Texas Department of Aging and Disability Services
Case Manager Medically Dependent Children Program Handbook
Revision: 14-1
Effective: February 3, 2014

Section 7000

Annual Reassessment

7100  Annual Reassessment Overview

Revision 14-1; Effective February 3, 2014

The case manager will coordinate with the Medically Dependent Children Program (MDCP) nurse to complete a face-to-face visit 60 to 90 days prior to the end date of the Individual Plan of Care (IPC) to reassess the individual's needs, redetermine MDCP eligibility and develop a new IPC. If the case manager and nurse cannot visit the individual on the same day, they may conduct separate face-to-face visits to prevent delays in redetermining MDCP eligibility. During the annual reassessment, the case manager must review service options and limitations of MDCP services. The case manager must review the Electronic Visit Verification (EVV) information on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and adequately explain the EVV requirements to the individual. Refer to Section 2370, Explaining Electronic Visit Verification Requirements, for talking points on explaining EVV requirements to the individual.

Note: DADS staff must not discard the original Form 2408, Individual Plan of Care Service Review, Form 2410, Medical-Social Assessment and Individual Plan of Care, or any other form or document completed during the face-to-face visit.  The case manager must file the original handwritten document in the case file even if the form is typed after returning to the office.

Outbreak of Transmittable Disease in the General Population

During the time when Texas experiences an increase in serious transmittable diseases in the general population, certain precautions are necessary to ensure the health and welfare of the case manager who may come in contact with an individual reporting he has a contagious illness.

While it is important that a required face-to-face visit is performed on a timely basis, there may be circumstances that could place the case manager at risk for contracting contagious illnesses.

If a case manager contacts an individual to schedule a visit and the individual states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the visit, including the stated illness. If possible, the case manager should schedule a future date for the visit when the individual thinks he will be better. If unable to schedule the visit for a future date, the case manager must contact the individual at least weekly until the visit can be made. The visit must be conducted in time for the case manager to redetermine MDCP eligibility and develop a new IPC prior to the end date of the current IPC.

Each contact must be documented in the case file on Form 2405, Narrative Notes. This documentation will be considered as an acceptable reason for delaying a required face-to-face visit.

7100.1  Opportunity to Register to Vote

Revision 14-1; Effective February 3, 2014

In addition to being offered voter registration assistance, as required by the National Voter Registration Act, at the time an individual applies for services, he must be offered this opportunity when he is reassessed annually for services. He must be given the opportunity to:

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

If the individual wishes to complete Form 0030 during the annual reassessment, DADS staff must review the form for completeness in the presence of the individual. If the form does not contain all the required information, including the required signature, DADS staff will ask him to complete Form 0030. DADS must transmit Form 0030 to the appropriate county voter registrar within five working days of the signature by the individual.

If the individual does not wish to complete Form 0030, the individual must complete and sign Form 1019, Opportunity to Register to Vote/Declination. If the individual refuses to sign the declination form, DADS staff must enter on the form a notation of that fact. DADS staff shall preserve in the individual's case record each declination form for at least 22 months after the date of signing.

The case manager must inform the individual of the option of requesting a ballot by mail if the individual is:

  • out of the county during early voting and on Election Day;
  • sick or disabled; or
  • confined to jail.

He or she can print an application for a ballot by mail (PDF) from the Texas Secretary of State website and mail it to the Early Voting Clerk.

7110  Annual Eligibility Requirements

Revision 12-2; Effective August 1, 2012

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

(1)
live in Texas;
(2)
be:
(A)
a citizen of the United States (U.S.);
(B)
an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641(b) or (c); or
(C)
an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1612(b) and §1613;
(3)
be under 21 years of age;
(4)
meet the financial Medicaid eligibility criteria described in Texas Administrative Code, Title 1, Chapter 358 (relating to Medicaid Eligibility), based on the person's income and resources;
(5)
for initial enrollment only, meet at least one of the disability criteria described in §51.205(b) of this chapter (relating to Disability Criteria);
(6)
meet medical necessity as described in §51.207 of this chapter (relating to Medical Necessity);
(7)
have an IPC with a cost for MDCP services at or below 50 percent of the reimbursement rate that would have been paid for the same individual to receive nursing facility services considering all other resources, including resources described in §40.1 of this title (relating to Use of General Revenue for Services Exceeding the Individual Cost Limit of a Waiver Program); and
(8)
if the person is under 18 years of age, reside:
(A)
with a family member; or
(B)
with a foster family that includes no more than four children unrelated to the individual.

