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

Section 4000

Services

4100  Medically Dependent Children Program (MDCP) Services

Revision 12; Effective May 1, 2013

MDCP provides Respite, Flexible Family Support Services, Minor Home Modifications, Adaptive Aids, Transition Assistance Services and Financial Management Services to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.

Utilization of Waiver Services

Federal guidelines require that applicants and individuals must need and use one or more waiver services to qualify and maintain eligibility for MDCP. All applicants and individuals must have a need for and use MDCP services on a monthly basis to qualify for MDCP. The case manager must inform all applicants and individuals that, at a minimum, one MDCP service must be used at least once a month to qualify and maintain enrollment in MDCP.

It is important for the case manager to accurately assess the need for services when developing the individual plan of care (IPC). For this reason, the case manager must identify the applicant's/individual's needs, the primary caregiver's ability to meet those needs, and determine the appropriate service to meet the identified needs.

4110  Respite

Revision 13-1; February 1, 2013

§51.103

(36)
Primary caregiver--A person who:
(A)
is legally responsible for an individual's routine daily care, provision of food, shelter, clothing, health care, education, nurturing, and supervision; and
(B)
provides daily, uncompensated care for the individual.
(40)
Respite services--Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Respite is a service that provides temporary relief from care giving to the applicant's/individual's primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/individual's parent(s), guardian, a family member or spouse, if married.

The case manager reviews the primary caregiver definition with the applicant/individual and the family, and identifies the applicant's/individual's primary caregiver on Form 2410, Medical-Social Assessment and Individual Plan of Care, Page 1, Item 4.

Respite may be delivered by the following providers:

  • Home and Community Support Service Agencies (HCSSAs);
  • Special care facilities licensed by the Texas Department of State Health Services (DSHS);
  • Day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
  • Hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • Nursing facilities licensed by the Department of Aging and Disability Services (DADS);
  • Camps licensed by DSHS and accredited by the American Camping Association; and
  • Host families, which are foster families approved by a DFPS child placing agency.

Respite also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option.

Respite delivered by an HCSSA or through the CDS option is not limited to the individual’s place of residence.  Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4112, Respite Service Limits.  Other community settings could include the park, the respite provider’s home, or a home of the individual’s relative.

Attendant with Delegated Tasks

The case manager may authorize an attendant with delegated tasks provider type to deliver Respite by an HCSSA. The attendant with delegated tasks provider type is not available through the CDS option.

A delegated task is defined in Section 1200, Program Definitions, as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate.

The individual with a skilled task need may use the attendant with delegated tasks provider type if a practitioner or RN delegates the skilled task required to meet the individual's needs.

Example: A three-year-old boy lives at home with his mother who is his primary caregiver. The individual's condition is stable and predictable. He is unable to take food by mouth and receives his entire nutritional intake via a gastrostomy button (G-button). The HCSSA nurse has assessed the individual and, in consultation with the mother, has determined the task of tube feeding this individual meets the Texas Board of Nursing criteria for delegation to an unlicensed person. The HCSSA nurse has instructed the unlicensed person in the tube feeding and has agreed to retain accountability for how the unlicensed person performs the tube feeding. The HCSSA nurse has determined, in consultation with the mother, the level of supervision and frequency of supervisory visits required, taking into account the individual's status and the specific task being delegated.

If the individual does not have a skilled task need for the delivery of Respite, he will not have a need for an attendant with delegated tasks. If the individual or primary caregiver requests the use of an attendant with delegated tasks, but DADS or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the case manager should not authorize an attendant with delegated tasks to deliver Respite. As noted in Section 3130, Individual Plan of Care Development, if there are disagreements regarding the use of provider types that may place the individual at risk, the case manager should convene a meeting to resolve the conflict. The meeting should include the individual, the primary caregiver, the provider or entity that participates in the individual's care, the case manager and the MDCP nurse. If necessary, staff also should involve the individual's physician. The decision reached by DADS staff involved in this consultation is final.

4111  Out-of-Home Respite

Revision 12-1; Effective May 1, 2012

Respite can be provided out of the home if the physician's order indicates that out-of-home respite is allowed (see Form 2428, Physician's Orders for Licensed Nursing Services).

Out-of-home respite providers are:

  • special care facilities licensed by the Texas Department of State Health Services (DSHS);
  • day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
  • hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • nursing facilities licensed by the Department of Aging and Disability Services;
  • camps licensed by DSHS and accredited by the American Camping Association; and
  • foster families approved by a DFPS child placing agency.

The case manager should review Section 4112, Respite Service Limits, when authorizing respite services delivered by a hospital or nursing facility.

4112  Respite Service Limits

Revision 13-4; Effective November 1, 2013

§51.103

(19)
Facility-based respite--Respite services provided to an individual in a licensed hospital or nursing facility.

§51.231

(a)
General. The individual or the individual's parent or guardian may not ask the provider to provide MDCP services to any other household member while serving the individual in the individual's residence.
(b)
Respite.
(1)
Respite services may not be provided in a setting in which identical services are already being provided.
(4)
Effective September 1, 2013, an individual may be admitted to facility-based respite for a maximum of 29 days during an IPC year with the amount of respite other than facility-based respite subject to the IPC cost limit as described in §51.203(7) of this subchapter (relating to Eligibility Requirements). If the DADS case manager receives information demonstrating the need of the parent or guardian to admit the individual to facility-based respite in excess of 29 days during an IPC year, the DADS case manager determines whether providing facility-based respite in excess of the limit is necessary for the IPC to meet the criteria described in §51.217(b) of this subchapter (relating to Individual Plan of Care).

The case manager may only authorize Respite during the time the primary caregiver would usually provide care to the individual. Therefore, the case manager may not authorize Respite during the time the primary caregiver is at work, attending school or in job training.

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including Respite, may not be provided to an individual who is admitted into a hospital or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). The case manager should not confuse this with facility-based respite. If an individual is admitted into the hospital for reasons such as illness, surgery or stabilization/treatments, then Respite may not be provided. The case manager may authorize Respite only if an individual enters an MDCP contracted hospital to receive Respite.

Since Respite is intended to provide relief to the primary caregiver, it may not be delivered while the individual is in school or in a school setting.

Facility-based respite is limited to 29 days per the individual plan of care (IPC) period. The 29-day limit applies to the total number of days an individual receives respite in a hospital or nursing facility.

The individual may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the case manager and the MDCP nurse must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. If there is no danger to the individual’s health and welfare, then staff should approve the request.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide Respite to an individual who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide Respite to an individual receiving out-of-home respite in a nursing facility.

All Respite settings must be located within the state of Texas.

The case manager may not authorize Respite for care delivered by:

  • the primary caregiver;
  • the individual's spouse; or
  • the individual's parent, representative, guardian or managing conservator, if the individual is under 18.

4113  Respite Service Authorizations

Revision 13-4; Effective November 1, 2013

The case manager follows the MDCP Respite definition and limitations to review all requests for Respite. The case manager authorizes Respite by completing Form 2065-B, Notification of Waiver Services, and Form 2415, Respite Service Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Respite. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2415 to identify the Respite hours the provider is authorized to deliver. When the case manager authorizes out-of home respite in an approved camp setting, as described in Section 4111, Out-of-Home Respite, the case manager must authorize only the number of hours an individual will utilize while receiving respite service at an approved camp setting. No additional administrative fees can be added to an individual plan of care (IPC). The case manager sends Form 2415 to the provider identified on the form and copies of Form 2415 to the individual. The case manager must complete and send Form 2065-B and Form 2415 within two working days of determining eligibility for the requested service.

The case manager determines how many units of respite 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 Form 2415 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.

Practitioner's Orders or Form 2428, Physician's Orders for Licensed Nursing Services

The Home and Community Support Service Agency (HCSSA) must determine if skilled tasks will be delivered. No practitioner's orders are required for services delivered by an attendant (Service Code 11). The delivery of skilled tasks is not required when an individual uses a registered nurse (RN) or licensed vocational nurse (LVN) to deliver Respite; however, the state has two reimbursement rates for Respite delivered by attendants dependent on the delivery of skilled tasks.

In brief, practitioner's orders are required when skilled tasks are delivered by an:

  • RN,
  • LVN, or
  • attendant with delegated tasks.

Practitioner's orders are not required when non-skilled tasks are delivered by an:

  • RN,
  • LVN, or
  • attendant.

The HCSSA is not required to use Form 2428 if the practitioner's orders are recorded on an HCSSA form or one from the practitioner's office. The practitioner order requirement only applies to HCSSA Respite providers and does not apply to any other Respite provider.

Practitioner's orders submitted to the case manager by an HCSSA must be signed by the applicant's or individual's practitioner as defined in 40 Texas Administrative Code (TAC) §51.103, (35), which defines a practitioner as:

  • a physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or an RN approved by the Texas Board of Nursing to practice as an advanced practice nurse; or
  • by a licensed physician currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities, even when they do not have a Texas license.

Neither a Consumer Directed Services (CDS) agency nor CDS employer is required to submit practitioner's orders to the case manager for individuals using the CDS option.

Case Manager Follow-up on Provider Response

The case manager must track the provider's response on Form 2415. The case manager must ensure the HCSSA completes this provider requirement. The case manager will submit a referral to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint within five working days if the required signed service authorization form with practitioner's orders, as applicable, was not submitted to the case manager within 14 working days from the date the provider receives the applicable service authorization form.

The case manager must identify the complaint is regarding a "Medically Dependent Children Program provider" and indicate the HCSSA is not complying with program requirements. The case manager documents the referral to CRS in the case file, using Form 2405, Narrative Notes.

If the case manager receives the applicable service authorization form indicating skilled tasks will be delivered within 14 working days from the date the provider receives a service authorization form, but no signed practitioner's orders are received, the case manager contacts the HCSSA and gives the provider until the 14th working day from the date the provider receives the service authorization form to submit practitioner's orders. If practitioner's orders are not received within 14 working days from the date the provider receives the service authorization form, the case manager must make a referral to CRS.

If the case manager authorized Respite to be delivered by an attendant with delegated tasks, the case manager must review the HCSSA's response regarding the delivery of skilled tasks. If the HCSSA indicates the individual does not require skilled tasks, the case manager must change the provider type to an attendant. The case manager must update the IPC, Form 2415 and Service Authorization System (SAS) data records. This change is not a service reduction, service denial or case closure, and therefore does not require a 30-day notification time frame. The case manager may indicate the HCSSA determined no skilled tasks will be delivered in the comment section on Form 2415. The case manager must contact the individual/primary caregiver to inform him of the change in provider type before sending the updated Form 2415.

In SAS, the case manager must cancel the Service Authorization record for the attendant with delegated tasks and create a new Service Authorization record with the appropriate service code using the same begin and end dates. Cancellation and creation of Service Authorization records must occur on the same day to avoid a gap in services and potential reimbursement recoupment. SAS data entries due to changes to the IPC must be processed following time frames in Section 4230, Service Authorization System (SAS).

The case manager applies the same procedures if an attendant provider type was authorized and the HCSSA response indicates skilled tasks will be delivered. If the change from an attendant to an attendant with delegated tasks results in a service reduction, the 30-day notification time frame applies. For this reason, the case manager must make every effort to discuss the appropriate use of an attendant with delegated tasks with the individual/primary caregiver when developing the IPC. See Section 4110, Respite.

No additional follow up is needed if the HCSSA indicated no skilled tasks will be delivered on Form 2415 for RN or LVN provider types.

If the request for assistance does not meet Respite criteria, the case manager must review the request following Flexible Family Support Services criteria. If the request does not meet Flexible Family Support Services criteria, the case manager must deny the individual's request for the service.

4114  Respite Service Schedule Changes

Revision 12-1; Effective May 1, 2012

§51.103

(45)
Service schedule—A schedule for delivering respite or adjunct support services to an individual that is agreed upon and signed by the individual or the individual's parent or guardian. A fixed service schedule specifies certain days, times of day, or time periods for delivery of the services. A variable service schedule specifies the number of authorized hours of services to be delivered per day, per week, or per month, but does not specify certain days, times of day, or time periods for delivery of the services.

§51.237

(a)
An individual or the individual's parent or guardian may make minor changes in the service schedule for respite and adjunct support services without prior approval if the changes:
(1)
do not exceed the individual's cost ceiling; and
(2)
do not increase the individual's total monthly hours, unless the individual approves the use of hours not used in a previous month and the use of hours not used in a previous month increases the total monthly hours by less than 50%.
(b)
DADS must give prior approval for the use of hours not used in a previous month if the use of those hours increases the total monthly hours by 50% or more.

The case manager may inform the individual that the case manager does not need to pre-approve all changes to the Respite service schedule.

The individual may adjust Respite service schedules without prior approval if the change in the schedule does not:

  • exceed the total number of Respite hours authorized by the case manager for the individual plan of care (IPC) period;
  • exceed the individual's IPC cost limit; and
  • increase the total monthly Respite hours by 50 percent or more.

Example: If the case manager authorized 60 monthly hours of Respite and the individual used 20 hours, the individual could not carry over the 40 unused hours to a following month. Fifty percent of 60 hours is 30 hours. The individual would only be able to carry over less than 30 hours from a previous month.

The case manager must inform the individual that he is responsible for:

  • tracking the total Respite hours used on a monthly basis;
  • ensuring service schedule changes remain within the Respite service criteria; and
  • contacting and notifying the case manager of any changes or adjustments to the service schedule.

If the individual requests a change in the service schedule that results in an increase of 50 percent or more, the case manager may approve the use of the increased number of hours. When the individual requests a schedule change resulting in an increase of 50 percent or more hours from a previous month, the case manager and the Medically Dependent Children Program (MDCP) nurse must review the individual's needs and the primary caregiver's ability to meet those needs, and determine the appropriate MDCP service to meet the identified needs within the IPC cost limit.

