, the initial and ongoing copayments on the reassessment ISP should be the same amount. This amount also should be the same as the ongoing copayment for the previous ISP unless there has been a change in the individual's income or deductions.

3645  Financial Eligibility for Annual Reassessments

Revision 13-3; Effective September 3, 2013

STANDARD.  The case manager must review Texas Integrated Eligibility Redesign System (TIERS) records to assure that the individual continues to be on a Medicaid type program which is appropriate for CBA before program eligibility is determined.

The financial eligibility must be certified by Medicaid for the Elderly and People with Disabilities (MEPD) staff at least annually with more frequent reviews required for variable income and other anticipated changes in circumstances. The case manager should assist the individual, as necessary, with completing the application (Form H1200, Application for Assistance – Your Texas Benefits) and obtaining other documentation required for the recertification. Coordination of efforts between the case manager and MEPD specialist is in the best interest of the individual and both workers.

Copayment information will be recorded in TIERS.

Envelopes Used by MEPD for Recertification

In order to maintain financial eligibility, Medicaid recertification packets must be returned to MEPD in a timely manner. An individual may not recognize the envelope as being an official Health and Human Services Commission (HHSC) document and, therefore, does not open the envelope. As a result, the individual’s recertification packet is not returned and his financial eligibility is denied.

The case manager must provide the individual with an explanation of the Medicaid recertification packet envelopes. Previously, envelopes contained the following wording, “Important Insurance Information.” Envelopes now state the following:

Image of wording, Time Sensitive stamp

The case manager must take examples of the envelopes to the face-to-face contact so the individual can become familiar with the new appearance of the envelopes. The case manager can make copies of the envelope examples located in Appendix XXV, Examples of HHSC Envelopes, to provide to the individual at the annual contact. The case manager must discuss with the individual the importance of returning Form H1200 to HHSC within the required time frame provided in the redetermination packet.

HHSC uses Form H1200-SR, Streamlined Redetermination for MEPD. Form H1200-SR is generated from TIERS. HHSC may determine an individual appropriate for a streamlined recertification if the individual has had a minimum of one annual recertification using Form H1200. The individual will receive Form H1200-SR instead of Form H1200. The cover sheet to Form H1200-SR provides specific directions for the individual to follow to determine if the form needs to be completed and returned to HHSC. The case manager must discuss with the individual the importance of thoroughly reviewing Form H1200-SR to determine if changes need to be reported to HHSC. If the individual has any questions regarding the information on Form H1200-SR, he should contact HHSC by mail or fax using the address or fax number on the application or by calling 211.

In addition to receiving one of the forms mentioned above from HHSC, the individual may also receive Form H1010, Texas Works Application for Assistance - Your Texas Benefits. The individual may only return Form H1010 thinking this form will suffice for all services the individual is receiving. The case manager must inform the individual Form H1200 or H1200-SR, and Form H1010 must both be completed and returned to HHSC. The case manager must make the individual aware he can track the status of his application using the “HHSC Your Texas Benefits” website at www.yourtexasbenefits.com, or by calling 211.

3650  Advocacy

Revision 12-4; Effective December 3, 2012

The ongoing case management function of advocacy is critical to the effective provision of cost-effective services to the individual in the Community Based Alternatives (CBA) program.

Advocacy follows the identification of needs by the interdisciplinary team (IDT) or problems found by the case manager during the monitoring of services and service response. The case manager advocates for the individual by speaking on the individual's behalf for the services necessary to address the individual's needs and help him achieve any goals needed to live in the community. Advocacy considers the individual's right to the choice of service location and responsibility for as much self-care as possible. Advocacy could be instituted to:

  • make existing services available to the individual;
  • make existing services meet the individual's needs; or
  • develop services to meet the individual's needs.

Existing community or non-waiver service providers may be able to change the admission criteria, services provided or other procedures to allow the individual to receive services. CBA providers must provide the services they have contracted to provide and must respond when the case manager informs the provider that services are unsatisfactory. The case manager will notify the contract manager if the CBA provider's services are not adequately corrected. Financial sanctions can be applied to CBA providers who do not correct deficiencies. Existing non-waiver providers can be encouraged to increase or provide needed services but no direct Department of Aging and Disability Services sanctions are available.

3660  Individual's Safety

Revision 12-4; Effective December 3, 2012

The case manager is responsible for assuring that the applicant or individual receives the services necessary to adequately meet his needs in the community. The individual service plan (ISP) for Community Based Alternatives (CBA) services includes waiver and non-waiver services, that when combined, should represent a service plan that has a reasonable expectation of adequately meeting the needs of the individual in the community setting within the individual's assessed ISP cost limit. The cost limit applies to the CBA-purchased services, which are documented on Form 3671-1, Individual Service Plan. If the applicant or individual has needs for CBA-purchased services that exceed the ISP cost limit, he is not eligible for CBA. Refer to Section 3421.2, Denial When Proposed ISP Exceeds the Cost Limit, for information. Before the denial of a CBA applicant or individual who has high needs, follow the protocol in Appendix XIII, Resources for Handling High Needs Applicants.

For an individual who is legally competent, the issue of adequacy of the ISP must also be balanced with the individual's right to choose services to meet his needs, his responsibility to provide as much self-care as possible and the related issues sometimes referred to as the "dignity of risk." For an individual who has been determined to be legally incompetent, the interdisciplinary team (IDT) must also consider the desires of the individual's guardian or legal representative as well as the adequacy of the ISP to meet the individual's needs in the community.

3661  Ongoing Case Management Duties Related to Medicaid

Revision 12-2; Effective June 1, 2012

The case manager must assure that the individual receives the Medicaid benefits for which he is eligible and that he continues to be eligible for these benefits. Some specific examples of areas related to Medicaid that may require the case manager's assistance are listed below.

3661.1  Your Texas Benefits Medicaid Card and Replacement

Revision 12-2; Effective June 1, 2012

Individuals who are determined eligible for Medicaid will receive the Your Texas Benefits (YTB) Medicaid card. The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services as the card is not proof of Medicaid eligibility.

  • Individuals receiving Medicaid must take the card to doctor or dental appointments and to the pharmacy. The YTB Medicaid card is expected to be for permanent use and the Health and Human Services Commission (HHSC) will only issue a new card if the card is lost or if the information printed on the card changes.
  • Individuals may call 1-855-827-3748 if the card is lost and they need a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line, so even if a card is lost, individuals may receive services and fill prescriptions. The card should not be thrown away, even if individuals are denied Medicaid, since the card will be reused if they later regain eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form, not available on the website and must be ordered. However, the form instructions are available on the Department of Aging and Disability Services (DADS) Forms website for completion of the form. Designated DADS staff may continue to assist individuals in the following situations:

  • Individuals receiving Medicaid benefits – DADS staff may assist with a manual Form H1027-A upon request because individuals either lost the YTB Medicaid card or did not receive it. DADS staff issuing Form H1027-A should inform individuals of the following:
    • Call 1-855-827-3748 for a replacement card.
    • The burden of verifying Medicaid eligibility is with the provider. Individuals who are Medicaid eligible, but do not have written proof of eligibility, should still be able to get services from their provider or to fill prescriptions. Medicaid providers and pharmacies can verify eligibility by phone using a provider dedicated line OR by using the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
  • Individuals who recently applied for Medicaid benefits – Eligibility information is not immediately available for providers or pharmacies to verify after the Medicaid is approved. DADS staff must refer individuals to the HHSC Benefits office to issue Form H1027-A between the time the eligibility is determined and the time the eligibility is available in the on-line systems.

Once individuals receive the replacement card, they present it to the Medicaid provider or pharmacy any time they request services. Individuals may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage, if they are not sure of Medicaid eligibility status.

More information about the new card is available at: www.yourtexasbenefits.com.

If Medicaid providers will not accept Form H1027-A as proof of Medicaid eligibility, case managers may assist individuals in dealing with the provider. Medicaid for the Elderly and People with Disabilities (MEPD) staff also may be asked to assist.

In situations where Medicaid eligibility cannot be verified on the Texas Integrated Eligibility Redesign System (TIERS), such as when supplemental security income (SSI) has been denied but should be reinstated with contiguous coverage, the MEPD staff may be able to assist in contacting the Social Security Administration (SSA) to determine if emergency manual certification procedures can be used. If SSA staff determine there is a medical emergency, the approvals required for issuance of Form H1027-A will be expedited.

It may be appropriate to request the assistance of the Department of State Health Services regional pharmacist for the vendor drug program. Pharmacists participating in the vendor drug program may contact pharmacy billing at 1-800-435-4165 to confirm eligibility for unlimited prescriptions for individuals with CBA individual service plans registered on the Service Authorization System (SAS).

3661.2  Reporting Changes Affecting Eligibility

Revision 13-1; Effective March 1, 2013

After an individual has been enrolled in the Community Based Alternatives (CBA) program, circumstances affecting his eligibility may change. The case manager should make the individual aware of changes that must be reported and should assist the individual in reporting these changes, if necessary. The following is a list of changes the individual must report to the Social Security Administration (SSA) or his designated Medicaid for the Elderly and People with Disabilities (MEPD) specialist:

  • changes in income, such as income from a job or workshop, retirement benefits, pensions, earnings, interest, dividends;
  • changes in address or living arrangements;
  • back payments or lump-sum payments from any source;
  • changes in bank accounts, savings accounts, certificates of deposit, Individual Retirement Accounts, and similar financial accounts;
  • changes in insurance policies, such as the purchase of a new policy, a policy cancellation, or change in beneficiary;
  • changes in property, such as the purchase, sale, lease, or transfer of property;
  • payments from insurance;
  • payments from the Prospective Payment Plan (PPP) program directly to the individual. (PPP funds are not counted as income for the month of receipt and are excluded as a resource for the month of receipt and the month following receipt);
  • inheritances;
  • contributions or gifts of money, property, or other valuable items;
  • births in the immediate family; and
  • deaths in the family.

If the individual receives Supplemental Security Income (SSI), the individual or his responsible party must contact SSA to request the residence address change. The MEPD specialist is able to change the address in the Texas Integrated Redesign System (TIERS), the address will revert back to the address on the SSI record at the next state cutoff. The individual or his responsible party must report any of these changes within 10 calendar days of occurrence.

In some cases, the case manager may report the change on behalf of the individual. Written proof is likely to be requested. It is very important to report changes promptly; if overpayments are made, this could lead to recoupment of the funds.

3661.3  Medicaid Resource Limit

Revision 02-0; Effective April 4, 2002

Because an individual who leaves a nursing facility (NF) in order to enter the waiver will receive or keep more income after leaving the NF, there is a greater possibility that the individual could become ineligible for Medicaid if his assets exceed $2,000 (the individual resource limit for Medicaid). The case manager should assist the participant, as necessary, to assure he does not lose his Medicaid eligibility because of excess resources. For example, the case manager may suggest to the participant that he purchase clothing or other personal items needed if he is near the resource limit.

3661.4  Income Eligibility Verification System

Revision 02-0; Effective April 4, 2002

The Medicaid for the Elderly and People with Disabilities (MEPD) program has access to information through the Income Eligibility Verification System (IEVS) which provides information on possible income or resources that may affect the participant's eligibility for Medicaid services. The MEPD specialist may share information with, or ask for assistance from, the case manager regarding a potential eligibility problem. Information obtained from the IEVS is confidential and must not be shared with anyone, including the applicant's or participant's representative or providers, under penalty of personal and/or agency liability for unauthorized disclosure.

3661.5  Medical Transportation

Revision 02-0; Effective April 4, 2002

Community based alternatives (CBA) participants, as recipients of Medicaid, are eligible to use the Medicaid medical transportation system for Medicaid-covered medical appointments. The Medicaid medical transportation system is accessed by calling the local contract agency whose number should be available from the local DADS office. Adult foster care/assisted living/residential care (AFC/AL/RC) providers are responsible for scheduling the transportation.

The local Medical Transportation contractors have procedures regarding service area limitations, schedules for traveling to certain areas, and requirements on the amount of notice required which will apply to CBA participants. The AFC/AL/RC provider must provide an escort for the participant, if necessary.

There may be questions about eligibility for participants who are living in AFC/AL/RC facilities. In cases of difficulties in scheduling or questions about eligibility for transportation, participants should contact the case manager to intercede on the participant's behalf with the local Medicaid medical transportation system.

3670  Prescriptions

Revision 12-2; Effective June 1, 2012

Prescribed drugs beyond the three per month limit available under the Texas Medicaid State Plan are provided to individuals enrolled in the Community Based Alternatives (CBA) program, unless the individual is dually eligible for both Medicaid and Medicare. Implementation of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, effective Jan. 1, 2006, affects how individuals receive their prescription drugs. The Medicare Prescription Drug Program is called Medicare Rx.

Before implementation of Medicare Rx, individuals received their prescriptions through the Texas Medicaid State Plan Vendor Drug program. With the implementation of Medicare Rx, individuals now receive prescriptions through the Medicaid Vendor Drug program or Medicare Rx, or a combination of both.

At initial intake, applicants requesting CBA services must be informed of prescription coverage available through the CBA program and the Medicare Rx program. The impact of the Medicare Rx program on individuals receiving CBA services must be explained to the applicant.

  • If individuals receive Medicaid only, they obtain prescription drugs through the Medicaid Vendor Drug program.
  • If individuals are considered dually eligible (receiving both Medicare and Medicaid), they obtain prescriptions first through Medicare Rx, or for certain prescribed drugs excluded from Medicare Rx, through the Vendor Drug program.
  • Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all prescribed medications required for individuals. Prescriptions not covered by Medicare Rx may be paid by the Medicaid Vendor Drug program; however, the Medicaid Vendor Drug formulary does not cover certain drugs and many over-the-counter medications.
  • Individuals who participate in Medicare Rx are responsible for purchasing any medications and copayments for medications not covered through Medicare Rx or the Medicaid Vendor Drug program.
  • Individuals not participating, or those choosing private insurance over Medicare Rx, are also responsible for purchasing medications and copayments for medications not covered by Medicare Rx or the Medicaid Vendor Drug program.
  • Individuals eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program. These individuals pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

Federal law prohibits the use of CBA funds for Medicare Rx prescriptions, copays and costs. CBA funds may not be authorized for prescriptions, copays and costs if the applicant or individual is eligible for Medicare Rx and chooses private insurance rather than participation in Medicare Rx. Non-covered medications cannot be billed through the CBA program as medical supplies or adaptive aids.

Copays for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through CBA.

Individuals who contribute to the cost of their care may be eligible to count Medicare Rx costs as an incurred medical expense if they:

  • reside in the community and have a Qualified Income Trust; or
  • receive CBA Assisted Living or Adult Foster Care services.

Refer to Section 3671, Incurred Medical Expenses.

For an individual to receive more than three prescriptions, the individual must be registered in the Service Authorization System (SAS) for CBA.

Pharmacists may verify the individual's eligibility for more than three prescriptions by calling Pharmacy Billing at 1-800-435-4165.

A list of the CBA enrollments is sent to the Medicaid Vendor Drug program daily. Vendor Drug staff will have the individual registered on their system within two days after the individual's enrollment record is registered in SAS for CBA services.

Home and Community Support Services Agency staff must check the individual's Medicaid eligibility monthly to ensure that the individual remains eligible for CBA services.

3670.1  Over-the-Counter Drugs

Revision 09-9; Effective December 1, 2009

The Community Based Alternatives (CBA) program does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

CBA consumers must receive medications through the Medicaid Vendor Drug program or Medicare Rx, or a combination of both if the consumer is dually eligible for Medicaid and Medicare RX. Medications, including over-the-counter drugs, not covered through the Medicaid Vendor Drug program, Medicare RX or other third party resources, cannot be paid for by the CBA program. Refer to Section 3670, Prescriptions, for additional information.

3671  Incurred Medical Expenses

Revision 09-9; Effective December 1, 2009

Incurred medical expenses (IMEs) are out-of-pocket expenses that a Medicaid consumer can incur for necessary medical services. IMEs include the cost of items that are medically necessary and not covered by Medicaid, such as Medicare Rx premiums.

Community Based Alternatives (CBA) consumers who contribute to the cost of their care may be eligible to count Medicare Rx costs (such as premiums, enhanced premiums, prescriptions drug copayments/deductibles and drugs not covered by Medicare Rx, the Medicaid Vendor Drug program and non-formulary drugs) as IMEs if they:

  • reside in the community and have a Medicaid copay as a result of a Qualified Income Trust (QIT); or
  • reside in an Adult Foster Care (AFC) home or an Assisted Living/Residential Care (AL/RC) facility.

IMEs are not allowed for Medicaid recipients who receive Medicaid only and receive prescription drugs through the Vendor Drug program.

Consumers who wish to use IMEs to pay for Medicare Rx costs should report these costs to the case manager or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist so that the costs can be included in the calculation of copay for waiver services. The consumer's statement of Medicare Rx expenses is acceptable. No written documentation is required from the consumer to support the declaration. The arrangement for payment of the prescriptions is between the consumer and the pharmacist.

Some drugs will not be covered by Medicare Rx, Medicaid or private drug coverage. In order for these non-formulary drugs to be considered as IMEs, a consumer must request an exception from the Medicare Rx plan for the drugs. The consumer will use the procedure for requesting an exception, as required by his Medicare Rx plan. Either the consumer or the Department of Aging and Disability Services (DADS) case manager can submit the results of the requested exception directly to MEPD staff.

If an exception is not requested, the non-formulary drugs will not be allowable IMEs and the cost will be the responsibility of the consumer.

case managers will apply the IME policy during the certification process to all new CBA consumers who meet the above criteria. Case managers will review Medicare costs and IMEs once every six months as part of the regular case monitoring, or whenever the consumer makes a request to update IME costs.

To process Medicare Rx costs as IMEs, the case manager:

  • lists the consumer's drugs and the amount of copayment for each drug;
  • lists the consumer's Medicare premium and deductible expenses;
  • sends the information to MEPD staff (Form H1263, Certification of Medical Necessity, is optional and may be used);
  • sends Form 2065-B, Notification of Waiver Services, to the consumer notifying him of the monthly copayment amount upon notification from MEPD staff;
  • sends the CBA provider the copayment amount that must be collected from the consumer; and
  • registers the copayment amount in the Service Authorization System (SAS).

If the information changes, the case manager completes the process and notifies MEPD staff in writing to request a change in the copayment amount. If Medicare Rx related expenses increase, the consumer will use his personal funds to pay the expenses until an adjustment is made to the monthly AL/RC, AFC or QIT copayment amount.