The individual is eligible for the Medically Dependent Children Program (MDCP) when all eligibility criteria are met. The case manager reviews the eligibility criteria during the annual reassessment with the exception of the disability criteria. A disability determination is only required at the initial enrollment; the case manager does not assess for the disability criteria at the annual reassessment. The case manager must verify and document applicable eligibility requirements on Form 2405, Narrative Notes.

If the individual does not meet eligibility requirements at the annual reassessment, the case manager must notify the individual of ineligibility following procedures in Section 9510, Ineligibility.

The case manager must complete the following before determining individual eligibility during the annual reassessment:

  • Confirm the individual still resides in Texas by any of the following items:
    • parent/guardian statement for a minor child;
    • current Texas driver license;
    • utility receipts;
    • voter registration card;
    • Texas Department of Public Safety identification card;
    • Social Security Administration award letter;
    • State On-Line Query (SOLQ) system;
    • Wire Third Party Query (WTPY) system; or
    • bank statements.

    Acceptable verification must include a street address or postal route; a post office box number alone is not sufficient.
  • Confirm the individual meets medical necessity by:
    • performing an inquiry through the Texas Medicaid & Healthcare Partnership (TMHP) web-based portal; or
    • viewing the Service Authorization System (SAS).

    The case manager must file a copy of the TMHP web-based portal screen or SAS inquiry screen in the case file.

    It is the MDCP nurse's responsibility to prepare and submit the Medical Necessity and Level of Care (MN/LOC) Assessment to TMHP for determination.
  • Confirm the Individual Plan of Care (IPC) costs for MDCP services are at or below the IPC cost limit considering all other resources.
  • Confirm that the individual, if under age 18, lives with a family member such as a parent, guardian, grandparent or sibling, as defined in Section 1200, Program Definitions. The case manager must review guardianship documentation or obtain a statement from the individual or family member regarding relation. The individual may reside with a foster family that includes no more than four other children unrelated to the individual.

    Examples:
    • An individual under age 18 may reside with a foster family that includes a biological sibling and four other unrelated foster children.
    • An individual under age 18 may not reside with a foster family that includes five or more children unrelated to the individual.
  • Confirm that the individual has a need for and uses MDCP services monthly.

7111  Financial Reassessments

Revision 13-3; Effective August 1, 2013

Health and Human Services Commission (HHSC) Medicaid for the Elderly and People with Disabilities (MEPD) redetermines financial eligibility annually for individuals receiving ME-Waivers Medicaid.

In order for individuals to maintain financial eligibility, redetermination packets must be returned to HHSC in a timely manner. Individuals may not recognize the envelope as being an official HHSC document and, therefore, do not open the envelope. As a result, redetermination packets are not returned and financial eligibility is denied.

Due to changes in the wording on the envelopes, the case manager must provide the individual with an explanation of the changes. Previously, the envelopes contained the following wording, “Important Insurance Information.” The envelopes now state the following:

Image of Time Sensitive Stamp

The case manager must take examples of the envelopes to the face-to-face visit so the individual can become familiar with the new appearance of the envelopes. The case manager can make copies of the envelope examples located in Appendix XXII, Examples of HHSC Envelopes, to provide to the individual at the face-to-face visit. The case manager must discuss with the individual at the face-to-face visit the importance of returning Form H1200, Application for Assistance-Your Texas Benefits, or Form H1200-A, Medical Assistance Only (MAO) Recertification, to HHSC within the required time frame provided in the redetermination packet.