The case manager must document all contact with the individual/primary caregiver and MDCP nurse in the case file, using Form 2405, Narrative Notes.

4120  Flexible Family Support Services

Revision 13-2; Effective May 1, 2013

§51.103

(2)
Activities of daily living--Activities that are essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer and ambulation, positioning, range of motion, and assistance with self-administered medications.
(4)
Adjunct support services--Direct care services needed because of an individual's disability that:
(A)
help an individual participate in:
(i)
child care;
(ii)
post-secondary education; or
(iii)
independent living; or
(B)
support an individual's move to an independent living situation.
(6)
Attendant--An employee of a provider or of an individual who has selected the consumer directed services option who provides direct care to the individual.
(7)
Basic child care--Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training, or at school.

§51.221

(a)
The individual's parent or guardian must be responsible for basic child care.

Flexible Family Support Services are individualized and disability-related services that support an individual to participate in:

  • child care;
  • independent living; and
  • post-secondary education.

Flexible Family Support Services include personal care supports for basic activities of daily living (ADL) and instrumental ADL, skilled task and delegated skilled task supports.

Examples of basic ADL include:

  • bathing or showering,
  • dressing,
  • toileting,
  • transferring in or out of a bed or chair,
  • using the toilet (continence), and
  • feeding.

Instrumental ADL may not be necessary for fundamental self-care, but may be useful for community living. These activities may include:

  • preparing meals,
  • shopping for groceries or personal items,
  • housekeeping,
  • using the telephone,
  • taking medications, and
  • managing money.

Flexible Family Support Services promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine.

Flexible Family Support Services may be delivered by the Home and Community Support Service Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option.

Documenting Flexible Family Support Services

The case manager documents the individual's need for Flexible Family Support Services using Form 2405, Narrative Notes, in the case file. The case manager documents specific ADL, instrumental ADL, skilled task, non-skilled task or delegated skilled tasks the individual needs that are not met by the setting in which Flexible Family Support Services are requested. The case manager identifies the amount of units determined to address each of the identified areas of the individual's needs. The case manager uses this information to complete the individual plan of care (IPC) and Form 2414, Flexible Family Support Services Authorization.

Example: A 10-year-old girl has a babysitter in the home while the primary caregiver works. The babysitter is in the home from 3-6 p.m., Monday through Friday and provides general supervision. The individual recently had orthopedic surgery and now has an external orthopedic device on her leg that requires care to the skin that surrounds the pins to the device (pinsite care). In addition, this individual has a feeding tube, and she now requires the administration of prescription medications through the feeding tube. The babysitter is unable to do the pinsite care or administer the prescribed medications. The pinsite care takes approximately 15 minutes and administering the medications takes an additional 15 minutes. The primary caregiver, case manager and MDCP nurse agree an LVN is required to deliver this service. The individual requires one half hour of Flexible Family Support Services delivered by an LVN daily from Monday through Friday.

Attendant with Delegated Tasks

The case manager may authorize an attendant with delegated tasks provider type to deliver Flexible Family Support Services by an HCSSA. The attendant with delegated tasks provider type is not available through the CDS option.

In Section 1200, Program Definitions, a delegated task is defined as a task that a practitioner or RN delegates in accordance with state law. In general, the Texas Board of Nursing defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate.

The individual with a skilled task need may use the attendant with delegated tasks provider type if a practitioner or RN delegates the skilled task required to meet the individual's needs.

Example: A three-year-old boy lives at home with his mother who is his primary caregiver. The individual's condition is stable and predictable. He is unable to take food by mouth and receives his entire nutritional intake via a G-button. The HCSSA nurse has assessed the individual and, in consultation with the mother, has determined the task of tube feeding this individual meets the Texas Board of Nursing criteria for delegation to an unlicensed person. The HCSSA nurse has instructed the unlicensed person in the tube feeding and has agreed to retain accountability for how the unlicensed person performs the tube feeding. The HCSSA nurse has determined, in consultation with the mother, the level of supervision and frequency of supervisory visits required, taking into account the individual's status and the specific task being delegated.

If the individual does not have a skilled task need for the delivery of Flexible Family Support Services, he will not have a need for an attendant with delegated tasks. If the individual or primary caregiver requests the use of an attendant with delegated tasks, but DADS or the HCSSA determines the use of this provider type places the individual's health and welfare at risk, the case manager should not authorize an attendant with delegated tasks to deliver Flexible Family Support Services. As noted in Section 3130, Individual Plan of Care Development, if there are disagreements regarding the use of provider types that may place the individual at risk, the case manager should convene a meeting to resolve the conflict. The meeting should include the individual, the primary caregiver, the provider or entity that participates in the individual's care, the case manager, and the MDCP nurse. If necessary, staff also should involve the individual's physician. The decision reached by DADS staff involved in this consultation is final.

4121  Flexible Family Support Services in Child Care

Revision 13-2; Effective May 1, 2013

§51.103

(7)
Basic child care--Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training, or at school.

§51.221

(a)
The individual's parent or guardian must be responsible for basic child care.

The individual's parent or guardian is responsible for basic child care either in or out of the individual's home. Flexible Family Support Services support the individual's participation in child care when the service provided by the child care does not support the individual's disability-related needs. If the individual's child care is not able to meet the individual's activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task needs, the case manager may authorize Flexible Family Support Services.

To determine the need for Flexible Family Support Services for participation in child care, the case manager must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the individual's home or both. The delivery of Flexible Family Support Services does not include basic child care, which is watchful attention or supervision of the individual while the primary caregiver is at work, in job training or at school. These remain responsibilities within the service delivered by the child care. The caregiver's cost for child care does not impact the individual's need for Flexible Family Support Services. The case manager must determine the amount of hours needed to support the individual's needs. The case manager should ask the parent or guardian about the individual's personal and skilled task needs and the time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual to address necessary safeguards that ensure the individual's health and welfare.

4122  Flexible Family Support Services for Independent Living

Revision 13-2; Effective May 1, 2013

An individual may indicate a desire for increased independence as he matures. If the individual needs assistance with activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task, the case manager may authorize Flexible Family Support Services to help the individual with his goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not an MDCP service, an independent living arrangement also can provide life-skills training to assist individuals in acquiring the skills they will need to live independently as adults.

To determine the need for Flexible Family Support Services for independent living, the case manager must discuss the individual's and primary caregiver's plan for independent living. When identifying the individual's need for this service, the case manager should address age appropriateness for the tasks required to meet these needs. The case manager must determine the amount of hours needed to support the individual's needs. The case manager must identify the individual's personal and skilled task needs and the time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual and the appropriateness of the living arrangement and service delivery regarding the individual's age, health and welfare.

As indicated in Section 4124, Flexible Family Support Services Limits, Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training.

4123  Flexible Family Support Services in Post-Secondary Education

Revision 13-2; Effective May 1, 2013

An individual can access Flexible Family Support Services to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task needs. If an individual has an ADL, instrumental ADL, skilled task, non-skilled task or delegated skilled task need prohibiting him from participating in post-secondary education, the case manager may authorize Flexible Family Support Services so the individual may participate in post-secondary education.

An individual may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in college or university. These educational institutions do not follow federal requirements for a free and appropriate education as required of elementary and secondary public schools. Post-secondary institutions can provide academic adjustments, but do not support the individual's personal, skilled and delegated skilled task needs.

To determine the need for Flexible Family Support Services in post-secondary education, the case manager must identify the individual's need for assistance and the amount of hours needed to support the individual's needs. The case manager should identify the individual's personal and skilled task needs and the amount of time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual and address necessary safeguards to ensure the individual's health and welfare.

As indicated in Section 4124, Flexible Family Support Services Limits, Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training.

4124  Flexible Family Support Services Limits

Revision 13-4; Effective November 1, 2013

§51.103

(36)
Primary caregiver--A person who:
(A)
is legally responsible for an individual's routine daily care, provision of food, shelter, clothing, health care, education, nurturing, and supervision; and
(B)
provides daily, uncompensated care for the individual.

§51.231

(a)
General. The individual or the individual's parent or guardian may not ask the provider to provide MDCP services to any other household member while serving the individual in the individual's residence.
(c)
Adjunct support services.
(3)
Adjunct support services may be used only when the primary caregiver is working, attending job training, or attending school.

Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the case manager may not authorize Flexible Family Support Services during the same time period the individual receives Personal Care Services.

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that Medically Dependent Children Program services, including Flexible Family Support Services, may not be provided to an individual who is admitted into a hospital or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

The case manager may not authorize Flexible Family Support Services during the individual's school hours in primary or secondary educational settings.

4125  Flexible Family Support Services Authorizations

Revision 13-4; Effective November 1, 2013

The case manager follows MDCP Flexible Family Support Services criteria, to review all requests for Flexible Family Support Services. The case manager authorizes Flexible Family Support Services by completing Form 2065-B, Notification of Waiver Services, and Form 2414, Flexible Family Support Services Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Flexible Family Support Services. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2414 to identify the Flexible Family Support Services hours the provider is authorized to deliver. The case manager sends Form 2414 to the provider identified on the form and copies of Form 2414 to the individual. The case manager must complete and send Form 2065-B and Form 2414 within two working days of determining eligibility for Flexible Family Support Services.

The case manager determines how many units of 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 Form 2414 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 flexible family support services per week. The case manager would authorize 15.50 hours of flexible family support services per week.

Practitioner's Orders or Form 2428, Physician's Orders for Licensed Nursing Services

The Home and Community Support Service Agency (HCSSA) must determine if skilled tasks will be delivered. No practitioner's orders are required for services delivered by an attendant (Service Code 11U). The delivery of skilled tasks is not required when an individual uses an RN or LVN to deliver Flexible Family Support Services; however, the state has two reimbursement rates for Flexible Family Support Services delivered by attendants dependent on the delivery of skilled tasks.

In brief, practitioner's orders are required when skilled tasks are delivered by an:

  • RN,
  • LVN, or
  • attendant with delegated tasks.

Practitioner's orders are not required when non-skilled tasks are delivered by an:

  • RN,
  • LVN, or
  • attendant.

The HCSSA is not required to use Form 2428 if the practitioner's orders are recorded on an HCSSA form or one from the practitioner's office.

Practitioner's orders submitted to the case manager by an HCSSA must be signed by the applicant's or individual's practitioner, as defined in 40 Texas Administrative Code (TAC) §51.103, (35), which defines a practitioner as:

  • a physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or an RN approved by the Texas Board of Nursing to practice as an advanced practice nurse; or
  • by a licensed physician currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities, even when they do not have a Texas license.

Neither a Consumer Directed Services Agency (CDSA) nor a CDS employer is required to submit practitioner's orders to the case manager for individuals using the CDS option.

Case Manager Follow-up on Provider Response

The case manager must track the HCSSA's response on the Service Authorization form. The case manager will submit a referral to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint within five working days if the required signed service authorization form with practitioner's orders, as applicable, were not submitted to the case manager within 14 working days from the date the provider receives the applicable service authorization form.

The case manager must identify the complaint is regarding a "Medically Dependent Children Program provider" and indicate the HCSSA is not complying with program requirements. The case manager documents the referral to CRS in the case file, using Form 2405, Narrative Notes.

If the case manager receives the applicable service authorization form indicating skilled tasks will be delivered within 14 working days from the date the provider receives a service authorization form, but no signed practitioner's orders are received, the case manager contacts the HCSSA and gives the provider until the 14th working day from the date the provider receives the service authorization form to submit practitioner's orders. If practitioner's orders are not received within 14 working days from the date the provider receives the service authorization form, the case manager must make a referral to CRS.

If the case manager authorized Flexible Family Support Services to be delivered by an attendant with delegated tasks, the case manager must review the HCSSA's response regarding the delivery of skilled tasks. If the HCSSA indicates the individual does not require skilled tasks, the case manager must change the provider type to an attendant. The case manager must update the individual plan of care (IPC), Form 2414 and Service Authorization System (SAS) data records. This change is not a service reduction, service denial or case closure, and therefore does not require a 30-day notification time frame. The case manager may indicate the HCSSA determined no skilled tasks will be delivered in the comment section on the updated Form 2414. The case manager must contact the individual/primary caregiver to inform him of the change in provider type before sending the updated Form 2414.

In SAS, the case manager must cancel the Service Authorization record for the attendant with delegated tasks and create a new Service Authorization record with the appropriate service code using the same begin and end dates. Cancellation and creation of Service Authorization records must occur on the same day to avoid a gap in services and potential reimbursement recoupment. SAS data entries due to changes to the IPC must be processed following time frames in Section 4230, Service Authorization System (SAS).

The case manager applies the same procedures if an attendant provider type was authorized and the HCSSA response indicates skilled tasks will be delivered. If the change from an attendant to an attendant with delegated tasks results in a service reduction, the 30-day notification time frame applies. For this reason, the case manager must make every effort to discuss the appropriate use of an attendant with delegated tasks with the individual/primary caregiver when developing the IPC. See Section 4120, Flexible Family Support Services.

No additional follow up is needed if the HCSSA indicated no skilled tasks will be delivered on Form 2414 for RN or LVN provider types.

If the request for assistance does not meet Flexible Family Support Services criteria, the case manager must review the request following Respite criteria. If the request does not meet Respite criteria, the case manager must deny the individual's request for the service.

