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

Section 3000

Eligibility Determination and Individual Plan of Care Development

3100  Eligibility Determination

Revision 12-1; Effective May 1, 2012

The applicant must meet all requirements in Section 1300, Eligibility, for Medically Dependent Children Program (MDCP) eligibility determination.

Within 30 calendar days of the initial home visit the case manager will:

  • verify medical necessity (MN);
  • verify financial eligibility;
  • negotiate the medical effective date (MED) with Medicaid for the Elderly and People with Disabilities (MEPD) staff for non-Supplemental Security Income (SSI) applicants (see Section 3110, Medicaid Eligibility for the Initial Application, for exception);
  • finalize Form 2410, Medical-Social Assessment and Individual Plan of Care, listing all authorized services and ensuring the individual plan of care (IPC) is below the cost limit;
  • verify that the IPC is signed by all applicable parties;
  • negotiate a service initiation date with the MDCP provider;
  • send Form 2410 and Form 2065-B, Notification of Waiver Services, and all appropriate service authorization forms to the individual and MDCP providers, including MEPD staff, if appropriate;
  • ensure the IPC is data entered and registered in the Service Authorization System (SAS) without errors; and
  • submit the individual's name and date of MDCP eligibility to the Community Services Interest List (CSIL) Unit for release closure following procedures in Section 2510, Contacting the CSIL Unit to Report the Status of Interest List Releases.

After all eligibility criteria have been met and the IPC has been finalized with the applicant and coordinated with providers, the case manager establishes the MDCP eligibility date. The case manager enters the eligibility date on Form 2065-B and signs the form on the same day. The case manager sends the notice to the individual and the provider(s) on the same day to indicate that the individual has met MDCP eligibility and the provider(s) is (are) authorized to deliver MDCP services.

If at any time during this process the case manager receives information indicating that the applicant is not eligible (due to MN, Medicaid or other factors), MDCP eligibility is denied within two workdays. The case manager must then:

  • send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the applicant, with copies to all appropriate providers, including MEPD staff, if appropriate;
  • refer the applicant to other DADS programs and third-party resources, as appropriate; and
  • submit the applicant's name to the CSIL Unit indicating the reason for denial following procedures in Section 2510.

The IPC service initiation date is the earliest date that providers are authorized to deliver services.

Confidential Information on Notifications

Confidential information supplied by the applicant/individual during the eligibility process must be protected. This includes inclusion of confidential information by 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 MDCP individual is being denied 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 $2,094." The comment should simply state, "Your income exceeds the eligibility limit."
  • An MDCP individual is being denied based on medical necessity. The individual does not require skilled nursing; the only diagnosis the individual 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 his diagnosis is a violation of his right to confidentiality. In all cases, the case manager must assess any information provided by the individual to determine if its release would be a confidentiality violation.

3110  Medicaid Eligibility for the Initial Application

Revision 13-4; Effective November 1, 2013

Medicaid Eligibility for the Initial Application

An applicant meets the Medicaid eligibility requirement for the Medically Dependent Children Program (MDCP) if the applicant is a Texas resident and receives Supplemental Security Income (SSI) or when the requirements in the following items are met:

The case manager must verify the applicant's current eligibility for an appropriate Medicaid program type from Medicaid for the Elderly and People with Disabilities (MEPD) staff. If the applicant is not a current Medicaid recipient, the case manager must initiate the Medicaid financial eligibility determination process.

As needed, case managers assist with the completion of Form H1200, Application for Assistance – Your Texas Benefits, during the home visit and help obtain necessary documentation for MEPD staff to establish financial eligibility. The case manager should explain the financial determination process and inform the applicant that MEPD staff may call for additional information.

No later than close of business on the second working day following the date of receipt of Form H1200, the case manager must fax or mail Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center (DPC). See Appendix XXI, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, for form completion procedures.

If the case manager faxes Form H1200 to MEPD, he must not send the original to MEPD. DADS staff must retain the original Form H1200 with the applicant's valid signature in the case file. The original form must be kept for three years after the case is denied or closed. Case managers must also retain a copy of the successful fax transmittal confirmation in the case file.

If unusual circumstances exist in which the original 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 file. Scanning Form H1200 and sending it by electronic mail is prohibited. The day DADS receives the Medicaid application form is day zero and starts the two working day time frame.

The case manager requests financial eligibility determination for MDCP on Form H1746-A. All available verifications provided by the applicant or individual must be attached. The case manager keeps a copy of all documents and records the date the application was faxed or mailed in the case file.

Example: Form H1200 is received on Sept. 18, which is a Friday. Friday is considered day zero. The case manager has until close of business on Tuesday, Sept. 22 to fax or mail the Medicaid application to DPC.

For Money Follows the Person (MFP) Medicaid applications, the case manager must fax or mail Form H1200 and Form H1746-A to MEPD no later than close of business on the second working day following the date of receipt of Form H1200 or by the date of the nursing facility admission, whichever occurs first. This will prevent delays in certification of financial eligibility.

If the applicant is admitted to the nursing facility on a weekend or holiday, the case manager sends the Medicaid application on the next working day and documents the delay in the case file on Form 2405, Narrative Notes.

For an applicant who is medically fragile applying for MDCP using the MFP option, the case manager must notify the designated MEPD program manager when sending a Medicaid application.  The MEPD program manager must be made aware of these applications in order to ensure they are processed quickly.

Case managers assisting with the completion of Form H1200 for applicants requiring a Medical Assistance Only (MAO) determination must understand the importance of providing the most complete packet possible to MEPD. Ensuring the following items are included will 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 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 Form 2121, Long Term Services and Supports, was shared with the applicant by checking the appropriate box on Form H1746-A, MEPD Referral Cover Sheet
  • Preneed funeral plans – name of company, policy/plan number, copy of preneed agreement
  • Correct up-to-date phone numbers
  • Power of Attorney or Guardianship – copy of the legal document
It is recommended that case managers explain to applicants that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

The case manager notifies MEPD staff of approved medical necessity (MN) and the individual plan of care (IPC) via the Eligibility Data Exchange and Notification (EDEN) system, as outlined in Section 3133, Notifying MEPD of Approved IPC and MN.

The case manager should obtain information from MEPD staff about the status of the financial determination. If the financial decision cannot be readily made, the case manager requests MEPD staff to provide notification when the decision can be made. The case manager should inform the applicant or the applicant's representative and potential providers of the delay in MDCP enrollment.

If the applicant does not have a Medicaid determination within 30 days of the initial home visit, the case manager has 14 days to determine MDCP eligibility from the date MEPD staff indicate that Medicaid eligibility requirements can be met.

Staff must follow procedures in Section 3500, Money Follows the Person Option, regarding Medicaid eligibility for applicants transitioning from a nursing facility to the community.

Establishing the Medical Effective Date

Once MEPD has processed the financial application and is ready to establish the medical effective date (MED), MEPD will send 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 will email the MEPD specialist indicating the date MDCP services will begin. The MED cannot be negotiated before the MN effective date or the date the case manager determined all other MDCP eligibility criteria were met. 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 receiving Community Attendant Services (CAS).

If the individual is receiving CAS, the case manager submits information to MEPD on Form 1746-A to request a program transfer from CAS to MDCP and explains in the additional comments section of Form 1746-A the individual currently receives CAS and is transferring to MDCP.  The case manager must also request in the additional comments section of Form 1746-A to end CAS financial eligibility the day before waiver services are to begin.  The MED will be the same as the IPC begin date. 

For MDCP applicants already on SSI, the MED was established when their SSI was granted.

Unsigned Applications

If MEPD receives an unsigned application from DADS even with Form H1746-A, MEPD Referral Cover Sheet, attached, MEPD will return the application to DADS with an annotation on Form H1746-A that the application is unsigned and must be signed before the Health and Human Services Commission (HHSC) can establish a file date. Once DADS staff receive an unsigned application from MEPD, it is DAD's responsibility to coordinate with individuals in getting the application signed and returned to MEPD for processing. Sending unsigned applications delays the MEPD and DADS eligibility processes and could adversely affect service delivery to individuals.

Refer to MEPD Policy Bulletin Number 11-07, Unsigned Applications, released Dec. 30, 2010, for complete information. The bulletin can be found at: www.dads.state.tx.us/handbooks/mepd_policy/index.htm.

If the individual submits a Medicaid application to DADS when a Medicaid application is not required, DADS staff must forward the application to MEPD within the two working day time frame. DADS staff must document on Form H1746-A that a Medicaid application was sent to DADS in error.

Requesting Form H1027-A

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 DADS Forms website for completion of the form. Designated DADS staff may continue to assist individuals in the following situations.

Ongoing Medicaid Recipients – DADS staff may assist with a manual Form H1027-A upon request because the recipient either lost the Your Texas Benefits Medicaid card or did not receive it. DADS staff issuing Form H1027-A should inform the recipient of the following:

  • Call 1-855-827-3748 for a replacement card.
  • The burden of verifying Medicaid eligibility is with the provider. An individual who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from his provider or to fill a prescription. Medicaid providers and pharmacies can verify eligibility by phone using a provider dedicated line OR by using the Texas Medicaid & Healthcare Partnership (TMHP) Tex Med Connect website.

New Medicaid Recipients - Eligibility information is not immediately available for providers/pharmacies to verify after Medicaid is approved. DADS staff must refer the recipient 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 system.

Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time he requests services. The recipient may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage, if he is not sure of his eligibility status.

More information about the new card is available at: www.yourtexasbenefits.com.

3110.1  Medicaid Buy-In and Medicaid Buy-In for Children

Revision 12-1; Effective May 1, 2012

The Medicaid Buy-In for Children (MBIC) program is an acceptable categorically eligible type of Medicaid for eligibility purposes for individuals applying for MDCP. The case manager can determine if an individual is an MBIC recipient by looking in the Texas Integrated Eligibility Redesign System (TIERS) database. The MBIC program is coded TA-88, and will display as ME-MBIC.

