6110 Program Overview

6111 Service Introduction

The service array under the HCBS STAR+PLUS Waiver (SPW) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities. Eligible members receive services according to their specific needs, as defined by an assessment process, based on informed choice.

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 6113, General Requirements for Participation, and in accordance with the ISP.

6112 Service Locations for HCBS STAR+PLUS Waiver (SPW)

All HCBS STAR+PLUS Waiver (SPW) services, except minor home modifications, can be provided to members in locations of their choice whenever services are needed, as long as the location is in the member's private residence or in their family's own home. Nursing services, therapy services, adaptive aids (including dental) and medical supplies may be provided to an SPW member residing in a licensed personal care facility contracted to provide SPW services.

6113  General Requirements for Participation

HCBS STAR+PLUS Waiver (SPW) providers must:

• provide the array of services identified below in accordance with Form H1700-1, Individual Service Plan — SPW (Pg. 1), through its own employees, subcontractors or personal service agreements with qualified individuals. Services include:
  • personal assistance services;
  • nursing services;
  • physical therapy;
  • occupational therapy;
  • speech pathology services;
  • adaptive aids (including dental);
  • medical supplies;
  • minor home modifications;
  • emergency response systems;
  • assistive living;
  • adult foster care;
  • meals;
  • dental services;
  • Transitional Assistance Services; and
  • respite care (in-home);
• provide trained and competent staff for member care;
• maintain documentation of the assessment and provision of services; and
• provide for the delegation and supervision of nursing tasks and personal care tasks.

The managed care organization (MCO) must identify and access Medicare and other third-party resources for any services identified on the member's individual service plan (ISP) for non-waiver services as needed by the member.

Agencies may subcontract with an individual or a group in order to provide the necessary services, as long as the group designates at least one signature authority for the contract. A document showing signature authority for the person signing is required.

If a Home and Community Support Services provider is not providing services as authorized on the ISP or meeting the contract requirements, the MCO may authorize a change to another provider.

6114  Service Plan

The individual service plan (ISP) delivered to the service providers by the managed care organization (MCO) may consist of:

• Form H1700-1, Individual Service Plan — SPW (Pg. 1);
• Form H1700-2, Individual Service Plan — SPW (Pg. 2);
• Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
• Form H1700-A1, Certification of Completion/Delivery of HCBS STAR+PLUS Waiver Items/Services;
• Form H1700-B, Non-HCBS STAR+PLUS Waiver Services;
• Form 8598, Non-Waiver Services; and
• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

The MCO will only post Form H1700-1 to the XXXISP folder in TxMedCentral using the appropriate naming convention. All other forms are maintained in the member's file folder.

Upon assessment of the member for medically necessary services, the MCO staff person must sign Form H1700-2 to certify that the proposed ISP accurately reflects the needs of the member.

6115  Individual Agreement for Services

Managed care organizations (MCOs) may choose to provide services through Medicare, private insurance or through private pay arrangement with individuals awaiting determination of HCBS STAR+PLUS Waiver (SPW) eligibility. Services arranged by the agency and the applicant and implemented prior to the determination of the SPW eligibility date are not reimbursed and are provided at the MCO’s own risk.

The provider cannot be held responsible for deficits or failure in areas not included in the provider’s portion of the member's individual service plan when gratuitous care or care by other resources is being provided. The provider is responsible for the nature and quality of care a member receives under his/her direction as set forth by the Board of Nurse Examiners for the state of Texas.

6116  Refusal to Serve Applicants/Members

If a provider refuses to serve an individual based on licensure limitation, the reason the provider cannot adequately meet the needs of the applicant/member must be stated in writing to the member’s managed care organization. The reason must be related to the individual himself/herself and not previous efforts.

6120  Description of Services

Managed care organizations (MCOs) authorize HCBS STAR+PLUS Waiver (SPW) services to the member living in his/her choice of care setting whether in his/her own home, an Assisted Living facility, an Adult Foster Care home or other locations where he/she needs services.

Services and care provided, as identified and authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1), must assist the member to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Services provided are tailored to meet the member's goals and needs based upon his/her medical condition, mental and functional limitations, ability to self-manage, and availability of family and other support.

The MCO must assure the member's informed choice and convenience are incorporated into the planning and provision of the member's care by involved professionals. Members must be encouraged and allowed to play an active role in determining their ongoing plan of care.