4126  Service Schedule Changes to Flexible Family Support Services

Revision 13-2; Effective May 1, 2013

§51.103

(45)
Service schedule — A schedule for delivering respite or adjunct support services to an individual that is agreed upon and signed by the individual or the individual's parent or guardian. A fixed service schedule specifies certain days, times of day, or time periods for delivery of the services. A variable service schedule specifies the number of authorized hours of services to be delivered per day, per week, or per month, but does not specify certain days, times of day, or time periods for delivery of the services.

§51.237

(a)
An individual or the individual's parent or guardian may make minor changes in the service schedule for respite and adjunct support services without prior approval if the changes:
(1)
do not exceed the individual's cost ceiling; and
(2)
do not increase the individual's total monthly hours, unless the individual approves the use of hours not used in a previous month and the use of hours not used in a previous month increases the total monthly hours by less than 50%.
(b)
DADS must give prior approval for the use of hours not used in a previous month if the use of those hours increases the total monthly hours by 50% or more.

The case manager may inform the individual that the case manager does not need to pre-approve all service schedule changes to Flexible Family Support Services.

The individual may adjust service schedules without prior approval if the change in the schedule does not:

  • exceed the total number of Flexible Family Support Service hours authorized by the case manager for the individual plan of care (IPC) period;
  • exceed the individual's IPC cost limit; and
  • increase the total monthly Flexible Family Support Services hours by 50 percent or more.

Example: If the case manager authorized 60 monthly hours of Flexible Family Support Services and the individual used 20 hours, the individual could not carry over the 40 unused hours to a following month. Fifty percent of 60 hours is 30 hours. The individual would only be able to carry over less than 30 hours from a previous month.

The case manager must inform the individual he is responsible for:

  • tracking the total Flexible Family Support Services hours used on a monthly basis;
  • ensuring service schedule changes remain within the service criteria for Flexible Family Support Services; and
  • contacting and notifying the case manager of any changes or adjustments to the service schedule.

If the individual requests a change in the service schedule that results in an increase of 50 percent or more, the case manager may approve the use of the increased number of hours. When the individual requests a schedule change resulting in an increase of 50 percent or more hours from a previous month, the case manager and the Medically Dependent Children Program (MDCP) nurse must review the individual's needs and the primary caregiver's ability to meet those needs, and determine the appropriate MDCP service to meet the identified needs within the IPC cost limit.

The case manager must document all contact with the individual/primary caregiver and MDCP nurse in the case file, using Form 2405, Narrative Notes.

4130  Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.103

(3)
Adaptive aid—A device that is needed to treat, rehabilitate, prevent, or compensate for a condition that results in a disability or a loss of function and helps an individual perform the activities of daily living or control the environment in which he lives.

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable individuals to:

  • perform activities of daily living; or
  • control the environment in which they live.

The case manager informs the applicant of the adaptive aids service at the initial home visit and reviews the service criteria at the annual reassessment or upon the individual's request.

At the initial home visit, the case manager must provide the applicant the Tool for Adaptive Aids, and the Tool for Van Lifts/Vehicle Modifications, found in Appendix II, Medically Dependent Children Program (MDCP) Tools.

The case manager must offer the individual the tool when the service criteria are reviewed at the annual reassessment if the individual requests adaptive aids. Whenever an individual requests an adaptive aid, the case manager must send the Department of Aging and Disability Services (DADS) resources and publications the individual may need to acquire adaptive aids within five working days of the request. The case manager should include the following DADS resources and publications in an MDCP adaptive aid packet:

  • Appendix II, Tool for Adaptive Aids;
  • Appendix II, Tool for Van Lifts/Vehicle Modifications;
  • MDCP rules link for providers and service delivery at: www.dads.state.tx.us. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:
    • Select "Rules and Statutes."
    • Select "Texas Administrative Code."
    • Select "DADS TAC references."
    • Select "Chapter 51, Medically Dependent Children Program."
    • Select "Subchapter D, Provider Requirements."
  • Form 2432, Vehicle Evaluation
  • Form 2435, Adaptive Aids Bid

4131  Individual Role in Adaptive Aids

Revision 12-1; Effective May 1, 2012

In the Medically Dependent Children Program (MDCP), the individual, primary caregiver or family assume primary responsibility for obtaining all necessary documentation to request adaptive aids.

The individual is responsible for obtaining written specifications for all requests for adaptive aids. See Section 4131.3, Specifications for Adaptive Aids, for requirements.

The individual is responsible for obtaining three bids for all requests for adaptive aids. See Section 4131.5, Bids for Adaptive Aids, for requirements.

The case manager must ensure the individual is aware of his role in obtaining adaptive aids and should assist the individual in understanding the prior authorization process.

4131.1  Third-Party Resources for Adaptive Aids

Revision 12-1; Effective May 1, 2012

All individuals have Medicaid and can access medically necessary durable medical equipment (DME) through Medicaid or the Texas Health Steps Comprehensive Care Program (CCP). In Texas, the Texas Medicaid and Healthcare Partnership (TMHP) reviews all requests for durable medical equipment and authorizes items that are medically necessary and allowable under Medicaid. Since TMHP reviews every request for medical necessity, there is no list of automatically approved or denied DME items.

If TMHP requests additional information, the individual or the DME supplier must submit the information to TMHP before the Department of Aging and Disability Services (DADS) reviews a request for adaptive aids.

The case manager must inform the individual of the individual's responsibility for pursuing adaptive aids through available third-party resources and obtaining specifications and bids before the case manager can process the request for adaptive aids. An individual with private insurance must first request adaptive aids from a DME company participating in the individual's insurance plan before requesting adaptive aids as a Medicaid benefit. The case manager must also inform the individual of the individual's responsibility to provide, as needed, hard copies of denials from private insurance, Medicaid or other third-party resources. The case manager must request these denials for items that may address a individual's medical need. An individual is not required to secure a third-party denial letter for a vanlift/vehicle modification request.

The case manager may only accept third-party resource denials that have assessed the individual's need for the item when reviewing a request for adaptive aids. The case manager must not accept third-party resource denial documentation that is not based on an assessment of need. Example: A third-party resource denial due to lack of documentation or failure to provide additional information has not assessed the individual's need for the item and is not an appropriate assessment. In this example, the case manager must request the individual to submit the information to the third-party resource.

DADS reviews the individual's request for an adaptive aid even if a third-party resource denies the request for an item citing a lack of medical need. An individual's lack of medical need for an item does not automatically disqualify the request for DADS review.

For adaptive aids authorized or previously authorized by DADS staff, the individual does not have to submit requests to TMHP for the following:

  • electrical work related to the use of adaptive aids;
  • installation of adaptive aids; and
  • repairs to adaptive aids not covered by warranty.

4131.2  Adaptive Aid Bidders

Revision 12-1; Effective May 1, 2012

§51.233

(b)
If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

The individual may choose a provider from a list of adaptive aid providers or a non-contracted entity to submit a bid. The individual should inform the non-contracted entity that it must apply for a contract with the Department of Aging and Disability Services (DADS) if the individual chooses the non-contracted entity to deliver adaptive aids. The case manager must refer the individual to the Medically Dependent Children Program (MDCP) rules governing provider and service delivery requirements for adaptive aids. The case manager must encourage the individual to refer non-contracted entities to these rules before applying to contract with DADS. MDCP rules are available on the Internet at www.dads.state.tx.us. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:

  • Select "Rules and Statutes."
  • Select "Texas Administrative Code."
  • Select "DADS TAC references."
  • Select "Chapter 51, Medically Dependent Children Program."
  • Select "Subchapter D, Provider Requirements."

The case manager must encourage the individual to refer non-contracted entities to the DADS Contracts Unit at telephone 512- 438-5430, to request an adaptive aid contract enrollment packet for MDCP. The case manager may only authorize contracted adaptive aid providers to deliver adaptive aids.

4131.3  Specifications for Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.303

(a)
An individual must obtain written specifications for each adaptive aid from:
(1)
a practitioner;
(2)
a physical therapist
(3)
an occupational therapist;
(4)
a speech pathologist; or
(5)
an adaptive aid provider.
(b)
The individual must ensure that the written specifications are recorded on a single document that includes:
(1)
the name and address of the individual receiving MDCP services;
(2)
a description of the adaptive aid being specified;
(3)
the written specifications;
(4)
the printed name and dated signature of the person preparing the written specifications; and
(5)
the individual's dated signature.

§51.305

(b)
The individual must make the same specification available to each bidder.

Written specifications are required for all requests for adaptive aids. The Department of Aging and Disability Services (DADS) will accept specifications prepared by the individual's:

  • practitioner;
  • physical therapist;
  • occupational therapist;
  • speech pathologist; or
  • adaptive aids provider.

On the written specification, the preparer must include the:

  • individual's name and address;
  • name and description of the item;
  • purpose of the item; and
  • printed name and signature of the person preparing the specifications, along with the date the form was signed.

In the purpose of the item, the specification must include the expected benefit regarding the individual's:

  • treatment;
  • rehabilitation; or
  • prevention or compensation for conditions resulting in a limited or a loss of function.

The specification must also indicate whether the individual needs adaptive aids to complete activities of daily living or to control the environment in which the individual lives. Activities of daily living are basic personal every day activities such as bathing, dressing, transferring, toileting, mobility and eating.

The individual must provide the same written specification to all providers and non-contracted entities submitting bids for adaptive aids.

The case manager must request the individual to submit the specification for adaptive aids to the case manager when submitting the bids for the requested item.

If the specification is incomplete, the case manager identifies the missing information and asks the individual to have the preparer submit the written specification with the missing information.

The case manager must document the specification preparer qualifications using Form 2405, Narrative Notes, or Appendix III, Adaptive Aids (AA) Checklist, in the case file.

Van lifts/vehicle modification specification requirements and procedures are identified in Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications.

4131.3.1  Specifications for Adaptive Aids with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

After determining a request for adaptive aids requires a personal cost contribution from the individual, the case manager informs the individual that updated specifications are needed to continue the service authorization process.

The case manager must inform the individual of the specification items that can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated specifications must meet the criteria listed in Section 4131.3, Specifications for Adaptive Aids, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The items in the updated written specifications should not differ from the ones listed in the original written specification.

The individual must submit the updated written specifications to the case manager to continue the adaptive aids authorization process.

See Section 4134, Individual Personal Costs for Adaptive Aids, for procedures to determine the individual's personal costs.

4131.4  Special Requirements for Van Lifts/Vehicle Modifications

Revision 12-1; Effective May 1, 2012

§51.301

(a)
Before procuring an adaptive aid costing $100 or more, an individual must submit a request for the adaptive aid, including the written specifications and bids, to the case manager for approval.

§51.309

(a)
For the purpose of this chapter, vehicle modifications and adaptive equipment are considered adaptive aids, and the individual must follow the procurement procedures for adaptive aids in this division in addition to the requirements of this section.
(b)
When requesting a vehicle modification, the individual provides the following information to the case manager:
(1)
information on the vehicle to be modified, including:
(A)
the year and model of the vehicle;
(B)
proof of ownership;
(C)
current state inspection and tags;
(D)
applicable state insurance; and
(E)
mileage;
(2)
information on the needed modifications; and
(3)
if the individual is not the owner of the vehicle, the individual must provide the vehicle owner's signed and dated written approval for the vehicle modification.
(c)
When an individual requests a vehicle modification that costs $1,000 or more and the vehicle has been driven more than 100,000 miles or is more than four years old, the individual must submit to the case manager:
(1)
a written evaluation by an experienced mechanic who is not the provider of the requested vehicle modification to document the sound mechanical condition of all major components of the vehicle; and
(2)
documentation of the experience of the mechanic who performed the evaluation.
(d)
Bids for a vehicle modification must include:
(1)
an itemized list of parts and accessories, including their prices;
(2)
an itemized list of required labor and charges; and
(3)
information on warranty coverage.

All bids for van lifts/vehicle modifications must include:

  • the individual's name and address;
  • the name and description of the modification;
  • an itemized price list of parts and accessories;
  • an itemized list of labor and charges; and
  • documentation of warranty coverage.

The individual must provide the same written specification to all providers and non-contracted entities submitting a bid for the van lift/vehicle modification.

The case manager must inform the individual a mechanical evaluation is required for:

  • a van lift/vehicle modification request costing $1,000 or more and the van/vehicle has more than 100,000 miles; or
  • a van/vehicle more than four years old.

The individual must obtain the evaluation from an experienced mechanic who is not the provider selected to complete the van lift/vehicle modification. The evaluation must include a statement indicating the van/vehicle is mechanically and structurally sound for the requested modification and include the mechanic's experience and qualifications. The case manager sends Form 2432, Vehicle Evaluation, to the individual upon the individual's request for a van lift/vehicle modification with the Tool for Van Lifts/Vehicle Modifications, in Appendix II, Medically Dependent Children Program (MDCP) Tools, if a mechanical evaluation is needed.

4131.5  Bids for Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.305

(a)
An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).
(b)
The individual must make the same specifications available to each bidder.
(c)
If the individual is unable to obtain three bids, the individual must contact the case manager and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about his efforts to secure three bids.

The Department of Aging and Disability Services requires a minimum of three bids for all requests for adaptive aids. The individual must provide the same written specification to all providers and non-contracted entities submitting bids. The individual is not limited to the list of adaptive aids providers. The individual may obtain bids from non-contracted entities. The case manager sends Form 2435, Adaptive Aids Bid, to the individual upon the individual's request for an adaptive aid.

If the individual is unable to get three bids, the individual must provide specific information to the case manager about his efforts to get the required bids. The case manager must document the individual's reason for obtaining less than three bids in the case file using Form 2405, Narrative Notes.

4131.5.1  Bids for Adaptive Aids with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

§51.305

(a)
An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).
(b)
The individual must make the same specifications available to each bidder.