The MBIC program was implemented by the Health and Human Services Commission (HHSC) effective Jan. 1, 2011, to provide Medicaid to children with disabilities up to the age of 19 with family income up to 300 percent of the Federal Poverty Level (FPL).

The Medicaid Buy-In (MBI) program is also an acceptable categorically eligible type of Medicaid for eligibility purposes for 19 and 20-year-old individuals applying for MDCP. The case manager can determine if an individual is an MBI recipient by looking in the TIERS database. The MBI program is coded TP-87, and will display as ME-Medicaid Buy-In.

The MBI program was implemented by HHSC effective Sept. 1, 2006, to provide Medicaid to disabled working individuals who, because of earnings, would otherwise be ineligible for Medicaid. Additional information about the MBI program can be found at www.hhsc.state.tx.us/MBI.html.

3110.2  Coordination of Disability Determinations

Revision 13-4; Effective November 1, 2013

In order for the Disability Determination Unit (DDU) to complete a disability determination, the case manager must obtain medical evidence from the applicant, or the applicant's parent or guardian. The medical evidence required is the most recent 12 months of medical records signed by the treating physician, listing the diagnosis and any impact the condition(s) has on the applicant's activities of daily living. The case manager must inform the applicant, or the applicant's parent or guardian, when scheduling the initial face-to-face contact that the medical evidence must be provided to the case manager at the initial face-to-face contact. If the case manager schedules the initial 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 initial face-to-face contact less than seven calendar days in advance, the case manager must present Form 2423 at the initial face-to-face contact.

The case manager must assist an applicant, or an applicant's parent or guardian, in completing Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact.

The case manager must transmit a complete packet to Medicaid for the Elderly and People with Disabilities (MEPD), or in the case of a Category 02 applicant, to the DDU within 14 calendar days of the home visit. The packet must contain Form H1746-A, MEPD Referral Cover Sheet. The packet must also contain Form H3034, Form H3035, Pages 1 and 2 of Form 2410, Medical-Social Assessment and Individual Plan of Care, and the medical evidence. The DDU may request additional information if needed.

If medical evidence is not available at the initial face-to-face contact, the case manager must allow the applicant 14 calendar days after the initial face-to-face contact to provide the medical evidence. If the medical evidence is not provided by the 14th day after the initial face-to-face contact, the case manager must transmit Form H3034 and Form H3035 to either MEPD or in the case of a Category 02 applicant, to the DDU within 20 calendar days of the face-to-face contact, indicating in the notes section of Form H3034 all requests for medical evidence and that none was provided.

Case managers transmit the DDU packet directly to the:

  • Office of MEPD for applicants who need a Medical Assistance Only (MAO) determination; or
  • DDU for applicants who have Medicaid established through programs other than Supplemental Security Income (SSI) or SSI-related Medicaid. For example, an applicant who has Medicaid through Texas Works would require a disability determination.

MDCP applicants who receive Medicaid through the Medicaid Buy-In (MBI) program or Medicaid Buy-In for Children (MBIC) program do not require a disability determination. MBI and MBIC require individuals to meet the same rules for disability used to establish SSI. Verification an individual receives MBI or MBIC is sufficient documentation that disability has also been approved.

The case manager will identify an applicant's Medicaid type in the Texas Integrated Eligibility Redesign System (TIERS), whose required evidence will be sent directly to DDU by using the chart below.

The case manager must wait for a determination from DDU or ME-Waiver approval before determining MDCP eligibility. Once DDU determines the applicant has a disability or the case manager receives confirmation of ME-Waiver approval, the case manager proceeds with the enrollment process. If the applicant is denied a disability determination, then the applicant has not met eligibility requirements and the case manager denies MDCP eligibility.

Medicaid Type Programs (TP) Category 02

SAVERR TP TIERS TP COVERAGE
40 40 Pregnant women (can include children)
45 45 Newborn children up to age one, born to Medicaid-eligible mothers
43 43 Children under age 1
48 48 Children ages 1 through 5
44 44 Children ages 6 through 18
47 47 Children ineligible for Temporary Assistance for Needy Families (TANF) or age-appropriate medical program because of income and the TANF budget includes income of a stepparent or a parent of a minor parent
01 08 Medical assistance for low income families
07 07 Legal parent began receiving or had an increase in gross earned income which denied TP-01/TP-08
20 20 New or increased child support
37 37 Loss of 90% earned income deduction
N/A 41 Women's Health Program – limited to family planning services (18 years of age and above)
55 – Address has MBCC Category 02 N/A Medicaid for Breast and Cervical Cancer (MBCC) (18 years of age and above) – full Medicaid
  70 Medical coverage for foster care youths age 18 – 21 who have aged out of foster care

Protective and Regulatory Services Category 02

SAVERR TP TIERS TP COVERAGE
N/A 91 Adoption Assistance – Federal Match – No Cash
N/A 92 Adoption Assistance – Federal Match – With Cash
N/A 93 Foster Care – Federal Match – No Cash
N/A 94 Foster Care – Federal Match – With Cash
N/A 95 Adoption Assistance – No Federal Match
N/A 97 Foster Care – No Federal Match – No Cash
N/A 98 Foster Care – No Federal Match – With Cash

3111  Qualified Income Trust (QIT)

Revision 12-1; Effective May 1, 2012

Applicants with a qualified income trust (QIT) may be determined eligible for the Medically Dependent Children Program (MDCP) even though their incomes are greater than the Medicaid income limit for waiver programs if they also meet all other MDCP eligibility criteria. Income diverted to the trust does not count for the purpose of financial eligibility determination, but is calculated for the determination of the co-payment for MDCP services.

Individuals with a QIT are responsible for contributing toward the cost of their MDCP services.

Medicaid for the Elderly and People with Disabilities (MEPD) staff provide information to the applicant about maintaining the QIT to remain eligible for Medicaid. A trustee is designated to manage the QIT and disburse payment to service providers on behalf of the individual. The case manager must emphasize that funds deposited into the trust must be used toward the co-payment for the cost of MDCP services.

For applicants who are financially eligible based on a QIT, the eligibility based on the level of care cost limit is determined before considering the co-pay to purchase services. The applicant must meet the initial individual plan of care (IPC) cost limit requirement before deducting the co-payment.

First, the case manager develops the IPC without consideration of the co-payment. If the applicant is eligible for MDCP within the cost limit, the co-payment is allocated to purchase MDCP services identified on Form 2410, Medical-Social Assessment and Individual Plan of Care. The IPC total and the amount of the provider's service authorizations are reduced by the amount of the co-payment. The individual will have to pay the provider(s) directly for services. The case manager must document the QIT in Item 36, Special Needs/Considerations, on Page 2 of Form 2410. The individual's continuing Medicaid eligibility through MDCP is contingent on payment to the provider(s).

3111.1  Determination of Co-payment

Revision 13-2; Effective May 1, 2013

After determining financial eligibility, Medicaid for the Elderly and People with Disabilities (MEPD) staff determine the amount of money available for co-payment. Case managers must verify the co-payment amount in the Texas Integrated Eligibility Redesign System (TIERS).

MEPD staff determine the applicant's co-pay by calculating the applicant's total monthly income in excess of the institutional income limit and subtract any allowable deductions.

Co-payments must first be applied to purchase Respite services. If there are funds remaining, the balance must be applied to Flexible Family Support Services, Adaptive Aids, Minor Home Modifications, Financial Management Services or Transition Assistance Services.

If the applicant has a qualified income trust (QIT), the case manager must complete and mail Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement, notifying the individual that co-payment must be paid to the provider for services. The case manager also documents the co-payment as a requirement of the applicant's eligibility on Form 2065-B, Notification of Waiver Services.

For applicants and individuals with a QIT, the case manager must:

  • use the co-payment amount verified in TIERS to determine the units of service to be purchased through the trust;
  • determine the units of service by dividing the monthly co-payment by the unit rate for the service, and rounding the result to the next lower quarter unit;
  • record the units and dollar amount of services on Form 2401 payable directly to the provider(s);
  • obtain the signature of the applicant on Form 2401;
  • provide a copy of the signed agreement to the applicant;
  • multiply the monthly units by 12 to determine an annual amount of services to be purchased through the co-payment;
  • deduct the annual units from Page 5 of Form 2410, Medical-Social Assessment and Individual Plan of Care, budget and adjust cost calculations for Respite and other services; and
  • complete another Form 2410, Page 5, annotated with "Adjusted QIT IPC" to reflect the new individual plan of care (IPC) total and service units, which have been reduced by the amount of the co-payment.

Example: The co-payment amount reduces the MDCP payment amount for Respite provided by an attendant on the Adjusted QIT IPC. For a co-payment adjustment for 1400 units of Respite included in the Adjusted QIT IPC, calculate the following on Form 2401:

  • co-payment of $577.05 per month divided by $11.66 = 49.48 units (Respite hourly rate by an attendant; see Appendix I, Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits, Provider Type and Service Rates, for a list of current rates);
  • round down to the next lower unit = 49;
  • enter "Respite" in Services to be Purchased;
  • enter $577.05 in Amount Available for Co-Payment;
  • enter $11.66 in Unit Rate;
  • enter 49 in Units to be Purchased;
  • enter $577.05 in Monthly Co-Payment Amount;
  • calculate 49 × 12 = 588 annual units; and
  • total calculated Respite hours allowed within cost allowance (1,400 − 588 annual units = 812 units authorized and paid by MDCP. This is the amount recorded on Form 2410, Page 5).

The case manager sends a copy of the updated Form 2410, Page 5, and a copy of Form 2401 to the provider(s) reimbursed by the co-payment. The updated Form 2410, Page 5, with the new IPC total is used for Service Authorization System (SAS) data entry.