While providing care under the standards of professional practice, MCOs must recognize and support the member's right to a dignified existence, privacy and self-determination.

6121  Personal Assistance Services

Personal assistance services provide assistance to the member, as authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1), with the performance of activities of daily living, household chores and nursing tasks delegated by a registered nurse. Taking care of household pets and ironing are not included under general household activities or chore services, and are not reimbursable under the HCBS STAR+PLUS Waiver (SPW).

6121.1  Description of Personal Assistance Services

• Personal assistance services (PAS) include, but are not limited to, the following:
  • assisting with the activities of daily living, such as feeding, preparing meals, transferring and toileting;
  • assisting with personal maintenance, such as grooming, bathing, dressing and routine care of hair and skin;
  • assisting with general household activities and chores necessary to maintain the home in a clean, sanitary and safe environment, such as changing bed linens, housecleaning, laundering, shopping, storing purchased items and washing dishes;
  • providing protective supervision;
  • providing extension of therapy services;
  • providing ambulation and exercise;
  • assisting with medications that are normally self-administered;
  • performing nursing tasks delegated by registered nurses; and
  • escorting the member on trips to obtain medical diagnosis, treatment or both.
• The managed care organization (MCO) must provide PAS as identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to members living in their own home and community settings.

Shopping

Because shopping is an authorized task, it may entail paying mileage to the attendant to perform the task. The member cannot be charged for transportation costs incurred in the performance of this task by either the attendant or the provider.

Ambulation

To facilitate safe member ambulation or movement, the attendant may need to, for example, rearrange furniture for members who use wheelchairs, walkers or crutches, or for blind members. The nurse addresses this activity during orientation for an attendant who provides services to a member needing this assistance.

Ambulation may be either a personal care task or a nursing task depending on the assessment by the MCO nurse. Ambulation, as a delegable nursing task, requires nursing intervention in response to a specific condition of the member. The member’s primary care physician (PCP) may or may not order specific ambulation orders. For example, the PCP may order "ambulation or activity as tolerated" for a member with congestive heart failure. This member experiences increased shortness of breath when ambulating. The nurse intervenes and delegates how to perform the ambulation (for example, member to walk no more than 10-15 steps without resting one to two minutes while taking several deep breaths before starting to walk again; attendant to support the member on one side while walking by holding on to his/her elbow).

Ambulation as a personal care task involves non-skilled assistance with walking/transferring while taking the usual precautions for safety (that is, standby assistance, gentle support of an elbow for balance or assuring balance of a walker). This does not involve nursing intervention. No special precautions are needed other than for safety measures.

If ambulation is authorized as a nursing task, the service coordinator must not authorize ambulation as a non-skilled task on Form 2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form 2060, the service coordinator must consider the individual's need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the service coordinator must document in the case record why and how the member requires both. The service coordinator can approve both if there is no duplication.

Escort

Escorting a member for medical diagnosis or treatment does not include the direct transportation of the member by the attendant. Transportation for Medicaid recipients is available in every county through the Medical Transportation Program. Transportation is not included as an activity in the escort task.

Therapy

Licensed therapists may choose to instruct the attendants in the proper way to assist the member in follow-up of therapy sessions. This assistance/support provides reinforcement of instruction and aids in the rehabilitative process.

Protective Supervision

Protective supervision is authorized by the MCO, and assures supervision of the member during instances in which the primary caregiver is out of the home.

Protective supervision is supervision only and does not require the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to his/her cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn himself/herself, or try to walk and then fall. Protective supervision is not routinely authorized because the unpaid caregiver is encouraged to be out when the personal care attendant is providing care in the member's home.

6121.2  Qualifications for Registered Nurse Supervisors

Supervision of personal care attendants is provided by the contracted agencies’ registered nurses (RNs) who:

• have proof of a current license from the Board of Nurse Examiners for the state of Texas, and
• practice in compliance with the Nurse Practice Act according to the rules and regulations of the Board of Nurse Examiners.

Proof of licensure can be validated by viewing the nurse's original current license and recording in a log the nurse's name, license number, date of expiration and initials of the individual who verified the license is current. If necessary, licenses can be verified with the Board of Nurse Examiners by telephone or written request.