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

After determining a request for adaptive aids requires a personal cost contribution from the individual, the case manager follows procedures in Section 4131.3.1, Specifications for Adaptive Aids with Individual Personal Costs. The individual must also obtain updated bids to reflect the changes in the updated specifications.

The case manager must inform the individual which items in the original bids can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated bids must meet the criteria listed in Section 4131.5, Bids for Adaptive Aids, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The actual bid items should not differ from the ones listed in the original bid.

The individual must submit the updated bids with the updated specifications to the case manager to continue the adaptive aids authorization process.

See Section 4134, Individual Personal Costs for Adaptive Aids, for procedures to determine the individual's personal costs.

4132  Service Limits on Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.231

(c)
Adaptive aids.
(1)
The cost ceiling for adaptive aids is $4,000 per IPC year.
(2)
Adaptive aids costing less than $100 are not reimbursable.

The service limit on adaptive aids is $4,000 per individual plan of care (IPC) period. The Department of Aging and Disability Services (DADS) does not authorize or reimburse adaptive aids costing less than $100.

Examples of adaptive aids covered in the Medically Dependent Children Program (MDCP) are:

  • van lifts
  • van modifications
  • jump seats
  • tumble form chairs
  • feeder seats
  • medically appropriate strollers
  • barrier-free lifts
  • stair lifts
  • environmental control units
  • alarm systems
  • support rails
  • electrical work related to use of authorized adaptive aids
  • installation of authorized adaptive aids
  • repairs to adaptive aids

DADS cannot authorize or reimburse adaptive aids that are primarily:

  • for recreation purposes (example: tricycle);
  • for educational purposes (example: computer); or
  • available from private insurance, Medicaid or other third-party resources.

Medical supplies are available as a Medicaid benefit and are not adaptive aids in MDCP.

4133  Bid Verification for Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.305

(a)
An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).
(b)
The individual must make the same specifications available to each bidder.
(c)
If the individual is unable to obtain three bids, the individual must contact the case manager and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about his efforts to secure three bids.

Upon receipt of appropriate documentation and request for adaptive aids, the case manager must verify all bids are comparable to the written specification. Bids for van lifts/vehicle modifications must include all required documentation identified in Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications.

The case manager must verify all bids match the specifications. The bids must list items separately and include the cost for each item.

4134  Individual Personal Costs for Adaptive Aids

Revision 12-1; Effective May 1, 2012

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

An individual may request an item or a combination of items that can either exceed the adaptive aids service limit or include items or options that are not approved by the Department of Aging and Disability Services (DADS).

If an individual requests an item with a cost exceeding the adaptive aids service limit, the case manager will review the request with the DADS nurse. If the DADS nurse approves the request, the case manager will inform the individual DADS will approve the request; however, the individual is responsible for the costs exceeding the adaptive aids service limit.

Example: The individual requests a van lift with a cost of $10,000. The case manager reviews the request with the DADS nurse and approves the request. The case manager completes Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, Section A and Section B, to notify the individual personal costs were identified.

If an individual requests an item (with accessories) that does not follow the adaptive aids service criteria, the case manager will review the request with the DADS nurse. The case manager and DADS nurse may approve the item and necessary accessories, but may not approve accessories that do not meet adaptive aids service criteria. The case manager must notify the individual of the items DADS will approve; however, the individual is responsible for personal costs for items not included in the adaptive aids service criteria.

Example: The individual requests a feeder seat, seat base and tray with a total cost of $1,100. The feeder seat is $300, the seat base is $300, and the tray is $500. The case manager and DADS nurse review the request and determine the feeder seat and seat base follow the service criteria and determine the tray does not. The case manager completes Section A and Section B on Form 2416 to notify the individual personal costs were identified.

4135  Adaptive Aids Service Authorization

Revision 12-1; Effective May 1, 2012

The case manager may use Appendix III, Adaptive Aids (AA) Checklist, to review the adaptive aid requests to ensure all appropriate documentation requirements are in the case file. The case manager may authorize adaptive aids only after benefits available through Medicare, Medicaid or other third-party resources have been exhausted. The case manager follows adaptive aids criteria to review all requests for adaptive aids, as well as the availability of funds remaining in the current individual plan of care (IPC) period. When a new IPC is developed and approved for the upcoming IPC period, the funds from the previous IPC period are no longer available for approving an adaptive aid.

Within two working days of determining eligibility for the requested items, the case manager must complete and send Form 2065-B, Notification of Waiver Services, and Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, to the individual and the provider to inform both of the case manager's decision and allowable costs covered by the Medically Dependent Children Program.

The case manager's signature on Form 2416 indicates the requested adaptive aid (AA) or minor home modification (MHM) is authorized. This means the request for the AA or MHM met all criteria and the individual submitted the appropriate documentation. If the request for the AA or MHM results in a personal cost, the case manager does not sign the form before sending it to the individual for acknowledgement of personal costs. As indicated in the Form 2416 instructions, if personal costs are identified, the case manager:

  • completes Sections A and B; and
  • submits a copy to the individual for signature.

Upon return of signed Form 2416 from the individual, the case manager:

  • completes Section C and D; and
  • sends the completed Form 2416 with the case manager's original signature to the individual and a copy to the provider.

The case manager's signature is located in Section C. The individual's acknowledgement of personal costs (when applicable) is required prior to authorizing the requested AA or MHM.

If the request for an item does not meet the adaptive aid criteria, the case manager must deny the individual's request for the service by completing Form 2065-B and documenting the reason for denying the request in the Comments field. The case manager must complete and send Form 2065-B within two working days of determining the request for the service did not meet adaptive aid service criteria.

The Department of Aging and Disability Services requires the provider to sign and return Form 2416 to the case manager within 14 days of receipt of the form. The case manager must file this copy in the case file. If the provider does not return Form 2416, the case manager may follow up with the provider no later than five working days from the date the provider should have returned Form 2416. The case manager must document the action in the case file using Form 2405, Narrative Notes.

From the time the individual submits the written specification and bids, the case manager must review all documentation, adjust the individual plan of care, as needed, and authorize or deny the request within 14 days.

For data entry procedures in the Service Authorization System, See Section 4200, Notification and Service Authorization System.

4135.1  Approval of Adaptive Aids Not Listed in Section 4132, Service Limits on Adaptive Aids

Revision 12-1; Effective May 1, 2012

The list of adaptive aids in Section 4132, Service Limits on Adaptive Aids, is not an all-inclusive list. When a case manager receives a request for an adaptive aid not listed in Section 4132, the case manager must review the request to determine if the request is complete per Section 4131, Individual Role in Adaptive Aids, Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications, and Section 4131.1, Third–Party Resources for Adaptive Aids. The case manager must also verify all bids submitted are comparable to the written specification per Section 4133, Bid Verification for Adaptive Aids.

If the case manager determines the request is complete, he must forward the request to the regional nurse for review. If the case manager determines the request is incomplete, he must contact the individual by phone to inform him of the actions needed to complete the request. Once the individual completes the request and returns it to the case manager, the case manager will forward the request to the regional nurse for review.

Regional Nurse Responsibilities

The regional nurse will review the request to determine if the adaptive aid request meets the criteria found in Section 4130, Adaptive Aids. If the regional nurse determines the request does not meet the criteria, he must inform the case manager that the request was denied. If the regional nurse determines that the request meets the criteria found in Section 4130, he must inform the case manager that the request was approved.

Once the regional nurse approves or denies an adaptive aid request, the case manager must follow policy found in Section 4135, Adaptive Aids Service Authorization, to ensure appropriate notification, service authorization and all documentation is in the case file.

State Office Consultation

If the DADS regional nurse is unsure about approving items, he may request the state office nurse:

  • review the adaptive aid criteria and rationale for requests for an adaptive aid not on the approved list; and
  • provide a final determination of approval or disapproval of the item(s).

The DADS regional nurse will submit a written request by email to the state office nurse for Community Services Policy and Curriculum Development.

The DADS regional nurse will:

  • provide a copy of the adaptive aid request with cost estimates, including written specification and three comparable bids;
  • provide a copy of any additional documentation of the relationship to the applicant's/individual's disability/medical condition; and
  • recommend approval or disapproval, with the rationale for the recommendation.

The state office nurse may request additional information if the documentation submitted is not sufficient to make a determination or does not support the regional recommendation. The state office nurse will approve or deny the request in writing to the DADS regional nurse, who will communicate the decision to the case manager.

4136  Adaptive Aid Delivery Time Frames and Confirmation

Revision 12-1; Effective May 1, 2012

§51.461

(a)
The provider must deliver the adaptive aid that meets the written specifications.
(b)
The provider must:
(1)
deliver the adaptive aid within 30 working days of one of the following dates, whichever is later:
(A)
the effective date of the IPC; or
(B)
the date the provider receives and date stamps the service authorization form; or
(2)
notify the individual and the case manager in writing of any delay in completing delivery of the adaptive aid, the reason for the delay, and the new proposed date of delivery.
(A)
The individual and the case manager must receive the notification on or before the 30th working day described in paragraph (1) of this subsection.
(B)
If DADS determines the documented reason for the delay is outside the provider's control, the provider is considered to be in compliance with this section.

§51.463

(a)
Within seven working days from the date the adaptive aid is delivered, the provider must contact the individual to:
(1)
verify the delivery of the adaptive aid;
(2)
determine and document the individual's satisfaction or dissatisfaction with the adaptive aid; and
(3)
orient the individual on the use of the adaptive aid.
(b)
The provider must make a home visit if the individual is dissatisfied with the adaptive aid or needs additional training or orientation on its use. If the provider can resolve the dissatisfaction, the provider must do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, the provider must contact the case manager within seven working days of the home visit.
(c)
Within 14 working days of the initial contact required in subsection (a) of this section, the provider must complete the home visit and document delivery of the adaptive aid as described in §51.505 of this chapter (relating to Purchase Completion Documentation).

§51.505

(a)
An adaptive aid or minor home modification provider must record the completion of purchase for a minor home modification or an adaptive aid on a single document that includes:
(1)
the name of the individual and the individual's parent or guardian, if applicable;
(2)
the individual's address;
(3)
a description of the modification or adaptive aid;
(4)
the date of completion or delivery;
(5)
a statement of satisfaction or dissatisfaction with the minor home modification or adaptive aid; and
(6)
the provider's name and vendor number.
(c)
In addition to the requirements in subsection (a) of this section, the adaptive aid provider must include the following on the purchase completion document:
(1)
the name and title of the person completing the orientation on the adaptive aid; and
(2)
the date of the orientation on the adaptive aid.
(d)
If the provider must make a home visit to the individual due to the individual's dissatisfaction or to provide additional orientation, the provider must send a copy of the purchase completion documentation to the case manager within seven working days of the home visit.
(e)
After all purchase completion documentation activities are complete, the provider's representative must sign and date the purchase completion document referenced in subsection (a) of this section and submit it to the case manager within seven working days of the dated signature.

The provider has 30 working days from either the individual plan of care (IPC) effective date or receipt of Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, whichever is later, to deliver the adaptive aid. The case manager and the individual should receive written notification of any delays in meeting the delivery time frame from the provider. The provider should propose a new delivery date in the written notification.

If requested by the individual or if the case manager does not agree with the provider's reason for the delay, the case manager is responsible for taking appropriate steps to address the concerns. Within five working days of receipt of the provider's written notification regarding the delay in delivering the adaptive aid, the case manager must contact the provider to review the proposed delivery date or address the individual's or case manager's concerns.

The case manager must inform the individual of the provider's responsibility to contact the individual within seven working days from the date the adaptive aid is delivered and installed to:

  • verify delivery of the adaptive aid;
  • determine and document the individual's satisfaction or dissatisfaction with the adaptive aid; and
  • orient the individual on the use of the adaptive aid.

The case manager must also inform the individual the provider must complete a home visit within 14 working days from the date of the contact and obtain the individual's signature acknowledging receipt of the adaptive aid.

The case manager may inform the individual that if the individual is dissatisfied with the adaptive aid, the provider must address the individual's concern within seven working days of the home visit. If the provider can resolve the dissatisfaction, the Department of Aging and Disability Services (DADS) requires the provider to do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, DADS requires the provider to contact the case manager within seven working days of the home visit.

DADS requires the provider to submit purchase completion documentation to the case manager within seven working days of the provider's signature or within seven working days of the home visit when the provider has completed all purchase and delivery activities.

The purchase completion documentation must include the:

  • name of the individual or the name of the individual's parent or guardian;
  • individual's address;
  • description of the adaptive aid;
  • date of the adaptive aid delivery or completion;
  • statement of either individual satisfaction or dissatisfaction;
  • provider's name and contract number;
  • name and title of the person completing the adaptive aid orientation; and
  • date of the adaptive aid orientation.

Purchase completion documentation does not have to be on Form 8605, Documentation of Completion of Purchase. If the provider does not submit purchase completion documentation within the required time frame, the case manager may follow up with the provider no later than five working days from the date the provider should have submitted the documentation. The case manager must document the action in the case file using Form 2405, Narrative Notes.

4140  Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.103

(33)
Minor home modification—A physical change to an individual's residence that is needed to prevent institutionalization or to support the most integrated setting for an individual to remain in the community.

A minor home modification is a physical modification to an individual's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the individual or to enable the individual to function with greater independence in his home.

The case manager informs the applicant of minor home modifications at the initial home visit and reviews the service criteria at the annual reassessment or upon the individual's request.

The case manager must provide the applicant the Tool for Minor Home Modifications, found in Appendix II, Medically Dependent Children Program (MDCP) Tools, at the initial home visit.

