Texas Department of Aging and Disability Services
Case Manager Medically Dependent Children Program Handbook
Revision: 14-2
Effective: September 1, 2014

Section 1000

Overview and Eligibility

1100  Program Goal and Handbook Purpose

Revision 14-2; Effective September 1, 2014

The Medically Dependent Children Program (MDCP) is a home and community-based service authorized under §1915(c) of the Social Security Act. MDCP provides Respite, Flexible Family Support Services, Minor Home Modifications, Adaptive Aids, Transition Assistance Services, Employment Assistance, Supported Employment and Financial Management Services.

MDCP Goal

To provide support services that help prevent unnecessary placement of an individual in a long-term care facility and to support de-institutionalization of individuals who reside in nursing facilities.

MDCP strives to:

  • enable children and young adults who are medically dependent to remain safely in their homes;
  • offer cost-effective alternatives to placement in nursing facilities and hospitals; and
  • support families in their role as the primary caregiver for their children and young adults who are medically dependent.

Handbook Purpose

To provide general program information and procedures for MDCP case managers and nurses.

1200  Program Definitions

Revision 14-2; Effective September 1, 2014

The following words and terms, when used in this handbook, have the following meanings, unless the context clearly indicates otherwise.

1915(c) waiver program — A home or community-based service authorized by §1915(c) of the Social Security Act and approved by the Centers for Medicare and Medicaid Services.

Activities of daily living — Activities that are essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer and ambulation, positioning, range of motion and assistance with self-administered medications.

Adaptive aid —A device that is needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps an individual perform the activities of daily living or control the environment in which the individual lives.

Appeal —A request for a fair hearing to challenge a program or service suspension, service reduction, service denial or termination.

Attendant — An employee of a provider or of an individual who has selected the consumer directed services option and who provides direct attendant care to the individual.

Basic child care — Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training or at school.

BON — Board of Nursing for the state of Texas.

Case closure — A Department of Aging and Disability Services (DADS) action that terminates an individual from the Medically Dependent Children Program (MDCP).

Consumer Directed Services — A means of service delivery in which an individual or the individual's parent or guardian is the employer of record.

Contract — A written agreement between DADS and an entity to provide MDCP services to an individual in exchange for payment.

Cost limit — The maximum dollar amount available to an individual for MDCP services per individual plan of care (IPC) period.

DADS — Department of Aging and Disability Services.

Day — Any reference to a day means a calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

Delegated task — A task that a practitioner or registered nurse (RN) delegates in accordance with state law.

DFPS — Department of Family and Protective Services.

Employment assistance — Assistance provided to an individual to help the individual locate paid employment in the community.

Facility-based respite — Respite services provided to an individual in a licensed hospital or nursing facility.

Family member — A person who is related by blood, affinity or law to an individual.

Financial Management Services (FMS) — Provides assistance to individuals with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.

Flexible Family Support Services — Direct care services needed because of an individual's disability that:

  • help an individual participate in
      • child care;
      • post-secondary education;
      • employment;
      • independent living; or
  • support an individual's move to an independent living situation.

Foster home — Means a foster home as defined in the Human Resources Code, §42.002.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

HHSC — Texas Health and Human Services Commission.

Host family — A provider with whom an individual lives when the individual's parents are unable to care for him.

Imminent danger — An immediate, real threat to a person's safety.

Individual — A person who has been determined eligible to receive MDCP services.

Interest list — A list of people who have contacted DADS and expressed an interest in MDCP services, but have not applied for nor been determined eligible for MDCP services.

IPC — Individual plan of care. A plan that documents:

  • services provided to an individual through both MDCP and third-party resources, and the sources or providers of those services;
  • medical information about the individual obtained by a DADS RN;
  • a social assessment of the individual and the individual's family obtained by the case manager;
  • the projected cost of the MDCP services;
  • the authorization begin date stated on the service authorization form; and
  • the respite or flexible family support services provider's service schedule.

IPC period — A period that is recorded on the IPC with a beginning and end date.

LVN — Licensed vocational nurse. A person licensed by the BON or who holds a license from another state recognized by the BON to practice vocational nursing in Texas.

MDCP — Medically Dependent Children Program. A §1915(c) waiver program that provides community-based services to help the primary caregiver care for an individual in the community.

Medical Necessity — The medical criteria an applicant and individual must meet for admission to a Texas nursing facility.

Minor home modification — A physical change to an individual's residence that is needed to prevent institutionalization or to support the most integrated setting for an individual to remain in the community.