6121.3  Qualifications of Personal Assistance Services Attendants

Personal assistance services are performed by personal care attendants who:

• are employed by a managed care organization-contracted agency; and
• are not spouses of members.

6121.4  Types of Personal Care Attendants

The two types of personal care attendants are:

• regular attendants who perform all of the personal attendant services available within their scope of competency; and
• special attendants who may be used to initiate services, prevent a break in service and provide ongoing service.

6210  Role of the SPW/HCSS Nurse with the TPR Nurse

When a managed care organization's (MCO) registered nurse (RN) or an RN from a Home and Community Support Services (HCSS) provider contracted with the MCO and an RN from a third-party resource (TPR), such as Medicare, share responsibility and care in a HCBS STAR+PLUS Waiver (SPW) case, each nurse is accountable for his/her own actions. If the RN is sharing nursing tasks with the Medicare nurse, it is expected that the nurses will collaborate in determining the necessary interventions and performance of tasks, with Medicaid being the last payer. The RN and the Medicare RN do not supervise each other.

6220  Role of the Licensed Vocational Nurse

The licensed vocational nurse (LVN) contracted with the managed care organization may deliver nursing services to include training attendants, Adult Foster Care providers and provider substitutes on nursing tasks after the registered nurse has assessed the member and established the plan of care. The LVN may not complete the Medical Necessity and Level of Care Assessment or initiate any service plan changes.

6230  Nursing Services in Members' Homes

Registered nurse supervisors delegate, supervise and monitor personal care attendants in the delivery of personal care and/or nursing tasks under personal assistance services. If nursing tasks cannot be delegated, for whatever reason, the agency must continue meeting the member’s identified needs for nursing care by direct delivery from licensed nurses.

6240  Nursing Services in Personal Care Facilities

Licensed nurses directly deliver care, with the exception of medication administration, to members requiring nursing services residing in personal care facilities. Delegation of nursing tasks to facility attendants is not allowed by licensure.

6250  Nursing Services in Adult Foster Care Homes, Levels I and II

The nurse provides direct delivery of nursing services, as well as delegation of nursing tasks, in Adult Foster Care (AFC) homes, Level I and II.

The nurse must orient and train the AFC provider and substitute provider simultaneously. This simultaneous training is intended to be cost-effective to avoid adverse impact on the member's individual service plan cost ceiling. It is the AFC provider’s responsibility to have the substitute provider available for the nurse’s training.

Following a condition change, a member may need increased nursing tasks on a short-term basis for stabilization or rehabilitation to previous health status. These nursing tasks may exceed the skill and ability of the AFC provider caring for the member and/or the AFC provider may not choose to learn these more complex nursing tasks. Or it could be that other criteria for delegation are not met. In these instances, to avoid disrupting the member's living situation, the service coordinator may authorize short-term direct nursing services or explore the possibility of accessing other resources for the provision of skilled care.

6251  Nursing Services in AFC Homes Operated by Licensed Nurses

In serving a member in any level HCBS STAR+PLUS Waiver (SPW) program Adult Foster Care home operated by a licensed nurse, the managed care organization completes the SPW program assessments.

6252  Interim Assessments

To assure quality of care for members in the HCBS STAR+PLUS Waiver (SPW) by identifying significant changes in conditions and initiating appropriate interventions on a timely basis, the managed care organization performs interim assessments on current SPW members contingent on changes in the member’s health condition.

6260  Specialized Nursing

Specialized Nursing (SN) services delivered by a registered nurse or licensed vocational nurse are available through the HCBS STAR+PLUS Waiver (SPW) program. SN services may be used when a member requires, as determined by a physician, daily skilled nursing to:

• cleanse, dress and suction a tracheostomy; or
• provide assistance with ventilator or respirator care.

The member must be unable to do self-care and require the assistance of a nurse for the ventilator, respirator or tracheostomy care.

6310  Initiation of Assessment and Therapy

Upon recommendation from the nurse, primary care physician, medical doctor or service coordinator for a therapy assessment, the managed care organization authorizes appropriate hours based on physician orders on the initial service plan for the assessment and the service initiation, if applicable.