The case manager must offer the individual the tool when the service criteria are reviewed at the annual reassessment if the individual requests a minor home modification. Whenever an individual requests a minor home modification, the case manager must send Department of Aging and Disability Services (DADS) resources and publications the individual may need to acquire minor home modifications within five working days of the request. The case manager should include the following DADS resources and publications in a minor home modification packet:

  • Tool for Minor Home Modifications, found in Appendix II
  • MDCP rules link for providers and service delivery at www.dads.state.tx.us. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:
    • Select "Rules and Statutes."
    • Select "Texas Administrative Code."
    • Select "DADS TAC references."
    • Select "Chapter 51, Medically Dependent Children Program."
    • Select "Subchapter D, Provider Requirements."
  • DADS Community Services Contract Unit telephone number, 512-438-5430
  • Form 2436, Minor Home Modification Bid

4141  Individual Role in Minor Home Modifications

Revision 12-1; Effective May 1, 2012

In the Medically Dependent Children Program, the individual, primary caregiver or family assume primary responsibility for obtaining all documentation needed to request minor home modifications.

The individual is responsible for obtaining written specifications for requests costing more than $1,000 for minor home modifications. See Section 4141.2, Specifications for Minor Home Modifications, for requirements.

The individual is responsible for obtaining three bids for requests costing more than $1,000 for minor home modifications. See Section 4141.3, Bids for Minor Home Modifications, for requirements.

The case manager must ensure the individual is aware of his role in obtaining minor home modifications and should assist the individual in understanding the prior authorization process.

4141.1  Minor Home Modification Bidders

Revision 12-1; Effective May 1, 2012

§51.233

(b)
If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

The individual may choose a provider from a list of minor home modification providers or a non-contracted entity to submit a bid. The individual should inform non-contracted entities that the non-contracted entity must apply for a contract with the Department of Aging and Disability Services (DADS) if the individual chooses the non-contracted entity to complete the minor home modification. The case manager must refer the individual to the Medically Dependent Children Program (MDCP) rules governing provider and service delivery requirements for minor home modifications. The case manager must encourage the individual to refer non-contracted entities to these rules before applying to contract with DADS. MDCP rules are available on the Internet at www.dads.state.tx.us. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:

  • Select "Rules and Statutes."
  • Select "Texas Administrative Code."
  • Select "DADS TAC references."
  • Select "Chapter 51, Medically Dependent Children Program."
  • Select "Subchapter D, Provider Requirements."

The case manager must encourage the individual to refer non-contracted entities to the DADS Contracts Unit at 512-438-5430, to request a minor home modification contract enrollment packet for MDCP. The case manager may only authorize contracted minor home modification providers to deliver minor home modifications.

4141.2  Specifications for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.103

(47)
Texas Accessibility Standards—Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.325

(a)
For a minor home modification costing $1,000 or more, an individual must obtain written specifications. The individual may obtain separate written specifications when different contractors will complete different parts of the modification.
(b)
A person with home modification experience must prepare the written specifications. The individual must document the experience of the person preparing the specifications and submit the documentation to the case manager with the request for the minor home modification.
(c)
The individual must record the specifications on a single document that includes:
(1)
the individual's name and address;
(2)
a description of the home modification being specified;
(3)
the written specifications, including any applicable local regulations, any construction requirements, and any applicable Texas Accessibility Standards;
(4)
the printed name and dated signature of the person who prepared the written specifications; and
(5)
the individual's dated signature.

Written specifications are required for minor home modification requests costing $1,000 or more. The Department of Aging and Disability Services will accept specifications prepared by a person with home modification experience.

On a single document, the preparer must include:

  • the individual's name and address;
  • name and description of the minor home modification;
  • written specifications;
  • any applicable local regulations;
  • any construction requirements;
  • any applicable Texas Accessibility Standards; and
  • the printed name and signature of the person preparing the specifications, along with the date the document was signed.

The individual must provide the same document to all providers and non-contracted entities submitting bids for minor home modifications.

The case manager must request the individual to submit the documentation with the written specification when submitting bids for minor home modifications.

If the documentation is incomplete, the case manager identifies the missing information and asks the individual to have the preparer submit the completed documentation.

The case manager must document the specification preparer qualifications using Form 2405, Narrative Notes, or Appendix IV, Minor Home Modification (MHM) Checklist, in the case file.

4141.2.1  Justifications for Minor Home Modifications Less Than $1,000

Revision 12-1; Effective May 1, 2012

The individual is not required to submit specifications for minor home modifications costing less than $1,000. To request a minor home modification costing less than $1,000, the individual must submit documentation that includes:

  • a description of the minor home modification;
  • an explanation of the individual's need for the minor home modification; and
  • the expected outcome of the minor home modification.

4141.2.2  Specifications for Minor Home Modifications with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

After determining a request for minor home modifications requires a personal cost contribution from the individual, the case manager informs the individual that updated specifications are needed to continue the service authorization process.

The case manager must inform the individual of the specification items that can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated specifications must meet the criteria listed in Section 4141.2, Specifications for Minor Home Modifications, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The items in the updated written specifications should not differ from the ones listed in the original written specification.

The individual must submit the updated written specifications to the case manager to continue the minor home modification authorization process.

See Section 4144, Individual Personal Costs for Minor Home Modifications, for procedures to determine the individual's personal costs.

4141.3  Bids for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.321

(a)
Before undertaking a minor home modification, an individual must submit a request for the minor home modification to the case manager. For a minor home modification costing $1,000 or more, the request must include written specifications and bids as described in this division.

§51.329

(a)
For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).
(b)
The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.
(c)
If the individual is unable to obtain three bids, the individual must contact the case manager to provide documentation to support the lack of three bids and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about all efforts to secure three bids.

§51.471

(c)
The provider must not hire or reimburse a spouse, parent, or guardian of an individual for work related to the modification, including preparation of the written specifications and the inspection.

The Department of Aging and Disability Services requires a minimum of three bids for minor home modification requests costing $1,000 or more. The individual must provide the same written specification documentation to all providers and non-contracted entities submitting bids. The individual is not limited to the list of minor home modification providers and may obtain bids from non-contracted entities. The case manager sends Form 2436, Minor Home Modification Bid, to the individual upon the individual's request for a minor home modification.

If the individual is unable to get three bids, the individual must provide specific information to the case manager about his efforts to get the required bids. The case manager must document the individual's reason for obtaining less than three bids in the case file using Form 2405, Narrative Notes.

The case manager must inform the individual:

  • all bids for bathroom modifications should include current and proposed floor plans;
  • all bids should include a materials list with costs;
  • the materials list should be of builder grade materials;
  • all bids should include labor and all overhead costs; and
  • the individual may obtain separate bids when different contractors will complete different parts of the modification.

Bids submitted by the individual must include written specification documentation and the cost for the actual work. Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

The case manager must inform the individual the provider cannot hire or pay the individual's spouse, parent or guardian to complete any portion of the modification, written specification completion or inspection.

4141.3.1  Bids for Minor Home Modifications Less Than $1,000

Revision 12-1; Effective May 1, 2012

The individual is not required to submit three bids for minor home modification requests costing less than $1,000. To request minor home modifications costing less than $1,000, the individual must submit at least one bid to the case manager. The bid must list each item separately and include a list of materials and the cost for each item. The bid should also include costs for labor and builder grade materials.

4141.3.2  Bids for Minor Home Modifications with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

§51.329

(a)
For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).
(b)
The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

After determining a request for a minor home modification requires a personal cost contribution from the individual, the case manager follows procedures in Section 4141.2.2, Specifications for Minor Home Modifications with Individual Personal Costs. The individual must also obtain updated bids to reflect the changes in the updated specifications.

The case manager must inform the individual which items in the original bids can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated bids must meet the criteria listed in Section 4141.3, Bids for Minor Home Modifications, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The actual bid items should not differ from the ones listed in the original bid.

The individual must submit the updated bids with the updated specifications to the case manager to continue the minor home modification authorization process.

See Section 4144, Individual Personal Costs for Minor Home Modifications, for procedures to determine the individual's personal costs.

4141.4  Home Owner Approval of Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.327

An individual must obtain written approval for a minor home modification from the property owner (if leasing or renting) before submitting the request to the case manager, unless the individual's lease or rental agreement for the property specifically allows for modifications. Owner approval must be recorded on a single document that includes:

(1)
the name and address of the person receiving MDCP services;
(2)
a description of the minor home modification;
(3)
the individual's approval of the modification;
(4)
the individual's dated signature;
(5)
the property owner's approval or disapproval of the modification as described in the written specifications; and
(6)
the property owner's printed name and dated signature.

The individual must obtain written approval for a minor home modification from the property owner (if leasing or renting) before submitting the request to the case manager, unless the individual's lease or rental agreement for the property specifically allows for modifications.

If the individual submits a written approval, the individual must document the owner's approval on a single document that includes the:

  • individual's name and address;
  • description of the requested minor home modification;
  • individual's approval of the minor home modification;
  • individual's dated signature;
  • property owner's approval of the minor home modification as described in the written specifications; and
  • property owner's printed name and dated signature.

The case manager must verify documentation of owner approval before processing the minor home modification request. The documentation required may be either a copy of the homeowner's written approval or a copy of the lease agreement allowing modifications to the property, and is filed in the case file with the minor home modification documentation.

4142  Service Limits on Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.103

(47)
Texas Accessibility Standards—Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.231

(d)
Minor home modifications. The cost ceilings for minor home modifications are:
(1)
$7,500 in an individual's lifetime; and
(2)
$300 for repairs and maintenance per IPC year.

§51.323

(a)
Minor home modifications covered under MDCP are limited to:
(1)
the purchase and installation of permanent and portable ramps;
(2)
widening of doorways;
(3)
modifications to bathroom facilities; and
(4)
modifications related to the approved installation or modification of ramps, doorways, or bathroom facilities.
(b)
A minor home modification must not create a new structure or add square footage to the home.

The minor home modification lifetime limit is $7,500. The case manager may authorize up to $300 per the individual plan of care (IPC) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The case manager does not include a $300 maintenance and repair limit as part of the $7,500 lifetime limit. A minor home modification must not create a new structure or add square footage to the home.

Minor home modifications are limited to:

  • purchase and installation of permanent and portable ramps not covered by other sources;
  • widening of doorways;
  • modification of bathroom facilities; and
  • modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

The Department of Aging and Disability Services will reimburse contracted providers for approved minor home modifications that:

  • adhere to Americans with Disabilities Act (ADA) requirements;
  • meet Texas Accessibility Standards;
  • meet all applicable state and/or local building codes; and
  • have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

4143  Bid Verification for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.321

(a)
Before undertaking a minor home modification, an individual must submit a request for the minor home modification to the case manager. For a minor home modification costing $1,000 or more, the request must include written specifications and bids as described in this division.

§51.329

(a)
For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).
(b)
The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.
(c)
If the individual is unable to obtain three bids, the individual must contact the case manager to provide documentation to support the lack of three bids and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about all efforts to secure three bids.

Upon receipt of appropriate documentation and the request for a minor home modification, the case manager verifies all bids are comparable to the written specifications and include all required documentation.

The bids must list each item separately and include a list of materials and the cost for each item. The bid should also include the costs of labor and builder grade materials. Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures. All bids for bathroom modifications must include current and proposed floor plans.

4144  Individual Personal Costs for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

An individual may request a minor home modification or a combination of modifications that can either exceed the service limit or include items or options that are not approved by the Department of Aging and Disability Services (DADS). See Section 4141.2.2, Specifications for Minor Home Modifications with Individual Personal Costs, and Section 4141.3.2, Bids for Minor Home Modifications with Individual Personal Costs.

The individual must obtain the updated specifications and the updated bids before the case manager can complete the minor home modification authorization process.

If an individual requests a minor home modification with a cost exceeding the service limit, the case manager will review the request with the DADS nurse. If the DADS nurse approves the request, the case manager will inform the individual of DADS' approval and the individual is responsible for costs exceeding the minor home modification service limit.

Example: The individual requests a modification to a bathroom facility with a cost of $10,000. The case manager reviews the request with the DADS nurse and approves the request. The case manager must complete Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, Section A and Section B, to notify the individual that personal costs were identified.

If an individual requests a minor home modification with fixtures that do not impact institutional prevention or affect the individual's ability to function with greater independence in his home, the case manager reviews the request with the DADS nurse. The case manager and DADS nurse may approve the minor home modification and fixtures addressing institutional prevention or influence an integrated setting, but the fixtures not meeting the minor home modification criteria may be purchased by the individual.

Example: The individual requests a bathroom modification to convert a tub into a shower. The bid includes tub removal, shower installation, shower rod, curtain, and the inspection fee with a total cost of $7,500. The tub removal and shower conversion are $7,300, the shower rod and curtains are $50, and the inspection fee is $150. The case manager and DADS nurse review the request and determine the tub removal and shower installation are necessary to prevent institutionalization and determine the shower rod and curtain do not meet the service criteria. The case manager must complete Form 2416, Section A and Section B, to notify the individual that personal costs were identified.

4145  Minor Home Modification Repairs and Maintenance

Revision 12-1; Effective May 1, 2012

§51.479

The provider is responsible for all repairs or replacement of a minor home modification during the first year after completion, unless the individual or the individual's family members caused the need for repair or replacement. If the individual or the individual's family members caused the need for repair or replacement, then the individual or the individual's parent or guardian is responsible for the repair or replacement.

An individual may request maintenance or repair of a previously purchased minor home modification. The case manager must verify the need for the service is not covered by the provider's warranty. The case manager may review the original bid for warranty information, if available, or contact the provider directly. The individual should submit a bid for the repair, but is not required to submit a specification.