If the individual is responsible for co-payment, the amount that the Department of Aging and Disability Services (DADS) pays to the provider will be reduced by the co-payment amount. The combined reimbursement from DADS and the individual co-payment cannot exceed the rate authorized for the MDCP service.

3111.2  Refusal to Participate

Revision 12-1; Effective May 1, 2012

If an individual refuses to sign Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement, the case manager must deny Medically Dependent Children Program services for failure to agree to pay co-payment.

3111.3  Refund of Copayment

Revision 13-1; Effective February 1, 2013

If services are not utilized by the individual or the provider is unable to complete service delivery, the provider must refund any unused co-payment funds to the trustee and notify the individual and case manager.

Example:

  • The provider collected $699.60 co-payment for 60 hours of Respite (60 hours × 11.66/hour = $699.60).
  • The provider delivered 10 hours of Respite because the individual entered the hospital (10 hours × $11.66/hour = $116.60).
  • The provider must refund the individual $583 ($699.60 - $116.60 = $583).

The case manager must notify the Medicaid for the Elderly and People with Disabilities (MEPD) staff of this refund on Form H1746-A, MEPD Referral Cover Sheet.

3111.4  Refusal to Pay the Copayment

Revision 13-1; Effective February 1, 2013

The trustee must pay the copayment directly to the provider by the 10th of the month, or no later than 10 days after MDCP services have started in situations when services did not start on the first of the month.

If the trustee did not pay the copayment to the provider, the provider is required to notify the case manager by the next working day following the 10-day time frame. When the case manager is made aware the copayment was not made, the case manager must notify MEPD staff of the trustee's failure to pay the copayment using Form H1746-A, MEPD Referral Cover Sheet.

The case manager must investigate the refusal to pay and contact the trustee to learn the reason for not paying within two working days of the provider's notification. The case manager must inform the trustee failure to pay the copayment may result in the loss of Medicaid. If the trustee is not the primary caregiver, the case manager must contact the individual/primary caregiver to inform them the refusal to pay the copayment may result in the loss of Medicaid.

MEPD staff will determine if the nonpayment results in a loss of Medicaid. If MEPD staff determines Medicaid must be denied, the case manager must follow procedures in Section 5500, Loss of Medicaid.

The case manager must document all contacts, dates of contact and outcome with the trustee, individual/primary caregiver and provider in the case file using Form 2405, Narrative Notes.

3120  Medical Necessity

Revision 12-1; Effective May 1, 2012

A Medically Dependent Children Program (MDCP) applicant must have a valid medical necessity (MN) determination before admission into MDCP. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The Resource Utilization Group (RUG) is calculated based on the MN/LOC Assessment.

The case manager may verify MN by viewing either the Medical record in the Service Authorization System (SAS) or the Texas Medicaid & Healthcare Partnership's (TMHP) web-based portal.

For applicants applying for Medicaid, staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) staff within three working days of the applicant's MN determination. Staff must notify MEPD staff via the Eligibility Data Exchange and Notification (EDEN) system as outlined in Section 3133, Notifying MEPD of Approved IPC and MN.

If the MN decision is not available to the case manager by 30 calendar days after the initial home visit, the case manager must complete the MDCP eligibility determination within 14 calendar days from the date of MN determination, provided all other eligibility criteria have been met. Staff must follow procedures in Section 3500, Money Follows the Person Option, regarding Medicaid eligibility for applicants transitioning from a nursing facility to the community.

3121  Medical Necessity Determination for Applicants Residing in Nursing Facilities

Revision 12-1; Effective May 1, 2012

During the initial contact with the applicant in the nursing facility (NF), the case manager must determine whether the applicant is a current Medicaid recipient, is applying for Medicaid or is on Medicare.

Current Medicaid Recipient

The applicant who is a Medicaid recipient has already received a medical necessity (MN) determination to satisfy Medicaid eligibility. Staff may view the Service Authorization System (SAS) to verify a valid MN determination, which is identified by a purpose code 2, 3, 4, R or E in the Level of Service record and a Yes in the MN record. In this situation, the MDCP nurse should not complete a new Medical Necessity and Level of Care (MN/LOC) Assessment. The MN determination on record for the NF is valid for an MN determination for MDCP. The NF completes the Minimum Data Set (MDS) to assess an NF resident's MN. Staff may ask the NF for a courtesy copy of the applicant's MDS for the case file. The case manager proceeds with the MDCP eligibility determination.

Applying for Medicaid

If an applicant is applying for Medicaid as a resident in the NF and is also applying for MDCP, the NF should complete the MDS. If the NF has not completed the MDS, the MDCP nurse must complete the MN/LOC Assessment for the applicant.

Current Medicare Recipient

If the applicant is currently on Medicare, the case manager needs to know the length of the Medicare stay. A different situation exists when an MDCP applicant enters the NF on Medicare. Although the NF completed an MDS, SAS will not register the NF resident's MN determination until the NF resident is on Medicaid. In this situation, the MDCP nurse may complete the MN/LOC Assessment to expedite an MN determination and avoid a delay for the NF resident returning to the community.

SAS Medical Necessity Record

For an applicant who satisfies the MDCP MN requirement based on the MN determination made while in an NF, a copy of the SAS record showing the applicant has MN approval must be filed in the case file. The case manager will use the initial individual plan of care (IPC) effective date as the MN effective date for MDCP and enter that date into the SAS MN record for MDCP. The case manager will use the initial IPC end date as the MN end date in the SAS MDCP MN record.

NF Residents Released from the Interest List

Policy in this section applies to applicants referred from the interest list. However, if an applicant remains in the NF and enrolls directly into MDCP, the case manager must determine eligibility following procedures in Section 3500, Money Follows the Person Option. If the applicant chooses to leave the NF before the case manager determines eligibility, the case manager will continue the application process for applicants released from the interest list.

3122  Medical Necessity Determination for Applicants Recently Discharged from Nursing Facilities

Revision 12-1; Effective May 1, 2012

The case manager may use the nursing facility (NF) medical necessity (MN) determination if the applicant has a valid MN at the time of NF discharge and has a negotiated service plan initiation date within 60 days of the discharge. The Medically Dependent Children Program (MDCP) nurse does not need to complete and transmit a Medical Necessity and Level of Care (MN/LOC) Assessment. If the applicant does not have a valid MN or if services will not begin within 60 days, a new MN determination is required.

To verify a valid MN determination for applicants recently discharged from an NF, the case manager follows the procedures identified in Section 3121, Medical Necessity Determination for Applicants Residing in Nursing Facilities.

Policy in this section is applicable to applicants referred from the interest list and to applicants who were former nursing facility residents, and may not be applied to applicants using the Money Follows the Person option. Staff must follow procedures in Section 3500, Money Follows the Person Option, for applicants utilizing that option.

3123  Medical Necessity Inquiry through the Online Portal

Revision 12-1; Effective May 1, 2012

The Texas Medicaid & Healthcare Partnership (TMHP) reviews the Medical Necessity and Level of Care (MN/LOC) Assessment, verifies medical necessity (MN) and calculates the Resource Utilization Group (RUG). The case manager must review the TMHP web-based portal for the status of the MN/LOC Assessment. TMHP will report the status of the MN/LOC Assessment as pending review, approved, MN denied.

If the TMHP web-based portal indicates that the status is pending review, it means TMHP received the MN/LOC Assessment and has not made a determination for MN. No information is processed in the Service Authorization System (SAS). Staff must check the TMHP web-based portal weekly for a change in this status.

If the TMHP web-based portal indicates that the status is approved, it means MN has been verified. The case manager may check the SAS Medical records for TMHP's results. If TMHP's results do not appear in SAS, the case manager must use the information available from the TMHP web-based portal and the MN/LOC Assessment to create Level of Service, Diagnosis and MN records in SAS. TMHP's results will not appear in SAS when information on the MN/LOC Assessment does not meet all the required SAS data entry criteria.

If the TMHP portal indicates MN Denied status, the MDCP applicant's physician has 14 business days to submit additional information. Once the TMHP portal indicates the 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 business 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 must not mail Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to deny the MDCP case until after 14 business days from the date the MN Denied status appears in the Long Term Care Portal. The case manager must meet initial certification and annual reassessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented on Form 2405, Narrative Notes, and filed in the case file.

Once the MN/LOC Assessment has been approved, the applicant has met the criteria for MN. The case manager may continue with MDCP eligibility determination.

3130  Individual Plan of Care Development

Revision 14-2; Effective September 1, 2014

§51.217

(a)
The IPC is developed by:
(1)
the individual;
(2)
the individual's parent or guardian;
(3)
the case manager;
(4)
a DADS RN; and
(5)
any other person who participates in the individual's care, such as the provider, a representative of the school system, or other third-party resource.

§51.221

(b)
The individual or the individual's parent or guardian must sign and return the completed IPC to the case manager within 10 days of receipt.

Within 30 days of the initial home visit, the case manager will complete the authorization of Medically Dependent Children Program (MDCP) services. The case manager is responsible for the development of the individual plan of care (IPC) and must ensure that all applicable policies and procedures associated with IPC development are carried out. The IPC is developed before MDCP services are authorized. The applicant and the applicant's primary caregiver must be involved in the development of the IPC.

The case manager must inform the applicant of:

  • the services that are available under MDCP;
  • service limitations;
  • the Consumer Directed Service option; and
  • provider choice.

To develop the IPC, the case manager must:

  • complete Form 2410, Medical-Social Assessment and Individual Plan of Care (Part I, Page 1, Medical Assessment, and Part IIA, Page 2, Social Assessment); see Section 2300, Initial Home Visit;
  • complete Form 2429, Job Interest Assessment, for all individuals 18 years of age through 20 years of age;
  • complete Form 2410, Part IIB, Page 3, MDCP Schedule Planning Grid; and
  • ensure that all eight pages of Form 2410 are completed.

