Case Manager Community Care for Aged and Disabled Handbook

Section 2000

Case Management
Table of Contents

NOTE: Click on the bold main headings to view sub-topics more quickly.

2100
Case Management
2110
Description of Case Management
2120
Case Management Process
2130
Your Texas Benefits Medicaid Card and Replacement
2200
Intake Procedures
2210
Requests for Services
2211
Applications and Referrals Routed from the Midland Document Processing Center
2220
Response to Requests for Service
2221
Requests for Services in STAR+PLUS Areas
2222
Reinstatement Procedures for Individuals Reapplying for Services After Loss of Financial Eligibility
2223
Caregiver Support Assessment Initiative
2230
Interest List Procedures
2230.1
Adding Individual's Name Back to CSIL
2231
Community Services Interest List Bypass Criteria
2231.1
Individuals Who May Receive Title XX Services with Regional Director Approval
2231.2
Bypass Criteria for Additional Services
2231.3
Individuals Who May Not Bypass the Interest List
2231.4
Bypass Approval
2232
The Community Services Interest List System
2240
Regional Procedures
2241
Supervisor Responsibilities
2242
Case Manager Responsibilities
2243
Conflicts of Interest
2300
Responding to Requests for Service
2310
Criteria for Immediate or Expedited Responses to Service Requests
2320
Case Manager Response
2330
Scheduling the Initial Interview
2331
Information and Referral (I&R)
2332
Requests for Services from Individuals Under Age 21
2333
Applications
2333.1
Required SAS Entries for Applications Withdrawn Early in the Process
2340
The Initial Interview and Application Process
2341
Financial Application Process
2341.1
Application for Assistance Form
2341.2
Application for Assistance Form Completion and Receipt Date
2341.3
Categorical Eligibility
2341.3.1
Effect of QI Benefits on Eligibility for Community Care Services
2341.4
Refusal to Cooperate with the Application Process
2341.5
Retroactive Payment Process
2342
Screening for Primary Home Care and Community Attendant Services
2342.1
Receipt Date of the Application Form
2342.2
Timely Referral to MEPD
2342.3
Additional Screening Criteria for PHC or CAS
2342.4
Applicants Not Referred for PHC or CAS
2342.5
Spouse Attendant in Family Care Services
2342.6
Disability Determination for Individuals Under Age 65 Applying for CAS
2343
Confidentiality
2344
Individual Rights and Responsibilities
2345
Registering to Vote
2346
Service Delivery Options
2347
Texas Medicaid Estate Recovery Program (MERP)
2347.1
Introduction
2347.2
Presentation of Information to Community Attendant Services Applicants
2347.3
Determining Grandfathered Status
2347.3.1
Determining the Application Date for MERP Grandfathered Status
2347.4
Medicaid Estate Recovery Program Exemptions
2347.5
MERP Claims and the Filing Process
2347.6
Allowable Claim Deductions
2347.7
Transfer of Assets
2347.8
Documenting Executor Information in SAS for CAS Individuals
2347.9
Additional MERP Information
2348
Retroactive Payments
2349
Procedures for Applicants Aging Out of PCS to PHC
2400
Assessment Process
2410
Overview of the Assessment Process
2411
Required Documentation
2420
Assessing the Applicant’s Needs
2421
Review of the Community Care Intake Form
2422
Form 2059, Summary of Client’s Need for Service
2422.1
Medical Diagnosis and Functional Limitations
2422.2
Home Environment
2422.3
Living Arrangement
2422.4
Documentation of Caregivers
2422.5
Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program
2422.6
Common Household Tasks, Duplicate Services and Services Provided to Other Family Members
2422.7
Assessment of Social and Community Resources
2423
Guardianship
2430
Functional Assessment
2431
Form 2060, Part A, Functional Assessment
2432
Scoring Persons Who Cannot Respond
2433
Determining Unmet Need in the Service Arrangement Column
2433.1
Assessment of the Caregiver
2433.2
Exploring Other Resources for Meeting the Applicant’s Needs
2434
Support Score and Establishing Priority
2440
Use of Form 2060, Part B, Task/Hour Guide, and Part C, Task/Minute and Subtask Guide
2440.1
Requesting Supervisory Approval for Time Outside the Minute Range
2441
Circumstances When Supervisory Approval is Not Required
2441.1
Exception for a Compelling Reason
2441.2
Exception for Assistance from a Caregiver or other Agency
2441.3
Time Allocation for Companion Cases
2442
Calculation of Time to be Authorized
2500
Service Planning
2510
Service Plan Development
2511
Caregiver Arrangements
2512
Caregiver Support
2513
Caregiver as the Paid Attendant
2514
Who Cannot Be Hired as the Paid Attendant
2520
Freedom of Choice
2521
Freedom of Choice in Living Arrangements
2522
Service Delivery in Alternate Locations
2523
Freedom of Choice in Agency Selection
2530
Other Resource Services
2531
Veterans Affairs Aid and Attendance and Housebound Benefits
2532
Skilled Home Health Services
2533
Hospice Services
2534
Mutually Exclusive Services
2534.1
Services Through the Texas Home Living Waiver
2534.2
Targeted Case Management and Other DADS Services or the STAR+PLUS Program
2535
Involvement of Volunteer Resources
2536
Program of All–Inclusive Care for the Elderly
2540
Priority Status Individuals
2550
Identifying Individuals at Risk
2551
Case Manager Actions for Individuals at Risk
2600
Authorizing and Reassessing Services
2610
Application Processing and Notification
2611
Processing Time Frames
2611.1
Processing Time Frames for Community Attendent Services
2612
Notification of Eligibility Decision
2613
Case Record Documentation
2620
Service Authorizations
2630
Referrals to the Provider
2631
Negotiated Referrals
2632
Routine Referrals
2640
Provider Requirements for Hiring a Paid Attendant
2650
Changes in Service Plans
2651
Disagreements about Service Plans
2652
Changing the Service Schedule Between Reassessments
2653
Provider Flexibility
2660
Reassessments and Recertification Procedures
2661
Individual Unavailable for Reassessment
2661.1
Delay in Home Visits Due to Individual Illness
2662
Redetermination of Financial Eligibility
2662.1
Financial Reassessments for Community Attendent Services
2663
Reassessment of Functional Need
2663.1
Annual Home Visit Required for Individuals Receiving PAS
2663.2
Determining When a Home Visit is Necessary for Other Services
2664
Redetermination of Unmet Need
2670
Notifications at Reassessment
2680
Recertification
2700
Service Monitoring, Changes and Transfers
2710
Monitoring Visits and Contacts
2710.1
Monitoring Initiation of Services
2710.2
Monitoring Ongoing Services
2710.3
Service Plan Changes at the Monitoring Contact
2710.4
Monitoring Documentation Requirements
2710.5
Actions Required After Monitoring
2711
Monitoring Community Attendant Services Individuals
2712
Six-Month Monitoring Contacts
2720
Interim Changes
2721
Service Plan Changes
2721.1
Individuals Responsibility to Report Changes
2721.2
Provider Responsibility to Report Changes
2721.3
Determining if a Home Visit is Necessary
2721.4
Revising the Service Plan
2721.5
Long-term Versus Short-term Changes in the Individuals’s Condition
2721.6
Authorizing and Documenting Changes
2722
Individual Moves and Case Transfers
2722.1
Procedures If the Losing Case Manager Initiates Action
2722.2
Procedures If the Gaining Case Manager Initiates Action
2722.3
Additional Procedures
2722.4
PHC and Title XIX DAHS Individuals Transferring into a STAR+PLUS Service Area
2722.5
Adult Day Care and Personal Attendant Services Individuals Transferring Out of a STAR+PLUS Service Area
2722.6
Shared Case Manager Responsibilities Related to Managed Care Individuals
2723
Freedom of Choice
2724
Medicaid Coverage for Individuals Denied SSI
2725
Certificates of Insurance Coverage
2730
Active Tuberculosis (TB) Diagnosis
2740
Special Procedures for Helping Individuals Enter or Leave a Nursing Facility, Institution or Hospice
2741
Individuals Entering a Nursing Facility
2742
Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility
2742.1
Individuals Entering a Nursing Facility
2742.2
Individuals Leaving a Nursing Facility
2742.3
Individuals Denied a Determination of Medical Necessity
2742.4
Promoting Independence Initiative
2743
Individuals Receiving Services through Local Authorities
2744
TDC Individuals Leaving TDC
2745
Individuals Who Need Hospice Services
2746
Complaints, Grievances or Suggestions
2746.1
Reporting Service Delivery Issues to the Consumer Rights and Services Hotline
2750
Fraud Detection and Documentation
2751
Provider Fraud
2752
Responding to Allegations of Provider Fraud
2753
Individual Fraud
2754
Responding to Allegations of Individual Fraud
2760
Fraud Referral
2761
Development of the Fraud Referral Packet
2762
Expedited Referrals
2763
Referral of Potential Fraud
2800
Notifications, Suspensions, Denials and Terminations
2810
Individual Notification Procedures
2811
Effective Dates
2812
Changes in the Individual's Need for Services
2813
Situations in Which the 12-Day Adverse Action Period May Be Reduced
2814
Transfers Between Primary Home Care, Community Attendant Services and Family Care
2814.1
Transfers from Community Attendant Services to Community Based Alternatives or Medically Dependent Children Program
2815
CCAD Individuals Receiving IHFSP
2820
Service Suspensions
2821
Service Suspension by Providers
2822
Service Suspension by Case Managers
2822.1
Hospital and Nursing Facility Stays
2830
Refusal to Comply with Service Delivery Provisions
 