If the request for the service is not covered by the provider's warranty, the case manager may authorize up to $300 to the individual's provider of choice. The $300 limit is available per the individual plan of care period for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

4146  Minor Home Modification Service Authorization

Revision 12-1; Effective May 1, 2012

§51.477

(a)
Reimbursement for inspection. The fee for inspecting a minor home modification, not to exceed $150, is reimbursable as part of the modification. The inspection fee must be approved as part of the bid.

The case manager may use Appendix IV, Minor Home Modification (MHM) Checklist, to review minor home modification requests to ensure all appropriate documentation requirements are in the case file. The case manager follows minor home modification criteria to review all requests for minor home modifications. Within two working days of determining eligibility for the requested services, the case manager must complete and send Form 2065-B, Notification of Waiver Services, and Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, to the individual and the provider to inform both of the case manager's decision and allowable costs covered by the Medically Dependent Children Program.

When authorizing minor home modifications, the case manager may authorize the lowest cost of the approved item(s) from the bids submitted or the service limit, whichever is less. Individuals and families have the option to pay the difference as a personal cost to pursue the requested item.

If the provider completed the specification, prepared a bid, included the specification fee in the bid and is the individual's provider of choice, the case manager may authorize no more than $200 for the specification fee. The specification fee is excluded from the total modification cost when determining if the modification is within the $7,500 limit.

The case manager may authorize no more than $150 for the inspection fee. The case manager must include the inspection fee as part of the $7,500 minor home modification lifetime service limit.

If the request for the service does not meet minor home modification criteria, the case manager must deny the individual's request by completing Form 2065-B and documenting the reason for denying the request in the Comments field. The case manager must complete and send Form 2065-B within two working days of determining the request for services did not meet minor home modification criteria.

The Department of Aging and Disability Services requires the provider to sign and return Form 2416 to the case manager within 14 days of receipt of the form. The case manager must file this copy in the case file. If the provider does not return Form 2416, the case manager should follow up with the provider no later than five working days from the date the provider should have returned Form 2416. The case manager must document the action in the case file using Form 2405, Narrative Notes.

From the time the individual submits the written specification and bids, the case manager must review all documentation, adjust the individual plan of care, as needed, and authorize or deny the request within 14 days.

For data entry procedures in the Service Authorization System, See Section 4200, Notification and Service Authorization System.

4147  Minor Home Modification Time Frames and Completion Confirmation

Revision 12-1; Effective May 1, 2012

§51.103

(47)
Texas Accessibility Standards--Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.473

The provider must:

(1)
ensure completion of the minor home modification within 30 working days of one of the following dates, whichever is later:
(A)
the effective date of the IPC; or
(B)
the date the provider receives and date stamps the service authorization form; or
(2)
notify the individual and the case manager in writing of any delay in completion of the modification, the reason for the delay, and the new proposed date of completion.
(A)
The notification must be received on or before the 30th working day described in paragraph (1) of this section.
(B)
If DADS determines the documented reason for the delay is outside the provider's control, the provider is considered to be in compliance with this section.

§51.475

(a)
The provider must ensure that someone who did not complete the minor home modification inspects the minor home modification.
(b)
The inspection must be made on-site within seven working days of the completion date to determine whether the modification:
(1)
was completed;
(2)
is in compliance with Texas Accessibility Standards and any other applicable standards or codes; and
(3)
is in compliance with the written specifications, if applicable.
(c)
For requirements concerning reimbursement of the inspection fee, see §51.477 of this chapter (relating to Reimbursement of Minor Home Modifications).
(d)
Within seven working days of the date a completed minor home modification is inspected, the provider must contact the individual to:
(1)
verify the completion of the minor home modification; and
(2)
determine and document the individual's satisfaction or dissatisfaction with the minor home modification.
(e)
The provider must make a home visit if the individual is dissatisfied with the minor home modification. If the provider can resolve the dissatisfaction, the provider must do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, the provider must contact the case manager within seven working days of the home visit.
(f)
Within 14 working days of the initial contact required in subsection (d) of this section, the provider must complete the home visit and document the completion and inspection of the minor home modification as described in §51.505 of this chapter (relating to Purchase Completion Documentation).

§51.505

(a)
An adaptive aid or minor home modification provider must record the completion of purchase for a minor home modification or an adaptive aid on a single document that includes:
(1)
the name of the individual and the individual's parent or guardian, if applicable;
(2)
the individual's address;
(3)
a description of the modification or adaptive aid;
(4)
the date of completion or delivery;
(5)
a statement of satisfaction or dissatisfaction with the minor home modification or adaptive aid; and
(6)
the provider's name and vendor number.
(b)
In addition to the requirements in subsection (a) of this section, the minor home modification provider must include the following on the purchase completion document:
(1)
the name and qualifications of the inspector;
(2)
whether the minor home modification was:
(A)
completed according to Texas Accessibility Standards; and
(B)
completed according to any required written specifications;
(3)
the inspector's dated signature; and
(4)
the individual's dated signature.
(d)
If the provider must make a home visit to the individual due to the individual's dissatisfaction or to provide additional orientation, the provider must send a copy of the purchase completion documentation to the case manager within seven working days of the home visit.
(e)
After all purchase completion documentation activities are complete, the provider's representative must sign and date the purchase completion document referenced in subsection (a) of this section and submit it to the case manager within seven working days of the dated signature.

The provider has 30 working days from either the individual plan of care (IPC) effective date or receipt of Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, whichever is later, to complete the minor home modification. The case manager and the individual should receive written notification of any delays in meeting the delivery time frame from the provider. The provider should propose a new delivery date in the written notification.

If requested by the individual or if the case manager does not agree with the provider's reason for the delay, the case manager is responsible for taking appropriate steps to address the concerns. Within five working days of receipt of the provider's written notification regarding the delay in completing the minor home modification, the case manager must contact the provider to review the proposed delivery date or address the individual's or case manager's concern.

The case manager must inform the individual the minor home modification must be inspected within seven working days from the modification completion date. The provider must send an inspector, someone who did not complete the modification, to inspect the minor home modification.

The case manager must inform the individual the provider must contact the individual no later than seven working days after the inspection to determine and document the individual's satisfaction or dissatisfaction with the minor home modification.

The case manager must inform the individual the provider must complete a home visit within 14 working days from the date of the contact and obtain the individual's signature acknowledging completion of the minor home modification.

If the individual is dissatisfied with the minor home modification, the case manager may inform the individual the provider must address the individual's concern within seven working days of the home visit.

The Department of Aging and Disability Services (DADS) requires the provider to submit purchase completion documentation when all service delivery activities are complete.

The purchase completion documentation must include the:

  • name of the individual or name of the individual's parent or guardian;
  • individual's address;
  • date of the modification completion;
  • statement of either individual satisfaction or dissatisfaction; and
  • provider's name and contract number.

The case manager should receive purchase completion documentation within seven working days of the provider's signature on the documentation or within seven working days of the home visit. DADS does not require providers to use Form 8605, Documentation of Completion of Purchase. The case manager must file purchase completion documentation in the case file within two working days of receipt from the provider. If the provider does not submit purchase completion documentation within the required time frame, the case manager may follow up with the provider no later than five working days from the date the provider should have submitted the documentation. The case manager must document the action in the case file using Form 2405, Narrative Notes.

4150  Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

§51.103

(49)
Transition assistance services—One-time service provided to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community to receive MDCP services.

The case manager must advise applicants who reside in a nursing facility (NF) or individuals whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or individual needs assistance in setting up a household when relocating into the community from the NF.

At the initial interview, the case manager will discuss the applicant's or individual's community living arrangement and ask where the applicant or individual intends to live upon discharge from the NF.

The applicant or individual may access TAS if the applicant or individual:

  • plans to rent an apartment;
  • plans to rent a house;
  • has a home, but the utilities have been off while in the NF;
  • has a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • needs belongings moved from the NF to the new residence.

If these or any other situation exists that creates a barrier to the applicant's or individual's transition, the case manager may continue reviewing TAS criteria.

4151  Transition Assistance Services (TAS) Description

Revision 12-1; Effective May 1, 2012

§62.5

(a)
Transition assistance services (TAS) assist Medicaid recipients who are nursing facility residents discharged from the facility to set up a household. TAS are only available to nursing facility residents who are discharged from the facility into a waiver program. TAS are not available to residents moving from a nursing facility who are approved for any of the following waiver services:
(1)
assisted living services;
(2)
adult foster care services;
(3)
support family services;
(4)
24-hour residential habilitation; or
(5)
family surrogate services.

TAS may be available to pay for non-recurring set-up expenses for applicants transitioning from nursing facilities (NFs) into the Medically Dependent Children Program (MDCP) and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant's or individual's transition into the community to set up a household.

TAS may include, but is not limited to, payment or purchases of:

  • security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
  • essential furnishings for the apartment or house;
  • moving expenses required to move into the house or apartment; and
  • site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

4151.1  Deposits

Revision 12-1; Effective May 1, 2012

§62.5

(b)
TAS include, but are not limited to:
(1)
payment of security deposits required to lease an apartment or home, or to establish utility services for the home

The case manager may authorize Transition Assistance Services (TAS) to pay deposits which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or individual's name.

Residential Leases

A security deposit is a one-time expense and the amount may be no more than the equivalent of two months rent. The case manager must not authorize TAS to pay rent.

TAS may be accessed to pay for pet deposits only if the pet is the applicant's or individual's service animal.

Household Utilities

TAS may be used to pay for utility deposits to establish accounts in the applicant's or individual's name or to pay for arrears on previous utilities if the account is in the applicant's or individual's name and the applicant or individual will not be able to get the utilities unless the previous balance is paid. The case manager must not authorize TAS for payment toward utilities.

TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The case manager must not authorize TAS to pay for any charges on upgrades.

TAS funds can be used to pay for initial setup or reconnection fees to propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call. The case manager must not authorize TAS to top off a tank with fuel when the applicant's or individual's home is connected and has a supply of butane or propane.

4151.2  Essential Furnishings

Revision 12-1; Effective May 1, 2012

§62.5

(b)
TAS include, but are not limited to:
(2)
purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, and food preparation items

The case manager may authorize Transition Assistance Services (TAS) to purchase essential furnishings and household items that, if absent, would pose a barrier to the applicant's or individual's transition into the community.

Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture

The case manager may authorize TAS to purchase furniture such as a bed, recliner or dinette if the applicant's or individual's place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances

The case manager may authorize TAS to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or individual identifies these appliances as needed items.

Housewares

The case manager may authorize TAS to purchase housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies

The case manager may authorize TAS to purchase cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other

The case manager may authorize TAS to purchase any special request from the applicant or individual not included in the general list that meets the criteria as a basic essential furnishing to transition into the community.

4151.3  Moving Expenses

Revision 12-1; Effective May 1, 2012

§62.5

(b)
TAS include, but are not limited to:
(3)
payment of moving expenses required to move into or occupy the home or apartment

The case manager may authorize Transition Assistance Services (TAS) to pay for moving expenses, which may include the cost of moving the applicant's or individual's belongings from the nursing facility to the community residence, or delivery charges on TAS items approved by the case manager.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or individual from the nursing facility to his residence in the community.

4151.4  Site Preparation

Revision 12-1; Effective May 1, 2012

§62.5

(b)
TAS include, but are not limited to:
(4)
payment for services to ensure the health and safety of the client in the apartment or home, such as pest eradication, allergen control, or a one-time cleaning before occupancy

The case manager may authorize Transition Assistance Services (TAS) to pay for preparing the applicant's or individual's place of residence for occupancy if the current condition of the residence prevents the applicant's or individual's transition from the nursing facility.

Site preparation purchased with TAS funds may include pest eradication, allergen control and a one-time residential cleaning.

Pest Eradication

The case manager may authorize TAS if the residence has been unattended and is in need of some type of extermination.

Allergen Control

The case manager may authorize TAS if the residence has been unattended or the applicant or individual is moving into a place that poses a respiratory health problem.

One-time Cleaning

The case manager may authorize TAS if the applicant's or individual's residence has been unattended or the applicant or individual is moving into a private home or apartment where pre-move-in cleaning should not be expected, for example, a family friend has an empty house available but cannot provide the cleaning.

4152  Limits on Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

§51.231

(e)
Transition assistance services:
(1)
An individual may access transition assistance services only once in the individual's lifetime; and
(2)
The cost ceiling for transition assistance services is $2,500.

§62.5

(a)
Transition assistance services (TAS) assist Medicaid recipients who are nursing facility residents discharged from the facility to set up a household.

The service limit on TAS is $2,500. An applicant or individual may access TAS only once in his lifetime.

A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services may receive a one-time TAS authorization if the case manager determines that no other resources are available to pay for the basic services or items needed by the applicant or individual.

The case manager may not authorize TAS for:

  • monthly rental or mortgage expenses;
  • current or future use of utilities;
  • service upgrades;
  • food items; or
  • any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications.

TAS is only available to applicants or individuals who are discharged from a nursing facility and require TAS to set up a household.

4153  Authorizing Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

§62.31

The provider agency must accept all clients of any waiver program whom the Texas Department of Human Services refers to the provider agency for services under this chapter.

§62.33

(a)
The provider agency must:
(1)
deliver to the client the specific transition assistance service that the case manager authorized in writing;
(2)
purchase services for the client within the dollar amount that the case manager authorizes; and
(3)
submit a claim for reimbursement to the Texas Department of Human Services only after the purchased services have been delivered to the client.

The case manager follows the Medically Dependent Children Program (MDCP) TAS definition and limitations to review all requests for TAS. The case manager authorizes TAS by completing Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The case manager authorizes the provider to deliver TAS on Form 8604. The case manager may estimate the costs of items and services if the actual cost is not known.