Service planning requires the synthesis of assessment results and the identification of goals and preferences of the applicant and caregiver into a comprehensive IPC that uses third-party resources and MDCP services to adequately serve the applicant in the community. Key purposes of the IPC are to summarize the services that will meet the needs identified during the assessment process and to document that MDCP services are feasible and cost-effective. There must be a reasonable expectation that the third-party resources and MDCP services on the IPC are adequate to meet the needs of the applicant in the community.

The IPC must reflect consideration of:

  • the applicant's existing condition that resulted in an application for MDCP services;
  • the applicant's physical and mental health, functional capacities for self care, and need for or availability of self-help or adaptive devices;
  • existing caregivers and the specific amounts and types of assistance they give and can continue to give the applicant;
  • the applicant's home environment and available third-party resources;
  • other services available from the Department of Aging and Disability Services necessary to help the applicant maintain self-sufficiency;
  • information secured from the applicant's doctor, friends or associates that may be necessary to develop an IPC suitable for the applicant's needs;
  • the number of service units to be authorized, and the rationale for the authorization;
  • the dates on which services are expected to begin; and
  • any special monitoring or case management procedures to be followed.

The case manager must document on Form 2410 if the applicant is using Aid and Attendance (A&A) or Housebound Benefits (HB) from Veterans Affairs to purchase respite care or flexible family support services. The use of these funds and services purchased must be considered in the development of the IPC.

By signing Form 2410, the applicant, the case manager and other people participating in the applicant's care certify that the MDCP services proposed on the IPC are necessary to avoid nursing facility (NF) care and are adequate and appropriate to meet the needs of the applicant in the community.

The case manager must meet with the applicant during the development of the IPC to allow the applicant the opportunity to review the assessment and make choices regarding the IPC. The case manager must inform the applicant of the feasibility and consequences of choices, including IPC cost limit implications. Example: If the applicant chooses only Respite provided by a registered nurse (RN), the cost of Respite services may cause the applicant to either be ineligible for MDCP because IPC costs exceed the cost limit or limit the amount of other MDCP services that can be purchased. The applicant's goal may be to obtain a much-needed bathroom modification. By using other supports to provide Respite under the supervision of an RN, the applicant may be able to obtain this goal.

The case manager determines how many units of respite or flexible family support services to authorize based on the need of the primary caregiver. The case manager must round units per week up to the next quarter-hour on the IPC because providers are only able to bill in quarter-hour increments. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour. Example: An individual's primary caregiver requested 15 hours and 20 minutes of respite per week. The case manager would authorize 15.50 hours of respite per week.

In cases in which the cost of all the services cause the applicant to be ineligible for MDCP because the IPC exceeds the cost limit, the applicant may choose to reduce or delay some services that are not critical for health or welfare. Example: The applicant may choose to delay a vehicle modification for the following IPC period in order to access Minor Home Modifications in the initial IPC.

The initial IPC identifies services to be provided after approval and enrollment of the individual and includes the schedule of authorized units for Respite, Flexible Family Support Services or both. Other eligibility factors, such as the financial eligibility, may be outstanding, so it is important that the case manager communicate to providers that services delivered before an eligibility determination are not reimbursable.

Once all eligibility factors are met, the case manager will notify Medicaid for the Elderly and People with Disabilities (MEPD) staff verbally or by Form H1746-A, MEPD Referral Cover Sheet, and a medical effective date (MED) will be negotiated. The case manager establishes the IPC effective date and enters it on Form 2410 and Form 2065-B, Notification of Waiver Services. The IPC effective date cannot be before the effective date for medical necessity or MED.

Coordinating Multiple Services

When the case manager is evaluating the need for MDCP services for an individual receiving nursing or attendant services through programs other than MDCP, he must first evaluate if there is a need for MDCP services based on the criteria found in Section 4100, Medically Dependent Children Program (MDCP) Services. He must also determine if MDCP services are needed at least monthly, as required by the MDCP waiver and that there is no duplication in services.

The primary caregiver identified on the IPC is ultimately responsible for providing care to the individual, regardless of whether there is a service provider in the home. Therefore, a caregiver could feasibly need respite during the time another service provider is in the home, provided there is no duplication of services.

Example: A Comprehensive Care Program (CCP) private duty nurse is in the home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing personal care services to the individual to relieve the caregiver of tasks he or she would normally be responsible for performing.

The only exception to the no duplication of services policy would be instances requiring two-person transfers. In that scenario, the CCP private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

The combined waiver and third-party resources may not be reduced below a level that is adequate to meet the applicant's needs. If there are disagreements between the applicant, the primary caregiver, the providers, the case manager or the MDCP nurse regarding the type or amount of necessary MDCP services, the case manager must convene a meeting to resolve the conflict. The meeting should include the applicant, the primary caregiver, the provider or entity that participates in the applicant's care, the case manager and the MDCP nurse. If necessary, staff should also involve the applicant's physician. The decision reached by DADS staff involved in this consultation is final.

3130.1  Setting Funds Aside in the IPC

Revision 12-1; Effective May 1, 2012

During the development of the Individual Plan of Care (IPC), an individual may wish to set funds aside for future service requests, such as adaptive aids or minor home modifications.

The case manager may document future service requests under Comments in Fields 47a through 47f of Part II C – Individual Plan of Care Summary on Form 2410, Medical-Social Assessment and Individual Plan of Care. As indicated in the form instructions, these fields are completed when the applicant/individual/family is selecting to use the service during the IPC period. The case manager must not document funds that are set aside for future service requests in Part III – MDCP Applicant/Consumer Plan of Care/Budget Worksheet. Information in Part III must reflect authorized services for the IPC period.

3130.2  Coordinating IPC Development with the Provider

Revision 14-2; Effective September 1, 2014

Case managers are required by 40 Texas Administrative Code (TAC), Chapter 51, §51.217, Individual Plan of Care (IPC), to include the provider in the development of an IPC. Case managers must contact the provider of choice by phone to discuss the draft IPC developed after the initial home visit. The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion with the provider must occur in time to meet the 30 day time frame for authorizing services from the initial home visit. Once all parties agree with the draft IPC, the service initiation date must be negotiated with the provider. Case managers should also include the MDCP nurse in the discussion, as appropriate, for any proposed changes to the IPC.

Case managers must also contact the provider of choice by phone to discuss draft IPCs developed at the annual reassessment. The provider may request time to review the draft IPC; therefore, the discussion with the provider must occur in time to authorize services before the end of the current IPC. See Section 7130, Individual Plan of Care Development.

Case managers must document all dates of contact with the provider on Form 2405, Narrative Notes. The documentation must include details of the case manager's efforts to coordinate the IPC development and any concerns the provider may have regarding the draft IPC.

Service Authorizations

The requirement in 40 TAC, Chapter 51, §51.411, General Service Delivery Requirements, states:

(a) A provider must provide services as indicated on the service authorization form.

The Department of Aging and Disability Services (DADS) MDCP case manager authorizes services on Form 2414, Flexible Family Support Services Authorization, and/or Form 2415, Respite Service Authorization, showing the services to be provided, the amount of services and the type of provider (RN, LVN, attendant with delegation or attendant) authorized to provide the service. The MDCP provider must sign Form 2414 and/or Form 2415, check a box in Section D of the form showing if skilled tasks will or will not be delivered, and then return the form to the DADS MDCP case manager. The provider type sent to provide the designated service must be at or above the skill level designated by the case manager.

The table below shows the type of providers and claims allowable in relation to the case manager's authorization.

Provider Authorized by Case Manager Provider Allowed to Provide Services Allowable Billing Rate
Specialized RN Specialized RN Specialized RN
Specialized LVN Specialized LVN
Specialized RN
Specialized LVN
RN RN RN
LVN RN, LVN LVN
Attendant with delegation RN, LVN, Attendant with delegation Attendant with delegation
Attendant RN, LVN, Attendant with delegation, Attendant Attendant
Employment Assistance Service Provider Employment Assistance Service Provider Employment Assistance Service Provider
Supported Employment Service Provider Supported Employment Service Provider Supported Employment Service Provider

If at any time after the development of an IPC the provider has concerns about the provider type authorized, the provider may contact the case manager who will discuss the change or issue with the individual or the individual's parent or guardian. If the concern is not resolved, the case manager will arrange a meeting, which will include the provider and the individual, or individual's parent or guardian, to discuss the provider's concern. If the provider type changes, the case manager must complete Form 2412, Budget Revision, for IPC changes. The case manager must also update Form 2414 and/or Form 2415 to reflect the changes in service authorizations.

3131  Determining Cost Effectiveness

Revision 12-2; Effective August 1, 2012

All applicants, at initial enrollment, must have a service plan within the individual plan of care (IPC) cost limit. The cost limit is the maximum dollar amount available to an applicant for Medically Dependent Children Program (MDCP) services per IPC effective period. A list of the MDCP IPC cost limits is located in Appendix I, Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits, Provider Types and Service Rates.

The applicant's IPC cost limit is based on the assigned RUG calculated from the Medical Necessity and Level of Care (MN/LOC) Assessment. The costs of MDCP services necessary for the IPC effective period are based on the estimated service needs included in Form 2410, Medical-Social Assessment and Individual Plan of Care.

If the case manager determines that the cost of MDCP services is within the IPC cost limit, MDCP is a feasible alternative to nursing facility care. The case manager may continue with MDCP eligibility determination.

The case manager must deny MDCP services if the applicant's initial IPC is not under the cost limit.