HHSC has also implemented Form H1200-SR, Streamlined Redetermination for MEPD. Form H1200-SR is generated from the Texas Integrated Eligibility Redesign System (TIERS). HHSC may determine an individual appropriate for a streamlined redetermination if the individual has had a minimum of one annual redetermination using Form H1200 or Form H1200-A. The individual will receive Form H1200-SR instead of Form H1200 or H1200-A. The cover sheet to Form H1200-SR provides specific directions for the individual to follow to determine if the form needs to be completed and returned to HHSC.

The case manager must discuss with the individual the importance of thoroughly reviewing Form H1200-SR to determine if changes need to be reported to HHSC. If the individual has any questions regarding the information on Form H1200-SR, he should contact HHSC by mail or fax using the address or fax number on the application or by calling 211.

In addition to receiving one of the forms mentioned above from HHSC, the individual may also receive Form H1010, Texas Works Application for Assistance – Your Texas Benefits. The individual may only return Form H1010 thinking this form will suffice for all services the individual is receiving. The case manager must inform the individual Form H1200, H1200-A, or H1200-SR and Form H1010 must both be completed and returned to HHSC. The case manager must make the individual aware he can track the status of his application using the “HHSC Your Texas Benefits” website at www.yourtexasbenefits.com, or by calling 211.

7120  Medical Necessity Determination

Revision 14-1; Effective February 3, 2014

§51.207

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

The individual must receive a medical necessity (MN) determination annually to remain eligible for the Medically Dependent Children Program (MDCP). The MDCP nurse is responsible for completing the Medical Necessity and Level of Care (MN/LOC) Assessment during the annual reassessment face-to-face visit.

To obtain a medical necessity determination at the annual reassessment, the MDCP nurse must:

  • complete and submit an MN/LOC Assessment electronically to Texas Medicaid & Healthcare Partnership (TMHP) for MN and Resource Utilization Group (RUG) calculation;
  • record the RUG and approval date on Page 1 of Form 2410, Medical-Social Assessment and Individual Plan of Care; and
  • complete and sign Page 1 of Form 2410.

Within three working days of the visit, the MDCP nurse must complete and transmit the MN/LOC Assessment to TMHP for review for MN redetermination. The MDCP nurse must ensure the MN/LOC Assessment is entered into TMHP at least 60 days prior to the end of the Individual Plan of Care (IPC).

If the nurse is unable to submit the MN/LOC Assessment within three working days due to situations out of the nurse's control, the nurse must notify the case manager either on Form 2067, Case Information, or by phone, reporting the reason for the delay and the date the nurse anticipates this task will be completed.

Within three working days of TMHP's decision regarding the MN/LOC Assessment, the MDCP nurse must send a copy of the signed and dated Page 1 of Form 2410, and the Document Locator Number (DLN) associated with the MN/LOC Assessment, to the case manager.

If the nurse is unable to send a signed and dated copy of page 1 of Form 2410, and the MN/LOC DLN to the case manager within three working days of TMHP's decision regarding the MN/LOC Assessment due to situations out of the nurse's control, the nurse must notify the case manager either on Form 2067 or by phone, reporting the reason for the delay and the date the nurse anticipates this task will be completed.

The case manager may, at any time following TMHP's decision, retrieve a copy of the MN/LOC Assessment by accessing the TMHP web-based portal.

7130  Individual Plan of Care Development

Revision 14-1; Effective February 3, 2014

The case manager and the Medically Dependent Children Program (MDCP) nurse coordinate the development of a new Individual Plan of Care (IPC) at least annually based on the annual reassessment. The case manager and regional nurse must complete the annual reassessment 60 to 90 days prior to the end of the current IPC in order to ensure all annual reassessment activities are completed timely. The regional nurse must continue to enter the Medical Necessity and Level of Care (MN/LOC) Assessment into the Texas Medicaid and Healthcare Partnership (TMHP) online portal within three working days of the visit. If the individual or individual’s parent or guardian does not participate in the development of the IPC 60 to 90 days prior to the end of the current IPC, the case manager must deny MDCP program eligility.

The case manager must contact the provider of choice by phone to discuss the draft IPC developed at the annual reassessment. The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion with the provider must occur in time to authorize services before the end of the current IPC. Once all parties agree with the draft IPC, the service initiation date must be negotiated with the provider. The case manager should also include the MDCP nurse in the discussion, as appropriate, for any proposed changes to the IPC.