The consumer or his representative may identify and request IMEs, or the DADS case manager may assist with the IME request if the consumer is unable to do so or does not have an authorized representative. Consumers who do not request assistance with Medicare Rx costs as IMEs will continue to pay for any Medicare Rx related expenses themselves.

3680  Reporting Service Delivery Issues to Consumer Rights and Services

Revision 11-2; Effective June 1, 2011

The case manager must follow specific guidelines and time frames to handle program provider service delivery issues reported or generated by:

  • the consumer/consumer's representative;
  • Department of Aging and Disability Services (DADS) staff, including issues discovered by the case manager or reports received during monitoring contacts; and
  • other individuals, including the consumer's family/friends.

Service delivery issues include any dissatisfaction expressed by the consumer regarding a service delivery provider. The consumer may express dissatisfaction about:

  • the quality of a service provided (care, treatment or services received);
  • aspects of interpersonal relationships, such as rudeness; or
  • the service provider's failure to:
    • respect the consumer's rights;
    • follow terms of contract or applicable rules; or
    • provide services which may or may not have had an adverse affect on the consumer.

This list is not all inclusive.

Within five working days of receiving a report or becoming aware of service delivery issues, the case manager must respond to the consumer and the provider either by phone or face-to-face contact to discuss the issues. The case manager must inform the provider of the service delivery issues and discuss resolutions. The case manager convenes an interdisciplinary team (IDT) meeting, if appropriate. The case manager coordinates with the consumer and provider to implement actions required to resolve the issues. The case manager must document the receipt of the report and contacts with the consumer and the provider in the case record. The case manager must document any barriers or hindrance by either party that interferes with resolution of the issues. The resolution of the issues and/or attempts to resolve the issues must be documented.

If service delivery issues cannot be resolved within 10 working days of the initial receipt of a report or becoming aware of service delivery issues, the case manager must:

  • report the service delivery issues to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858;
  • inform the consumer of his right to call the CRS hotline to register a complaint regarding the provider, including a Consumer Directed Services Agency (CDSA); and
  • inform the consumer of his right to choose another provider.

The case manager must make the report to CRS within three working days after the 10-working-day resolution period ends.

In situations where service delivery issues may compromise the consumer's health and safety, the case manager must call CRS as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case manager must also contact Adult Protective Services or Child Protective Services within 24 hours if there is an immediate or imminent threat to the health and safety of the consumer. The case manager must continue to work with the consumer and provider to resolve the issues within the 10-working-day time frame.

The case manager must identify the specific service the provider is delivering when calling CRS to report a complaint. For example, the case manager identifies the provider as a "CBA provider" when making a referral to CRS that involves CBA service delivery issues. The case manager must provide specific information related to the service delivery issue, including actions taken to resolve the issues and why the actions did not resolve the issue. CRS will log the information into the automated system and forward the complaint to the appropriate DADS division for action.

3700  Service Monitoring

Revision 13-3; Effective September 3, 2013

STANDARD. The case manager has the primary responsibility for assessing the individual’s need for services, service planning, authorizing services, utilization of non-waiver resources and monitoring services. The case manager or other designated Department of Aging and Disability Services (DADS) staff evaluate the appropriateness and adequacy of both waiver and non-waiver services through contact with the individual.

The case manager must complete case activities, including monitoring contacts and developing the individual service plan (ISP), with the individual unless the individual cannot complete the action due to communication or health conditions that prohibit him from adequately communicating his needs. The case manager must document in the case record:

  • the individual is present at the interview;
  • the necessity for a person to assist on behalf of the individual;
  • why the individual cannot participate or provide the necessary information;
  • the name of the person(s) who will provide the information on behalf of the individual; and
  • the relationship of the person(s) to the individual.

If the individual's caregiver is the paid attendant and there is no other caregiver or family member available who is aware of the care being provided, the case manager may complete the monitoring contact with the caregiver/paid attendant. The case manager must use observation skills and professional judgment to determine if the answers provided by the caregiver/paid attendant appear to be consistent with the individual’s condition and the appearance of the care provided to the individual. The case manager must document that observation skills were used to substantiate the information provided during the monitoring contact.

3710  Monitoring Contacts and Telephone Contacts

Revision 13-3; Effective September 3, 2013

Thirty-day, six-month and annual monitoring contacts are required for every individual receiving Community Based Alternatives (CBA) services. Contacts are made more frequently, when appropriate. Form 2314, Satisfaction and Service Monitoring, must be completed and entered into the Service Authorization System (SAS) monitoring wizard for all required monitoring contacts.

30-Day Monitor Contact

Department of Aging and Disability Services (DADS) staff must contact every individual within 30 days of the initial individual service plan (ISP) effective date. The case manager ensures that CBA services were initiated within 30 days of the effective date. Thirty-day contacts may be made face-to-face or by telephone. Completion of Form 2314 is required for the 30-day monitoring contact.

Refer to Section 3714, Monitoring of Adult Foster Care (AFC), and Section 3715, Monitoring of Assisted Living (AL), for 30-day requirements related to AFC and AL services.

Six-Month and Annual Monitor Contacts

Two contacts are required each ISP year. The first contact is completed by the end of the sixth month after the effective date of the ISP as entered on Form 2065-B, Notification of Waiver Services, for the initial enrollment or annual reassessment ISP. The second six-month contact coincides with the annual reassessment.

To determine six-month contact due dates, begin counting months with the first month after the ISP effective date month.

Examples:

  • Initial ISP effective period: June 13 – June 30 next year.
    First contact due by: December 31.
    Second contact due by: June 30 next year.
  • Initial ISP effective period: June 1 – May 31 next year.
    First contact due by: December 31.
    Second contact due by: May 31 next year.
  • Reassessment ISP effective period: June 1 – May 31 next year.
    First contact due by: December 31.
    Second contact due by: May 31 next year.

The first six-month contact may be completed by telephone. The second six-month contact that coincides with the annual reassessment must be completed face-to-face. Form 2314 completion is required for the six-month and annual monitoring contact.

Form 2314 comments may be used to document information that substantiates a discrepancy with the individual's perception of an issue.

At regional discretion, Form 2314 may be used to record other case actions or contacts. The SAS scheduler function is used to record due dates for required contacts.

Telephone Contacts

If a telephone contact is allowed for a monitor and the individual does not have a telephone or cannot communicate by telephone and a caregiver or relative can provide accurate information about the individual's condition, service needs and the adequacy of the service delivery, the contact may be with a caregiver or responsible party. If contact cannot be made by telephone with the individual, caregiver or responsible party, a face-to-face visit is required.

Consider a face-to-face visit if:

  • the telephone contact indicates a significant change and the case manager cannot adequately assess the situation without a home visit;
  • the contact indicates a need to add a service or increase services;
  • the individual indicates dissatisfaction with services (including a home modification or adaptive aid) and the case manager cannot adequately assess the situation without a home visit; or
  • any other circumstances exist that would require a face-to-face contact to adequately review the ISP. Factors to be considered include the following:
    • Is the case manager already very familiar with the individual's situation?
    • Does the information reported about the change appear clear and reliable?
    • Is the reported change relatively simple or more complex? (Examples: Several changes happen at once or there is sudden and severe deterioration in functioning.)
    • Is there disagreement between what others say the individual now needs and what the individual is saying?

Monitoring for Form 3671-K, Service Backup Plan

During a service monitor contact for an initial, annual reassessment or ISP change completed by the Home and Community Support Services Agency (HCSSA), the case manager will ask the individual if he had a need to implement his service backup plan. Since implementation of the service backup plan is a new program requirement, the individual may not remember that he has one, if it was used, or both. The case manager must remind the individual the HCSSA completed Form 3671-K with the individual and included names and telephone numbers of people the individual would contact in case the service provider is absent. The case manager must ask the individual if he had a need to implement the service backup plan. If the individual indicates the service backup plan was implemented, the case manager asks if the service backup plan was effective. If the individual indicates the service backup plan was effective, the case manager checks the yes box on Form 2314 and proceeds to Section VI, Adequacy of the Service Plan. If the individual indicates the service backup plan was not effective, the case manager checks the no box, documents the reason why the plan was not effective and proceeds to Section VI. If the individual indicates the service backup plan was not implemented, the case manager checks the no box on Form 2314 and proceeds to Section VI.

When the individual indicates the service backup plan was not effective, the case manager informs the HCSSA following current procedures for contacting the HCSSA when issues or concerns are identified during the service monitor contact. Refer to Section 3716, Documentation of Monitoring, and Section 3717, Actions Following Monitoring, for HCSSA contact and documentation procedures.

All Contacts

It is the case manager's responsibility to determine if any situations exist that jeopardize the individual's health and safety, and if so, determine whether adequate information can be obtained by telephone. If adequate information is not obtained during a telephone contact or the case manager has doubts that the individual's health and safety is ensured, a home visit is required. The case manager interviews the individual to obtain the individual's assessment of how well CBA services are meeting his needs. Supervisors must ensure that every individual is seen as frequently as necessary to ensure the individual's safety and well-being are not compromised.

The results of the interview are used to develop changes in the plan of care and to evaluate services for the individual.

The case manager is responsible for following up on problems reported or any changes requested by the individual. The case manager may need to contact the reporter for additional information to ensure that the problems are resolved. The case manager is also responsible for addressing any changes requested by the individual.

While the case manager is responsible for monitoring the individual's satisfaction with services and ensuring the overall quality of the services delivered, monitoring activities may also be conducted by the contract manager, the DADS regional nurse and by other designated DADS staff.

See Section 3716.1, Service Authorization System (SAS) Monitoring Documentation, for more details on documenting Form 2314 using the SAS monitoring wizard.

3711  Six-Month Review of the Individual Service Plan (ISP)

Revision 08-8; Effective June 24, 2008

STANDARD.  The Department of Aging and Disability Services case manager must contact the consumer to review the individual service plan (ISP) and develop a new plan for any necessary changes. Document the review of the ISP for each Community Based Alternatives consumer two times per ISP year.

The purpose of the six-month review of the ISP is to determine the appropriateness and adequacy of services on the ISP and to ensure that the services are being delivered as authorized. This six-month review should determine the current condition and situation of the consumer, the current status of informal support systems and the appropriate delivery of services. The six-month review is required in addition to the ongoing requirement that the ISP be reviewed and revised as often as necessary to accurately reflect the service needs of the consumer.

3712  Review by the DADS Regional Nurse

Revision 11-1; Effective March 1, 2011

The Department of Aging and Disability Services (DADS) regional nurse may be designated to complete monitoring contacts to supplement the required contacts made by the DADS case manager.

3713  Monitoring of Providers

Revision 02-0; Effective April 4, 2002

Documentation submitted or maintained by providers regarding services and the participant's response should also be reviewed periodically, but must be reviewed at least semiannually by DADS personnel.

Generally, the contract managers will be responsible for reviewing the providers for contract and standards compliance, and financial and billing procedures for all providers except adult foster care providers.

3714  Monitoring of Adult Foster Care (AFC)

Revision 12-1; Effective March 1, 2012

STANDARD.  In addition to the required monitoring for all individuals receiving Community Based Alternatives (CBA) services, as outlined in Section 3710, Monitoring Contacts and Telephone Contacts, the Department of Aging and Disability Services (DADS) case manager must contact individuals residing in Adult Foster Care (AFC) homes at least monthly for the first three months of their residence in an AFC home. The monthly contacts must be completed for individuals who are certified for an AFC home or when an individual moves to another AFC home. Two of the three monthly contacts may be completed by telephone, but at least one of the three monthly monitoring contacts must be held privately, face-to-face with the individual in the AFC home. The AFC contacts may or may not coincide with other required monitors. If the individual's situation warrants more frequent monitors, other contacts must be scheduled. The case manager must talk with the individual or a responsible party knowledgeable of the situation and may not complete the contact by talking with the AFC provider.

The case manager also maintains contact with the Home and Community Support Services Agency registered nurse supervising the provision of nursing tasks to the AFC provider and with DADS contract managers who monitor the AFC providers for contract and standard compliance and financial and billing procedures.

The case manager monitors the needs of the individual, evaluates the adequacy and appropriateness of the CBA waiver and non-waiver services to meet the individual's needs, and participates in utilization review and monitoring activities conducted by other DADS staff upon request. Completion of Form 2314, Satisfaction and Service Monitoring, is required for the monthly monitoring contacts for individuals living in AFC homes. The case manager sends a copy of Form 2314 to the contract manager if the interview with the individual reveals a complaint or problem that needs the attention of the contract staff.

3715  Monitoring of Assisted Living

Revision 12-1; Effective March 1, 2012

STANDARD.  The case manager must contact individuals entering Assisted Living (AL) settings within 30 days of the initiation of AL services. This contact may be a face-to-face or telephone contact.

Completion of Form 2314, Satisfaction and Service Monitoring, is required for the initial 30-day monitoring contact for individuals living in AL settings. Other required CBA monitors outlined in Section 3710, Monitoring Contacts and Telephone Contacts, apply to individuals living in AL settings.

3716  Documentation of Monitoring

Revision 12-1; Effective March 1, 2012

Documentation of monitoring activities is included in the individual's case record and must include:

  • information from Form 2314, Satisfaction and Service Monitoring, for required monitoring contacts:
    • Pages 1 and 2 for the form; and
    • Service Authorization System (SAS) automated Form 2314 must be filed in the case record;
  • initial enrollment and annual reassessment individual service plans (ISPs) in which the interdisciplinary team (IDT) determines if the individual's services are adequate to meet his needs;
  • six-month reviews of the ISP in which the case manager, or other Department of Aging and Disability Services (DADS) staff members, document on the individual's assessment the appropriateness and adequacy of services;
  • narrative documentation must include information on any change in the individual's eligibility, condition, situation, satisfaction or need for change in services or providers;
  • documentation or correspondence regarding the quality of the services delivered by the various Community Based Alternatives (CBA) providers;
  • documentation of any actions taken in a crisis; and
  • information regarding the individual's complaints regarding CBA services and the provider's response.

See Section 3716.1, Service Authorization System (SAS) Monitoring Documentation, for additional documentation requirements.

3716.1  Service Authorization System (SAS) Monitoring Documentation

Revision 12-1; Effective March 1, 2012

Regional management must ensure the use of the SAS monitoring wizard. Use of the system enhances accuracy of the individual's satisfaction, provides a database for provider monitoring and ensures compliance with federal regulations for service delivery. Information documented on Form 2314, Satisfaction and Service Monitoring, must be entered into SAS for all required monitoring contacts including the 30-day, six-month and annual contacts. Form 2314, Pages 1 and 2 must be completed and filed in the case record. Pages 3 and 4 of Form 2314 are used as a worksheet for entering the coding into the SAS monitoring wizard; therefore, Pages 3 and 4 are not required to be retained in the case record. However, a copy of the SAS automated Form 2314 must be filed in the case record.

Entry of Form 2314 into the SAS monitoring wizard must occur no later than the end of the month in which the action is due.

All responses from the individual indicating dissatisfaction with services, or when the individual requires or requests a change in the service plan or service delivery, must be addressed and require a reason for dissatisfaction and an action code. If the individual requests or requires a change in his service plan, this would be an indication that he is somewhat dissatisfied with his services and therefore requires the use of the drop down boxes to record a reason for dissatisfaction and an action code. In SAS, the dissatisfaction is recorded as Problems Alleged. This allows the case manager to access the drop down reason/action boxes.

Form 2314 records satisfaction with the provider of each specific service as well as overall satisfaction with Community Based Alternatives services. In SAS, overall satisfaction is scored on the Client Satisfaction screen. Overall satisfaction is recorded after resolution of any alleged dissatisfaction.

Some action codes result in a referral to other Department of Aging and Disability Services staff, such as a contract manager, regional nurse or supervisor. Referral to other staff and the action taken is also recorded in SAS.

At regional discretion, the SAS monitoring wizard may be used to document:

  • all calls received from individuals that require case manager action (for example, requests for changes in the service plan);
  • all complaints received from individuals regarding their service plan; and
  • Day Activity and Health Services provider changes.

See Form 2314, Instructions, for additional details for completing Form 2314 and enter the information in SAS.

3717  Actions Following Monitoring

Revision 13-1; Effective March 1, 2013

If problems are identified during monitoring, the case manager is responsible for taking appropriate steps including, but not limited to:

  • notifying the provider of the apparent need for a change in the service plan or reconvening the interdisciplinary team, if necessary, to address new needs of the individual or the change in the individual service plan (ISP);
  • referring any suspected cases of abuse or neglect to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS) division;
  • referring potential provider fraud through Department of Aging and Disability Services established procedures;
  • encouraging the individual to comply with the ISP in those situations in which the individual is unwilling to allow the providers to deliver services as identified in the ISP, or otherwise is refusing to comply with his service plan; or
  • soliciting the cooperation of the contract manager under certain circumstances to institute steps to correct the problem.

See Section 3610, Revising the Individual Service Plan (ISP), for time frames related to the actions, Section 3716, Documentation of Monitoring, for required documentation of monitoring activities and Section 3716.1, Service Authorization System (SAS) Monitoring Documentation, for additional SAS documentation requirements related to follow-up actions.

3718  Transmittable Diseases

Revision 10-5; Effective December 1, 2010

While it is important that required home visits are performed on a timely basis, there may be circumstances that could place staff at risk for contracting contagious illnesses. With the increase in serious transmittable diseases in the general population, it is important to ensure the health and welfare of staff members who may come in contact with consumers reporting they have a contagious illness.

If a case manager contacts an applicant/consumer to schedule a home visit (initial, reassessment or monitoring visit) and the consumer states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case manager should schedule a future date for the visit when the consumer thinks he will be better. If unable to schedule the visit for a future date, the case manager must contact the consumer at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

3800  Suspensions, Notifications, Denials and Terminations

Revision 13-1; Effective March 1, 2013

This section provides information, procedures and references pertaining to suspension, denial and termination of Community Based Alternatives services to an applicant or individual receiving services, along with adequate notice of the applicant's or individual's rights and opportunities to due process.