2830.1
Individuals Who Refuse to Comply with Electronic Visit Verification Requirements
2831
Suspensions Due to Refusal to Comply with Service Delivery Provisions
2832
Documentation of Compliance Issues
2833
Reauthorization of Services After Termination for Refusal to Comply
2840
Threats to Health or Safety
2840.1
Sharing Information with New Providers Regarding Health and Safety Issues
2841
Reinstatement of Services Terminated for Threats to Health or Safety
2841.1
Sharing Information on Previous Actions for Reinstatement
2900
Appeals and Fair Hearings
2910
Individual’s Right to Appeal and Request a Fair Hearing
2911
Notice to the Provider for Continuing Services
2912
Special Procedures for Denials of Community Attendant Services (CAS) Individuals
2913
Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings
2913.1
Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered
2914
Withdrawal of an Appeal
2920
Request for Increase in Services During an Appeal
2930
Fair Hearing Procedures
2931
Processing Fair Hearing Requests Using TIERS
2932
Coordination of Fair Hearings with MEPD Utilizing OES CRU
2933
Submitting the Appeals Evidence Packet
2934
Presentation of Evidence at the Fair Hearing
2935
Action Taken on the Hearing Decision
2935.1
Action Taken after the Hearing Decision for Reductions
2935.2
Action Taken after the Hearing Decision on Terminations
2935.3
Fair Hearings Officer Orders a New Assessment
2935.4
Reporting the Action Through TIERS
2936
Fair Hearing Exception Process