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

The case manager must complete all procedures necessary to authorize waiver services and enter the new IPC into the Service Authorization System (SAS) before the expiration date of the current IPC. The effective date of the new reassessment IPC is the first day of the new IPC period, which is the day after the last day of the previous IPC. The effective dates are the same on Form 2410 and Form 2065-B, Notification of Waiver Services. The case manager signature date and the date at the top of Form 2065-B must be the same date. This signature date and the date at the top of the form is the date the case manager completes the form and must be before the IPC expires. The date at the top of the form does not take into consideration the mail date of the form. Applicants and individuals must be notified within required time frames.

The case manager must not enter an annual reassessment IPC in SAS unless the individual meets all eligibility criteria.

Coordinating Multiple Services

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

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

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

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

7131  Setting Funds Aside in the IPC

Revision 12-1; Effective May 1, 2012

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

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

7132  Completing the Annual Reassessment IPC

Revision 14-1; Effective February 3, 2014

To complete the annual reassessment Individual Plan of Care (IPC), the case manager must complete all of the following activities before the expiration of the current IPC:

  • Verify medical necessity (MN) through the Service Authorization System (SAS) or the Long Term Care (LTC) web-based portal.
  • Verify continued financial eligibility. See Section1340, Financial Eligibility.
  • Calculate the copayment for any individual whose financial eligibility involved a Qualified Income Trust. See Section 3111, Qualified Income Trust (QIT), for details.
  • Review and complete Form 2410, Medical-Social Assessment and Individual Plan of Care, and the applicable service authorization forms below:
    • Form 2402, Consumer Directed Services Option – Respite/Flexible Family Support Services Authorization;
    • Form 2414, Flexible Family Support Services Authorization;
    • Form 2415, Respite Service Authorization; and
    • Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.
  • Review the selection of providers and confirm agreement with the completed IPC. Calculate IPC costs and determine if the IPC is within the cost limit.
  • Send the providers copies of the IPC and applicable service authorization forms.
  • Verify that the IPC has been signed appropriately by all applicable parties.
  • Prepare the notification on Form 2065-B, Notification of Waiver Services.
  • Send Form 2065-B, along with Form 2410, to the individual, all appropriate MDCP service providers and the Medicaid for the Elderly and People with Disabilities staff, if appropriate.
  • Authorize the services in SAS according to the time frames in Section 4230, Service Authorization System (SAS).

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

If the annual reassessment IPC is submitted and current MN information is not found in SAS, the IPC will suspend. The IPC will also suspend if the Texas Integrated Eligibility Redesign System (TIERS) records do not reflect eligibility for a correct Medicaid type program at the time the IPC annual reassessment is data entered.

For individuals who appeal the denial of their annual reassessment IPC timely, MDCP services can be continued into the reassessment period, if requested by the individual. However, the case manager must complete the reassessment IPC and it must be registered into the SAS system. The case manager will notify the providers via Form 2067, Case Information, to continue services until the outcome of the appeal is determined.

Any gaps in concurrent coverage of the MN/LOC Assessment or the IPC will cause the loss of payment to the providers and unnecessarily jeopardize the care of the individual.

7133  Personal Care Services

Revision 12-1; Effective May 1, 2012

Personal Care Services (PCS) are available to Medicaid recipients under the age of 21 who are eligible for Texas Health Steps (THSteps).

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

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

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

7133.1  PCS Data Reports

Revision 12-1; Effective May 1, 2012

Department of Aging and Disability Services (DADS) case managers are required to coordinate services with Personal Care Services (PCS) case managers for individuals who are receiving both PCS and DADS waiver services. PCS data reports are available online at: ftp://dads4svtuvok/PCS.

DADS case managers will access the PCS data reports before annual reassessments to determine if coordination of services with PCS case managers is needed.

7133.2  Using the PCS Data Reports

Revision 12-1; Effective May 1, 2012

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

Note: The fiscal year and quarter will change as warranted.

PCS Match File 1 FY10 Q3 lists individuals currently receiving both waiver services and PCS, and is utilized at annual reassessments.