6320  Responsibilities of Licensed Therapists in SPW

Responsibilities of the licensed therapists include, but are not limited to, the following:

• assessing the member's need for therapy, adaptive aids and minor home modifications;
• delivering direct therapy as authorized in the individual service plan;
• supervising delivery of therapy rendered by the therapy assistant as authorized in the plan of care;
• informing the physician and other team members of changes in the member's health status requiring a service plan change;
• training the member to use adaptive aids; and
• participating in interdisciplinary team meetings, when appropriate and requested by the managed care organization.

6410  List of Adaptive Aids and Medical Supplies

Adaptive aids and medical supplies are covered by the HCBS STAR+PLUS Waiver (SPW) only after the member has exhausted any third-party resources, including Medicare and Medicaid home health the member is eligible to receive. Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of but are not limited to following:

• lifts:
  • wheelchair lifts porch or stair lifts;
  • hydraulic, manual or other electronic lifts;
  • stairway lifts;
  • bathtub seat lifts;
  • ceiling lifts with tracks;
  • transfer bench;
• mobility aids, including batteries and chargers:
  • manual/electric wheelchairs and necessary accessories;
  • three-wheel scooters;
  • mobility bases for customized chairs;
  • braces, crutches, walkers and canes;
  • forearm platform attachments for walkers and motorized/electric wheelchairs;
  • prescribed prosthetic devices;
  • prescribed orthotic devices, orthopedic shoes and other prescribed footwear;
  • prescribed exercise equipment and therapy aids;
  • portable ramps;
• respiratory aids:
  • ventilators/respirators;
  • back-up generators;
• positioning devices:
  • standing boards, frames and customized seating systems;
  • electric or manual hospital beds, tilt frame beds and necessary accessories;
  • egg crate mattresses, sheepskin and other medically related padding;
  • trapeze bars;
  • lift recliners;
• communication aids (including repair, maintenance and batteries):
  • augmentative communication devices:
    • direct selection communicators;
    • alphanumeric communicators;
    • scanning communicators;
    • encoding communicators;
    • speaker and cordless telephones for persons who cannot use conventional telephones;
  • speech amplifiers, aids and assistive devices;
  • interpreters;
• control switches/pneumatic switches and devices:
  • sip and puff controls;
  • adaptive switches/devices;
• environmental control units:
  • locks;
  • electronic devices;
  • voice-activated, light-activated and motion-activated devices;
• medically necessary durable medical equipment not covered in the state plan for the Texas Medicaid Program;
• temporary lease/rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment;
• payment of premium deductibles and co-insurance (for items covered under the waiver), including rentals for Medicare or third-party resources, if not covered under the Qualified Medicare Beneficiary or the Medicaid Qualified Medicare Beneficiary programs;
• modifications/additions to primary transportation vehicles:
  • van lifts;
  • driving controls:
    • brake/accelerator hand controls;
    • dimmer relays/switches;
    • horn buttons;
    • wrist supports;
    • hand extensions;
    • left-foot gas pedals;
    • right turn levers;
    • gear shift levers;
    • steering spinners;
  • medically necessary air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature;
  • removal or placement of seats to accommodate a wheelchair;
  • installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle;
  • raising the roof of the vehicle to accommodate a member riding in a wheelchair;
  • installation of frames, carriers, lifts for transporting mobility aids;
• sensory adaptations:
  • eyeglasses;
  • hearing aids;
  • auditory adaptations to mobility devices; and
• adaptive equipment for activities of daily living:
  • assistive devices:
    • reachers;
    • stabilizing devices;
    • weighted equipment;
    • holders;
    • feeding devices, including:
    • electric self-feeders;
    • food processors and blenders – only for individuals with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances;
  • variations of everyday utensils:
    • shaped, bent, built-up utensils;
    • long-handled equipment;
    • addition of friction covering;
    • coated feeding equipment;
  • medication reminder systems (manual);
  • walking belts and physical fitness aids;
  • specially adapted kitchen appliances;
  • toilet seat reducer rings unless member resides in an Assisted Living (AL) facility;
  • hand-held shower sprays unless member resides in an AL facility;
  • shower chairs unless member resides in AL/residential care facility;
  • electric razors;
  • electric toothbrushes;
  • water piks;
  • service animals;
  • over-bed tray tables unless member resides in an AL facility;
  • safety restraints and safety devices:
    • bed rails;
    • safety padding;
    • helmets;
    • safety restraints;
    • flutter boards;
    • life jackets;
    • elbow and knee pads;
    • visual alert systems;
  • medically necessary heating and cooling equipment for individuals with respiratory or cardiac problems, people who cannot regulate temperature or people who have conditions affected by temperature; and
  • medical supplies necessary for therapeutic or diagnostic benefits for:
    • tracheostomy care;
    • decubitus care;
    • ostomy care;
    • pulmonary, respirator/ventilator care; and
    • catheterization.