3810  Program Suspension or Termination to an Individual Receiving Services

Revision 13-1; Effective March 1, 2013

The purpose of the rules and Community Based Alternatives (CBA) procedures in this section is to provide an individual receiving services protection, prevent unauthorized suspension of services by providers and assure the right of due process in circumstances that may result in suspension or termination of CBA, while recognizing the need to protect provider staff from threats to their safety. The rules will not be used to terminate CBA program eligibility based on uncontrollable behavior due to the individual's disability. The provider must follow guidelines for use of appropriate interventions and opportunities for conflict resolution through mediation or other techniques before initiating action to suspend or terminate services, unless reckless behavior which results in imminent danger to the health and safety of the service provider is exhibited by the individual or someone in his home.

Before the case manager terminates CBA, the contract manager should be informed if a provider does not follow rules, such as suspending services because the individual does not comply with mandatory program requirements.

3810.1  12-Day Adverse Action

Revision 13-1; Effective March 1, 2013

The Department of Aging and Disability Services (DADS) must provide a written notice to the individual at least 10 calendar days before the action date. An individual is entitled to be notified in writing 10 calendar days before any reduction or termination from the Community Based Alternatives (CBA) program, or to have the notification mailed 12 calendar days before the date of reduction or termination. When reducing or terminating services an individual is receiving or terminating CBA eligibility, the individual must be given the full 12-day adverse action period. Instructions on how to calculate time periods is provided in §311.014 of the Code Construction Act. It specifies that:

  • In computing a period of days, the first day is excluded and the last day is included.
  • If the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 12-day adverse action period is extended based on whether the twelfth day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 12-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when DADS offices are officially open, even with limited workforce.

The following examples demonstrate how to apply this requirement for any adverse action taken.

Example 1: This example assumes that the 12th day does not fall on a weekend or holiday.

Nov. 26: The case manager sends termination notification to the individual. This is day zero.
Dec. 8: This is day 12. The individual has through the end of the business day to file an appeal and have services continue.
Dec. 9: Day 12 passed without an appeal from the individual. This is the first day the individual will not receive services (if terminated from CBA) or receive service at the lower level (if services are reduced).

Example 2: The example assumes that the 12th day falls on a Sunday.

Jan. 26: The case manager sends termination notification to the individual. This is day zero.
Feb. 7: This is day 12 which falls on a Sunday.
Feb. 8: The individual has through the end of this business day to file an appeal and have services continue.
Feb. 9: The extended 12-day period passed without an appeal from the individual. This is the first day the individual will not receive services (if terminated from CBA) or receive service at the lower level (if services are reduced).

The full adverse action period may be waived if the individual signs a statement to waive the adverse action period.

The case manager must ensure the adverse action period is correctly calculated and documented on Form 2065-B, Notification of Waiver Services, and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The effective date for the action must be accurate in the Service Authorization System (SAS).

For a reduction in services, the Form 2065-B Effective date, the Provider Authorization effective date and the SAS effective date will be the first date the lower amount of services will be received by the individual.

For termination of one Community Based Alternatives (CBA) service delivered by the Home and Community Support Services Agency (HCSSA), the Effective date and the Provider Authorization Termination Date on Form 2065-B for the service being terminated will be the first date services will not be received by the individual. In SAS, the effective date of the service being terminated will be the last date services will be received.

For termination of services not delivered by the HCSSA, such as Emergency Response Services (ERS) or Home-Delivered Meals, the Effective date and the Provider Authorization Termination Date on Form 2065-B will be the first date services will not be received by the individual. The Provider Authorization Termination effective date and the SAS effective date of the service being terminated will be the last date services will be received.

If more than one change is being completed in SAS at the same time, for example reduction of Personal Assistance Services and termination of ERS, the case manager must complete the two changes separately in order to produce Form 3671-1, Individual Service Plan, with the correct effective date for each action.

For termination of CBA eligibility, the Form 2065-C Effective date, the Provider Authorization Termination effective date and the SAS effective date will be the last date services will be received.

Note: All references to the 12-day adverse action period in this section are based on this method of calculation.

3810.2  Responding to Situations of Threat to Health and Safety

Revision 13-1; Effective March 1, 2013

The case manager must take special precaution when an applicant's or individual's comments or behavior appears to be threatening, hostile or of a nature that would cause concern for the safety of the applicant or individual, a service provider staff or the case manager. If during the initial contact an applicant exhibits such behavior, the case manager must immediately notify his supervisor. Regional management will review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's or individual's safety may be at risk, the case manager must follow current policy regarding notification to the Department of Family and Protective Services. If the case manager believes there is a potential threat to others, regional management should determine the best method for notifying the provider and for addressing the applicant's or individual's needs without placing a staff member at risk.

When an individual receiving services exhibits threatening or hostile behavior, the case manager should follow policy outlined in Section 3814, Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice, and Section 3811.9, Termination Due to Hazardous Condition for the Service Provider's Health and Safety.

3810.3  Denying Requests to Exceed the New Service Limit

Revision 13-1; Effective March 1, 2013

When an individual is not granted an exception to the new service limits, the case manager must notify him of the denial of the requested service by sending Form 2065-B, Notification of Waiver Services, with specific language and program rule citations.

The case manager must list the specific exception criteria the individual did not meet in the comments section of Form 2065-B. When denying a request for a service or item, the case manager must document in the Effective section, "Your request for (units, hours, or dollars) of (service) is being denied because it exceeds the maximum amount of (the new service limit in hours, units or dollars) of (service) allowed during a service plan period and you did not meet the exception criteria to exceed the maximum allowed. Reference 40 Texas Administrative Code, §48.6084, Service Limits and Claim Limits, and §48.6085, Exception to Service Limit – Effective Dec. 1, 2011."

When denying more than one service or item, the case manager must repeat the specific language on separate notification forms to identify each service or item being denied.

3811  Circumstances Requiring Termination of CBA Services with Advance Notice

Revision 12-4; Effective December 3, 2012

§48.6098 — Circumstances Requiring Termination of CBA Services with Advance Notice.

(a)
If one or more of the circumstances specified in paragraphs (1) – (10) of this subsection occur, the CBA provider must provide written documentation to the DADS case manager within two DADS workdays of the occurrence to support a recommendation for termination of CBA services.
(1)
The individual leaves the state for more than 90 days. DADS retains authority to extend this time in extraordinary circumstances.
(2)
The individual has been legally confined or has resided in an institutional setting for longer than 120 days. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state school, nursing home, or intermediate care facility for persons with mental retardation/related conditions (ICF-MR/RC). DADS retains authority to extend this time in extraordinary circumstances.
(3)
The individual is not financially eligible for Medicaid benefits.
(4)
The individual does not meet the medical necessity criteria (MN) for nursing facility care.
(5)
HCSSAs have refused to serve the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's home.
(6)
The individual or someone in the individual's home refuses to comply with mandatory program requirements, including the determination of eligibility or the monitoring of service delivery.
(7)
The individual fails to pay room and board expenses or copayment in the adult foster care (AFC) or assisted living/residential care (AL/RC) setting.
(8)
The individual fails to pay the required qualified income trust copayment.
(9)
The situation, individual, or someone in the individual's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the service provider.
(10)
The individual or someone in the individual's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider.
(b)
The supporting documentation submitted by the CBA provider must include a detailed description of the interventions attempted by the CBA provider prior to deciding to recommend the termination of CBA services. The documentation must justify the reasons for termination and describe the strategies, outcomes, and negotiations with the individual in accordance with CBA program policies, rules, and the provider manual.
(c)
If the DADS case manager determines the documentation supports the termination of CBA services, the DADS case manager provides written notice of the termination of CBA services to the individual with a copy to the CBA provider within two DADS workdays after receiving the documentation described in subsection (b) of this section. The written notice must specify:
(1)
the reason for termination;
(2)
the effective date of termination;
(3)
the regulatory reference; and
(4)
information regarding the individual's right to request a fair hearing in accordance with §48.6010 of this subchapter (relating to Individual's Right to Appeal).
(d)
If the individual submits a request for a fair hearing before the effective date of the termination specified in the written notice, the CBA provider continues CBA services at the current authorized level while the appeal is pending.

Note: Policy allows a 180-day suspension period for (a)(1) and (a)(2) above which is greater than rule language.

See Section 3812, Circumstances Requiring Termination of Services and Medicaid Eligibility Without Advance Notice, and Section 3812.2, Other Mandatory Terminations Without Advance Notice, for rule references for terminating program eligibility for individuals who have been in an institution for less than 180 days.

Within two working days of determining services should be terminated, the case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. Include the rule reference (§48.6098) and the effective date, based on the 12-day adverse action period. In the comments section, include a clear statement in plain language describing why services are being terminated. If the individual loses Medicaid coverage, the effective date is the last date of eligibility for Medicaid.

3811.1  Extension of Suspension

Revision 10-5; Effective December 1, 2010

The Department of Aging and Disability Services (DADS) retains the option to approve a 30-calendar day extension beyond the 180-day suspension period if the consumer anticipates resuming program participation within 30 calendar days. There is no limit on the number of 30-calendar day extensions that DADS may approve. The consumer or a family member must clearly indicate the wish for services to resume. The DADS case manager must initiate contact with the consumer or family member prior to the 180th day or 30th day for subsequent extensions, allowing enough time to receive a decision from state office if an extension is requested. Each time an extension is requested by the family, the DADS case manager must review evidence to determine if the request should be submitted to state office. Examples of evidence that would support an extension are listed below.

Consumer Residing in an Institution

  • Documentation or verbal communication from a treating professional that demonstrates the consumer will be able to return to his home in the community within 30 calendar days;
  • Proof of having a home in the community to live in upon discharge from the institution; or
  • Resources in the community (e.g., involved family) that will be available to help support the consumer when he moves back to the community.

Consumer Living or Traveling Outside the State or Service Area

  • Confirmation of having made a rental deposit for a home/apartment in Texas; or
  • Evidence that the barriers previously preventing the consumer from returning to Texas have been eliminated (e.g., consumer has identified a residence in Texas; consumer will be discharged from an out-of-state institution).

If, in the case manager's judgment, there is clear and convincing evidence the consumer can resume service within 30 calendar days, the case manager will submit the request for an extension to the Unit manager, Community Services Policy and Curriculum Development Unit, Community Services and Program Operations, Mail Code W-351. Title the email subject: Request for Extension – 180-Day Suspension. A new request must be submitted for each 30-calendar day extension. The request may be sent by email and must include the following information:

  • Consumer name
  • Region number
  • Program name, CBA, ICMW or CWP
  • Date of contact with consumer or family requesting an extension
  • Circumstances related to the request, such as consumer is out of state or consumer is in an institution
  • Evidence to support the request for the extension, including a projected return date
  • Case manager name and phone number

State office will notify the case manager of the decision regarding the request for extension.

State office staff will also consider requests for extended suspensions for consumers, other than those who are traveling out of state or who enter an institution, who have unusual circumstances.

3811.2  Reinstating CBA Services After Being Institutionalized

Revision 10-5; Effective December 1, 2010

If services are terminated when the consumer enters a nursing facility (NF) but the consumer is discharged after fewer than 180 calendar days and requests Community Based Services (CBA) services again, the case manager may reinstate CBA services without considering this a new enrollment in CBA. The interdisciplinary team (IDT) may need to be convened to assure the appropriateness of the service plan.

Service coordination is essential to assure the new individual service plan (ISP) is adequate to meet the consumer's needs in the community and is within the cost limit. If the consumer is discharged from the NF after the ISP expires, the effective date of the ISP is the date of discharge, if all other CBA criteria are met. The ISP end date remains the same as if the ISP had not expired and CBA services were continued. For example, the ISP period is Feb. 1, 2009, through Jan. 31, 2010. The consumer enters the NF on Dec. 15, 2009, and is discharged March 10, 2010. The reassessment packet was completed timely by the Home and Community Support Services Agency (HCSSA) and the consumer meets all other CBA criteria on the discharge date of March 10, 2010. The new ISP period is March 10, 2010 through Jan. 31, 2011.

All other mandatory program requirements must also be met. The consumer must have a valid ISP within his assessed cost limit, the HCSSA must have accepted the consumer with the proposed service plan and the consumer must still be financially eligible.

The consumer may be residing in the NF or hospitalized when the annual assessment by the HCSSA is due. In this circumstance, the HCSSA may conduct the annual reassessment in the NF or hospital. Refer to Section 3811.2.1, HCSSA Annual Assessments in a Nursing Facility or Hospital.

3811.2.1  HCSSA Annual Assessments in a Nursing Facility or Hospital

Revision 08-10; Effective September 1, 2008

In the Community Based Alternatives (CBA) program, the Home and Community Support Services Agency (HCSSA) must annually reassess a consumer's eligibility and the appropriateness of the individual service plan (ISP). Case manager approval to conduct this reassessment is not required.

HCSSAs must follow specific procedures and maintain documentation related to the CBA reassessments:

  • HCSSAs are not required to conduct a CBA reassessment for a consumer who is not expected to return to the community from a hospital or nursing facility (NF), but the reason the consumer is not expected to return should be clearly documented in the consumer's record. The HCSSA should notify the Department of Aging and Disability Services (DADS) case manager if the HCSSA becomes aware the consumer is not expected to return to the community.
  • HCSSAs may delay the reassessment for a consumer receiving CBA services when it is not appropriate to visit the consumer in the hospital or NF due to his medical condition, or when the consumer is in a hospital or NF that is outside of the HCSSA's approved service area. In this circumstance, the HCSSA should document the reason for the delay and notify the DADS case manager.
  • If the consumer is at a location within the HCSSA's service area, a reassessment may be performed for a consumer who is away from home for reasons other than being hospitalized or temporarily residing in an NF.

The HCSSA must follow specific procedures for a reassessment claim to be paid. The HCSSA must:

  • conduct the reassessment in the hospital or NF within the required time frame;
  • submit a claim to the Texas Medicaid & Healthcare Partnership (TMHP) as "nursing services," (this claim will be denied); and
  • upon notice of claim denial, contact the DADS Regional Claims Management System (CMS) coordinator.

The CMS coordinator will then instruct the HCSSA on how to resubmit the bill to be paid as a "client specific administrative payment."

Case managers will use the reassessment packet completed by the HCSSA to coordinate and re-initiate CBA services to the consumer when discharged from the facility.

3811.2.2  Personal Assistance Services (PAS) and Temporary Nursing Facility or Hospital Stays

Revision 10-5; Effective December 1, 2010

When a Community Based Alternatives (CBA) consumer enters a nursing facility or hospital, PAS must be suspended and specific procedures followed.

Temporary Nursing Facility Stay

When the CBA consumer enters a nursing facility on a temporary basis (180 days or less), the CBA service authorization must be closed in the Service Authorization System (SAS) with a Code 35, Temporary Nursing Facility Stay, while the consumer is in the nursing facility. Closure of CBA service authorizations allows nursing facility payment. The PAS service authorization is closed effective the date of nursing facility entry. Upon return of the consumer to the community, the case manager reinstates CBA services effective the date of the consumer's discharge from the nursing facility. The case manager enters in the SAS Units field on the Service Unit/Rate Entry screen:

  • the weekly amount of PAS hours authorized before nursing facility entry; or
  • a new weekly amount as approved by the case manager upon the consumer’s return home.

The PAS hours that would have been used during the nursing facility stay cannot be used by the consumer after release from the nursing facility. If the CBA consumer's needs have changed and additional PAS hours are needed, the Home and Community Support Services Agency (HCSSA) should ask the case manager to review and increase the PAS hours as appropriate.

Temporary Hospitalization

The procedure differs when a CBA consumer enters a hospital for a temporary stay. CBA services are suspended using Form 2067, Case Information, but service authorizations are not closed in SAS. When the CBA consumer returns home from a hospital stay, the hours that would have been used during the hospital stay are still available in the PAS monthly authorization and can be used if the consumer needs additional hours of assistance. If the CBA consumer's needs have changed and additional PAS hours are needed, the HCSSA should ask the case manager to review and increase PAS hours as appropriate. Refer to Section 3610.6, Agency Flexibility, and CBA Provider Manual Section 4451.1, Schedule Flexibility/PAS Outside the Home.

3811.2.3  Code 35 Procedures

Revision 12-3; Effective September 4, 2012

When an individual enters a nursing facility (NF) on a temporary basis (180 calendar days or less), the Community Based Alternatives (CBA) service authorization must be closed, using the wizards in the Service Authorization System (SAS) with a Code 35, Temporary Nursing Facility Stay, while the individual is in the NF. Upon discharge, the case manager uses the SAS wizards to remove the Code 35 and reinitiate CBA services.

Example: A CBA applicant is certified for services effective Jan. 15, 2010, through Jan. 31, 2011. He enters the NF on Feb. 25, 2010, and remains in the NF through March 31, 2010. The case manager will complete a Code 35 action in SAS effective Feb. 25, 2010. When the NF submits Form 3618, Resident Transaction Notice, and the Minimum Data Set assessment for medical necessity (MN) determination, the forms automatically open the records to create the NF service authorization. The case manager reinstates CBA services by removing the Code 35 and registers a service authorization with a Begin Date of April 1, 2010, through Jan. 31, 2011, when the individual returns to the community.

Service authorizations may be closed by an automated process prior to the case manager learning of and completing the Code 35 action. When Form 3618 is submitted by the NF for an individual, all CBA service authorization records except Service Code 20, Emergency Response Services (ERS), and Service Code 60, Prescriptions, will be closed by an automated batch process. The automated batch process runs five times weekly and uses the date on Form 3618, Item 11, to close the CBA service authorization records effective the date of NF entry. A daily report is posted to the Claims Management Project Documents website. Regional Claims Management System (CMS) coordinators will access the reports and notify case managers of individuals whose service authorization records are closed by the batch process.

Although service authorizations will be closed by the automated batch process, the case manager must still complete the Code 35 action in SAS wizards, which includes an additional manual step to prorate units before submitting the authorization. The additional step preserves the history of SAS wizards and keeps authorizations more accurate once the individual is discharged from the NF back to the community. Refer to the SAS Help Files for procedures to complete Code 35 actions.

A Code 35 action is not required for an individual who enters a hospital. The effective date of the annual reassessment individual service plan (ISP) in SAS may be the date after the current ISP expires. The case manager must ensure that CBA services are not delivered by the Home and Community Support Services Agency (HCSSA) while the individual is hospitalized by sending the HCSSA Form 2067, Case Information, documenting the suspension.

Code 35 and Monitored Medication Units

The adaptive aid service authorization record in SAS is closed effective the date of NF entry. For an individual who has a monitored medication (MM) unit and upon his return to the community, the case manager reinstates CBA services effective the NF discharge date. To continue authorization of the MM unit as an adaptive aid, the case manager enters in the SAS Units field on the Service Unit/Rate Entry screen the:

  • amount of the MM unit monthly fee authorized from the start of the ISP to the date of NF entry plus the cost of adaptive aids previously delivered to the individual; and
  • remaining amount of the MM unit monthly fee from the date of NF discharge to the end date of the ISP plus the cost of adaptive aids to be delivered to the individual after the NF discharge date.