PCS Match File 2 FY10 Q3 lists individuals receiving PCS who are being released from a waiver interest list, and is utilized at initial assessments.

PCS Match File 3 FY10 Q3 is used by the Department of State Health Services to identify individuals receiving waiver services.

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

7133.3  Procedures for Individuals Not Receiving PCS

Revision 12-1; Effective May 1, 2012

The Department of Aging and Disability Services (DADS) case manager must explain Personal Care Services (PCS) and give the individual the Texas Medicaid & Healthcare Partnership (TMHP) toll-free PCS Line (1-888-276-0702). TMHP will forward referral information to the appropriate Department of State Health Services staff. The DADS case manager must review the status of PCS eligibility at the following six-month monitor. The DADS case manager continues with Medically Dependent Children Program (MDCP) eligibility re-determination and documents the PCS program referral in the case file.

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

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

7134  Coordinating with IDD Services During the Development of the Annual IPC

Revision 12-2; Effective August 1, 2012

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

7135  FMS for the MDCP Individual Accessing CDS

Revision 12-2; Effective August 1, 2012

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

7136  Coordination of Services in the MDCP IPC and the Personal Care Assessment Form

Revision 13-2; Effective May 1, 2013

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

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

DSHS Region 1
806-655-7151

DSHS Region 2/3
817-264-4627

DSHS Region 4/5 N
903-533-5231

DSHS Region 6/5 S
713-767-3111

DSHS Region 7
254-778-6744

DSHS Region 8
210-949-2155

DSHS Region 9/10
915-834-7682

DSHS Region 11
956-423-0130

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

The DADS case manager must document all verbal communication with the PCS case manager in the case file, using Form 2405, Narrative Notes.

7140  Notifications for Program Eligibility and Service Authorizations

Revision 14-1; Effective February 3, 2014

The case manager documents the individual's eligibility and authorizes Medically Dependent Children Program (MDCP) services by completing Form 2065-B, Notification of Waiver Services. Within two working days of determining program eligibility, the case manager sends Form 2065-B with the case manager's original signature, to the individual, provider and Medicaid for the Elderly and People with Disabilities (MEPD) specialist, when applicable.

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 individual/employer and provider, as appropriate:

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

The case manager must apply the adverse action period when reducing or terminating a service across Individual Plan of Care (IPC) years. For example, if an individual was receiving 20 hours per week of respite but will only receive 15 hours per week in the new IPC year, the case manager must notify the individual of the reduction in respite when sending Form 2065-B. The case manager does not need to indicate one-time purchased items, such as adaptive aids, authorized in the current IPC that are not requested on the new annual reassessment IPC on Form 2065-B. In order for the case manager to establish if an adverse action period is needed, the case manager must finalize the IPC at least 30 days prior to the end of the current IPC.

When a service is reduced from one IPC year to the next, the case manager must document the reduction in the comments section on Form 2065-B.

Example: The individual currently receives 40 hours per week of respite and received an adaptive aid during the current service plan. The individual’s annual reassessment service plan includes a reduction in respite from 40 hours per week to 20 hours per week. No adaptive aid is requested on the new service plan. When the case manager sends Form 2065-B to the individual advising him of his continued eligibility, the case manager documents the following statement in the comments section: “Your respite has been reduced from 40 hours per week to 20 hours per week.” The case manager does not need to comment about the adaptive aid because it was a one-time purchased item on the previous service plan.

7141  Respite Service Authorizations

Revision 13-4; Effective November 1, 2013

The case manager follows the Medically Dependent Children Program 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. The case manager must follow procedures in Section 4113, Respite Service Authorizations, for rounding respite units per week up to the next quarter-hour on Form 2415. 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.

7142  Flexible Family Support Services Authorizations

Revision 13-4; Effective November 1, 2013

The case manager follows Medically Dependent Children Program 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 must follow procedures in Section 4125, Flexible Family Support Services Authorizations, for rounding flexible family support services units per week up to the next quarter-hour on Form 2414. 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.