3132  The Individual Plan of Care Service Initiation Date and Effective Period

Revision 13-1; Effective February 1, 2013

Once the case manager determines that all Medically Dependent Children Program (MDCP) eligibility requirements are met, the case manager must negotiate the individual plan of care (IPC) effective date with the applicant, the applicant's parent or guardian, the provider (Home and Community Support Services provider or the Consumer Directed Services Agency) and the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable.

The case manager must document communication with the MEPD specialist, if applicable, regarding the Medicaid eligibility date using Form H1746-A, MEPD Referral Cover Sheet, email correspondence, or Form 2405, Narrative Notes, in the case file. The case manager must also document the individual's/parent's/guardian's and provider's participation in determining the IPC effective date in the case file.

The IPC effective date must occur within 30 days of MDCP eligibility determination, as documented on Form 2065-B, Notification of Waiver Services.

For applicants determined eligible who cannot be without services, such as an applicant returning to the community from a hospital or nursing facility, the case manager must negotiate a service initiation date for the applicant's discharge date.

If the case manager has negotiated a service initiation date with the provider, the case manager must also fax Form 2067, Case Information, to the provider documenting the negotiated service initiation date.

The case manager must not delay the IPC effective date if a provider is not able to provide services as negotiated. A delay in initiating the IPC may delay services provided by Medicaid or other authorized MDCP services.

For an initial IPC, the case manager must negotiate the earliest possible date. If the case manager negotiates the service initiation date for the first of the month, the "to" date of the IPC must be the last day of the 12th month. For example, if the negotiated date for an initial IPC falls on Oct. 1 of the current year, the "to" date for the IPC will be Sept. 30 of the following year. If the case manager negotiates the service initiation date for any other date besides the first of the month, the "to" date for the IPC must be the last day of the 13th month. For example, if the negotiated date for an initial IPC falls on Dec. 12 of the current year, the "to" date for the IPC will be Dec. 31 of the following year. The effective period for the next IPC will be from Jan. 1 to Dec. 31. If the applicant's 21st birthday falls within the effective period, then the IPC is effective until 12 a.m. the day of the applicant's birthday.

3132.1  Determining the Number of Weeks in the Initial IPC Period

Revision 13-3; Effective August 1, 2013

When determining the length of the Individual Plan of Care (IPC) period, case managers round up for the total number of weeks. If the length of the IPC period is exactly 12 months, case managers must use 53 weeks to calculate the cost of services.

To calculate the number of weeks in an IPC period, case managers must:

  • determine the number of days in the IPC period, including the begin and end dates;
  • divide the total number of days by seven; and
  • if the division results in a;
    • whole number, use the whole number; or
    • fraction, round up to the next whole number.

Example: An initial IPC period is from July 15, 2010, through July 31, 2011.
Step 1: July 15, 2010, through July 31, 2011 (including the first and last day), is 382 days.
Step 2: 382 days divided by seven days equals 54.57 weeks.
Step 3: 54.57 weeks is rounded up to 55 weeks.
The total number of weeks for this IPC period is 55.

Case managers apply the same methodology to determine the number of weeks in the IPC period for an applicant who will age out during the initial IPC period.

Case managers must not reduce the amount of weeks for other services when including camp in the IPC.  The time spent at camp does not affect the number of weeks authorized for other services.  Case managers must authorize services based on the amount of weeks in the IPC year.  During the time the individual is attending camp, the parent can make minor changes in the service schedule and may utilize those unused hours later in the week or later in the month.

Example: Joe Smith has an IPC year of Feb. 1, 2013 to Jan. 31, 2014.  He will attend one summer camp session during the IPC year.  His primary caregiver requests 15 hours per week of respite at the face-to-face visit.  On Form 2410, Medical-Social Assessment and Individual Plan of Care, Section 56, the case manager documents 53 weeks for respite on one line and one week of camp on the second line.

3133  Notifying MEPD of Approved IPC and MN

Revision 12-3; Effective November 1, 2012

The Eligibility Data Exchange and Notification (EDEN) system is a web-based program that allows DADS and the Health and Human Services Commission to exchange information on waiver cases. The system is accessed through the Health and Human Services (HHS) Enterprise Portal and DADS Work Center. Refer to EDEN Permissions below.

Once an approved individual plan of care (IPC) and approved medical necessity (MN) are ready, the information must be transmitted to Medicaid for the Elderly and People with Disabilities (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 for new individuals. The following information will be provided to MEPD:

  1. Approved IPC.
  2. Approved Medical Necessity/Level of Care (MN/LOC).

On the Initial Functional Assessment Screen, the Client Name will be populated. Continue with the following steps:

  1. Enter the begin date (which is the date the case manager has an accepted IPC and valid MN/LOC).
  2. Select the Service Group from the drop down menu. The Service Code and the functional boxes are not applicable and are reserved for future use.
  3. On the IPC screen, select Approved or Denied from the drop down menu.
  4. On the MN/LOC screen, select Approved or Denied from the drop down menu.
  5. Check the Information Complete box and click on Send to TIERS.
  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 they 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.

3134  Other Resources and Services

Revision 14-2; Effective September 1, 2014

The case manager is responsible for identifying, determining and assessing all possible third-party resources (TPR) that can benefit the applicant. Available resources must first be used to meet the applicant's needs rather than services purchased through the Medically Dependent Children Program (MDCP).

Case managers are responsible for assisting the applicant to apply for and use all available TPRs. Case managers must first consider TPRs in the development of the individual plan of care (IPC). Authorized MDCP services must supplement TPRs and must not replace available TPRs.

The use of Medicare, Medicaid, private insurance, home health services provided by a community agency, supported employment or employment provided by the Department of Assistive and Rehabilitative Services, personal care provided by friends or relatives and other community services must be explored to determine if any of the individual's needs can be met through these resources. Staff must ensure that requests for services must first be sought through these resources. Example: If the applicant needs an adaptive aid, the Comprehensive Care Program (CCP) available through Medicaid must be used before requesting the adaptive aid through MDCP. Any available benefits should be documented in the case file and used before MDCP services are used.

The provision of MDCP and TPRs must be a cooperative and collaborative effort between the various providers and is coordinated by the case manager. For applicants receiving funds from other sources, the case manager must consider whether the intended use of these funds is to pay for a service or item that is available in MDCP.

To determine the services available through TPRs, the case manager must attempt to obtain copies of documents from the applicant, the applicant's family or other agencies providing funds and services. If a service plan or other documentation is not available, a summary of services or the applicant's statement is sufficient to determine need and develop the IPC.

Information on the applicant's TPRs, such as private insurance, Medicare or Medicaid, and informal supports, such as family members, friends and other involved organizations providing services to the applicant, is recorded on Form 2410, Medical-Social Assessment and Individual Plan of Care (Part IIB, Page 3, MDCP Schedule Planning Grid), and included in the case file.

The IPC identifies services for the applicant to remain in or return to the community. The IPC must include those services funded by MDCP and TPRs provided by, or funded by, the applicant/family/guardian, a TPR or another private or government program.

3135  Coordinating with IDD Services During the Development of the Initial IPC

Revision 12-2; Effective August 1, 2012

Home and Community-based Services (HCS), Texas Home Living (TxHmL) and Local Authority (LA) general revenue services are intellectual developmental disability (IDD) services that must not be accessed in coordination with Medically Dependent Children Program (MDCP) services. In order to prevent dual enrollment with these programs, the MDCP case manager or intake screener must check the Client Assignment and Registration (CARE) System to see if an individual is receiving LA services, which could be mutually exclusive with other DADS services. The DADS case manager checks the mutually exclusive chart for programs that are not mutually exclusive. The chart is in Appendix V, Mutually Exclusive Services.

3135.1  Access to the CARE System

Revision 12-2; Effective August 1, 2012

The Client Assignment and Registration (CARE) System is used for enrollment for the following programs: Home and Community-based Services (HCS), Texas Home Living (TxHmL) and Local Authority (LA) general revenue services. The Instructions for Access to the CARE System and CARE Logon and Inquiry attachments are located in Appendix IX, Instructions and Access to CARE.

3200  Personal Care Services (PCS)

Revision 12-1; Effective May 1, 2012

The PCS program is available to Medicaid recipients under the age of 21 who are eligible for Texas Health Steps (THSteps).

PCS provides assistance with activities of daily living (ADL), instrumental ADL and health-related functions due to a physical, cognitive or behavioral limitation related to a disability or chronic health condition. The PCS program is administered by the Texas Health and Human Services Commission (HHSC); however, the Department of State Health Services (DSHS) determines eligibility for services.

MDCP applicants may receive services from PCS, in addition to receiving services from MDCP. Since PCS addresses different needs than those met by MDCP services, the applicant's/individual's decision to access PCS should not affect the MDCP services authorized by DADS case managers. The DADS case manager must document the applicant was referred to PCS on the Individual Plan of Care (IPC) or on Form 2405, Narrative Notes, in the case file.

For applicants receiving services from both PCS and MDCP, close coordination between DADS and PCS case managers is necessary to ensure the IPC accurately reflects all services being received.

3200.1  PCS Data Reports

Revision 12-1; Effective May 1, 2012

Department of Aging and Disability Services (DADS) case managers are required to coordinate services with Personal Care Services (PCS) case managers for individuals who are receiving both PCS and DADS waiver services. PCS data reports are available online at: ftp://dads4svtuvok/PCS. DADS case managers will access the PCS data reports before completing initial assessments to determine if coordination of services with PCS case managers is needed.

3200.2  Using the PCS Data Reports

Revision 12-1; Effective May 1, 2012

After clicking the link ftp://dads4svtuvok/PCS, Department of Aging and Disability Services (DADS) case managers will find a zipped folder named PCS Files SFY10 Q3.zip. Double click that folder to access three excel spreadsheets: PCS Match File 1 FY10 Q3, PCS Match File 2 FY10 Q3 and PCS Match File 3 FY10 Q3. Note: The fiscal year and quarter will change as warranted.