The applicant or individual selects a provider from the list of contracted TAS providers. The Department of Aging and Disability Services (DADS) requires TAS providers to accept all applicants and individuals referred by the case manager.

The applicant or individual signs Form 8604 to indicate the items listed are necessary to establish a household in the community and to let the selected provider purchase the approved items and services.

The case manager must inform the applicant or individual that TAS items or services must be purchased and delivered before the applicant or individual leaves the nursing facility. DADS requires the provider to have all services and items completed two days before the applicant's or individual's discharge date.

The case manager must explain to the applicant that the service will not be authorized until the applicant is determined eligible for MDCP services and the applicant is notified in writing of MDCP eligibility. The case manager must contact the applicant before eligibility determination to verify the applicant has arranged for community relocation and has a projected discharge date. The case manager sends Form 8604 to the provider and applicant or individual before the discharge date. At a minimum, the case manager must allow five days between the authorization date and the discharge date. Example: If the applicant's discharge date is Tuesday, the case manager must send the forms to the applicant and provider no later than Wednesday of the previous week.

Upon receipt of Form 8604, if the provider has questions regarding the authorized items or services, DADS requires the provider to contact the case manager by the following working day and before purchasing any items or services. The case manager will contact the applicant or individual, if necessary, to clarify any information. The case manager will revise Form 8604 and send it to the provider and applicant or individual within two working days if the case manager changes any authorized item or service. See Section 4153.1, Changes to Transition Assistance Services (TAS) Authorization.

The case manager must not authorize the full TAS limit of $2,500 without regard to the applicant's or individual's identified needs.

If the applicant's or individual's request for an item or service does not meet the TAS criteria, the case manager must deny the request for TAS.

For an applicant accessing TAS, the case manager delays Service Authorization System (SAS) data entries for all MDCP services included in the initial individual plan of care (IPC) until the applicant has been discharged from the nursing facility. The case manager must data-enter authorized MDCP services in SAS no later than 14 days from the IPC service initiation date.

For an individual accessing TAS, the case manager must create and update SAS records by the effective date of the IPC change if services are utilized during the IPC period. If service delivery coincides with the annual reassessment, the case manager data enters TAS and other MDCP services by the end of the previous IPC period.

4153.1  Changes to Transition Assistance Services (TAS) Authorization

Revision 12-1; Effective May 1, 2012

If the provider, the applicant or individual identify additional items or services are required after Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, has been sent, the provider should submit a request in writing to update the authorization to the case manager. The case manager must update Form 8604 when a new item is requested or when the cost of items exceeds the previous total authorized amount if the request is within the scope and limit for this service. The case manager must send an updated Form 8604 to the provider within two working days from the date the Department of Aging and Disability Services received the provider's written request.

If a change request is received and the original authorization has been entered into the Service Authorization System (SAS), the case manager modifies the units in the TAS service authorization and the service plan SAS records.

If a provider submits a request to update Form 8604 to change the costs estimated for specific items or services, but the change does not result in exceeding the total TAS amount that was originally authorized, the case manager does not need to update Form 8604.

The case manager must request a review and approval from the Medically Dependent Children Program supervisor to authorize delivery of TAS after the nursing facility discharge date.

4154  Transition Assistance Services (TAS) Delivery Time Frames and Confirmation

Revision 12-1; Effective May 1, 2012

§62.33

(b)
The provider agency must complete the delivery of services to the client at least two days before the client's nursing facility discharge date.
(c)
The provider agency may fail to deliver authorized services to the client by the applicable due date described in subsection (b) of this section only if the reason for the delay is beyond the control of the provider agency, and only if the provider agency makes an ongoing effort to deliver the services. The provider agency must document any failure to deliver the authorized services by the applicable due date, including:
(1)
a description of the pending services;
(2)
the reason for the delay;
(3)
either the date the provider agency anticipates it will deliver the pending services or specific reasons why the provider agency cannot anticipate a delivery date; and
(4)
a description of the provider agency's ongoing efforts to deliver the services.
(d)
The provider agency must orally notify the case manager of any failure to deliver any of the authorized services before the applicable due date described in subsection (b) of this section. Oral notice means directly speaking with the case manager and does not include a message left by voice mail.

The provider purchases the authorized items or services and arranges and pays for the delivery of the purchased items, if applicable. The provider purchases only items or services identified, and within the total dollar amount authorized by the case manager, on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The case manager must inform the applicant or individual that the provider may contact the applicant or individual or the applicant's or individual's authorized representative, if necessary, to coordinate service delivery.

The Department of Aging and Disability Services (DADS) requires the provider to deliver the authorized services by the completion date recorded on Form 8604. DADS requires the provider to give copies of the purchase receipts and any original product warranty information to the applicant or individual. The provider should maintain the original purchase receipts, including sales tax, delivery or installation charges.

The case manager must allow at least five days between the date of authorization and the completion date on Form 8604. The completion or delivery date should be two days before the applicant's or individual's nursing facility (NF) discharge date. The provider should contact the applicant or individual by the completion date to confirm that all authorized items or services were delivered.

If a provider cannot deliver all authorized items or services at least two days before the applicant's or individual's NF discharge date, the provider should directly notify the case manager before the discharge date to give:

  • a description of the pending services;
  • a reason for the delay;
  • an anticipated date of service delivery or state why the provider cannot anticipate a delivery date; and
  • a description of the provider's efforts to deliver the services.

DADS requires the provider to orally notify the case manager of any failure to deliver any of the authorized items or services before the due date. Oral notice means directly speaking with the case manager and does not include a message left by voice mail.

The case manager must contact the applicant or individual to inform the applicant or individual of the provider's delay in delivering TAS.

4155  Failure to Leave the Nursing Facility

Revision 12-1; Effective May 1, 2012

While the case manager makes every effort to confirm the applicant or individual has definite plans to leave the nursing facility (NF), there may be situations when the applicant or individual changes his mind or has a change in his health, making it impossible for him to relocate to the community as planned. In this situation, the case manager notifies the Transition Assistance Services (TAS) provider that the applicant or individual is no longer moving and no further items or services are to be purchased.

The Department of Aging and Disability Services (DADS) requires the provider to attempt to return any item(s) purchased on behalf of the applicant or individual and refund the amount of the purchase. DADS also requires the provider to attempt to recoup security, utility and other deposits paid on behalf of the applicant or individual.

If the provider is unsuccessful in returning the item(s) for the amount of monies paid or the deposits paid on behalf of the applicant or individual cannot be recouped, the provider is entitled to the cost of the item(s) and reimbursement for deposits paid, not to exceed the amount authorized by the case manager. DADS requires the provider to send the case manager written notice stating the item(s) could not be returned or the deposits could not be recouped. DADS staff must contact a local charity to donate the items and must make arrangements for pick-up. The charity must serve individuals whose needs are similar to those of the applicant or individual for whom the items were purchased or must be dedicated to assisting individuals establishing a home. The case manager documents the outcome of the donated items in the case file using Form 2405, Narrative Notes, before closing the case file.

If the provider is able to return the item(s) or receives the deposits back, the provider is not entitled to reimbursement. If the provider recoups part of the monies paid, the provider is entitled to the costs of the item(s) or deposits less any monies recouped. DADS requires providers to adjust any claims filed and paid for items, services or deposits and pay monies back to DADS.

If a service has already been delivered, such as pest eradication, then the provider is entitled to the costs of the service, not to exceed the authorized amount.

If the individual is only in the community for a few days and returns to the NF, the individual keeps the item(s) purchased through TAS.

The provider can bill for the TAS fee in all of the above situations.

DADS will reimburse the provider for any authorized item or service purchased. To data enter TAS and the TAS fee in the Service Authorization System (SAS) for an applicant or individual who is not enrolled in the waiver program, the case manager must select "100 – 100% State" option from the drop down feature in the Fund field and select "Force" in the Service Authorization record. In the Force Comment field, the case manager enters "Forcing 100% state funds for individual not discharged from NF." The case manager must complete all SAS data entries within two working days of notification the applicant/individual will not transition to the community.

4160  Financial Management Services

Revision 12-1; Effective May 1, 2012

Financial Management Services (FMS) provides assistance to individuals with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers. The FMS provider, referred to as the Consumer Directed Services Agency (CDSA), also serves as the individual's employer-agent, which is the Internal Revenue Service's (IRS) designation of the entity responsible for IRS-related responsibilities on behalf of the individual. As the employer-agent, the CDSA also files required forms and reports to the Texas Workforce Commission.

The CDSA also:

  • provides assistance in the development, monitoring and revision of the individual's budget;
  • provides training related to recruiting, hiring and firing employees including identifying the need for special skills and determining duties and schedules;
  • provides guidance on supervision and evaluation of employee performance;
  • provides assistance in determining employee wages and benefits subject to state limits, assistance in hiring by verifying employee citizenship status and qualifications, and conducting required criminal background and registry checks;
  • verifies and maintains documentation of employee qualifications, including citizenship status, and documentation of services delivered;
  • collects timesheets, processes timesheets of employees, processes payroll and payables and makes withholdings for, and payment of, applicable federal, state and local employment-related taxes; and
  • tracks disbursement of funds and provides quarterly written reports to the individual of all expenditures and the status of the individual's CDS budget, and maintains a separate account for each individual's budget.

See Section 8000, Consumer Directed Services, for policy regarding the service delivery option.

4170  Employment Assistance (EA)

Revision 14-2; Effective September 1, 2014

Employment services are intended to assist individuals to find employment and maintain employment. Senate Bill 45, passed by the 83rd Legislature, required that all Medicaid waivers offer Employment Assistance (EA) and Supported Employment (SE). DADS is also adding the Consumer Directed Services option for both EA and SE.

4171  Process to Authorize EA Services

Revision 14-2; Effective September 1, 2014

For individuals who are competitively or self-employed, the case manager/service coordinator, in consultation with the service planning team (SPT), including the individual, the case manager/service coordinator and any other parties the individual chooses to participate, such as family members and service providers, determine if the individual needs paid supports to sustain employment.

The case manager completes Form 2429, Job Interest Assessment, at the initial face-to-face visit for every individual 18 years of age through 20 years of age. For individuals already enrolled in the Medically Dependent Children Program (MDCP), the case manager completes Form 2429 at the reassessment following the individual’s 18th birthday.

If Form 2429 indicates a "yes" response on all of the last three questions, the case manager uses the "First Steps to Employment for People with Significant Disabilities" tool to guide the individual’s SPT, including the individual, to consider the individual’s interests, strengths and supports available before applying for Department of Assistive and Rehabilitative Services (DARS). While the tool was developed in consultation with DARS, considering these topics should help an individual be successful in employment even if he or she does not receive DARS. 

For any individual under age 22, the case manager will ensure that employment services are not available to the individual from the individual’s school district before authorizing waiver Employment Assistance (EA) services. The case manager documents the method by which he or she determined availability of school district-funded employment services.

The case manager refers the individual to DARS within 30 days of completing Form 2429 at the initial face-to-face visit. The case manager should contact the local DARS office to identify the referral process used by that office. Local DARS offices may be located at http://www.dars.state.tx.us/drs/offices/OfficeLocator.aspx or by calling l-800-628-5115.

If an individual refuses to contact DARS, he or she may not receive waiver-funded EA.

An individual who has been referred for DARS or contacted DARS himself is eligible to receive waiver-funded EA until DARS has developed the Individualized Plan of Employment (IPE) and the individual has signed it.  The DADS case manager authorizes 10 hours for EA using Form 2430, Employment Assistance and Supported Employment Authorization. Employment assistance can be authorized up to 180 days. The individual or provider may request more hours for EA if needed.

Upon request and with proper authorization for disclosure, the case manager will assist the individual to provide the DARS Vocational Rehabilitation Counselor (VRC) with the following items described in the DARS Guide for Applicants at http://www.dars.state.tx.us/drs/DRSguide.shtml:

  • Photo identification;
  • An original Social Security card;
  • Individual’s home address and mailing address;
  • Names and addresses of any doctors the individual has seen recently;
  • Names and addresses of any schools the individual has attended;
  • Information about the individual’s medical insurance;
  • A list of places the individual has worked, including type of job, dates, the reason for leaving and salary;
  • Proof of income for the individual and his or her spouse, or parents (if the parents claim the individual as a dependent on their income tax);
  • Proof of expenses related to monthly mortgage/rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
  • Names, addresses and phone numbers of two people who will always know how to contact the individual;
  • Any reports of recent medical exams, school records or other information that may help the VRC understand the individual’s disability;
  • Individual's most recent service plan;
  • Any current vocational assessments or person-directed plans that focus on employment opportunities;
  • Any other available records pertaining to the individual's disabilities, including but not limited to medical, psychological and psychiatric reports;
  • A copy of the individual's court-ordered guardianship documents, if any guardian has been appointed; and
  • Contact information for the individual's case manager.

If the VRC determines that DARS is not the appropriate resource to meet the individual's needs and does not take an application for services, documentation of this decision in the individual’s record serves as sufficient evidence that DARS is not available and the individual is eligible to receive waiver-funded EA.

DARS will:

  • Notify an individual in writing if the individual is determined to be eligible, ineligible or if DARS is unavailable;
  • Notify an individual in writing when DARS is completed;
  • Develop with the eligible individual an IPE within 90 days of determination of eligibility for services;
  • After the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
  • Upon request and with proper authorization for disclosure, provide copies of any of the individual's records to the case manager, including the following documents:
    • A completed copy of the individual's application statement;
    • An individual's completed IPE;
    • Written documentation specifying an individual's eligibility status; and
    • The notification letter indicating DARS is completed.