The case manager authorizes the cost of the MM unit monthly fee for the month of the NF stay if the individual was admitted and discharged from the NF in the same month.

Code 35 and Emergency Response Services

The ERS provider is entitled to leave ERS equipment in the home while an individual is temporarily in the NF for a 180-day suspension. The ERS provider is eligible for payment if the system checks are completed by the ERS provider during the 180-day suspension period. The Department of Aging and Disability Services (DADS) will pay the ERS provider for services only through the last day of the ISP period. The ERS authorization should not be extended past the ISP end date to allow payment for the rest of the 180-day suspension period.

When completing the Code 35 change, the case manager must send Form 2067 to the ERS provider as notification the individual has entered the NF. Form 2067 must clearly state the date of NF entry and the last date ERS services are authorized in SAS, which will be the last date of the 180-day suspension period or the date the ISP expires, whichever comes first. The ERS provider is entitled to remove the ERS equipment from the home when the ERS service authorization expires. Once the individual discharges from the NF, ERS services may be reauthorized with the new ISP if all eligibility criteria are met.

ERS SAS Actions for Code 35

Special procedures apply to ERS and the Code 35 action. The SAS Code 35 action closes CBA services effective the date of NF entry. For individuals who are authorized ERS, SAS automatically extends the ERS authorization 120 calendar days past the NF entry date, unless the individual's ISP ends before the 120-day period. If the individual's ISP ends before the end of the 120-day suspension period, SAS ends the ERS authorization the last day of the ISP period.

The 180-day suspension policy applies to the ERS provider. The SAS system only allows a 120-day suspension. Special procedures must be followed to ensure the Code 35 action is completed accurately in SAS.

180-Day Suspension and SAS ERS 120-Day Suspension Edit Fall Within the Current ISP Period

The case manager uses the CBA SAS wizard to complete and "generate" the Code 35 action. The SAS service authorization records end the date of NF entry, except the ERS service authorization record and the service plan record, which are extended to 120 days. Before "submitting" the Code 35 action, the case manager manually changes the SAS ERS service authorization record to the 180th day, and the service plan record to the end of the current ISP.

Each time a 30-calendar day extension is granted, the case manager must manually update the SAS ERS service authorization record to include 30 additional calendar days, unless the current ISP period ends before the 30th day.

Example: The last day of the 180-day suspension is March 20. A 30-calendar day extension is granted. The case manager manually changes the end date on the ERS SAS service authorization record to April 19, unless the current ISP expires on March 31. If the current ISP expires March 31, the end date of the SAS ERS service authorization record must be March 31, and the service plan record end date will already be March 31, the last day of the current ISP.

180-Day Suspension and SAS ERS 120-Day Suspension Edit Fall after the Current ISP Period

The case manager uses the CBA SAS wizard to complete and "generate" the Code 35 action. The SAS service authorization records end the date of NF entry, except for the ERS service authorization record and the service plan record, which will end the last day of the current ISP period. The end date of the service plan record coincides with the SAS ERS service authorization record end date, and at a later date prevents the MN determination from processing with an incorrect date if the Medical Necessity and Level of Care Assessment is submitted and processed after the Code 35 action is completed.

The ERS provider is not entitled to payment for services past the ISP end date.

180-Day Suspension Falls After the Current ISP Period but the SAS ERS 120-Day Suspension Edit Falls before the End of the Current ISP Period

The case manager uses the CBA SAS wizard to complete and "generate" the Code 35 action. The SAS service authorization records end the date of NF entry, except for the ERS service authorization record, which will be extended for 120 days. Before "submitting" the Code 35 action, the case manager manually changes the SAS ERS service authorization record to end the last day of the current ISP period.

The ERS provider is not entitled to payment for services past the ISP end date, even if the 180-day suspension period or approved 30-day extension periods end after the ISP end date.

When the individual is discharged from the NF to the community, the case manager uses the SAS CBA wizard to complete a Code 35 action to reinstate the individual's services. There are no special steps required for the Code 35 reinstatement action.

When extensions to the 180 days are approved, the case manager will manually update the SAS ERS service authorization record to include the 30-day extension(s), unless the ISP ends first, after generating but prior to submitting the Code 35 action.

3811.3  Medical Necessity (MN) Denials

Revision 08-10; Effective September 1, 2008

For procedures pertaining to MN denials and appeals, refer to Section 3832, Appeal Procedures for MN Denial.

3811.4  Loss of Medicaid

Revision 13-1; Effective March 1, 2013

If the individual enrolled in Community Based Alternatives (CBA) has Medicaid eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff and loses the eligibility, CBA eligibility must be terminated and notification with right of appeal sent to the individual. The MEPD specialist sends the individual Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, with a copy to the case manager as notification of the Medicaid denial. The case manager must coordinate the CBA termination date with the Medicaid denial effective date established by the MEPD specialist. Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is sent within two working days of verifying of the loss of Medicaid. The individual's CBA eligibility must not continue past the last date of Medicaid coverage. If the individual appeals the Medicaid denial and Medicaid is reinstated until the appeal hearing is held, the individual's CBA services may continue.

If there will be a gap in Medical Assistance Only (MAO) coverage as determined and notified by the MEPD specialist, CBA services must be suspended for the gap period when there is no Medicaid coverage. CBA service providers must be notified of the suspension and termination of CBA services due to loss of Medicaid. The case manager should discuss MAO gaps with the MEPD specialist to determine how long the gap will affect the CBA suspension. Service Authorization System (SAS) records may remain open if the case manager documents the individual is in the process of providing requested information to MEPD to support continued Medicaid eligibility.

Loss of Supplemental Security Income (SSI)

An individual who becomes financially ineligible for SSI and loses SSI Medicaid must be terminated from CBA and provided notification of the right to appeal. Form 2065-C is sent within two working days of verifying the loss of SSI Medicaid. The termination effective date is the last date of SSI Medicaid coverage. Delivery of CBA services must be suspended even if the individual files a timely appeal because there is no Medicaid coverage. Inform the individual on Form 2065-C that an application may be submitted to MEPD to determine MAO eligibility and the possibility of continuation of CBA services once the individual is eligible for MAO. CBA service providers must be notified of the suspension and termination of CBA due to loss of SSI Medicaid.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied SSI Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the denial of Medicaid is ongoing. The case manager can contact the individual, obtain a copy of the letter from the Social Security Administration (SSA) or contact the local SSA office to verify this information.

If Medicaid will be reinstated the beginning of the next month without a gap in coverage, no further action is required. Document in the case record the continuation of CBA due to no gap in Medicaid coverage.

For an individual whose loss of SSI Medicaid will result in a gap or SSI will be denied ongoing, the case manager must quickly begin the MEPD MAO financial eligibility process. The case manager must obtain Form H1200, Application for Assistance – Your Texas Benefits, and as much verification as possible and send to the MEPD specialist. When the MEPD specialist receives Form H1200, the MEPD specialist will determine ongoing Medicaid eligibility or eligibility for the gap period by verifying resources and income. SAS records may remain open if the case manager documents the individual is in the process of applying for Medicaid eligibility or providing requested information to support continued Medicaid eligibility.

During the period the MEPD specialist is determining eligibility, CBA services are suspended by sending Form 2067, Case Information, to the CBA providers. If Form H1200 is not received back from the individual or the MAO financial eligibility is denied, CBA service authorizations must be terminated in SAS effective the last date of Medicaid eligibility. If Form H1200 is submitted and MAO eligibility is denied, send Form 2065-C to the individual indicating termination of CBA is based on financial reasons.

When Medicaid eligibility is re-established and the individual service plan (ISP) has expired, the case manager must not reinstate services until all CBA eligibility criteria are met. The effective date of the ISP is the date all other CBA criteria are met, and the ISP end date remains the same as if the ISP had not expired and CBA services were continued.

An individual may be ineligible for SSI for a short period before SSI is reinstated. This might occur when eligibility is based on earned weekly income, normally with four paychecks, but some months five paychecks are received. In these situations, the case manager must work with the individual and the MEPD specialist to prevent a gap in waiver coverage. The case manager must assist the individual in submitting Form H1200. The MEPD specialist will use the institutional income limit to process the application for MAO coverage. If MAO eligibility criteria are met, the MEPD specialist will certify the individual for waiver Medicaid (TA-10), and notify the case manager of the Medicaid eligibility for the gap in SSI coverage. If a gap period reoccurs, MEPD will use the same application to determine eligibility for the subsequent gap periods for up to a year from receipt of the Form H1200.

3811.5  Exceeding the Cost Limit

Revision 13-1; Effective March 1, 2013

Refer to Section 3421.2, Denial or Termination When Proposed ISP Exceeds the Cost Limit, for procedures pertaining to denial of applications or termination of program eligibility due to exceeding the cost limit.

3811.6  Refusal to Serve an Individual

Revision 13-1; Effective March 1, 2013

Before an individual enrolled in Community Based Alternatives (CBA) is terminated from the program due to Home and Community Support Services Agency (HCSSA) refusing to serve him on a basis of a reasonable expectation that the individual’s medical and nursing needs cannot be adequately met in his residence, the case manager should consult with and obtain his supervisor's approval. The case manager must make a concerted effort to look at other providers who may be able to meet the individual's needs. This will be determined by the number of available providers, as well as the individual's wishes. All attempts to find a workable solution should be well documented, including offering alternative living arrangements, exhausting all third-party resources (TPRs) such as Medicaid home health, Medicare home health and family support. The HCSSA may consider an individual responsibility arrangement in which the individual expresses a desire to take responsibility for certain needs or to leave certain needs unmet, rather than have the HCSSA meet all of the needs. An interdisciplinary team meeting must be held before terminating the individual from CBA.

3811.7  Refusal to Comply with Mandatory Program Requirements and Service Delivery Provisions

Revision 13-2; Effective June 3, 2013

STANDARD.  If the individual receiving services repeatedly and directly or knowingly and passively condones the behavior of someone in his home and thus refuses more than three times to comply with service delivery provisions, the case manager may terminate the individual from the Community Based Alternatives (CBA) program. Refusal to comply with CBA requirements includes actions by the individual or someone in his home that prevent determining eligibility, carrying out the service plan, or monitoring the services. Before CBA is terminated, the individual is entitled to receive written notification that he will be terminated from CBA if he does not comply with CBA requirements or if he continues to condone someone's behavior that results in noncompliance. Also, before CBA is terminated, a referral to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS) is made if the individual is abused, neglected or exploited by the person who prevents compliance with CBA requirements. Services continue pending the outcome of the DFPS APS investigation. If an applicant's services were terminated in the past due to his failure to comply with his service plan, the applicant must agree to cooperate with Department of Aging and Disability Services (DADS) staff to facilitate service delivery.

A termination based on refusal to comply with CBA requirements must be approved by the supervisor. Document the conference and approval in the case narrative. There is no time period during which time the instances of refusing to comply must occur. Opinions or evaluation conclusions are not appropriate documentation to substantiate termination from the program. Documentation should stress a factual statement of actions constituting noncompliance.

If an individual who receives Primary Home Care (PHC), who has a documented history of refusing to comply with the service plan, is transferred to the CBA program and continues to refuse to comply with CBA requirements, the documented history of the individual's refusal to comply with the service plan for Personal Attendant Services under the PHC program can be considered if CBA is being terminated for refusing to comply with the service plan. The same applies if the individual enrolled in CBA refuses to comply with the delivery of Personal Assistance Services for activities of daily living.

Examples of refusal to comply with CBA program requirements include, but are not limited to, the following.

  • The individual is often away from his place of residence at the time his service is scheduled and repeatedly fails to notify the CBA provider that he will be gone, even though the individual has been counseled about this problem and its implications.
  • The individual or someone in his home refuses the attendant to use the individual’s home telephone to call in the attendant’s time in and time out for a provider required to participate in Electronic Visit Verification (EVV) and is also refusing to allow a Fixed Visit Verification (FVV) device placed in his home. A provider is required to participate in EVV for services delivered by an attendant. An individual who refuses to allow the attendant to record hours worked through EVV, either through the use of the individual’s telephone or a FVV device, is non-compliant with his service delivery plan. The individual is essentially not allowing the provider to carry out services in accordance with provider requirements.
  • The individual or someone in his home regularly will not allow provider staff to perform one or more of the tasks in the service plan even though the case manager has discussed the individual's wishes with him and the CBA provider and has modified the service plan accordingly.
  • The individual refuses service because of dissatisfaction with the provider staff after the CBA provider has made bona fide efforts to find and place provider staff satisfactory to him.
  • The individual refuses to follow physician's orders or does not take medication as prescribed.
  • The individual refuses to release necessary medical information.
  • The individual agrees to accept therapy services and later refuses.

If a CBA provider contacts the case manager regarding the individual's refusal to comply with CBA program requirements, the case manager must contact the individual or other party involved and attempt to resolve the problem in a way that is satisfactory to the individual and other parties involved. The supervisor should be consulted. It may be necessary to hold an interdisciplinary team meeting with the CBA provider and the individual, his responsible party, or both. If the individual or the offending party in his home rejects or obstructs all efforts to deliver services, notify the individual in writing that he will be terminated from CBA because of noncompliance with program requirements. This notice must be made before CBA termination and the individual or other offending party must be allowed the opportunity to comply with the written notice. If the individual continues to refuse to comply with program requirements, CBA may be terminated with supervisory approval. Supervisors may consult with appropriate DADS staff such as, but not limited to the regional attorney, regional nurse or civil rights officer.

If an individual receives services from a particular CBA provider and will be terminated because of refusal to comply with program requirements that involve that provider, determine if the individual can be successfully served by another CBA provider. If so, consult with the individual to select another CBA provider and refer the individual for services following supervisory approval.

Documentation is required in all situations involving an individual's refusal to comply with program requirements. Determine and document whether the individual is aware of and able to understand the consequences of his or other's actions. If he is not aware of his behavior or that of someone in his home, inform him of the behavior. Refer the individual to DFPS APS, if necessary. Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian, to resolve the problem if the individual is abused, neglected or exploited.

3811.8  Failure to Pay Copayment or Room and Board

Revision 13-1; Effective March 1, 2013

If the individual refuses to pay a required copayment or room and board, Community Based Alternatives (CBA) must be terminated, providing a 12-day advance notice of the adverse action and the right to appeal on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. Before CBA is terminated for nonpayment of room and board or copayments, procedures relating to case management duties in Section 4252, Copayment and Room and Board Requirements, for Adult Foster Care, and Section 4341, Room and Board and Copayment Requirements, for Assisted Living, must be followed.

3811.9  Termination Due to Hazardous Condition for the Service Provider's Health and Safety

Revision 13-1; Effective March 1, 2013

When there is no immediate threat to the health or safety of the service provider, but the situation, individual receiving services or someone in his home is hazardous to the health and safety of the service provider is the reason for termination, appropriate documentation is essential. For example, a situation where the individual has a large dog, which may bite if let loose, could be resolved if the individual, his neighbor or a family member will agree to restrain the dog during times of service delivery. However, if the service provider shows up on numerous occasions at the designated time and the dog is loose, and the service provider has documented a substantial pattern of being unable to deliver services due to this, the individual could be terminated from the Community Based Alternatives (CBA) program.

Similarly, if there are illegal drugs in the individual's home used by the individual or others, the service provider may not be in immediate danger, yet the situation still poses a threat. It is imperative that all available interventions are presented and the opportunity offered for the individual to get rid of the illegal drugs and users, and agree to refrain and not allow the illegal drug use to resume. An interdisciplinary team (IDT) meeting should be held if the illegal drug usage occurs again and the individual must be warned in writing of the potential termination of CBA for allowing this activity to continue.

On those cases where program termination is appropriate, the case manager must send notification on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual, provider and other members of the IDT, as appropriate. The individual should be referred to other services as needed and must be referred to the Department of Family and Protective Services Adult Protective Services (APS), if appropriate. A home visit must be made and an IDT must be held with the individual, the Home and Community Support Services Agency staff and the case manager to try to resolve the problem before CBA is terminated. Termination is a last resort and should be pursued only when all other methods of problem resolution have failed.

If the individual has been terminated from CBA in the past due to the situation, the individual or someone in his home being hazardous to the health and safety of the service provider, and the individual subsequently reapplies for CBA, the case manager must follow the procedures in Section 3814.6, Reinstatement of Services Terminated for Threats of Health or Safety, to determine if services can be provided.

3811.9.1  Active Tuberculosis (TB) Diagnosis

Revision 13-1; Effective March 1, 2013

An applicant or individual receiving services with a TB diagnosis cannot be denied or terminated from the Community Based Alternatives (CBA) program as a consequence of his disease.

Under state law, physicians must report all cases of TB to the Department of State Health Services (DSHS). Upon receiving the physician's report, DSHS assigns a representative to monitor the applicant or individual through "directly observed therapy." This process involves observation of the applicant or individual taking his medication; it may also involve health-related training and the provision of additional care of the applicant or individual.

Upon notification and confirmation that an individual or someone in his home has an active outbreak of TB, the Home and Community Support Services Agency (HCSSA) may suspend CBA services without advance notice. The HCSSA must immediately report the incident to the local health authority or the regional director of DSHS. The local health authority or DSHS regional director will provide guidance to the HCSSA regarding testing the individual and the length of the contagious period.

The HCSSA must verbally notify the case manager by the next working day following the date services were suspended, and must follow up in writing within two working days of verbal notification.

The case manager sends a notice of suspension on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and initiates an interdisciplinary team (IDT) meeting, which includes the individual, the DSHS representative, the HCSSA nurse, the Department of Aging and Disability Services (DADS) regional nurse and others, as needed, to determine a plan of care for the individual. The IDT meeting may be held by phone due to the contagious nature of TB. The IDT members will ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct DADS to suspend CBA while the TB remains active; if so, it will provide care for the individual during this period. Most individuals become negative for TB within a few weeks of drug therapy.

Note: Refer to Section 1800, Disclosure of Information and Confidentiality, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

3812  Circumstances Requiring Termination of Services and Medicaid Eligibility Without Advance Notice

Revision 12-4; Effective December 3, 2012

§48.6100 — Circumstances Requiring Termination of Services and Medicaid Eligibility Without Advance Notice.