  • PCS Match File 1 FY10 Q3 lists individuals currently receiving both waiver services and PCS, and is utilized at annual reassessments.
  • PCS Match File 2 FY10 Q3 lists individuals receiving PCS who are being released from a waiver interest list, and is utilized at initial assessments.
  • PCS Match File 3 FY10 Q3 is used by the Department of State Health Services to identify individuals receiving waiver services.

DADS case managers must review PCS Match File 1 FY10 Q3 prior to conducting an initial assessment to search for individuals receiving PCS. DADS case managers open the PCS Match File by double clicking the file, and may search in column A by Medicaid number or column B by name for individuals being assessed. If the applicant is found in PCS Match File 1 FY10 Q3, DADS case managers must coordinate with PCS case managers to evaluate the level of PCS being delivered and the need for DADS waiver services.

3210  Procedures for the MDCP Applicant Who Receives PCS

Revision 12-1; Effective May 1, 2012

If the applicant receives services from Personal Care Services (PCS) and wants MDCP services, the DADS case manager must inform the applicant of the coordination of services that must occur between the DADS case manager and the PCS case manager. The DADS case manager must request a copy of the PCS Personal Care Assessment Form (PCAF) from the PCS case manager. The DADS case manager is not required to complete Form 0003, Authorization to Release Information, since DADS and the Department of State Health Services are state agencies within the HHSC Enterprise. The PCS case manager may provide DADS with a copy of the PCAF, which provides details on delivered PCS services. The PCAF is an assessment tool and an overview of services and may not necessarily follow the PCS delivery schedule.

The DADS case manager may accept the applicant's statement regarding the amount of PCS hours authorized and delivery schedule, and documents the applicant's use of PCS when developing Form 2410, Medical-Social Assessment and Individual Plan of Care (IPC). When developing the IPC, the DADS case manager must document that services through the PCS program assist the applicant with activities of daily living (ADL), instrumental ADL or health-related functions, and MDCP services address other needs.

The DADS case manager must inform the PCS case manager of the applicant's MDCP eligibility within two working days of eligibility determination. If the applicant is eligible for MDCP, the DADS case manager sends a copy of Form 2410 and Form 2067, Case Information, to the PCS case manager. On Form 2067, the DADS case manager informs the PCS case manager of the name of the MDCP provider(s) or Consumer Directed Services Agency (CDSA) and the contact information for the individual.

If the applicant is denied eligibility, the DADS case manager sends Form 2067 within two working days of eligibility determination to the PCS case manager indicating the MDCP applicant was denied MDCP eligibility.

If the applicant decides that PCS meets all of his needs and voluntarily withdraws from the MDCP application process, the DADS case manager closes the interest list referral and follows procedures in Section 2220, Declining MDCP Services, and Section 2510, Contacting the CSIL Unit to Report the Status of Interest List Releases. The DADS case manager sends Form 2067 within two working days of the individual's decision to the PCS case manager, indicating the MDCP individual withdrew his application from MDCP.

3220  Procedures for the MDCP Applicant Who Does Not Receive PCS

Revision 12-1; Effective May 1, 2012

The DADS case manager must explain Personal Care Services (PCS) and give the MDCP applicant the Texas Medicaid & Healthcare Partnership (TMHP) toll-free PCS Line (1-888-276-0702). TMHP will forward referral information to the appropriate Department of State Health Services staff. The DADS case manager must review the status of PCS eligibility at the following six-month monitor.

The DADS case manager must not delay the applicant's MDCP enrollment by waiting for a PCS eligibility determination. The DADS case manager continues with MDCP eligibility determination and documents the PCS program referral in the case file. The DADS case manager processes an MDCP application following policy in Section 2000, Intake and Interest List Procedures, and Section 3000, Eligibility Determination and Individual Plan of Care Development.

If the MDCP applicant contacts the PCS case manager and requests PCS, the PCS case manager will provide PCS information describing the benefits of the program available to the MDCP applicant/individual. The PCS case manager will inform the MDCP applicant that both the PCS case manager and the DADS case manager must work together to coordinate the delivery of PCS and MDCP services. The PCS case manager will contact the DADS case manager to request the Individual Plan of Care (IPC). The DADS case manager must fax the applicant's/individual's IPC and provider names, including the Consumer Directed Services Agency, and contact information using Form 2067, Case Information, to the PCS case manager within five working days of the request.

Once the MDCP applicant is determined PCS eligible, the PCS case manager will provide a copy of the final Personal Care Assessment Form to the DADS case manager with the PCS case manager's name and contact information.

3230  FMS for the MDCP Applicant Accessing CDS

Revision 12-1; Effective May 1, 2012

If the applicant is using the Consumer Directed Services (CDS) option and wants to continue to use the option for both Personal Care Services (PCS) and MDCP, he must use only one CDS agency for both programs. If the applicant has a CDS agency serving both programs, he may continue to use the current CDS agency. If the applicant has a CDS agency that does not contract to deliver Financial Management Services (FMS) for both programs, the applicant must select a CDS agency that serves both PCS and MDCP.

3240  Coordination of Services in the MDCP IPC and Personal Care Assessment Form

Revision 13-2; Effective May 1, 2013

Although Respite and Flexible Family Support Services have different service criteria and are authorized to address different needs than Personal Care Services (PCS), coordination of service delivery is required of both the DADS case manager and the PCS case manager. Duplication of services will not be permitted. Duplication is defined as two different services providing an individual the same assistance at the same time without the presence of an unmet need. Both case managers must review the needs of the applicant/primary caregiver and reach an agreement on the Individual Plans of Care (IPCs) for service delivery for MDCP and PCS.

The DADS case manager must document all coordination efforts and decisions with the PCS case manager in the case file, using Form 2405, Narrative Notes.

The DADS case manager may contact the Department of State Health Services (DSHS) for information for current PCS individuals at the following telephone numbers:

DSHS Region 1
806-655-7151

DSHS Region 2/3
817-264-4627

DSHS Region 4/5 N
903-533-5231

DSHS Region 6/5 S
713-767-3111

DSHS Region 7
254-778-6744

DSHS Region 8
210-949-2155

DSHS Region 9/10
915-834-7682

DSHS Region 11
956-423-0130

DSHS regions differ slightly from DADS. To determine which DSHS office to call, the DADS case manager may access a list of DSHS regional offices and a DSHS County/Region map located at www.dshs.state.tx.us/regions/default.shtm.

3300  Targeted Case Management (TCM)

Revision 12-2; Effective August 1, 2012

Local Authorities (LAs) provide service coordination to individuals with intellectual developmental disability (IDD) in the DADS LA priority population. This service is called Targeted Case Management (TCM).

3300.1  Coordination of TCM and MDCP Services

Revision 12-2; Effective August 1, 2012

DADS waiver services, including the Medically Dependent Children Program (MDCP), are mutually exclusive with Targeted Case Management (TCM). An individual receiving MDCP services cannot receive TCM at the same time.

The MDCP case manager can identify if TCM services are being used in the Service Authorization System (SAS). TCM services are identified in SAS as Service Group 14, Service Code 12A or 12C.

Since waiver programs provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The DADS case manager must contact the Local Authority to coordinate closing TCM for the waiver service to begin.

The MDCP case manager must refer to Appendix V, Mutually Exclusive Services, to determine if the individual can receive other DADS services, as some services are mutually exclusive and others are not. If the individual is receiving another DADS service and the requested MDCP service is mutually exclusive, then the case manager will contact the individual, or individual’s parent or guardian, to allow a choice of services.

3400  Reserved for Future Use

Revision 12-1; Effective May 1, 2012

3500  Money Follows the Person Option

Revision 12-1; Effective May 1, 2012

Money Follows the Person (MFP) allows individuals residing in a nursing facility to request services through the Medically Dependent Children Program (MDCP) waiver and bypass the MDCP interest list.

3500.1  Individuals Without Medicaid

Revision 12-3; Effective November 1, 2012

Individuals without Medicaid who request Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option must remain in the nursing facility (NF) for no less than 30 days to meet the Health and Human Services Commission (HHSC) eligibility criteria to qualify for Medicaid. Individuals cannot leave the NF until MDCP eligibility is determined and waiver services have been authorized to allow for continuity of services. The MDCP eligibility process could potentially take longer than the 30 day HHSC eligibility criteria requirement for Medicaid. Case managers must follow current time frames for processing an application for MDCP.

For individuals who cannot reside in an NF for 30 days because they meet the medically fragile criteria, Medicaid for the Elderly and People with Disabilities (MEPD) can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP waiver to meet the 30-day requirement. See Section 3520, Limited Nursing Facility Stay for Medically Fragile Individuals.

3500.2  Individuals With Medicaid

Revision 12-1; Effective May 1, 2012

Individuals with Medicaid who request MDCP services through the Money Follows the Person (MFP) option cannot leave the nursing facility until MDCP eligibility is determined and waiver services have been authorized to allow for continuity of services. Case managers must follow current time frames for processing an application for MDCP.

3510  Individuals Currently Residing in a Nursing Facility

Revision 12-1; Effective May 1, 2012

For individuals residing in a nursing facility (NF) who are interested in utilizing the Money Follows the Person (MFP) option to transition from an NF must request to utilize the MFP option to transition from an NF once they have been admitted to the NF. The initial visit to begin the eligibility determination process must occur in the NF. The individual must be determined eligible for MDCP prior to discharge from the NF as described in Section 3500.1, Individuals Without Medicaid, and Section 3500.2, Individuals With Medicaid.

The state office Community Services Interest List (CSIL) unit will forward the name of the individual, or the individual's parent or guardian, interested in the MFP option to the appropriate regional MDCP supervisor or other regionally designated representative. This will not be a release from the interest list, but a referral of an individual interested in by-passing the interest list through the MFP option.