Parent — An individual's natural or adoptive parent or the spouse of the natural or adoptive parent.

Personal Cost — An individualís contribution towards the cost of adaptive aids or minor home modifications for items or services that exceed the waiver service limit or that do not meet the waiver service criteria.

Practitioner — A physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or an RN approved by the BON to practice as an advanced practice nurse, or a licensed physician currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities, even when he does not have a Texas license.

Primary caregiver —Aperson, including a parent or guardian, who cares for an individual who receives:

  • a service other than Flexible Family Support Services, and provides daily uncompensated care; or
  • Flexible Family Support Services and routinely provides uncompensated care for the individual.

Protective device — An item or device, such as a safety vest, lap belt, bed rail, safety padding, adaptation to furniture, or helmet, if used only to protect an individual from injury or for positioning the individual to ensure health and safety, and not used as a mechanical restraint to modify or control behavior.

Provider — An entity that has a contract with DADS to provide MDCP services.

Reckless behavior — Acting with conscious indifference to the consequences.

Residence — The place where an individual lives.

Respite services — Direct care services needed because of an individual's disability that provides a primary caregiver temporary relief from care giving activities when the primary caregiver would usually perform such activities.

Restrictive intervention — An action or procedure that limits an individual’s movement, access to other individuals, locations or activities, or that restricts an individual’s rights.

RN — Registered nurse. A person licensed by the BON or who holds a license from another state recognized by the BON to practice professional nursing in Texas.

Service authorization form — Document that shows DADS' approval for a provider to deliver MDCP services.

Service initiation date — The first day an individual begins receiving MDCP services.

Service planning team — A team comprised of persons convened and facilitated by a DADS case manager for the purpose of developing, reviewing and revising an individual’s IPC. In addition to a DADS case manager, the team includes the individual and primary caregiver, and may include the program provider and other persons whom the individual or primary caregiver invite to participate.

Service reduction — A temporary or permanent decrease in the number of service hours delivered to an individual.

Service schedule —A schedule for delivering respite or flexible family support services to an individual that is agreed upon and signed by the individual or the primary caregiver. A fixed service schedule specifies certain days, times of day or time periods for delivery of the services. A variable service schedule specifies the number of authorized hours of services to be delivered per day, per week or per month, but does not specify certain days, times of day or time periods for delivery of the services.

Service suspension — A temporary stoppage of MDCP services without loss of program or Medicaid eligibility.

Supported employment — Assistance provided in order to sustain paid employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.

Texas Accessibility Standards — Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

Third-party resources — Goods and services available to an individual from a source other than MDCP, such as Medicaid home health, Texas Health Steps Comprehensive Care Program, local community resources and private insurance.

Transition Assistance Services (TAS) — One-time service provided to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community to receive MDCP services.

Working day — Any day except Saturday, Sunday, a state holiday or a federal holiday.

1300  Eligibility

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(1)
live in Texas;
(2)
be:
(A)
a citizen of the United States (U.S.);
(B)
an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641(b) or (c); or
(C)
an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1612(b) and §1613;
(3)
be under 21 years of age;
(4)
meet the financial Medicaid eligibility criteria described in 1 TAC Chapter 358 (relating to Medicaid Eligibility), based on the income and resources of the individual;
(5)
for initial enrollment only, meet at least one of the disability criteria described in §51.205(b) of this chapter (relating to Disability Criteria);
(6)
meet medical necessity as described in §51.207 of this chapter (relating to Medical Necessity);
(7)
have an IPC with a cost for MDCP services at or below 50 percent of the reimbursement rate that would have been paid for the same individual to receive nursing facility services 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); and
(8)
if the person is under 18 years of age, reside:
(A)
with a family member; or
(B)
with a foster family that includes no more than four children unrelated to the individual.

If the applicant/individual does not meet eligibility requirements, the case manager must deny the application following procedures in Section 9000, Service Reductions, Suspensions, Denials, Case Closures, Appeals and Fair Hearings.

1310  Residency

Revision 12-2; Effective August 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(1)
live in Texas;

The case manager must confirm that the applicant/individual resides in Texas by any of the following items:

  • parent/guardian statement for a minor child;
  • current Texas driver license;
  • utility receipts;
  • voter registration card;
  • Texas Department of Public Safety identification card;
  • a Social Security Administration award letter;
  • Wire Third Party Query (WTPY) System, State On Line Query (SOLQ) reports; or
  • bank statements.

Acceptable verification must include a street address or postal route; a post office box number alone is not sufficient.