(a)
If one or more circumstances specified in paragraphs (1) – (6) of this subsection occur, the DADS case manager terminates CBA services without advance notice.
(1)
DADS or its designee has factual information confirming the death of an individual;
(2)
DADS or its designee receives a clear written statement signed by the individual that:
(A)
the individual no longer wishes services; or
(B)
gives information that requires termination and indicates that the individual understands that this must be the result of supplying that information;
(3)
The individual's whereabouts are unknown and the post office returns agency or designee mail directed the individual indicating no forwarding address;
(4)
The CBA provider or its designee establishes the fact that the individual has been accepted for Medicaid services by another state;
(5)
A change in the level of medical care is prescribed by the individual's physician; or
(6)
The notice involves an adverse determination made with regard to the preadmission screening requirements.
(b)
Within one DADS workday after becoming aware that a situation described in subsection (a) of this section exists, the CBA provider must notify the DADS case manager by phone of the reason for termination and follow up with written documentation on the case information form within two DADS workdays of the phone notification.
(c)
The CBA provider is not required to continue to provide CBA services to the individual.

See Section 3812.2, Other Mandatory Terminations Without Advance Notice, for individuals receiving services who are being terminated and have been in an institution less than 180 days. The case manager sends a termination notice using Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual, the provider and the Medicaid for the Elderly and People with Disabilities specialist, if appropriate, within two working days of determining the individual should be terminated from the CBA program.

3812.1  Termination Due to Death

Revision 13-1; Effective March 1, 2013

After learning of the individual's death, the case manager should send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the provider within two working days of verifying the death of the individual. A copy of Form 2065-C, along with Form H1746-A, MEPD Referral Cover Sheet, should be sent to the Medicaid for the Elderly and People with Disabilities specialist, if appropriate. Do not send a notice to the individual's address or family. The effective date is the date of death.

If the individual was receiving Supplemental Security Income (SSI) and the eligibility records reflect that the SSI has been denied, the case manager must use the same termination effective date as the SSI denial date. If the eligibility records reflect the SSI is still active, the case manager must contact the Social Security Administration to notify it of the date of the individual's death.

If the individual's Medicaid eligibility has been denied due to death on the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries must be made to terminate Service Authorization System (SAS) records.

3812.2  Other Mandatory Terminations Without Advance Notice

Revision 13-1; Effective March 1, 2013

All reasons for a termination require documentation in the case record to justify the termination. If terminating due to voluntary withdrawal, §48.6100(a)(2), a copy of the written request received by the provider should be in the case record and must be followed up by the case manager with a telephone call (when appropriate) or face-to-face visit with the individual.

Advance notice is not required if a written statement signed by the individual is received by the Department of Aging and Disability Services (DADS). If a signed, written statement is not received by DADS, advance notice must be given. Refer to Section 3810.1, 12-Day Adverse Action. The individual retains the right to appeal.

When the individual provides a signed, written statement or signs Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to verify that he has orally requested services be reduced or terminated, document the individual's reason in the comments section. The effective date of the action is the date that Form 2065-C is dated and mailed or given to the individual. The case manager may honor a specific termination date if requested by the individual.

Services may be suspended for up to 180 calendar days for an individual who enters an institution temporarily. For institutional stays that become permanent before the 180 days end and a written statement is not received from the individual, completion of Form 2065-C must provide 12 days advance notice and the date of entry into the institution. The day before the effective date on Form 2065-C ("Effective ____, you will not be eligible for") is the last day services may be received. This is determined by calculating the adverse action period per instructions in Section 3810.1. The effective date of termination in the provider authorization block is the date of nursing home entry. The Service Authorization System (SAS) effective date is the date of nursing facility entry; this allows the nursing facility to bill. The case manager should mail a termination notice, using Form 2065-C, to the individual, provider and the Medicaid for the Elderly and People with Disabilities specialist, if appropriate, within two DADS working days of determining CBA should be terminated.

Section 48.6100(5) applies to changes in the level of medical care as ordered by the physician when the individual is hospitalized.

3813  Circumstances Which May Result in Termination of Services and Require Advance Notice

Revision 12-2; Effective June 1, 2012

§48.6102 — Circumstances Which May Result in Termination of Services and Require Advance Notice.

(a)
If one or both circumstances specified in paragraphs (1) and (2) of this subsection occur, the DADS case manager may terminate CBA services. The CBA provider must provide written documentation to DADS to support the reason for the termination of services.
(1)
The individual or someone in the individual's home has a substantial and demonstrated pattern of verbal abuse and harassment of service providers, not related to the individual's disability, that results in the CBA provider being able to provide service(s) to the individual.
(2)
The individual or someone in the individual's home has a substantial and demonstrated pattern of discrimination against the service providers on the basis of race, color, national origin, age, sex, or disability that has not improved with appropriate intervention and which results in the CBA provider being unable to provide service(s) to the individual.
(b)
The DADS case manager must provide written notice to the individual with a copy to the CBA provider no later than 12 DADS workdays before the effective date of termination identified in the written notice. The notification must specify:
(1)
the reason for the termination of services;
(2)
the effective date of termination;
(3)
the regulatory reference; and
(4)
information regarding the individual's right to request a fair hearing in accordance with §48.6010 of this subchapter (relating to Individual's Right to Appeal).
(c)
If the individual submits a request for a fair hearing before the effective date of the termination specified in the written notice, the CBA provider must continue to provide CBA services at the current authorized level while the appeal is pending.

3813.1  Demonstrated Pattern of Abuse or Discrimination

Revision 13-1; Effective March 1, 2013

A substantial demonstrated pattern of verbal abuse or discrimination by the individual receiving Community Based Alternatives (CBA) services or someone in his home must be clearly established and documented by both the provider and the case manager before services can be terminated for either of these reasons. This means multiple occurrences of the inappropriate behavior, which have been followed up with face-to-face discussions with the individual, his responsible party or legal representative, explaining that the Department of Aging and Disability Services (DADS) does not condone discrimination and verbal abuse. Appropriate interventions must be sought. This may mean counseling or referral to other case management agencies that provide opportunities for socialization.

There must be an interdisciplinary team (IDT) meeting that may include outside agencies, when appropriate, such as Adult Protective Services (APS). The results must be documented in letters sent to the individual, offering an opportunity to stop the behavior, with clear indication that failure may result in termination from CBA. Copies of written warnings must be sent to all who attend the IDT meeting and a copy must be retained in the case record.

3813.2  Termination Due to Verbal Abuse, Harassment or Discrimination

Revision 13-1; Effective March 1, 2013

If the situation persists and results in an inability to deliver services, at regional discretion, the individual receiving services may be terminated. Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is sent within two working days of the termination decision, offering the individual advance notice of the adverse action and the right of appeal. Include the Texas Administrative Code (§48.6102), the effective date and a clear statement in the comments section. If the individual appeals before the effective date of the termination, services must be continued pending the decision of a hearings officer.

Note: If the termination is being considered due to verbal abuse or harassment of the service provider, the case manager must determine if this behavior is directly related to the individual's disability. If the individual produces a letter from his physician indicating the behavior stems from the individual's disability, then CBA must not be terminated for this reason. Appropriate interventions to ensure service delivery as noted above should still be pursued.

3814  Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice

Revision 12-2; Effective June 1, 2012

§48.6104 — Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice.

(a)
If the individual or someone in the individual's home exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the DADS case manager and the CBA provider must:
(1)
immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to the Department of Family and Protective Services for appropriate crisis intervention services; and
(2)
immediately suspend the individual's CBA services.
(b)
The DADS case manager must immediately provide written notice to the individual with a copy to the CBA provider of the suspension of CBA services. The written notice must specify:
(1)
the reason for suspension of services;
(2)
the effective date of the suspension;
(3)
the regulatory reference; and
(4)
information regarding the individual's right to request a fair hearing in accordance with §48.6010 of this subchapter (relating to Individual's Right to Appeal).
(c)
The CBA provider must inform the DADS case manager by phone by the following DADS workday of the reason for the immediate suspension and follow up with written notification to DADS within two DADS workdays of the phone notification.
(d)
The DADS case manager must make a face-to-face visit to the individual to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the DADS case manager.
(e)
With prior authorization by DADS, the CBA provider may continue providing services to assist in the resolution of the crisis. This service will be reimbursed as an administrative expense.
(f)
If the crisis is not satisfactorily resolved, the DADS case manager provides written notice to the individual with a copy to the CBA provider of the termination of services. The written notice must specify:
(1)
the reason for termination;
(2)
the effective date of termination;
(3)
the regulatory reference; and
(4)
information regarding the individual's right to request a fair hearing in accordance with §48.6010 of this subchapter.
(g)
If the individual submits a request for a fair hearing, the CBA provider is not required to continue to provide CBA services to the individual.

3814.1  Suspension Procedures Pertaining to Imminent Danger

Revision 13-1; Effective March 1, 2013

Imminent danger in the context of requiring a Community Based Alternatives (CBA) suspension is not to be treated lightly, nor is it to be used loosely. For example, an extremely frail elderly individual threatening to harm or kill someone when there are no weapons in the home and it would be physically impossible for the individual to carry out these threats, is not imminent danger and is not a cause for suspension. If this happens frequently, it may result in program termination if a demonstrated pattern of verbal abuse has been established and documented. However, an individual or someone in his home brandishing a weapon, or having a history of physical violence and making threats that the individual or someone in his home is clearly capable of carrying out, may be imminent danger. Having or using illegal drugs in the home may not be imminent danger, and yet may be valid reason for initiating program termination, but not for suspending services.

When a case manager receives notice from the Home and Community Support Services Agency (HCSSA) that services are suspended due to imminent danger to the health and safety of the service provider, a referral to Adult Protective Services and the police (if appropriate) must be made the same day that the case manager is aware of the suspension. By the next working day, the individual must be notified of the temporary suspension by means of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. This notice must include the Texas Administrative Code (§48.6104), the effective date, which is the date the case manager became aware of the action, as well as a clear statement in the comments such as, "Your CBA services have been temporarily suspended due to... If this situation is not resolved within 12 calendar days, you will be terminated from CBA. You will be contacted by your case manager to determine if this problem can be resolved." The case manager must contact the individual and try to resolve the problem within 12 calendar days.

If the individual was terminated from CBA in the past due to the situation, the individual or someone in his home being hazardous to the health and safety of the service provider, and the individual subsequently reapplies for CBA, the case manager must follow the procedures in Section 3814.6, Reinstatement of Services Terminated for Threats to Health or Safety, to determine if services can be provided.

3814.2  Administrative Payment During Suspension

Revision 13-1; Effective March 1, 2013

If the Community Based Alternatives (CBA) Home and Community Support Services Agency (HCSSA) wishes to continue services during the suspension, and if the case manager determines that the suspension of services constitutes a threat to the health and safety of the individual, the case manager can request supervisory approval to authorize services to continue. Payment for all services to be reimbursed during a suspension must be authorized as an administrative payment using state funds.

3814.3  Crisis Interventions

Revision 13-1; Effective March 1, 2013

Suspensions for this reason must be clearly documented in the case record and discussed with the case manager's supervisor. A face-to-face contact should be made within three working days of the case manager becoming aware of the suspension to attempt to resolve the problem which has caused the suspension. The case manager must attempt to resolve the problem within 12 calendar days of the date services were suspended. This meeting of the interdisciplinary team (IDT) should include family members, caregivers and other parties as appropriate. The individual must be made aware of the potential loss of services if circumstances are not resolved. The Home and Community Support Services Agency (HCSSA) should have a registered nurse at this meeting if at all possible, and Adult Protective Services may also need to be involved. The individual service plan (ISP) should be reviewed to determine if there are changes that can be made to alleviate any problems the individual is having. If an agreement can be reached between the case manager, the individual and the provider, services should be resumed.

If the issues cannot be resolved, the provider may report it will no longer serve the individual due to health and safety concerns. In some situations, the case manager may initiate services with a new provider. In other situations, the case manager may terminate the individual from the Community Based Alternatives (CBA) program due to health and safety issues. The individual may reapply for CBA services. Before terminating the individual from CBA, the case manager must make a referral to a new provider and must determine how much information to share with the new provider regarding the previous actions.

The case manager must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

The case manager must use good judgment in determining the needed information to share and, if in doubt, consult with his supervisor for guidance.

If no compromise is possible, the individual should be offered institutional care; however other community options must be explored first.

3814.4  Termination After Suspension

Revision 13-1; Effective March 1, 2013

If a resolution is not in place by the 12th calendar day from the date Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, was sent suspending services, the individual must be terminated from the Community Based Alternatives program, and another Form 2065-C must be sent giving the individual the opportunity to appeal the termination. Form 2065-C is sent with an effective date of the day services were suspended, the regulatory reference (§48.6104, Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice) and a clear statement in the comments section, "You have 12 days to appeal this decision. Services will not continue pending the outcome of an appeal, even if appealed within the 12 day action period."

3814.5  Immediate Suspension with Advance Notice

Revision 13-1; Effective March 1, 2013

§48.6106 — Immediate Suspension with Advance Notice. If the participant has been legally confined or resides in an institutional setting, the Community Based Alternatives (CBA) provider agency is required to immediately suspend CBA services. The Texas Department of Human Services case manager shall immediately furnish notice of suspension to the participant and explain the right of appeal to a fair hearing. An institution includes an acute care hospital, state hospital, rehabilitation hospital, state school, nursing home, or intermediate care facility.

The case manager is not required to send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to an individual when he is temporarily admitting in an institution, such as a hospital or a nursing facility. Form 2065-C will be sent only if the stay in the institution will be a permanent stay and that will terminate participation in the CBA program.

Form 2065-C will be sent only to suspend services when situations listed in §48.6104, Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice, occur.

3814.6  Reinstatement of Services Terminated for Threats of Health or Safety

Revision 13-1; Effective March 1, 2013

STANDARD.  An applicant whose Community Based Alternatives (CBA) participation was previously terminated due to the applicant or someone in his home being a threat to the health and safety of the applicant, may enroll in CBA if he signs Form 0003, Authorization to Furnish Information, authorizing release of information and:

  • the applicant or person in the home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist or psychologist and can furnish a letter saying that he is no longer a threat to himself or others; or
  • the applicant or person in the home allows collateral contact with his physician, psychiatrist or psychologist and the contact indicates that the applicant or person is no longer a threat to himself or others; or
  • the person in the home who posed the threat no longer poses a threat.

If requested, the case manager may share general information with the selected Home and Community Support Services Agency (HCSSA), but not specific detailed information about past incidences. For example, the case manager may share that Department of Aging and Disability Services (DADS) has experienced problems in the past with the individual's behavior, but should not share specific information such as the individual tried to shoot the attendant and was terminated from CBA.

3814.7  Reinstatement of Suspended Services

Revision 08-10; Effective September 1, 2008

The case manager may contact the provider to solicit its cooperation in making changes that will allow services to continue. Examples of provider actions include modifications of the schedule, staff or agency changes, counseling or other mutually agreeable actions. Home and Community Support Services are expected to continue pending resolution except in cases of mandatory or elective suspension, as identified above or in situations which endanger the provider.

In situations where the problems that caused the suspension are resolved, the case manager must:

  • evaluate the individual service plan (ISP) and convene the interdisciplinary team (IDT) to change the ISP as necessary;
  • negotiate with the provider agency a date for reinitiation of services, including any change in the ISP; and
  • confirm the resolution of the problem and service reinitiation agreement on Form 2067, Case Information, to the provider.

3815  Sanctions

Revision 08-10; Effective September 1, 2008

§48.6108 — Sanctions. The Texas Department of Human Services (DHS) may sanction, up to and including contract termination, any Community Based Alternatives provider agency that:

(1)
has discontinued services to a participant for a reason other than what is allowed in §48.6104 of this title (relating to Crisis Intervention Requiring Immediate Suspension or Reduction of Services Without Advance Notice) and §48.6106 of the title (relating to Immediate Suspension with Advance Notice); or
(2)
uses the information cited in §48.6104 of this title to discontinue services to a participant when the provider agency knew or should have known that the cited information did not apply to the participant.

Suspected violations of this policy should be reported by the case manager to the appropriate contract manager. The initial referral may be by telephone, but should be followed up in writing by either electronic mail or Form 2067, Case Information, with a copy provided to the case manager's supervisor.

When services are suspended because the Department of Aging and Disability Services enforced sanctions against the provider, the case manager should consult with regional contract management and administrative staff to determine if it will be necessary for the consumer to change agencies. The case manager must contact the consumer to select another agency when necessary.

3820  Individual's Rights

Revision 13-1; Effective March 1, 2013

3821  Notifications

Revision 13-1; Effective March 1, 2013

§48.6010 — Individual’s Right to Appeal. An applicant whose request for enrollment into the CBA Program is denied or is not acted upon with reasonable promptness, or an individual whose CBA Program services have been denied, suspended, reduced, or terminated by DADS, is entitled to a fair hearing in accordance with Texas Administrative Code, Title 1, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).

The case manager is responsible for preparing and sending notifications to the applicant or individual advising of actions taken regarding eligibility for the Community Based Alternatives (CBA) program and the right to a fair hearing. Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff. The case manager must coordinate service changes or termination of CBA eligibility with Medicaid denial decisions made by the MEPD specialist.

Although the MEPD specialist is required to notify the applicant or individual of all Medicaid eligibility decisions, the case manager is required to send the applicant or individual and providers the notification of service changes or denial or termination of CBA eligibility on Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. Since MEPD is sending denial notices related to the financial denial, MEPD policy citations or denial messages are not required on CBA Form 2065 notices. Fair hearings must be coordinated with MEPD when the CBA case action appeal is based on a Medicaid eligibility decision.

Send the MEPD specialist a copy of Form 2065-B or Form 2065-C at initial enrollment, annual reassessment, termination and other case actions that involve Medicaid eligibility.

3821.1  General Information Regarding Notifications

Revision 13-1; Effective March 1, 2013

STANDARD.  The case manager is required to notify an applicant or an individual receiving services on Form 2065-B, Notification of Waiver Services, when any case action is taken except for denial of a Community Based Alternatives (CBA) application or termination of CBA program eligibility. Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is used to notify an applicant of CBA denial or an individual of CBA termination.

Form 2065-B also serves as an authorization to CBA providers and provides information on effective dates of service authorization and termination. The notification forms also include information on the individual's room and board charges and copayment, if applicable.