If the referral from the CSIL unit indicates the individual is currently residing in an NF, the regional MDCP supervisor must assign a case manager and notify the CSIL unit by email of the assignment within five working days of receipt of the referral. The case manager must conduct the initial visit with the individual, or the individual's parent or guardian, within 14 calendar days from the CSIL assignment date to begin the enrollment process. The MDCP supervisor must notify the CSIL unit by email within three working days once the individual is enrolled in MDCP.

3520  Limited Nursing Facility Stay for Medically Fragile Individuals

Revision 13-1; Effective February 1, 2013

Individuals who request MDCP services through the Money Follows the Person (MFP) option, but are too medically fragile to reside in a nursing facility (NF) for an extended period of time, may request to complete a limited NF stay. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care.

The Department of Aging and Disability Services (DADS) regional nurse will review the medical fragility of an individual requesting a limited NF stay. Medical judgment of the DADS physician will be applied on a case-by-case basis when the below criteria do not capture the severity/fragility of the individual's medical condition. An individual must meet two or more of the following criteria to be considered medically fragile:

  • Ventilator dependent with a tracheostomy
  • Renal dialysis
  • 24 hour/day oxygen dependence
  • Total parenteral nutrition (TPN)
  • Tracheostomy
  • Daily recurrent seizures within the past six months requiring medical intervention during the seizure activity (e.g., medication administration, oxygen)
  • Documented immune deficiency confirmed by lab findings (i.e., IgA or IgG deficiency) or on immunosuppressive drug therapy
  • Total nutrition via enteral tube feeding
  • Congestive heart failure requiring hospitalization within the past six months
  • Hospice

Individuals determined medically fragile by the DADS physician and approved for a limited NF stay must stay at least part of two days in the NF. Admission and discharge from the facility must be on different days. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services (and establish Medicaid in an NF).

3520.1  MFP Procedures for Requesting a Limited Nursing Facility Stay

Revision 13-1; Effective February 1, 2013

Individuals who request MDCP services through the Money Follows the Person (MFP) option may contact the state office Community Services Interest List (CSIL) Unit at 877-438-5658 or a local DADS office. If an individual contacts a local DADS office, the local DADS office will refer the individual to the CSIL Unit. The CSIL Unit will forward the name of the individual, or the individual's parent or guardian, interested in the MFP option to the appropriate regional MDCP supervisor or other regionally designated representative. This will not be a release from the interest list, but a referral of an individual interested in by-passing the interest list through the MFP option.

Within five working days of receipt of the individual's name from the CSIL Unit, the regional MDCP supervisor assigns a case manager. The case manager must contact the individual requesting to by-pass the interest list, or the individual's parent or guardian, by phone within five working days from assignment to explain the following:

  • The individual must:
    • complete a limited nursing facility stay if the individual is determined to be too medically fragile to complete an extended nursing facility stay;
    • obtain documentation from the individual's physician on Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, regarding his recommendation for the length of stay the individual can complete in a nursing facility; and
    • obtain admission and discharge documentation from the nursing facility.

If the individual's physician recommends a limited stay, a DADS regional nurse will review the documentation and approve the limited stay request if the physician documentation clearly supports the individual meets two or more of the criteria on Form 2406. If, based on the documentation submitted, the applicant does not meet two or more criteria, the form and all medical documents submitted are scanned and emailed to the designated state office representatives for state office physician review.

If the individual, or the individual's parent or guardian, decides to pursue services through the MFP option, the case manager will inform the MDCP supervisor within three working days of being informed of the decision, and the MDCP supervisor must inform the CSIL Unit by email within three working days of being notified by the case manager. After being notified by the MDCP supervisor of the decision, the CSIL Unit will place the individual in an MFP release status in the CSIL database. The MFP release status does not initiate the MDCP application or eligibility process.

Form 2406 will be used as the physician's verification that the individual meets the medically fragile criteria. Case managers must follow the procedures outlined in this policy before initiating the MDCP eligibility process.

The case manager informs the individual, or the individual's parent or guardian, that Form 2406 must be completed by the individual's physician and returned to the case manager within 30 calendar days of the initial contact with the individual, or the individual's parent or guardian. The individual cannot access MDCP services through the limited nursing facility stay until the physician completes and signs Form 2406 and DADS approves the limited nursing facility stay. The case manager mails Form 2406 to the individual within three working days of the contact with the individual, or the individual's parent or guardian.

3520.2  Case Manager Receipt of Form 2406

Revision 13-4; Effective November 1, 2013

Upon receipt of Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, the case manager reviews the documentation to determine the physician's recommendation. If the physician does not recommend a limited nursing facility stay, within three working days of receipt of Form 2406, the case manager contacts the individual by phone to inform him of the physician's recommendation, and of the option to transition from a nursing facility as described in Section 3510, Individuals Currently Residing in a Nursing Facility, to access MDCP through the Money Follows the Person (MFP) option. If the individual does not choose to transition from a nursing facility as described in Section 3510, his name will remain on the interest list. The case manager will inform the MDCP supervisor within three working days of being informed of the decision, and the MDCP supervisor must inform the Community Services Interest List (CSIL) Unit by email within three working days of being notified by the case manager. The CSIL Unit will remove the individual's name from the MFP release status and his name will remain on the interest list.

If the physician recommends a limited nursing facility stay, the case manager reviews Form 2406, in consultation with the regional nurse, to ensure it contains the required information.

If Form 2406 does not contain the required information, the case manager contacts the individual, or the individual's parent or guardian, within three working days of receipt, to discuss the elements of the form that are incomplete. The case manager informs the individual, or the individual's parent or guardian, that the form is being returned for completion by the individual's physician, and must be returned to the case manager within 30 calendar days of contact. The case manager returns Form 2406 to the individual, or the individual's parent or guardian, within three working days of contact with the individual, or the individual's parent or guardian. If Form 2406 has not been returned by the 30th day, the case manager notifies the individual that his request to access MDCP services through the MFP option is closed. The MDCP supervisor notifies the CSIL Unit by email within three working days of notifying the individual that his request to access MDCP services through the MFP option is closed. The CSIL Unit will remove the individual's name from the MFP release status and his name will remain on the interest list.

Attachments to Form 2406

Form 2406 must be completed by an individual's physician to be considered for a determination. The physician must attach documentation (such as a visit note, patient summary or hospital discharge summary) of permanent conditions to Form 2406. The medical documentation provided must document the current health status of the individual and substantiate the boxes checked on the form; this means the medical documentation must be within 12 months of the date the documentation is being submitted. If all medical documentation submitted is over 12 months old, the submission of Form 2406 is incomplete. The case manager must contact the individual, parent or guardian to inform them of the requirement that medical documentation be within 12 months of the date the documentation is being submitted. All incomplete forms will be returned to the region to be completed before a determination can be made by the DADS regional nurse or the DADS state office physician.

The case manager documents delays in obtaining a completed Form 2406, and conversations with the individual regarding the MFP option on Form 2405, Narrative Notes.

3520.3  Regional Nurse Approval

Revision 13-1; Effective February 1, 2013

Case managers must ensure the form is completed in its entirety. This includes ensuring the individual's name is printed on the form and is legible, the physician's name and address are complete in the Physician's Name and Address field on the first page of the form, and the physician's license number is entered on the second page of the form. If these items are not complete and legible when submitted to the regional nurse, they will be returned to the case manager as incomplete submissions.

A DADS nurse in each region will review each Form 2406, Physican Recommendation for Length of Stay in a Nursing Facility, received by the region. The case manager must submit Form 2406 to the DADS regional nurse within three working days of receipt to determine if the individual meets the medically fragile criteria.

The DADS nurse will approve the limited stay request if the physician documentation clearly supports the individual meets two or more of the criteria on Form 2406.

3520.4  Submission of Form 2406 to the DADS Physician

Revision 13-1; Effective February 1, 2013

If, based on the documentation submitted, the individual does not meet two or more criteria, Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and all medical documents submitted are scanned and emailed to the designated state office representatives for state office physician review. The case manager who received the Form 2406 must be included in the email. Before sending Form 2406 to state office, the regional nurse must ensure the form is complete. Complete is defined as the entire document being legible, all blanks filled in, physician’s signature and license number present and medical records attached.

When submitting Form 2406 to the state office physician, staff must submit each request in a separate email and must submit it as a secure email. The email's subject line must read: MDCP Form 2406 for XX. The "XX" in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "MDCP Form 2406 for AS."

3520.5  Determination of Medical Fragility by the DADS Physician

Revision 13-1; Effective February 1, 2013

The DADS physician will determine if the individual meets the medically fragile criteria. State office will respond via email to the regional nurse and the case manager. The response will be either Meets Criteria or Does Not Meet Criteria. The case manager contacts the individual, or the individual's parent or guardian, by phone within three working days of receipt of the DADS state office email to advise the individual of the outcome of the limited stay request. If the state office physician has a comment regarding the information submitted, this will be noted in the state office response to the region.  The case manager must include this comment when advising the applicant of the outcome of the limited stay request.  If the applicant submits additional documentation, it must be submitted to regional staff with a complete Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and will be considered a new request.

If a limited nursing facility stay is approved, the case manager must stress to the individual, or the individual's parent or guardian, the importance of coordinating the limited stay with the case manager.

If the DADS physician determines the individual does not meet the medically fragile criteria, the case manager contacts the individual, or the individual's parent or guardian, by phone within three working days of receipt of the DADS state office email. The case manager will inform him that a limited nursing facility stay is not approved, and the individual has the option to transition from a nursing facility stay as described in Section 3510, Individuals Currently Residing in a Nursing Facility, to access MDCP through the Money Follows the Person (MFP) option. If the individual does not choose to complete a nursing facility stay as described in Section 3510, his name will remain on the interest list. The case manager will inform the MDCP supervisor within three working days of being informed of the decision, and the MDCP supervisor must inform the Community Services Interest List (CSIL) Unit by email within three working days of being notified by the case manager. The CSIL Unit will remove the individual's name from the MFP release status and his name will remain on the interest list.