7143  Practitioner's Orders or Form 2428 for Respite or Flexible Family Support Services

Revision 13-2; Effective May 1, 2013

The Home and Community Support Services 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 or Flexible Family Support Services; 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, Physician's Orders for Licensed Nursing Services, 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 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
  • 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 2414, Flexible Family Support Services Authorization, or Form 2415, Respite Service Authorization. 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, 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 Respite or Flexible Family Support Services to be delivered by an attendant with delegated tasks, the case manager must review the HCSSA 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 or Form 2415, and the 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 2414 or Form 2415. The case manager must contact the individual/primary caregiver to inform the individual/primary caregiver of the change in provider type before sending the updated Form 2414 or 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 the 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, or 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 or Form 2415 for RN or LVN provider types.

If the request for assistance does not meet Respite or Flexible Family Support Services criteria, the case manager denies the individual's request for the service.

7144  Program Ineligibility at Annual Reassessment

Revision 14-1; Effective February 3, 2014

If the individual does not meet eligibility criteria at the annual reassessment, the case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations/Codes (see the Form 2065-C instructions) to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination to the individual and providers. The case manager must send Form 2065-C to the individual no later than 30 days before the end of the individual's Individual Plan of Care (IPC) period. The day the case manager completes Form 2065-C is day zero and starts the 30-day time frame for the notification period.

The case manager does not complete any service authorization forms when denying Medically Dependent Children Program (MDCP) services for an individual at the annual reassessment.

For case closures resulting from loss of Medicaid, see Section 5500, Loss of Medicaid.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center by fax within two working days of the program ineligibility determination.

If the individual or individual’s parent or guardian does not participate in the development of the IPC 60 to 90 days prior to the end of the current IPC, the case manager must deny MDCP program eligibility. The case manager must mail Form 2065-C to the individual at least 30 days prior to the end of the current IPC and list the last day of the current IPC as the last day the individual is eligible to receive services.

7150  Service Authorization System Data Entry

Revision 13-2; Effective May 1, 2013

The case manager must data enter the Individual Plan of Care (IPC) developed during the annual reassessment in the Service Authorization System (SAS) by the end of the previous IPC period. 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.

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

The case manager must document all delays if SAS data entry cannot be completed at the same time as completion of:

  • Form 2065-B, Notification of Waiver Services;
  • Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services; or
  • a change to the IPC as a result of federal or state law.

The case manager must verify the information in SAS matches the new plan of care and service authorization forms. The plan of care form is Form 2410, Medical-Social Assessment and Individual Plan of Care, used for initial enrollments or annual reassessments.

The service authorization forms are:

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

7160  In-Home Record Review

Revision 12-1; Effective May 1, 2012

§51.219

(a)
To maintain enrollment in MDCP, the individual or the individual's parent or guardian must:
(6)
keep in the residence the most recent seven days of service delivery documentation as referenced in §51.503 of this chapter (relating to In-Home Record) and make it available to DADS upon request.
(b)
An individual may lose eligibility for MDCP if the individual or the individual's parent or guardian fails to comply with the requirements in subsection (a) of this section.

§51.503

A respite or adjunct support services provider must maintain an in-home record in the individual's residence that contains:

(1)
service delivery records from the last seven days of service;
(2)
the individual's practitioner's name and telephone number;
(3)
a signed copy of the Client's Rights and Responsibilities form;
(4)
a written evacuation plan;
(5)
emergency contact numbers;
(6)
an alternative service delivery plan for provider coverage;
(7)
contact numbers for reporting complaints, abuse, or neglect;
(8)
practitioner's orders for any skilled care or tasks, medications, or delegated tasks, signed within the preceding 12 months, if applicable; and
(9)
if applicable, signed and dated nursing notes that must include the following information:
(A)
medication administration or treatment;
(B)
nursing interventions completed according to practitioner's orders; and
(C)
the nursing assessment completed at the beginning of each shift.