Case managers must document verification of residency of an applicant by completing Form 2438, Applicant Eligibility Checklist, and placing it in the case file. Case managers must document verification of residency of an individual during the annual reassessment by completing Form 2405, Narrative Notes, and place it in the case file.

1320  Citizenship

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(2)
be:
(A)
a citizen of the United States (U.S.);
(B)
an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641(b) or (c); or
(C)
an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1612(b) and §1613;

The case manager must confirm the applicant is a citizen of the U.S. or a qualified alien by viewing one of the following documents:

  • U.S. birth certificate;
  • valid U.S. Passport;
  • certificate of naturalization (N-550 or N-570);
  • certificate of U.S. citizenship (N-560 or N-561);
  • Your Texas Benefits Medicaid Card;
  • certification of birth abroad (Form FS-545 or Form DS-1350);
  • report of birth abroad of a citizen of the U.S. (Form FS-240);
  • U.S. Citizen Identification Card (Form I-197);
  • American Indian Card issued by the Department of Homeland Security with the classification code "KIC";
  • Northern Mariana Identification Card;
  • hospital record of birth in one of the 50 states, District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, America Samoa, Swain's Island or Northern Mariana Islands;
  • 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 individual's age at the time the record was made;
  • individual statement of citizenship; or
  • Immigration and Naturalization Service documentation regarding the status of a qualified alien under 8 U.S.C. §1641(b) or (c); or 8 U.S.C. §1612(b) and §1613.

The case manager must document verification of citizenship by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file. Proof of citizenship is required to determine Medicaid eligibility (see Section 1340, Financial Eligibility).

1330  Age

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(3)
be under 21 years of age;

The case manager must confirm the applicant's age by reviewing any of the following documents:

  • Medicaid documents;
  • medical records, such as immunization records;
  • birth certificate;
  • Texas Department of Public Safety identification card;
  • school records; or
  • other official records that establish age.

The case manager must document applicant age by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file.

1340  Financial Eligibility

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(4)
meet the financial Medicaid eligibility criteria described in 1 TAC Chapter 358 (relating to Medicaid Eligibility), based on the income and resources of the individual;

Applicants/individuals who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. 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).

Case managers must determine if an applicant/individual is currently on Medicaid and check TIERS to confirm the current status of an applicant/individual. An MEPD determination may have already been completed for an applicant and must be used unless there have been changes in the applicant's financial situation.

Case managers must document financial eligibility of an applicant by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file. Case managers must document financial eligibility of an individual during the annual reassessment on Form 2405, Narrative Notes, and place it in the case file.

If the applicant does not have a Medicaid eligibility determination, it is the case manager's responsibility to assist the applicant with completing the application and obtaining the necessary verifications to establish eligibility. See Section 2300, Initial Home Visit, for details.

Applicants/individuals who have qualified income trusts may still be eligible for MDCP if they meet all other MDCP eligibility criteria. Income applied to the trust does not affect eligibility, but is included for the calculation of the copay for MDCP services.

1350  Disability

Revision 13-3; Effective August 1, 2013

§51.203 — To be eligible to participate in MDCP, a person must:

(5)
for initial enrollment only, meet at least one of the disability criterian described in §51.205(b) of this chapter;

§51.205 (b) — A person meets the disability criteria if the person:

(1)
receives disability benefits from:
(A)
Supplemental Security Income;
(B)
federal old-age, survivors, and disability insurance; or
(C)
railroad retirement; or
(2)
has a disability determination by HHSC.

Case managers must confirm at initial enrollment only that the applicant receives disability benefits by reviewing:

  • Wire Third Party Query (WTPY) System, State On Line Query (SOLQ) reports,
  • Supplemental Security Income (SSI) documentation,
  • Retirement Survivor and Disability Insurance (RSDI) benefits documentation, or
  • Railroad Retirement benefits documentation.

If the applicant does not meet any of the above criteria, the case manager will assist the applicant with the disability determination process. See Section 3110.2, Coordination of Disability Determinations.

Case managers must document disability by completing Form 2438, Applicant Eligibility Checklist, attaching a copy of the verification documentation and placing it in the case file. Documentation of ME-Waiver approval in the case file is sufficient documentation that disability determination has also been approved.

1360  Medical Necessity

Revision 13-2; Effective May 1, 2013

§51.203 — To be eligible to participate in MDCP, a person must:

(6)
meet medical necessity as described in §51.207 of this chapter (relating to Medical Necessity);

§51.207

(a)
An entity contracted by HHSC determines medical necessity.
(b)
A determination that an individual meets medical necessity is valid for one year. An individual must receive a determination of medical necessity annually to remain eligible for MDCP.