The case manager must notify the applicant on Form 2065-B of the initial approval of CBA eligibility within two working days of the decision.

The case manager must notify the applicant on Form 2065-C of the denial of his CBA application within two working days of the decision.

If the individual continues to be eligible for CBA at the annual reassessment, the case manager must send Form 2065-B to the individual and providers.

The case manager completes Form 2065-B to notify an applicant or individual of:

  • initial approval of his CBA application;
  • his continued eligibility for CBA at the annual reassessment;
  • a change in the authorized categories, units, or both, of any CBA service;
  • a change in the authorized provider;
  • a change in his copayment, room and board charges, or both;
  • reduction in services;
  • denial of his request for a particular adaptive aid, medical supply or minor home modification; or
  • changes in services, for example from Adult Foster Care (AFC) to Assisted Living (AL).

The case manager must notify an individual of any termination or reduction in specific services, or increase in copayment or room and board charges, at least 12 calendar days before the effective date of the decision to reduce services and 12 calendar days before terminating CBA program eligibility.

The notification must clearly state the action taken and the reason the action is being taken. Reference to the handbook section or the rule citation number is required on the notice. Comments should be limited to describing the action being taken and dates.

Confidential information supplied by the applicant or individual during the eligibility process must be protected. This includes inclusion of confidential information by Department of Aging and Disability Services (DADS) staff to third parties who receive a copy of a notification of eligibility form. The case manager must ensure that no confidential information is included on the eligibility notice that should not be shared with the service provider or another third party. For example:

  • An individual is being terminated from CBA due to an increase in income. It is a violation of confidentiality to record on Form 2065-C, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "Your income exceeds the eligibility limit."
  • An applicant is being denied based on medical necessity. The applicant does not require skilled nursing; the only diagnosis the applicant has is arthritis. It is a violation of confidentiality to record on Form 2065-C, "You do not meet medical necessity. Your diagnosis of arthritis is not enough to require skilled care."

In the examples, revealing the amount of the individual's income or the applicant's diagnosis is a violation of his right to confidentiality. In all cases, the case manager must assess any information provided by the applicant or individual to determine if its release would be a confidentiality violation.

The case manager is not required to send Form 2065-B if there is an addition or reduction of a specific task within a service category with no change in units, for example, bathing within the Personal Assistance Services (PAS) service category. Completion of Form 2065-B will be necessary if a service category is being added or deleted. For example, if nursing services are being deleted, a notice would be required but no notice would be required if a particular nursing task is being deleted with no change in authorized units. Completion of Form 2065-B is required when a provider submits a change to request an adjustment of a previous authorization to remove unused money. For example, $5,000 is requested for a home modification. Once the home modification is completed, the actual cost is only $4,500. The Home and Community Support Services provider submits a change request to adjust the home modification to $4,500. The 12-day advance notice for the adverse action is not applicable because the action is favorable to the individual.

The case manager uses Form 2065-C to notify an applicant of the denial of CBA eligibility or an individual of the termination of CBA eligibility.

The case manager must follow protocol in Appendix XIII, Resources for Handling High Needs Applicants, before the denial of an applicant or the termination of an individual who has high needs.

Notifications require a cooperative effort between Medicaid for the Elderly and People with Disabilities (MEPD) and the case manager, particularly because of the specific notification requirements that exist for Medicaid eligibility decisions and the time frames required for adverse actions and monthly cutoff processing. The case manager must notify MEPD staff within one working day of changes that will affect Medicaid eligibility. The case manager must send the MEPD specialist a copy of Form 2065-B or Form 2065-C as notification for actions that involve individuals who have Medical Assistance Only (MAO).

Refer to Section 3810.1, 12-Day Adverse Action, for determining the effective date of an adverse action period. Refer to Section 3821.1.1, Completion of Form 2065-B and Form 2065-C Notifications, for additional information about completing and sending the forms to ensure notification timeliness.

3821.1.1  Completion of Form 2065-B and Form 2065-C Notifications

Revision 13-1; Effective March 1, 2013

Form 2065-B, Notification of Waiver Services, and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, are the legal notices sent to an applicant or individual of the actions taken regarding Community Based Alternatives (CBA) services. The forms must be completed in plain language that can be understood by the applicant or individual. The language preference of the applicant or individual must be considered.

Form 2065-B and Form 2065-C completion requirements are established to enhance rule requirements and ensure timeliness of notification.

  • Form 2065-B and Form 2065-C are completed to document the case decision and provide notification. As listed in other handbook items, the case manager may be required to send Form 2065-B or Form 2065-C within a specific amount of time, such as two days, once it is determined that a case action must be taken.
  • Once it is determined that a case action must be taken, Form 2065-B or Form 2065-C must be prepared and mailed to the applicant or individual the same date the form is signed by the case manager.
  • The case manager’s signature date on Form 2065-B and Form 2065-C is the case action date.
    • Initial Enrollment — The case manager's signature on Form 2065-B is the date all eligibility factors are met and valid and the case manager authorizes services.
    • Annual Reassessment — The case manager's signature on Form 2065-B is the date all eligibility factors are met and valid and the case manager authorizes services.
    • Termination or Denial — The case manager's signature on Form 2065-C is the date of the case manager's action to deny an initial enrollment or terminate CBA program eligibility.
    • Changes to Increase or Add Services — The case manager's signature date on Form 2065-B is the first date the change in services can take effect or new services can be added to the service plan, unless there is documentation of a negotiated effective date or a special circumstance requiring a retroactive effective date, such as the emergency delivery of Personal Assistance Services (PAS), medical supplies or adaptive aids. The signature date is recorded on Form 2065-B in the Effective section and provider authorization effective date, and the effective date on Form 3671-1, Individual Service Plan, unless there is documentation of a negotiated effective date.
    • Changes to Decrease or Deny Services or Terminate Program Eligibility — The case manager's signature date on Form 2065-B or Form 2065-C is the date of the case manager's action to decrease a service, deny an item or service, deny a request for a change in the level of service or terminate program eligibility. An adverse action notice must be given unless waived by a written statement from the individual. The effective date of the change is determined by the adverse action period.
  • All signatures required on the individual service plan forms (Form 3671-1, Form 3671-2, Individual Service Plan, and Form 8598, Non-Waiver Services) and the attachments (Form 3671-B, Therapy Service Authorization, Form 3671-C, Nursing Service Plan, Form 3671-C-Alternate, CBA Individual Service Plan – Nursing Service Plan for Consumer Directed Services (CDS) and/or Specialized Nursing or Health Maintenance Activities (HMAs), Form 3671-D, Minor Home Modifications, Form 3671-E, Adaptive Aids and Medical Supplies, Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or similar documentation, Form 3671-H, Dental Services, Form 3671-J, Dental Services – Proposed Treatment Plan, Form 2060-A, Addendum to Form 2060 for Personal Assistance Services, or other necessary forms requiring signatures) must be signed prior to the case manager’s signature date.

Refer to Section 3434, Establishment of the Eligibility Date and Effective Date on Form 2065-B, and Section 3643, Annual Update of the ISP, for detailed information for completing Form 2065-B for an initial enrollment or annual reassessment. Refer to Section 3810.1, 12-Day Adverse Action, for information about determining the effective date for required adverse actions.

3821.2  Notification of Approval of CBA Application

Revision 08-10; Effective September 1, 2008

The case manager must notify the Community Based Alternatives (CBA) applicant on Form 2065-B, Notification of Waiver Services, of the decision regarding eligibility within two Department of Aging and Disability Services (DADS) business days of determining the individual is eligible.

For applicants determined to be eligible for CBA services, the case manager uses Form 2065-B to notify an applicant of:

  • approval of his application for CBA services, the effective date and the names of the providers; and
  • his room and board charges and initial and ongoing copayment amounts, if applicable.

The case manager must send a copy of Form 2065-B showing the effective date for CBA services to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Form 2065-B must be sent to providers authorized to provide waiver services within two DADS business days of the applicant's eligibility date for CBA services.

The case manager should note in the comments section of Form 2065-B the denial of a request for a particular adaptive aid, medical supply or minor home modification. The consumer may appeal the denial. If the denial is overturned, the item is added to the individual service plan (ISP) after the hearings officer's decision and the cost is reflected in the ISP in effect at the time of the hearing. Refer to Section 4140, Adaptive Aids and Medical Supplies, and Section 4150, Minor Home Modifications.

The case manager must send the consumer, providers and MEPD staff, if involved, Form 2065-B at the time of the annual reassessment if the consumer continues to be eligible for CBA services.

3821.2.1  Notification of Approval of CBA Application for Individual Aging Out

Revision 11-3; Effective September 1, 2011

The case manager follows special procedures for completing Form 2065-B, Notification of Waiver Services, for individuals aging out of the Medically Dependent Children Program (MDCP)/Comprehensive Care Program (CCP) to Community Based Alternatives (CBA), when the individual's 21st birthday falls on a weekend or holiday.

Once all waiver criteria are met with the exception of the age requirement, the case manager completes and sends Form 2065-B to the applicant, CBA providers, and interdisciplinary team members (IDT), using the following guidelines:

  • Date Mailed: Date of case manager's signature on Form 2065-B
  • Eligibility Date: Date of individual's 21st birthday
  • Effective Date: Date of individual's 21st birthday
  • Signature – DADS staff: Date the case manager completes and signs the form

In the Form 2065-B Comments section, the case manager documents, "The individual will meet all eligibility requirements on (date of 21st birthday). Services may begin on that date."

The case manager follows policy in Section 3440.1, Registration of the Individual Service Plan (ISP), Non-Money Follows the Person (MFP) Certifications, to enter the ISP in the Service Authorization System.

3821.3  Notification of Denials and Terminations

Revision 08-10; Effective September 1, 2008

The case manager uses Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to notify an applicant or consumer of:

  • denial of his Community Based Alternatives (CBA) application; or
  • termination of his CBA eligibility including denial at the annual reassessment (see Section 3821.4, Reasons for Denial and Termination of CBA Services).

The case manager must notify the consumer on Form 2065-C of termination of services providing an adverse action period. Refer to Section 3810.1, 12-Day Adverse Action, for how to calculate the adverse action period.

Form 2065-C must include the specific rule reference, including subsections and a clear statement of the reason for denial. Comments should be in terms easily understood by the applicant/consumer. Related rule and/or handbook references should be include on Form 2065-C.

3821.4  Reasons for Denial and Termination of CBA Services

Revision 13-1; Effective March 1, 2013

Refer to the instructions and attachments for Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for denial or termination reasons, Service Authorization System codes and rule references.

Eligibility criteria used when denying initial requests for Community Based Alternatives (CBA) services or terminating CBA at the annual reassessment and Title 40 of the Texas Administration Code §48.6003, Eligibility Criteria, are found in Section 3211.1, Basic Eligibility Criteria.

3821.5  Notification of Approval of CBA at the Annual Reassessment

Revision 13-1; Effective March 1, 2013

For an individual determined to be eligible for Community Based Alternatives (CBA) services at the annual reassessment, the case manager uses Form 2065-B, Notification of Waiver Services, to notify the individual of approval of CBA services, the effective date, names of the providers, the room and board charges and ongoing copayment amounts, if applicable. The case manager must note in the comments section of Form 2065-B the denial of a request for a particular adaptive aid, medical supply, minor home modification or other CBA service or the denial of a request for a change in the level of service that was included in the assessment packet received from the Home and Community Support Services Agency (HCSSA) or made by the individual during the development of the individual service plan (ISP). The rule/handbook section must be noted.

At the annual reassessment, the new ISP may reflect a decrease in services or termination of services authorized on the previous ISP. For example, the previous ISP may have authorized five units of a certain medical supply and home delivered meals. At the request of the individual, home-delivered meals may be terminated beginning with the new ISP and only three units of the medical supply authorized. Since this is a new ISP authorization period, advance notice of this decrease/termination is not necessary. The case manager is not required to note the changes in services or provide a rule/handbook section on Form 2065-B. The individual's eligibility is established for a new ISP period and the individual signs Form 3671-2, Individual Service Plan, which acknowledges agreement with the new ISP (but retains the right to request an appeal).

Along with Form 2065-B, the case manager sends Form 3671-2 and other applicable ISP attachments to inform the individual of the services included in the new ISP. Upon receipt and review of the new ISP, the individual may request a change to the ISP. The case manager must review the requested change with the individual according to policy in Section 3610.2, Case Manager Response to Routine Change Requests, and make a decision to approve or deny the request. Form 2065-B, notifying of approval or denial of the requested change, is sent to the individual.

The individual has the right to appeal the denial of items or a change in the level of services requested at the annual reassessment (or in response to a requested change received) after Form 2065-B, Form 3671-2 and attachments are sent. If the denial is overturned, the item is added to the ISP after the hearings officer's decision and the cost is reflected in the ISP in effect at the time of the hearing.

The case manager sends Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, if CBA program eligibility is terminated at the annual reassessment.

The case manager must send Form 2065-B or Form 2065-C to the individual, providers and Medicaid for the Elderly and People with Disabilities staff, if involved.

3830  Appeals

Revision 12-3; Effective September 4, 2012

3831  General Information Regarding Appeals

Revision 13-3; Effective September 3, 2013

The applicant or individual has the right to appeal any type of decision made regarding Community Based Alternatives (CBA) services, even those decisions that may be considered to be positive or favorable, such as notification of eligibility for services. The applicant or individual may want to appeal the decision, for example, regarding the types or quantity of service authorized.

The applicant's or individual's right to appeal and a fair hearing are explained on page 2 of Form 2065-B, Notification of Waiver Services, and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager is expected to act promptly to notify the applicant or individual of case actions so the applicant or individual has as much time as possible to plan and respond to the notification. The applicant or individual may appeal the decision for up to 90 calendar days after the date shown on Form 2065-B or Form 2065-C.

If an individual who is terminated from CBA, including terminations because of loss of medical necessity, Supplemental Security Income (SSI) or financial eligibility, appeals before the termination effective date, within the 12-day adverse action period, CBA services may continue until a decision is rendered by the hearings officer, if the individual wants continued services. If CBA services are reduced, the individual may receive services at the current level if an appeal is filed within the 12-day adverse action period and the individual wants services continued at the current level. Refer to Section 3810.1, 12-Day Adverse Action, for how to calculate the 12-day adverse action period, and other items in Section 3800, Suspensions, Notifications, Denials and Terminations, for detailed information about service continuation if the individual appeals during the 12-day adverse action period.

An applicant or individual may request a fair hearing orally or in writing. If Form 2065-B or Form 2065-C is received unsigned, the case manager must assume this is a request to appeal. The applicant or individual should be contacted by telephone, if possible, to determine if the applicant or individual wants to appeal or is just returning the form. If the applicant or individual wants to appeal, the notice should be returned to him for his signature but the 12-day adverse action period or 90-day time frame is considered to be met if the unsigned notice was received within those time frames.

When a request for a fair hearing is received from the applicant or individual orally or in writing, the case manager must refer the request to the hearings officer within five calendar days from the date of the request. The request for the fair hearing is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by a regionally designated data entry representative.

Upon receipt of the fair hearing request, the case manager completes Form 4800-D, DADS Fair Hearing Request Summary. All questions in Section 3, “Appellant Details Programs” must be answered. In Subsection D, “Summary of Agency Action and Citation,” the case manager must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

The case manager must indicate the individual service plan (ISP) begin and end date, as applicable, in Section 3.D., “Summary of Agency Action and Citation.” The begin and end dates must also be mentioned during the fair hearing so the hearings officer is aware of when the ISP year ends when rendering a decision.

The case manager includes on Form 4800-D the names and titles, addresses and telephone numbers of all persons the case manager wants to attend the hearing. The attendees will vary depending on the type of hearing. The case manager must be present in hearings involving cost limit, reduction or denial of services and program terminations. Other appropriate program staff that may be present include the DADS regional or utilization review (UR) nurse, Home and Community Support Services Agency (HCSSA) nurse, or the waiver section manager or designee, depending on the individual responsible for the reduction of services or denial of items or cost. If the request for a fair hearing is due to a UR finding, the case manager must notify the UR nurse who completed the review and must identify the UR nurse and UR nurse manager as participants on Form 4800-D. Other participants may be appointed by the case manager to be present, depending on the nature of the fair hearing. Refer to Form 4800-D instructions for specific details about how to enter names of participants required for the fair hearing. Form 4800-DA, 4800-D Addendum, is used to record and submit additional names when there are more than three other participants who require notification of the date and time of a hearing. Form 4800-DA is attached to Form 4800-D.

The case manager sends the form to the regional data entry representative and the unit supervisor within three calendar days of the request for a fair hearing. The three-day time frame allows the data entry representative two days to enter the information into TIERS.

Within two calendar days of receipt of Form 4800-D, the data entry representative enters the information into the TIERS Fair Hearings and Appeals system. For fair hearing requests regarding medical necessity or Medicaid denials, the data entry representative must enter the agency representative name documented on Form 4800-D by using the "MOR Search" function in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry person will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the case manager and supervisor.

TIERS will automatically alert the Fair Hearing Division of the request for an appeal and generate a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The Fair Hearing Division will send Form H4800 to each of the following:

  • the appellant, along with the original Form H4803;
  • the appellant's representative, if appropriate;
  • the agency representative and supervisor entered in TIERS; and
  • persons listed as other participants, including persons outside the program area scheduled to participate in the hearing.

The case manager and supervisor will receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the fair hearing. It is the supervisor's responsibility to ensure that the case manager or designated representative participates in the fair hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

The case manager sends Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer after Form 4800-D is prepared and sent. The hearings officer's name is found on Form H4803. The appeal ID number assigned by TIERS must be written at the top of Form H4800-A. Examples of supporting documentation include but are not limited to:

  • Texas Register rules;
  • handbook citations;
  • policy updates;
  • summary of events;
  • other documentation supportive of the decision such as documentation of telephone calls, visit summaries, etc.; and
  • a copy of the denial or termination letter from DADS staff, if applicable.

The case manager should provide the hearings officer with all related documentation necessary to support the case action decision to reduce or deny services or terminate program eligibility 10 calendar days before the fair hearing. Refer to Section 3836, Fair Hearings Evidence Packets and Presentation, for more detailed information about uploading the hearing packet to TIERS and presentation of the evidence at the hearing.

If the appellant is not satisfied with the hearings officer's decision, he may request the hearings officer conduct an administrative review. Program staff may disagree with the hearings officer's decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to management for further review. Refer to Section 3835, Fair Hearings Exception Process.