7161  MDCP Nurse Procedures

Revision 13-4; Effective November 1, 2013

The Medically Dependent Children Program (MDCP) nurse completes Form 2425, In-Home Record Review, reviewing the in-home record at the annual reassessment for the required documentation in accordance with 40 Texas Administrative Code (TAC) §51.503 and §51.219. If services are delivered by the Home and Community Support Services Agency (HCSSA), all items under HCSSA Option on Form 2425 apply. For individuals utilizing an attendant providing non-delegated tasks who is employed by an HCSSA, the nurse is not required to review service delivery records from the last seven days of service. Time sheet data, whether in written format or electronic format, such as Electronic Visit Verification (EVV), will serve as documentation that attendant services and non-delegated tasks were rendered in accordance with an individual’s service plan developed by the HCSSA. Regional nurses must write in “N/A” next to this criterion on Form 2425 when this applies. This only applies to non-delegated tasks delivered by unlicensed persons through an HCSSA. Regional nurses must continue to monitor service delivery records for attendants with delegated tasks and licensed nurses through the HCSSA option.

For individuals fully participating in EVV and the CDS option, the nurse will not monitor for Form 1745 but will instead verify if the individual or individual's parent or guardian has the "Visits Summary By Client" report from the Santrax system in the in-home record and document this on Form 2425 under the CDS option. For individuals utilizing the CDS option and choosing the Partial Participation option or the No Participation option in EVV, the nurse must review Form 1745. The MDCP nurse must forward the completed Form 2425 to the case manager within five working days after the in-home record review.

7162  Case Manager Procedures

Revision 12-1; Effective May 1, 2012

Within five working days of receipt of Form 2425, In-Home Record Review, from the Medically Dependent Children Program nurse, the case manager must review the form to determine if additional action is required:

  • If the form indicates all items were present for the applicable delivery option, send a copy of Form 2425 to the Home and Community Support Services Agency or the Consumer Directed Services employer and file the original in the case file.
  • If the form indicates some items were not present, the case manager must follow up using the procedures identified below.

7163  Case Manager Procedures Regarding HCSSAs When Additional Action is Required

Revision 12-1; Effective May 1, 2012

Within five working days of receipt of Form 2425, In-Home Record Review, from the Medically Dependent Children Program nurse indicating items were not present in the in-home record, the case manager must contact the Home and Community Support Services Agency (HCSSA) by phone to request the missing documentation be filed in the in-home record. The case manager must also document the request on Form 2067, Case Information, and forward to the HCSSA. The HCSSA must fax or send the items not present in the in-home record to the case manager and confirm that it has been placed in the in-home record. If the Department of Aging and Disability Services does not receive the missing documentation within 10 working days after the request from the case manager, the case manager must call the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint. The case manager must identify the complaint is regarding a "Medically Dependent Children Program HCSSA," document the referral to CRS on Form 2405, Narrative Notes, and file it in the case file.

7164  Case Manager Procedures Regarding the Consumer Directed Services Option When Additional Action is Required

Revision 13-4; Effective November 1, 2013

Within five working days of receipt of Form 2425, In-Home Record Review, from the Medically Dependent Children Program (MDCP) nurse indicating that Form 1745, Service Delivery Log with Written Narrative/Written Summary, was not present in the in-home record for individuals choosing the Partial Participation option or the No Participation option in Electronic Visit Verification (EVV), the case manager must notify the individual, or the individual's parent or guardian, by sending Form 2421, In-Home Record Review Follow-Up. Form 2421 will indicate Form 1745 was not present during the in-home record review, and a follow up to ensure the form has been included in the in-home record will be conducted during the six-month monitoring contact. Form 2421 will also inform the individual, or the individual's parent or guardian, that non-compliance with the required documentation per 40 Texas Administrative Code (TAC) §51.219(a)(6) may result in the individual being disenrolled from MDCP services.

At the six-month monitoring contact, the case manager will request the individual, or the individual's parent or guardian, to provide a copy of Form 1745 to the case manager and confirm the form has been placed in the in-home record. This form can be given to the case manager if the contact is a home visit, or it can be faxed or sent to the case manager. If the individual, or the individual's parent or guardian, does not complete this requirement within 10 working days after the monitoring contact, the case manager must initiate case closure by sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services to the individual. The case manager will indicate on Form 2065-C that failure to meet the requirement in TAC §51.219(a)(6) is the reason for initiating case closure.