If the limited nursing facility stay is approved, or the individual chooses to transition from a nursing facility as described in Section 3510, the case manager will inform the MDCP supervisor within three working days of being informed of the decision, and the MDCP supervisor must inform the CSIL Unit by email within three working days of being notified by the case manager. After being notified by the MDCP supervisor of the decision, the CSIL Unit will place the individual in an MFP assigned status in the CSIL database, and the case manager will proceed with the application process.

If the state office physician did not approve a limited nursing facility stay, the individual may re-apply in the future by contacting the case manager and submitting a new Form 2406. Once a determination has been rendered by the DADS state office physician, additional information regarding an individual's condition will not be considered as part of the original request.

3520.6  Initial Home Visit for Individuals Approved for a Limited Nursing Facility Stay

Revision 13-1; Effective February 1, 2013

The 14-day time frame for completing the initial home visit begins from the date the individual, or the individual's parent or guardian, informs the case manager of the decision to complete a limited nursing facility stay. At the initial home visit, the case manager will inform the individual, or the individual's parent or guardian, of the MDCP eligibility process and that he must present Form 3618, Resident Transaction Notice, to the case manager showing the time and date of the limited stay admission and discharge before MDCP services can be authorized. MDCP services must be authorized within 24 hours of the nursing facility discharge date to meet Money Follows the Person funding requirements.

3520.7  Coordination of the Limited Nursing Facility Stay

Revision 13-3; Effective August 1, 2013

The case manager must coordinate the limited stay in the nursing facility (NF) with the MDCP applicant or his primary caregiver to ensure the case manager is available to authorize MDCP services within 24 hours after discharge. Case managers must stress that compliance with Money Follows the Person (MFP) policy for continuity of services may be difficult if an applicant chooses to discharge from an NF on a Friday, Saturday, Sunday, or any day preceding or the day of a state holiday. However, if an applicant is unable to conduct a limited NF stay any other day, case managers can coordinate the NF stay and discharge. Case managers must be able to ensure services are authorized within 24 hours after the discharge from the NF.

The case manager must discuss with an applicant the risk of conducting a limited NF stay on a date other than the date coordinated with the case manager. If services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP policy and MDCP services cannot be authorized. However, if an applicant conducts a limited stay on a date other than the date coordinated with the case manager, and the case manager is available to authorize services within 24 hours after discharge, the applicant has met the MFP requirement for continuity of services after the NF discharge.

Case managers must coordinate with the MDCP supervisor to make him aware of all upcoming MFP limited NF stays. If a case manager is out on the date of an arranged NF discharge, MDCP supervisors must make certain that services are authorized within 24 hours after the NF discharge.

The case manager must ensure all eligibility requirements listed in Section 3100, Eligibility Determination, are met prior to the applicant completing the limited stay.  The only exception to these requirements is Medicaid approval for MFP applicants approved for a limited stay.

Once the individual is receiving MDCP services, the MDCP case manager notifies:

  • the Community Services Interest List (CSIL) Unit in state office by email that the individual should be removed from the MDCP interest list; and
  • Medicaid Eligibility via Form H1746-A, MEPD Referral Cover Sheet, that the individual has transferred from an NF to the MDCP waiver.

The case manager must monitor MDCP services for 30 calendar days after services begin to ensure all necessary services are being provided.

3520.8  Delay in Limited Nursing Facility Stay

Revision 13-4; Effective November 1, 2013

If the nursing facility (NF) stay cannot be completed within 40 days after the date Form H1200, Application for Assistance-Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD), the case manager must request that MEPD delay certification. The case manager documents the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and submits the forms to MEPD. The case manager should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of waiver services is pending.” The delay request, if approved, will extend the MEPD time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for applicants requiring a disability determination, MEPD will deny the application. Once the case manager confirms the Medicaid denial, he must deny MDCP program eligibility and follow current policy in MDCP handbook Section 9510, Ineligibility.

If the individual, parent or guardian chooses to continue to pursue the Money Follows the Person (MFP) limited stay option after program eligibility has been denied, the MFP limited stay application process must start over. The case manager must follow current policy in Section 3520.1, MFP Procedures for Requesting a Limited NF Stay. The case manager must inform the individual, parent or guardian a new Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed if the physician’s signature date at the bottom of the form is more than 365 days old. If the date is signed within the previous 365 days, the individual, parent or guardian may use the previously submitted Form 2406.  

If the new initial home visit is completed within 90 days of the MEPD denial, the case manager may obtain a letter signed by the individual, parent or guardian requesting to reopen the Medicaid application. The request must be sent with Form H1746-A marked “Application.” The MEPD time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to MEPD, the case manager must request that MEPD delay certification. However, MEPD may not approve the additional requests for delay in certification based on the amount of time that has passed since the original application file date. If MEPD denies the request to delay certification due to the age of the application, the case manager must assist the individual, parent or guardian in completing a new Form H1200. If MEPD approves the request for delay in certification, the case manager must proceed with coordination of the NF stay and enrollment procedures.

3530  Money Follows the Person Demonstration (MFPD)

Revision 12-3; Effective November 1, 2012

Effective May 23, 2008, Money Follows the Person Demonstration (MFPD) was implemented for the Medically Dependent Children Program (MDCP). MFPD is intended to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities (NFs) and receive necessary long-term services in the setting of their choice.

MFPD is available to individuals applying for services through the Money Follows the Person (MFP) option who reside continuously in an institutional setting for at least 90 calendar days prior to the waiver program eligibility date and are enrolled from a Medicaid-certified NF. The continuous 90 day requirement must not include any Medicare paid days in an NF including full Medicare payment and Medicaid co-pay. In the Service Authorization System (SAS), an NF Service Authorization record will have a Service Group (SG) 1 and a Service Code (SC) 3A for Part-A full Medicare payments, and SG 1 and an SC 3 for a co-insurance (Medicaid co-pay) record. An NF Service Authorization record will have SG 1 and an SC 1 for a full Medicaid payment record. The SG 1, SC 3A record will always appear if the individual meets the 20 day qualifying stay for Medicare. Staff may have to contact the NF, hospital or other institution to verify the actual Medicare days or other institutional days.

Individuals who participate in MFPD must transition from an NF to the waiver program. For MFPD, an institutional setting is defined as an NF, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), hospital or state hospital. The 90-calendar-day residency rule may be met by a continuous stay in a combination of the settings.

Example: An individual may have resided continuously in an NF for a full month, in a hospital for a full month, and then re-entered the NF for another full month. This would meet the 90-calendar-day residency rule for MFPD.

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

  • view the Service Authorization System (SAS) for institutional records;
  • contact the NF for admission dates;
  • contact the Home and Community Support Services Agency (HCSSA) for hospital stays; and
  • obtain confirmation from the individual 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:

  • SG 1, SC 1, NF – daily care;
  • SG1, SC3, NF – extended care facility;
  • 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-day continuous stay requirement for MFPD.

The regional MDCP supervisor or designated program manager must contact the state office MDCP policy specialist for procedures when case managers identify potential MFPD participants.

3530.1  MFPD 365-Day Entitlement Period

Revision 12-1; Effective May 1, 2012

Money Follows the Person Demonstration (MFPD) individuals are entitled to participate in the demonstration for 365 days, beginning the date an individual agreeing to participate in the demonstration is enrolled in the waiver program. Tracking of institutional days is required to ensure MFPD individuals receive the full 365-day entitlement period.

The individual'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 individual is considered to be institutionalized for MFPD tracking purposes.

3540  Closing NF Authorizations for Individuals Transitioning to Community Services

Revision 12-1; Effective May 1, 2012

Closure of nursing facility (NF) records may be necessary when registering an individual plan of care (IPC) 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 NF record in SAS be closed so Medically Dependent Children Program (MDCP) services can be authorized. The case manager must confirm the individual has been discharged from the NF and MDCP 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 individual 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 Service Code 60. The case manager documents the contact in the case record.

3550 Accessing Relocation Services

Revision 12-1; Effective May 1, 2012

If the applicant wants to move to the community but needs help in locating housing or other transition planning and has no other informal supports, the case manager may refer a request for relocation services to relocation contractors. Relocation services consist of, but are not limited to:

  • assessment for relocation;
  • information about Medicaid waiver and non-waiver services and supports;
  • information on and assistance with applying for affordable, accessible housing;
  • coordination with the various state agency services for which the applicant may be eligible;
  • coordination of community services and resources that can assist with the transition to the community;
  • development of person or family-directed transition plans and arrangements;
  • support and assistance to applicants making the transition and their families; and
  • follow-up assessment after transition.

The case manager must contact the relocation contractor by telephone and send Form 1579, Referral for Relocation Services, within two working days of the initial interview, if the applicant indicates a need for relocation services.

The case manager must complete Form 1579 in its entirety to document specific details regarding the applicant's needs, resources and plans for relocation. The case manager must include any information that could be helpful to the relocation contractor in assisting the applicant in the relocation process.

The case manager 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 before sending the form to the relocation services provider. This ensures the opportunity for facilitation of the relocation process for all applicants choosing to return to the community. The case manager files a copy of Form 1579 in the case file.

Some of the relocation contractors may also provide Transition Assistance Services (TAS). If the applicant chooses the relocation contractor as a TAS provider, the case manager completes the TAS authorization for this provider according to the procedures in Section 4150, Transition Assistance Services (TAS), and Section 4220, Provider Notification.