Case managers must confirm that the applicant or individual meets medical necessity by:

  • performing an inquiry through the Texas Medicaid & Healthcare Partnership (TMHP) web-based portal; or
  • viewing the Service Authorization System (SAS).

TMHP assigns a Document Locator Number (DLN) to each electronic copy of a Medical Necessity and Level of Care (MN/LOC) Assessment that allows the case manager, regional nurse, case analyst or utilization review nurse access to the information from the MN/LOC Assessment. 

The case manager must file a copy of the TMHP web-based portal screen or SAS inquiry screen in the case file or document in the case file the DLN, the resource utilization group (RUG) value and whether the medical necessity determination was approved or denied.  The case manager must also complete Form 2438, Applicant Eligibility Checklist.

It is the MDCP nurse's responsibility to prepare and submit the MN/LOC Assessment to TMHP for determination.

1370  Individual Plan of Care (IPC)

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(7)
have an IPC with a cost for MDCP services at or below 50 percent of the reimbursement rate that would have been paid for the same individual to receive nursing facility services 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);

The individual plan of care (IPC) is developed and signed by the applicant/individual, applicant's/individual's parents or guardian, case manager, MDCP nurse and others who participate in the individual's care.

1380  Living Arrangement

Revision 12-1; Effective May 1, 2012

§51.203 — To be eligible to participate in MDCP, a person must:

(8)
if the person is under 18 years of age, reside:
(A)
with a family member; or
(B)
with a foster family that includes no more than four children unrelated to the individual.

Case managers must confirm that the applicant/individual, if under age18, lives with a family member such as a parent, guardian, grandparent or sibling as defined in Section 1200, Program Definitions. The case manager must review guardianship documentation or obtain a statement from the applicant/individual or family member regarding relation.

The applicant/individual may reside with a foster family that includes no more than four other children unrelated to the applicant.

Example:

  • An applicant/individual under 18 may reside with a foster family that includes a biological sibling and four other unrelated foster children.
  • An applicant/individual under 18 may not reside with a foster family that includes five or more children unrelated to the applicant.

Case managers must document living arrangement by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file.

1390  Monthly Service Utilization

Revision 12-1; Effective May 1, 2012

MDCP Waiver - Appendix B-6a: MDCP Waiver: TX0181.90.R3 Appendix B-6a - Reasonable Indication of Need for Services: An Individual must require the provision of at least one waiver service and the provision of waiver services at least monthly.

The case manager must confirm that the applicant has a need for and will use MDCP services monthly to be eligible at initial enrollment. Case managers should review MDCP service criteria with applicants to determine the need for waiver services.

1400  Safeguarding Personally Identifiable Information

Revision 12-1; Effective May 1, 2012

All personally identifiable information (PII) obtained from the Social Security Administration (SSA) must be safeguarded. Wire Third Party Query (WTPY) System, State On Line Query (SOLQ) or other SSA documentation is considered SSA-protected and cannot be printed or kept in the case record.

Staff must not print or file PII (WTPY/SOLQ) printouts in applicant/individual case records. Staff must document the date they verified and viewed the online/printed verification, the amount of income and source (WTPY, SOLQ, other) used to verify the information.

If a WTPY or SOLQ report must be printed for a specific purpose, such as a legal request or legislative inquiry, the document must not be filed in the case record or sent for imaging. The SSA documents must be stored in a central locked filing cabinet only accessible by Health and Human Services Commission or Department of Aging and Disability Services authorized staff.

1410  Requests for Information About a Deceased Individual

Revision 12-1; Effective May 1, 2012

Case managers may apply the following list of acceptable documentation for recording a request and release of information to the requestor:

  • Release form or statement signed by the deceased (dated prior to death) authorizing release of information to the specific person requesting the information.
  • Copy of an order from a probate court appointing the requestor as estate administrator or guardian.
  • Copy of other type of order from a court authorizing the requestor to administer the affairs of the deceased.
  • Documentation demonstrating the requestor has authority under Texas law to act for the deceased.

A person who has authority under Texas law to act on behalf of a deceased individual or the deceased's estate includes a surviving spouse, an adult child, a parent or an heir.

Case managers should first ask the requestor for any available document. If a document is not available, the case manager must determine and document if the requestor has authority under Texas law to act for the deceased individual. The case manager may release information to the requestor if one of the documentation requirements identified in this section is met and filed/recorded in the case record.