3831.1  Termination of Community Based Alternatives (CBA) Eligibility if the Individual Does Not Appeal

Revision 13-1; Effective March 1, 2013

For terminations when an individual does not meet CBA eligibility criteria at the annual reassessment, if the individual does not request a fair hearing, all CBA providers are authorized to deliver CBA services through, but not later than, the end of the current individual service plan (ISP) period or the end of the 12-day advance notice of the adverse action time period, whichever is later.

For terminations of CBA program eligibility during the ISP year, if the individual does not request a fair hearing, all CBA providers are authorized to deliver CBA services through the end of the 12-day advance notice of the adverse action time period. The 12-day time period determines the termination effective date on the notification form sent to the individual and to CBA providers.

If the ISP effective period ends before the 12-day advance notice of the adverse action time period expires, the case manager will notify the providers, via Form 2067, Case Information, to continue services as authorized on the ISP through the 12-day time period. The case manager must register the services in the Service Authorization System (SAS) and force a medical necessity record in SAS to avoid billing rejections and allow services delivered to be billed through the Claims Management System (CMS).

Notify the Medicaid for the Elderly and People with Disabilities specialist of the CBA termination for an individual who does not receive Supplemental Security Income or receives another categorically eligible Medicaid program and ensure Medicaid eligibility remains in effect until the last day CBA services may be provided.

3831.2  Continuation of Community Based Alternatives (CBA) Services During an Appeal

Revision 13-1; Effective March 1, 2013

CBA services must continue until the hearings officer makes a decision regarding the appeal of an individual, if the appeal is filed within the 12-day adverse action period and the individual requests continued services pending the appeal. If an appeal was requested within the 12-day adverse action period, the case manager should promptly notify the authorized providers via Form 2067, Case Information. CBA services should continue to be provided until the hearings officer renders his decision. Follow procedures in Section 3833, Coordination of Appeals Involving Medicaid, to coordinate with the Medicaid for the Elderly and People with Disabilities programs, as applicable, to continue Medicaid eligibility for an individual who does not receive Supplemental Security Income or another categorically eligible Medicaid program.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, the case manager must finalize all annual reassessment activities before the ISP expiration date in order to assure that providers can be paid for services delivered after the expiration date of the current ISP and until the outcome of the appeal is determined.

The case manager must determine that the individual meets all CBA eligibility criteria, except the eligibility criteria that resulted in the termination of CBA, obtain the individual's signature on the ISP and register the reassessment ISP in the Service Authorization System (SAS). The reassessment ISP should reflect the needs of the individual at the time of the annual reassessment. Notify CBA providers via Form 2067 to deliver services identified on the reassessment ISP until the outcome of the appeal. Do not send Form 2065-B, Notification of Waiver Services, to the individual or providers notifying of continued eligibility related to the continuation of services until the appeal decision is made. The case manager must ensure a medical necessity record is forced in SAS to avoid provider billing rejections until the outcome of the appeal is known. Force comments must explain that the individual has filed a timely appeal and services will continue during the appeal process.

Services may not continue during the appeal process for terminations that do not require a 12-day advance notice of the adverse action. Refer to other items in Section 3800, Suspensions, Notifications, Denials and Terminations, for actions that do not require advance notice.

3831.3  Case Manager Responsibilities, Appeal Decisions and Effective Dates

Revision 13-3; Effective September 3, 2013

After the hearing is held, the hearings officer will send a decision letter to the applicant or individual and send copies to the case manager and the unit supervisor. Notification is sent via email to those participants with an email address. Decisions to dismiss and withdraw the hearing request can be viewed in the History Correspondence tab of the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals System. The hearing decision can also be viewed under the Decision tab. Within 10 calendar days of receipt of the hearings officer's decision, the case manager must take appropriate case action to implement the hearings officer's decision. The case manager must place a copy of the decision in the case record and ensure a copy of Form 4807-D, DADS Action Taken on Hearing Decision, is entered into the Fair Hearings and Appeals system. Follow procedures in Section 3833, Coordination of Appeals Involving Medicaid, to coordinate hearing decisions with Medicaid for the Elderly and People with Disabilities (MEPD).

Second Assessment Appeal Decisions

If the hearings officer’s final decision orders completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or Medical Necessity and Level of Care (MN/LOC) Assessment, the hearing is closed as a result of this ruling. The case manager must notify the individual of the results of the new assessment on Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, DADS staff must indicate in Section 3.D., “Summary of Agency Action and Citation,” of Form 4800-D, DADS Fair Hearing Request Summary, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision.

If the individual requests an appeal of the new assessment and services are continued, services are continued until the second fair hearing decision is implemented. For example, an individual is denied medical necessity (MN) at an annual reassessment and requests a fair hearing and services are continued. The case manager continues services at the level the individual was receiving prior to the MN denial. The hearings officer then orders a new MN/LOC Assessment which results in another MN denial. The case manager sends Form 2065-C to the individual informing him of the MN denial. The individual then requests another fair hearing and services are continued pending the second fair hearing decision. The case manager would continue services at the same level services were continued prior to the first fair hearing. If the new MN/LOC Assessment results in an approved MN but services are reduced due to a lower resource utilization group (RUG) value and the individual requests a fair hearing due to reduction in services, the case manager would continue services at the same level services were continued prior to the first fair hearing.

Sustained Appeal Decisions

When the hearings officer's decision sustains the termination of Community Based Alternatives (CBA), the case manager must:

  • notify the individual via telephone (or letter, if the individual does not have a telephone) of the hearings officer’s decision and the CBA termination effective date;
  • notify all CBA providers via Form 2067, Case Information, to deliver services through the CBA termination effective date if services were continued during the appeal process;
  • ensure CBA (program group 3) service records are closed in the Service Authorization System (SAS); and
  • coordinate the hearings officer's decision and the termination effective date of CBA services with MEPD staff for an individual who does not receive Supplemental Security Income (SSI) or receives another categorically eligible Medicaid program.

When the hearings officer's decision sustains a reduction in service during the individual service plan (ISP) year, the case manager must:

  • notify the CBA providers via Form 2067 to provide services as directed in the decision;
  • assure that the ISP is registered in SAS with the appropriate services and effective date; and
  • provide the CBA provider with an accurate ISP.

Do not send another Form 2065-C to notify the applicant of the sustained denial or the individual of the sustained termination, or Form 2065-B to notify the individual of the sustained decision for the reduction in service.

A copy of the hearings officer's decision to sustain the denial of an applicant will be provided to him by the hearings officer. No other notification is required to be sent by the case manager.

Sustained Decisions – Effective Dates

When the individual is terminated from the CBA program at the annual reassessment due to not meeting eligibility criteria, including medical necessity, and services are continued until the appeal decision is known, the termination effective date is:

  • 30 calendar days from the hearings officer's decision date, the date the order is signed as recorded on the decision letter, when the hearings officer's decision date is:
    • less than 30 calendar days before the end of the ISP in effect when the appeal was filed; or
    • after the end of the ISP in effect when the appeal was filed, and a new ISP was developed to continue services past the ISP end date until the appeal decision was made; or
  • at the end of the ISP in effect at the time the appeal was filed in cases where the hearings officer's decision is 30 calendar days or more prior to the end of the ISP in effect when the appeal was filed.

When services are reduced during the ISP year or the individual is terminated from CBA, the CBA reduction in service or termination effective date is the effective date of the hearings officer's decision as recorded on the decision letter.

When an applicant is denied CBA, the effective date is the date of the hearings officer's decision as recorded on the decision letter.

Reversed Appeal Decisions

When the hearings officer's decision reverses the denial of an applicant, the termination of an individual, or the reduction in services during the ISP year, the hearings officer sends Form H4807, Action Taken on Hearing Decision. The hearings officer specifies the corrective action to be taken and a 10-day time frame for completing the action. The case manager actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) system within the 10-day time frame.

The case manager completes Form 4807-D, DADS Action Taken on Hearing Decision, recording case actions taken, and sends it to the unit supervisor and the designated data entry representative. The case manager must send Form 4807-D within the 10-day time frame to allow at least two days for the data entry representative to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, Form 4807-D is completed and sent to the unit supervisor and data entry representative providing a reason for the delay. Acceptable reasons are listed on the form and the begin delay date and the end delay date must be included.

The case manager must:

  • notify CBA providers via Form 2067, as appropriate, to provide services to the individual as directed in the decision;
  • send Form 2065-B:
    • to the individual who was terminated at the annual reassessment and all CBA providers to notify them that the termination was reversed and the individual is eligible for CBA for the new ISP year; and
    • to the CBA applicant who was denied at application and all CBA providers to notify them of eligibility for CBA services;
  • assure the ISP is registered or updated in SAS with the correct services and effective dates;
  • provide the accurate Form 3671-1, Individual Service Plan, Form 3671-2, Individual Service Plan, Form 8598, Non-Waiver Services, and attachments to the CBA providers and individual; and
  • coordinate with MEPD, as appropriate, to continue Medicaid eligibility.

Reversed Decisions – Effective Dates

The hearings officer's decision date recorded on the decision letter or Form H4807 is considered the eligibility or effective date for all reversed decisions involving:

  • termination of CBA at the annual reassessment due to not meeting eligibility criteria, regardless if services continued during the appeal process or not;
  • denial or reduction of services during the ISP year; or
  • application denials.

The effective date for reversals related to medical necessity denials is the date the Texas Medicaid & Healthcare Partnership received the Medical Necessity Level of Care (MN/LOC) Assessment.

Refer to Section 3832, Appeal Procedures for MN Denial, for information on how to process a medical necessity denial.

When a fair hearing decision reverses a case action but DADS cannot implement the fair hearing decision within the required time frame, the case manager must complete Section C, “Implementation Delays,” on Form 4807-D. Form 4807-D must be submitted within the required time frame.

3831.4  Requests for Fair Hearing Withdrawals

Revision 13-3; Effective September 3, 2013

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. The case manager should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts the case manager regarding the withdrawal, the case manager must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to the case manager, the case manager must forward the written request to the hearings office. A fair hearing will not be dismissed based on a Department of Aging and Disability Services decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw the appeal within 14 calendar days of the fair hearing date, the hearings officer will notify the case manager by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw the appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility and Redesign System and a written notice will be sent to participants informing them of the fair hearing cancellation.

3832  Appeal Procedures for MN Denial

Revision 13-3; Effective September 3, 2013

The following procedures describe the roles and responsibilities of the case manager in relation to denial of medical necessity (MN) for an applicant or individual receiving Community Based Alternatives (CBA) and appeals of those denials. Information on the roles and responsibilities of Texas Medicaid & Healthcare Partnership (TMHP) staff, the hearings officer and Department of Aging and Disability Services (DADS) regional or utilization review (UR) nurse are included so the case manager may be aware of expected actions of those persons.

If after the hearings officer renders a decision that substantiates the denial of MN, and only if the case manager believes a change in the individual's medical condition now requires routine nursing care and the individual service plan (ISP) has not expired, the case manager:

  • has the DADS regional nurse confirm that the individual's medical condition has changed since the date of the hearing and the individual may now meet MN criteria;
  • authorizes the Home and Community Support Services Agency (HCSSA) to complete a new Medical Necessity and Level of Care (MN/LOC) Assessment and transmit the completed form to TMHP; and
  • approves CBA eligibility if TMHP approves the MN and the individual meets all other CBA eligibility criteria.

If the ISP expires before the MN determination is made, the individual is terminated from CBA effective the day after the last day of the ISP. If the case manager feels the individual's condition has changed to the point that the individual may now meet MN criteria and the hearing has been held but the hearings officer has not made a decision, the case manager must contact the hearings officer immediately so this new information can be considered.

Roles and Responsibilities of the Case Manager

The case manager will:

  • check the Long Term Care (LTC) online portal or Service Authorization System (SAS) to identify the MN denial determination from TMHP or use the TMHP status report provided to the case manager by the HCSSA to identify MN denials; and
  • notify the applicant or individual of the MN denial by sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, with the appropriate rule reference. TMHP phone numbers must not be included on Form 2065-C for MN denials.

Note: For an individual who does not receive Supplemental Security Income (SSI) or receives another categorically eligible Medicaid program, the case manager must coordinate with the Medicaid for the Elderly and People with Disabilities (MEPD) staff about the effective date of the Medicaid denial, which will be at the end of the month or the following month, depending on the Texas Integrated Eligibility Redesign System (TIERS) cutoff. If the individual appeals timely and requests services continue during the appeal, coordinate the continuation of Medicaid eligibility with MEPD staff. Refer to Section 3833, Coordination of Appeals Involving Medicaid.

Additional Procedures for MN Denial and a Timely Appeal was Filed

In addition to the procedures outlined in Section 3831, General Information Regarding Appeals, the case manager must also complete the following when processing the request for an MN denial:

  • Include on Form 4800-D, DADS Fair Hearing Request Summary, the:
    • name of the TMHP representative, Paula Ortiz, as the agency representative;
    • names of DADS regional or UR nurse who completed the MN/LOC Assessment in the Other Participants section, if applicable; and
    • case manager's name and supervisor's name in the Other Participants section. (Refer to Form 4800-D instructions for more details on how to complete accurate referrals to the hearings officer. Use Form 4800-DA, 4800-D Addendum, in conjunction with Form 4800-D when there are more than three other participants who require notification of the date and time of a hearing.)
  • Submit Form 4800-D and additional fair hearing request forms, as applicable, to the designated data entry representative. Refer to procedures in Section 3831, General Information Regarding Appeals, for submitting fair hearing requests to the designated data entry representative.
  • Complete Form H4800-A, Fair Hearing Request Summary (Addendum), and include the following as supporting documentation for the fair hearing evidence packet:
    • A copy of the MN/LOC Assessment to the hearings officer, along with other required documents.
    • A copy of the CBA explanation of MN and resource utilization group (RUG) value calculation found in Appendix XXIII, Medical Necessity Determination and Resource Utilization Group Value Calculation Explanation, if MN determination or RUG value change or calculation is in question.
  • Submit additional information that may be relevant to the MN decision to the TMHP nurse before the hearing. Contact the TMHP nurse directly at 1-800-727-5436.
  • If the MN denial is overturned before the hearing, as documented by verification from TMHP, the case manager will:
    • continue processing the applicant's or individual's ISP;
    • notify the applicant or individual by telephone of the MN denial overturned by TMHP; and
    • do one of the following:
      • If the individual had a hearing scheduled only because of the denial of MN, the case manager will inform the applicant or individual that the applicant, individual or his representative may request to withdraw his appeal orally by calling the hearings office (See Section 3831.4, Requests for Fair Hearing Withdrawals, for procedures for requesting a fair hearing withdrawal); or
      • If the individual had a hearing scheduled for MN and other reasons, the case manager will:
        • verbally instruct the individual that although his MN denial has been overturned the hearing will continue for the other reason(s),
        • verbally notify the hearings officer of the reversal of the MN denial by TMHP, and
        • provide verbal cancellation notice within three days of receipt of MN overturn notice from TMHP to the participants previously notified by the hearings officer to be present at a MN denial hearing.
  • If the hearings officer's decision will not be made until after the ISP expiration date and a timely appeal was filed, the case manager will:
    • finalize all annual reassessment activities including obtaining the individual's signature on Form 3671-2, Individual Service Plan, before the ISP expiration date in order to assure that providers can be paid for services delivered after the expiration date of the current ISP;
    • assure that the annual reassessment ISP is data entered in SAS; and
    • ensure an MN record is forced in SAS to allow payment to continue pending the outcome of the appeal of the MN denial.

If the MN denial is overturned at the fair hearing, the case manager will verify the denial is overturned by obtaining a copy of the hearings officer's decision, viewing SAS or the LTC online portal showing the MN denial changed to MN approval, or receiving notification by email from TMHP.

TMHP will receive an email from the hearings officer notifying of an overturned decision. TMHP will change the status in the LTC portal to "approve" and send a second email to the case manager and supervisor. Upon receipt of the second email from TMHP, which includes the fair hearings decision document, the case manager must implement the overturned decision and complete Form 4807-D, DADS Action Taken on Hearing Decision, and submit for data entry into TIERS within seven calendar days from the receipt of the email. (This is 10 days from the hearings officer sending the decision to TMHP.) The day TMHP receives the decision is considered "Day 0." TMHP has three calendar days to reverse the MN assessment in the LTC Portal and notify DADS. When the notification is received, the case manager must complete and send Form 4807-D to the data entry representative, allowing two days for data entry.

An applicant or individual may notify the case manager directly if the applicant or individual does not agree with the MN denial decision or if he wishes to withdraw the request for a fair hearing when the letter from TMHP that an MN decision has been overturned is received. Refer to Section 3831.4 for procedures for withdrawing a fair hearing.

Refer to Section 3831.3, Case Manager Responsibilities and Effective Dates of Appeal Decisions, for effective dates for sustained and reversed denials.

The case manager will be available for MN appeals on an "as needed" basis to serve as a consultant for policy clarification only.

Roles and Responsibilities of TMHP

TMHP will:

  • Send a letter to the applicant or individual, his physician, and the HCSSA that includes the phone number for the TMHP Help Desk, 1-800-626-4117, Option 2. The physician or the HCSSA can call this number, select Option 2 and submit additional medical information to a TMHP nurse before the MN denial is final.
  • Submit the MN denial letter to the applicant's or individual's physician informing him that the MN denial will be final if additional information supporting the need for licensed nursing services is not submitted to TMHP by fax or telephone.
  • Submit a letter to the applicant or individual informing him to contact his physician for assistance in supporting his MN.
  • Mail a copy of the MN/LOC Assessment, with all pertinent comments that may have been entered by nurse analysts in response to conversations with the HCSSA nurse and copies of any additional documentation supporting the MN denial to the hearings officer within seven working days of receipt of Form 4800-D.
  • Review any new information submitted by the HCSSA nurse, DADS nurse or the case manager that is received by telephone, fax or from the LTC online portal. TMHP must accept and consider any clinical information provided after MN has been denied up to two working days prior to the hearing for electronic information (including telephonic and portal information) and up to three working days for paper information (including faxes).
  • Review any additional new medical information submitted by the applicant's or individual's physician within 14 days before the hearing or before the termination of services, whether the applicant or individual has or has not appealed, and communicate with the HCSSA nurse or DADS nurse if clarification is needed.
    • If the MN denial is overturned, TMHP will:
      • notify the applicant or individual and his physician that the MN denial has been overturned as soon as the decision is reached and no later than 10 working days before the scheduled hearing;
      • fax a copy of the MN denial overturn letter to the case manager and hearings officer as soon as the decision is reached, and no later than 10 working days before the scheduled fair hearing if there is a fair hearing scheduled or if there is not a fair hearing scheduled; and
      • send DADS (via the automated process) the MN approval to be reflected in the LTC online portal or in SAS in the MN record.
    • If the MN denial is sustained, TMHP will notify the physician and the applicant or individual.
  • Review any medical information presented during the fair hearing or subsequent to the fair hearing, if requested by the hearings officer, and provide a written MN determination to the hearings officer within seven working days of receipt of the written request for review.
  • Participate in the hearing to explain or defend the MN action taken by TMHP.
  • Send DADS (via the automated process) the hearings officer's decision from the fair hearing.