If DARS has not notified the individual of an eligibility decision within 60 days of the initial DARS appointment, the individual’s case manager will attempt to contact the assigned DARS VRC to determine the status of the application and document the contact in the narrative notes.

The individual’s case manager will ensure that communication is maintained with the assigned DARS VRC regarding waiver-funded services provided between the DARS Vocational Rehabilitation (VR) referral and the "start date" of DARS, as defined in the individual's DARS VR IPE.

The case manager will complete Form 2065-B, Notification of Waiver Services, to notify the individual of the last day EA services will be provided using waiver funds.

At the request of an individual determined eligible for DARS, the case manager, along with the individual, will:

  • if possible, attend any DARS planning meetings related to the individual's employment, or ensure other members of the individual’s SPT attend, as appropriate;
  • if possible, take an active role in providing input to the DARS IPE, or ensure other members of the individual’s SPT provide input, as appropriate;
  • review the long-term services and supports listed on the DARS IPE and if any of those services and supports are available through the waiver, incorporate them in a revision to the individual’s service plan prior to DARS closure. The provider must begin providing or subcontracting for those services and supports approved in the individual’s service plan without a gap between the provision of DARS and waiver services.

4180  Supported Employment (SE)

Revision 14-2; Effective September 1, 2014

Supported Employment (SE) services provide assistance to help an individual sustain competitive employment or self-employment.

Competitive employment is work:

  • in the competitive labor market in which anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
  • for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community in which applicants or eligible individuals interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

  • groups of people with disabilities work in an area that is not part of the general workplace where people without disabilities work; or
  • a mobile crew of people with disabilities work in the community.

Self-employment is work in which the individual:

  • solely owns, manages and operates a business;
  • is not an employee of another person, entity or business; and
  • actively markets a service or product to potential customers.

SE services include:

  • assistance provided to an individual in order to sustain competitive employment, and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed;
  • employment adaptations, supervision and training related to an individual’s assessed need; and
  • individuals earning at least minimum wage, if not self-employed.

SE may be provided through the waiver if documentation is maintained in the individual’s record, for an individual under age 22, that the service is not available to the individual under a program funded under the Individuals with Disabilities Education Act  (IDEA). (20 U.S.C. §1401 et seq.)

The provider must ensure provision of SE, as needed, for an individual to sustain competitive employment or self-employment, if the services are not available through the local school district for an individual under age 22.

4181  Role of the Case Manager

Revision 14-2; Effective September 1, 2014

The DADS case manager coordinates with other agencies, including the Texas Health and Human Services Commission, regarding an individual’s continued Medicaid eligibility once he or she begins working. The DADS case manager also coordinates with the Department of Assistive and Rehabilitative Services (DARS) and the local school districts, seeking third party resources before using employment assistance (and supported employment, in the case of school districts).

Activities include:

  • devoting time during an individual’s initial service planning meeting to discuss employment with the individual and family and the process to obtain employment services and supports;
  • making the referral to DARS, assisting with completing the application form, and documenting the referral and outcome of the referral in the individual’s case record;
  • continuing to explore the possibility of employment at subsequent service planning meetings for an individual who is not employed in the community;
  • affirming or explaining how an individual can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
  • explaining rights to appeal if services are denied, reduced or terminated; and
  • monitoring whether the individual and family are satisfied with the employment supports.

4200  Notification and Service Authorization System

Revision 12-1; Effective May 1, 2012

The case manager completes Form 2065-B, Notification of Waiver Services, to document the applicant's initial and individual's ongoing eligibility for Medically Dependent Children Program (MDCP) services and to authorize the provider to deliver MDCP services.

See Section 4231, Service Authorization System (SAS) Data Entry, for procedures for data entering information in SAS.

4210  Applicant/Individual Eligibility Notification

Revision 13-2; Effective May 1, 2013

Notifications for Program Eligibility

The case manager reviews all eligibility criteria in Section 1300, Eligibility. The applicant is eligible for the Medically Dependent Children Program (MDCP) when all eligibility criteria are met. Since a disability determination is only required at the initial enrollment, the case manager does not assess for a disability at annual reassessments, as directed in Section 1350, Disability. The case manager documents the applicant's/individual's eligibility and authorizes MDCP services by completing Form 2065-B, Notification of Waiver Services. The case manager sends Form 2065-B to the applicant/individual with the case manager's original signature within two working days of determining program eligibility.

In addition to Form 2065-B and also within two working days of determining program eligibility, the case manager completes and sends the following service authorization forms to the applicant/individual, as appropriate:

  • Form 2402, Consumer Directed Services Option – Services Authorization;
  • Form 2414, Flexible Family Support Services Authorization;
  • Form 2415, Respite Service Authorization; and
  • Form 2416, Minor Home Modifications and Adaptive Aids Services Authorization.

The applicant/individual is not eligible for MDCP services if the case manager determines he does not meet all eligibility criteria. The case manager documents program ineligibility by completing and sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, with the case manager's original signature to the applicant/individual within two working days from the date the case manager determined program ineligibility.

Notifications for Specific Services

If the applicant/individual requests a change to the individual plan of care (IPC) at a time other than the initial or annual reassessment, upon determination the request meets MDCP service criteria, the case manager completes and sends Form 2065-B to the applicant/individual with the case manager's original signature within two working days.

If the applicant/individual requests a specific service and the case manager determines the request does not meet MDCP service criteria but the denial does not affect the applicant's/individual's program eligibility, the case manager must complete and send Form 2065-B to the applicant/individual within two working days from the date the case manager determined the individual's request did not meet MDCP service criteria.

4220  Provider Notification

Revision 13-2; Effective May 1, 2013

§51.413

(a)
A provider must receive the service authorization form from the case manager before delivering services.
(b)
Within 14 days after receiving the service authorization form, the provider must send the case manager:
(1)
a signed copy of the service authorization form; and
(2)
a signed copy of the practitioner's orders. This paragraph applies only to a respite or adjunct support services provider that is:
(A)
a home and community support services agency using:
(i)
an RN;
(ii)
an LVN; or
(iii)
an attendant with delegated nursing tasks;

The case manager authorizes providers to deliver services by completing Form 2065-B, Notification of Waiver Services. The case manager sends the appropriate service authorization form and appropriate service plan to each provider. Within two working days of program eligibility determination or approval for a specific service and in addition to Form 2065-B, the case manager sends:

  • Form 2410, Medical-Social Assessment and Individual Plan of Care;
  • Form 2411, Interim Plan of Care;
  • Form 2412, Budget Revision;
  • Form 2402, Consumer Directed Services Option – Services Authorization, to Financial Management Services providers;
  • Form 2414, Flexible Family Support Services Authorization, to Flexible Family Support Services providers;
  • Form 2415, Respite Service Authorization, to respite providers; or
  • Form 2416, Minor Home Modifications and Adaptive Aids Services Authorization, to adaptive aid providers and minor home modification providers.

For Respite and Flexible Family Support Services, the case manager may use the comments section of Form 2414 or Form 2415 to give specific instructions to providers about the applicant's/individual's service arrangement. These include specific instructions about unique applicant/individual concerns or the home environment, the requested nurse type or information about qualifications for potential attendants.

By completing Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, the case manager authorizes TAS providers to deliver TAS. The case manager completes and sends Form 8604 to the TAS provider no later than five days before the applicant's/individual's nursing facility discharge date. The case manager does not send a copy of Form 2065-B to TAS providers.

4230  Service Authorization System (SAS)

Revision 12-1; Effective May 1, 2012

The case manager must data enter individual plan of care (IPC) information in SAS by appropriate time frames and then ensure accuracy of the information submitted. SAS maintains information relevant to the individual's authorized services. The case manager must data enter authorized services into SAS before a provider can receive payment for services delivered to an individual.

4231  Service Authorization System (SAS) Data Entry

Revision 13-2; Effective May 1, 2013

SAS Data Entry Time Frames

The SAS data entry must be completed at the same time Form 2065-B, Notification of Waiver Services, is completed on initial authorizations, redeterminations or changes, or when Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is completed for a change resulting in denial or termination of MDCP services. When the SAS data entry cannot be completed at the same time Form 2065-B or Form 2065-C is completed, the delay must be documented. There is an exception to this for Money Follows the Person (MFP) certifications.

MFP Certifications

The case manager notifies the individual applying for MDCP services through MFP of MDCP eligibility and the negotiated nursing facility (NF) discharge date, which is the effective date of MDCP services on Form 2065-B.

Completion of SAS data entry must meet the following time frames:

  • Extended NF Stay MFP enrollments — Verification of the NF discharge date and SAS data entry must be completed within 14 days of the effective date on Form 2065-B.
  • Limited NF Stay MFP enrollments for applicants with Medicaid — SAS data entry must be completed within 14 days of the effective date on Form 2065-B.
  • Limited NF Stay MFP enrollments without Medicaid — SAS data entry must be completed within five working days of the individual's Medicaid certification.

The case manager must verify the information in SAS matches the new or updated plan of care and service authorization forms. The plan of care forms are:

  • Form 2410, Medical-Social Assessment and Individual Plan of Care, used for initial enrollments or annual reassessments;
  • Form 2411, Interim Plan of Care, used for plan of care changes that include a change to the individual's Resource Utilization Group (RUG); and
  • Form 2412, Budget Revision, used for all other plan of care changes.

The service authorization forms are:

  • Form 2402, Consumer Directed Services Option – Services Authorization;
  • Form 2414, Flexible Family Support Services Authorization;
  • Form 2415, Respite Service Authorization;
  • Form 2416, Minor Home Modifications and Adaptive Aids Services Authorization; and
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

If the SAS data entry cannot be completed within the identified time frames, the case manager must document the delay and complete the SAS data entry as soon as possible. The case manager must document all SAS data entry delays in the case file using Form 2405, Narrative Notes.

4232  Service Authorization System (SAS) Data Entry for Service Reductions, Suspensions, Denials and Case Closures

Revision 13-2; Effective May 1, 2013

SAS data entry should be completed at the same time Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is completed, or when federal or state law requires a change resulting in a reduction, denial or termination of MDCP services. When SAS data entry cannot be completed, the delay must be documented.

Below are exceptions to the requirement for completion of Form 2065-B or Form 2065-C, and SAS data entry at the same time.

  • Suspensions due to a nursing facility admission – SAS data entry must be completed within five working days of Form 2065-C completion.
  • Denials and case closures – SAS data entry must be completed by the end of the previous individual plan of care (IPC) period or within five working days of Form 2065-C completion for case closures occurring during the IPC period.

For case closures, the case manager must enter the appropriate termination code in all active Service Authorization records for Service Group 18. SAS termination codes are found in the drop-down menu in the Service Authorization record "Term Code" field.

The case manager must verify the information in SAS matches the new or updated plan of care and service authorization forms. The plan of care forms are:

  • Form 2410, Medical-Social Assessment and Individual Plan of Care, used for initial enrollments or annual reassessments;
  • Form 2411, Interim Plan of Care, used for plan of care changes that include a change to the individual's Resource Utilization Group (RUG); and
  • Form 2412, Budget Revision, used for all other plan of care changes.

The service authorization forms are:

  • Form 2402, Consumer Directed Services Option – Services Authorization;
  • Form 2414, Flexible Family Support Services Authorization, to Flexible Family Support Services providers;
  • Form 2415, Respite Service Authorization, to respite providers;
  • Form 2416, Minor Home Modifications and Adaptive Aids Services Authorization, to adaptive aid providers and minor home modification providers; and
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

If the SAS entry cannot be completed within the identified time frames, the case manager must document the delay and complete the SAS data entry as soon as possible. The case manager must document all SAS data entry delays in the case file using Form 2405, Narrative Notes.

4233  SAS Data Entry Procedures for CDSA Provider Transfers

Revision 13-2; Effective May 1, 2013

When completing a provider transfer, the case manager must ensure the Service Authorization System (SAS) Service Authorization record reflects service units available for the new provider and utilized units for the previous provider.

To update the Service Authorization record in SAS for the losing provider, the case manager must enter the number of units or the costs of services delivered by the losing provider in the Units field. The case manager enters the day before the individual plan of care (IPC) change is effective in the End Date field.

The case manager creates a new Service Authorization record for the receiving provider and enters the number of units or the cost of services determined for the receiving provider in the Units field. The case manager enters the IPC change effective date in the Begin Date field, which is the date the receiving provider is authorized to deliver services. The case manager enters the end date of the IPC period in the End Date field.

The total number of units or the cost of services for all Service Authorization records must not exceed the total number of units or the cost of services the case manager authorized in the IPC period.

To update the Service Authorization record in SAS for the losing Consumer Directed Services Agency (CDSA), the case manager enters the dollar amounts reported by the losing CDSA to update the Units field in the Service Authorization record for Respite and/or Flexible Family Support Services for the applicable service code(s).

To update the Service Authorization record for Financial Management Services for the losing CDSA, the case manager enters the day before the transfer date in the End Date field. The case manager creates a new Service Authorization record for the gaining CDSA and enters the date of the transfer date in the Begin Date field and the last day of the IPC period in the End Date field. The case manager does not enter half units or create separate Service Authorization records if the CDSA transfer date occurs on any date other than the first of the month.

SAS Records and Time Frames

If the provider transfer results in a change to the total authorized services cost amount, the case manager must update the new amount in the Service Plan record. The case manager must complete all SAS data entry updates within five working days of the IPC change effective date.

If the losing provider requests additional units/amount added to a closed Service Authorization record after the provider transfer action is completed, the case manager must update SAS to add the additional units/amount to the Service Authorization records for the losing provider, if appropriate.