Upon receipt of an email from the hearings officer notifying of an overturned decision, TMHP will:

  • forward the email to the case manager and supervisor the day it is received as notification the MN decision was overturned;
  • change (reverse) the assessment MN status to "approve" via the LTC online portal;
  • notify the case manager and supervisor by email of the MN decision reversal in the portal within three calendar days of receipt of the decision (excluding state holidays); and
  • email copies of all decisions (upheld, reversed, withdrawn and dismissed) from the hearings officer to the case manager and supervisor.

Roles and Responsibilities of HHSC Hearings Officers

The Health and Human Services Commission (HHSC) hearings officer will:

  • notify the appellant (applicant or individual) and all persons listed on Form 4800-D of the date, time and location of the hearing;
  • prepare a final order disposing of an appeal through withdrawal and send copies of this order to the appellant and TMHP upon written notification from the appellant to withdraw an appeal;
  • conduct the hearing;
  • utilize the TMHP nurse to determine whether any new medical information introduced at the fair hearing meets the MN criteria for nursing facility care;
  • reserve the right to hold an appeal open after a fair hearing pending medical review by TMHP physicians;
  • submit a written request for medical review to TMHP for all new medical information presented at a fair hearing in situations where the TMHP nurse determines that the new medical information presented does not meet the MN criteria;
  • render a decision; and
  • send a copy of all fair hearing decisions, as appropriate, to TMHP, the case manager, the HCSSA nurse, DADS regional or UR nurse, and other participants within five days of making the decision.

Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant. Program staff may disagree with the decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to the regional attorney. Refer to Section 3835, Fair Hearings Exception Process, for procedures to request program management review of a hearings officer's decision.

Roles and Responsibilities of the DADS Nurse

The role of the DADS nurse in the MN denial appeal process is to continue to improve the accuracy of the information on the MN/LOC Assessment, through UR and satisfaction interviews with the individual. The DADS nurse will focus on the accuracy of the current attending physician's name on the MN/LOC Assessment. Accuracy of the current attending physician is necessary in order for TMHP to contact an individual's physician for additional information should MN be denied.

The DADS nurse will ensure the attending physician's information on the MN/LOC Assessment is correct and notify the HCSSA if the physician information is incorrect. The HCSSA must ensure TMHP is notified of any change in physician for the appeal process. The DADS nurse should notify the contract manager if an HCSSA has shown a trend in incomplete or inaccurate completion of the MN/LOC Assessment.

The DADS nurse may submit additional clinical information to TMHP after a denial of MN. The DADS nurse may submit information electronically (telephonic and portal) up to two working days prior to the fair hearing, and may submit paper information (including faxes) up to three working days prior to the hearing.

If the DADS nurse cannot make contact with the TMHP nurse who reviewed the MN/LOC Assessment, the DADS nurse should call TMHP at the following phone numbers:

  • 1-800-727-5436; or
  • 1-800-626-4117.

The DADS nurse chooses option "2" for MN; this will forward the call to a TMHP nurse.

The DADS nurse who completes the UR process will participate in MN denial hearings related to MN/LOC Assessments completed as part of the UR process. DADS nurses familiar with an applicant's or individual's health status may also participate, when requested by program staff or the hearings officer, to provide professional nursing judgment or information regarding a specific applicant's or individual’s health status.

3833  Coordination of Appeals Involving Medicaid

Revision 13-1; Effective March 1, 2013

The Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) Centralized Representation Unit (CRU) handles all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) staff. CRU staff replace the MEPD specialist in specific steps related to the denial of an MEPD application or recertification. CRU staff:

  • represent HHSC OES in fair hearings;
  • complete and implement all MEPD case actions based on fair hearing decisions; and
  • coordinate actions required with regional MEPD staff and Department of Aging and Disability Services (DADS) staff.

The case manager must coordinate all appeals when MEPD staff determine financial eligibility for a Community Based Alternatives (CBA) applicant or individual receiving services. The case manager must remember CRU staff replace the local MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

An applicant or individual may appeal a decision orally, in person or in writing. The case manager is responsible for completing Form 4800-D, DADS Fair Hearing Request Summary, and submitting the appeal request to designated regional staff for entry in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant or individual requests a fair hearing. The method in which the form is completed depends on the action being appealed. The case manager must determine if the appealed action is:

  • a denial for an initial request or termination of CBA program eligibility when the DADS action on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is based on CBA program criteria other than the MEPD financial decision; or
  • a denial for an initial request or termination of CBA program eligibility when the DADS action on Form 2065-C is based on an MEPD denial action.

If the appealed action is related to CBA criteria other than an MEPD financial denial action, the case manager completes Form 4800-D and enters his name as the agency representative. In the "Other Participants" field, the case manager enters "CRU Supervisor" (enter Kristi Rojas) and "CRU Administrative Assistant" (enter Esmeralda Mendiola). The CRU supervisor and administrative assistant names must be entered by using the "MOR Search" function. This will assure that all the correct information is populated in TIERS and both the CRU supervisor and the administrative assistant will receive the notice of the appeal.

If the appealed action is the result of an MEPD financial denial action, the case manager completes Form 4800-D and enters "CRU Supervisor" (enter Kristi Rojas) as the agency representative. This information must be entered through the "MOR Search" function for CRU to receive the hearing information. List the case manager name or supervisor and title in the "Other Participants" section. The name of the local MEPD specialist is not entered by staff on Form 4800-D for MEPD financial appeals. The case manager (or supervisor) must include his title, such as DADS Case Manager or DADS Supervisor. Enter the DADS staff email address and include the name of the CRU administrative assistant in "Other Participants" using the "MOR Search" function.

In Section 6 of Form 4800-D, the case manager must also select "Yes" to the question: "Are you an OES Texas Works or MEPD employee?" (The case manager is actually responding to this question on behalf of the CRS supervisor, so "Yes" is the correct answer. On the Agency Representative page select "Yes" in the drop-down list. Failure to answer "Yes" to this item will result in the CRU not being notified of the hearing. This only applies to MEPD financial denials. For non-MEPD financial denials, continue to answer "No."

When Form 4800-D is sent to the designated data entry representative, the case manager sends an email notification regarding the request for an appeal to CRU. The email is sent to the CRU supervisor and CRU administrative assistant.

The email must include the:

  • applicant's or individual's name;
  • Medicaid number (if available);
  • type of CBA service; and
  • specific information requesting the MEPD financial case remain active/open during the appeal if the applicant or individual appealed in a timely manner. Example: The financial case or application may need to remain open pending an appeal decision regarding medical or functional eligibility. The case manager must notify CRU staff to keep the MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU staff request the MEPD evidence packet from the local MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent MEPD at the hearing, if required, and takes steps to ensure the appropriate MEPD financial case action is taken once a hearings officer's decision is rendered.

When a hearing decision is rendered by the hearings officer for a CBA denial or termination action based on CBA program criteria other than the MEPD financial decision, the case manager (staff name entered as agency representative) will be notified via email of the decision by the hearings officer. Based on the fair hearing decision, the case manager determines the appropriate action for CBA services according to program specific time frames. The case manager may need to coordinate effective dates of reinstatement with CRU staff and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. The case manager reports the implementation of the hearing decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

The local MEPD specialist will continue to notify the case manager if an appeal is filed by MEPD regarding a financial eligibility decision and refer the MEPD case to CRU staff to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU staff will notify the case manager via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision for the MEPD financial denial action, the case manager determines the appropriate action for CBA services. The email sent by CRU staff will include:

  • the applicant's or individual's name;
  • Medicaid number;
  • a copy of the hearing decision; and
  • the effective or denial date of Medicaid eligibility.

The case manager must not put an applicant or individual back on the CBA interest list while an MEPD denial is in the appeal process. The case manager must take appropriate action to authorize, deny or terminate CBA eligibility, or resume CBA services once the MEPD hearing decision is rendered. The applicant or individual may choose to be added back to the CBA interest list once the case manager denies or terminates CBA eligibility.

3834  Appeal Procedures for Utilization Review Findings

Revision 13-2; Effective June 3, 2013

If the applicant or individual requests a fair hearing as a result of a utilization review (UR) finding for a concurrent and prospective review, the case manager must inform the UR nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR finding.

The case manager will complete Form 4800-D, DADS Fair Hearing Request Summary, and list the UR nurse in Section 6, Agency Representative, and UR regional manager in Section 7, Agency Representative Supervisor. The case manager will be listed in Section 8, Other Participants. The case manager must confirm the correct UR nurse and UR regional manager to list on the form. The case manager includes the UR nurse whose name is located in Section A of the UR tool. The case manager identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The regional data entry representative (DER) will be responsible for uploading the case manager’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The case manager’s evidence packet will include Form 2065-B, Notification of Waiver Services. If available, the case manager includes the signed Form 2065-B returned by the applicant or individual. The case manager does not include any other documentation in the case manager’s evidence packet.

The UR nurse and UR regional manager will develop the UR fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or individual. The UR evidence packet will include a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the UR evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for the case manager’s evidence packet and UR’s evidence packet. The DER and UR representative must upload the applicable fair hearing evidence packet in TIERS no later than 10 calendar days before the fair hearing date. The case manager and UR nurse must forward a copy of the applicable evidence packet to the applicant or individual no later than 10 calendar days before the fair hearing date.

The UR nurse, UR regional manager (optional) and case manager will participate in the fair hearing to admit the applicable fair hearing packet into evidence and provide testimony regarding the case action.

3835  Fair Hearings Exception Process

Revision 13-3; Effective September 3, 2013

To help ensure that policy is consistently applied by Department of Aging and Disability Services (DADS) staff and a Health and Human Services Commission (HHSC) hearings officer, the fair hearings exception process may be used when a fair hearing decision seems to be in conflict with DADS policy. However, even if an exception is being filed, policy requires that the case manager must implement the hearings officer's decision once it has been rendered.

When a fair hearing decision is rendered, the case manager must implement the decision of the fair hearings officer within the applicable time frame, including the restoration of services.

If the case manager disagrees with the fair hearing decision, the case manager discusses the decision and all applicable policy with the supervisor. If the supervisor agrees with the case manager, the supervisor submits a fair hearing exception request, outlining the details of the hearing decision and all relevant rules and policy citations from the rules and handbooks, to the regional director (RD). The documentation must include:

  • case actions taken by the case manager that lead to the appeal;
  • a summary of the hearings officer's decision;
  • points of disagreement; and
  • pertinent policy citations.

The request must be sent to the RD within 10 calendar days of the receipt of the hearing decision. The RD reviews the information and if not in agreement with the request, indicates that decision and sends an appropriate response back to staff. If the RD is in agreement with the request for the exception, DADS staff complete and send Form 1590, Request for a Fair Hearing Exception, to the Community Services Policy (CSP) unit manager. A copy of Form 1590 is kept in regional files, not in the case record.

Upon reviewing the region's exception request, the CSP unit manager will decide whether to forward the exception request for consideration by HHSC. If the CSP unit manager (or designee):

  • concurs with the regional assertion that policy was misapplied, the form is forwarded to the Fair and Fraud Hearings section.
  • determines a clear error of law or fact was made by the hearings officer, requests that HHSC review the case action. If HHSC is in agreement, it issues a revised hearing decision.
  • does not concur with the regional request, the request will not be forwarded to HHSC.

Regional staff will be notified of the decision whether the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames. Regional staff must mail Form 1015, Fair Hearing Exception Letter, and a copy of Form 1590 to notify the applicant or individual when the DADS state office staff sends an exception request regarding a fair hearing decision to HHSC. Regional staff must place Form 1015 and Form 1590 in the outgoing mail by the close of the next working day following receipt of the notification from the CSP unit manager. Copies of Form 1015 and Form 1590 must be placed in the case record.

If DADS state office staff request HHSC to review the case action, the Fair Hearings manager conducts a preliminary review of the decision with input from relevant stakeholders. If the Fair Hearings manager agrees with the exception request and does not uphold the fair hearing decision, a response is sent back to the CSP unit manager who forwards the information to the RD, along with any additional instruction regarding necessary case actions.

If the Fair Hearings manager upholds the fair hearing decision and if the CSP unit manager and policy staff still disagree with the fair hearing decision, the information is sent to the DADS attorney for review and additional rule and policy citation. If the DADS attorney agrees to uphold the fair hearing decision, the information is sent back to the RD noting the rule and policy citations. If the DADS attorney does not agree to uphold the fair hearing decision and determines that a correct decision was made by DADS staff, then the CSP unit manager prepares a response containing the information from the DADS attorney regarding the policy. This final decision memorandum is signed and sent to the:

  • DADS attorney;
  • RD;
  • Fair Hearings administrator; and
  • Fair Hearings manager.

The exception process ensures that policy has been interpreted correctly, provides feedback to regional staff and allows for communication with the Fair Hearings Division. While the outcome of the fair hearing may not change, this process provides guidance for the hearings officer and regional staff with correct policy and procedures for future decisions.

3836  Fair Hearings Evidence Packets and Presentation

Revision 13-2; Effective June 3, 2013

When an applicant or individual receiving services requests a fair hearing, the burden of proof to uphold the Department of Aging and Disability Services (DADS) decision rests with DADS. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency decision.

Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification (ID) number assigned by the Texas Integrated Eligibility and Redesign System (TIERS) must be written on the top of Form H4800-A.

Provide the names and titles, addresses and telephone numbers of all persons or their designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send additional staff (e.g., the regional nurse, regional attorney, etc.); however, it is mandatory that the following attend:
  • Texas Medicaid & Healthcare Partnership (TMHP) staff – for Medical Necessity denials;
  • Medicaid for the Elderly and People with Disabilities (MEPD) or the Centralized Representation Unit (CRU) staff – for financial denials;
  • the case manager or designee – for all case actions or decisions; and
  • the Utilization Review (UR) nurse – if applicable to the appeal action.

All related documentation necessary to support DADS decision must be sent to the hearings officer as soon as possible, but no later than 10 calendar days before the fair hearing. Examples of additional information and who is responsible for submitting that information to the hearings officer and appellant include, but are not exclusively limited to:

  • the case manager or designee:
    • Texas Administrative Code or policy handbook references related to the case action;
    • summary of events;
    • a copy of any individual service plans, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, assessment, or other official documentation forms including form instructions;
    • other documentation supportive of the decision, such as records of telephone calls, visit summaries, etc.;
    • any relevant UR findings;
    • a signed copy of the denial notification form returned by the applicant or termination notification form returned by the individual, if available (if unavailable, send unsigned copy); and
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed Medicaid denial form returned by the applicant or individual, if available (if unavailable, send unsigned copy); and
  • TMHP:
    • a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment; and
    • other documentation supporting the decision.

Regional Responsibilities

TIERS generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case manager and his supervisor receive a copy of Form H4800 and the letter identifying the assigned hearings officer, and the time and location of the fair hearing. The case manager or designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case action to represent DADS during the fair hearing.

Each entity involved in the fair hearing is responsible for preparing its fair hearing packet and forwarding the packet to both the hearings officer identified on Form H4800 and the appellant no later than 10 calendar days prior to the hearing date. All documentation must be neatly and logically organized, and all pages numbered.

Presentation of the Evidence

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: I want to offer the following packet as evidence in the appeal filed on behalf of Joe Smith. Pages 1-10 contain information relating to the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Case Manager Community Based Alternatives Handbook which relate directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to consumer rights. Page 21 contains Form 2065-B, Notification of Waiver Services, which was mailed to the applicant on March 2, 2012.

Usually, the hearings officer can only consider the specific information offered in evidence when making the hearing decision. For example, the case manager may clearly explain how the loss of the individual's informal support increased the cost of waiver services to the point where it exceeded the cost limit. However, if documentation backing up that explanation is not contained in the packet, the explanation will not be considered.

Oral testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if he received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record in order to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case action has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

Scanning Evidence Packets into TIERS

All evidence packets must be scanned into the TIERS Fair Hearings and Appeals system using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation (also referred to as the appeals packet) to the fair hearings officer. The appeal ID number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 working days prior to the fair hearing date, the case manager must:

  • go to the multi-function office Workcenter and scan in the documentation;
  • save the document by either allowing the default document name or by entering a name of the user's choosing;
  • retrieve the scanned documents and attach to an email; and
  • send the document to the regional DER.

Within two working days after receipt, but no later than 10 calendar days before the fair hearing date, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal and select the Appeals tab, without launching TIERS;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select Hearing Evidence Packets Upload and enter the Appeal ID;
  • select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
  • select Validate;
  • check the details to ensure the right person has been selected;
  • browse for the document; and
  • select Upload.

A DER who makes a mistake he is unable to reverse may contact the state office Document Maintenance manager to assist in correcting the error and upload the appropriate information.

The DER can update the agency representative information any time before the hearing occurs. Any hearing correspondence sent prior to the update of agency representative will not be re-sent; only correspondence mailed after the update will be sent to the participants listed.

The case manager completes Form H4800-A to submit all other changes prior to the hearing. The case manager must enter the applicant's or individual's name, appeal ID and only the fields with information that is changing. The case manager sends Form H4800-A in an email to the appropriate mailbox listed below:

Regions

Email Address

01, 02, 05, 09 and 10

HHSC Reg12510appeals@hhsc.state.tx.us

03

HHSC Reg03appeals@hhsc.state.tx.us

04 and 07

HHSC Reg04_07appeals@hhsc.state.tx.us

06

HHSC Reg06appeals@hhsc.state.tx.us

08 and 11

HHSC Reg8/11appeals@hhsc.state.tx.us

All Regions (ADHs)

HHSC admindisqualhear@hhsc.state.tx.us

The above process must be used until the functionality for uploading changes in the TIERS Appeals Application is complete.