Other types of supplies include:

• diapers, linens and other incontinence supplies;
• nutritional supplements;
• enteral feeding formulas and supplies;
• diabetic supplies (strips, lancelets, syringes);
• Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs;
• stethoscopes, blood pressure monitors and thermometers for home use; and
• blood glucose monitors.

6411  Adaptive Aids

Transportation and Mobility Aids

Wheelchairs and scooters that primarily enable the individual to increase his/her abilities to perform activities of daily living in the home and in the community are reimbursable as a STAR+PLUS Waiver (SPW) adaptive aid. Specialized wheelchairs may be approved with documentation of medical necessity and cost effectiveness. Wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports do not meet waiver requirements and are not covered by the SPW waiver.

Repairs are part of normal vehicle maintenance and cannot be covered. Installation of heavy-duty shocks as required by a lift installation may be included as part of the vehicle modification. A trailer (including taxes) for transporting wheelchairs or scooters may be approved with documentation of medical necessity.

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Posturpedic- or Tempurpedic-type mattresses are not generally the most cost-effective way to meet a member's needs. Medicare/Medicaid can cover hospital beds and specialty mattresses for skin breakdown. Specialty sheets, such as hospital bed sheets, may be covered.

The SPW program does not pay for central air conditioning and heat. SPW funds can be used to purchase window air conditioners (including wiring), etc., for a member's principal living area, such as a bedroom. SPW does not pay for multiple air conditioners to cover a member's residence.

SPW will pay for a Geri-chair if the member is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and SPW does not pay for restraints.

Medical alert bracelets may be purchased.

Count-A-Dose® (registered product) medication systems specifically designed for diabetics and other medication reminder systems (manual) may be approved if medical necessity exists. Approval of a sharps or biohazard container requires approval from the managed care organization (MCO).

Anti-embolism hose/stockings such as Thromboembolic Disease (T.E.D.) hose require MCO approval. The nurse or service coordinator may approve subsequent requests if there has not been a change in the member's condition and ability to apply and remove the hose.

Bedside commodes may be purchased as adaptive aids.

6412  Medical Supplies

Oxygen

Equipment necessary to provide oxygen is specifically covered by Medicaid.

Tubing, masks, cylinder refills and distilled water are examples of some medical supplies necessary for pulmonary and respirator or ventilator care and are covered by Medicaid.

Paying the co-insurance for oxygen provided on a rental basis through Medicare or private insurance is a cost-effective way of providing service to an individual when purchase is not considered or the oxygen can be rented with the option to buy. If this is the case, the oxygen co-insurance is billed under adaptive aids.

Incontinence Supplies

"Linens" as incontinence supplies could include sheets, towels and washcloths if the items are documented as medically necessary. Feminine protection products used as a cost-effective replacement for other incontinence supplies may be approved if adequately documented.

Other types of incontinence supplies that may be purchased as medical supplies are skin barrier products, enemas and wipes. Regular or antiseptic wipes may be approved if a medical need is documented. The managed care organization (MCO) may approve moisture skin barriers if a medical need is documented and the product is verified as a skin barrier product.

Diabetic Supplies

Medicare pays for glucose monitors, test strips and lancets for all diabetic members at 80% of the cost. The STAR+PLUS Waiver (SPW) can cover the 20% co-insurance if no other resources are available. For instances in which the individual is not covered by the Qualified Medicare Beneficiary or Medicaid Qualified Medicare Beneficiary programs or a third-party resource for items covered through SPW and identified on the individual service plan, the co-insurance can be authorized under adaptive aids on Form H1700-1, Individual Service Plan — SPW (Pg. 1), for payment through SPW.

Insulin syringes and needles are obtained by the member through the Vendor Drug Program of the Texas Health and Human Services Commission, not through SPW.

Diabetic shoes are paid for through Medicare if there is a physician order. If the member does not have Medicare, the MCO may approve diabetic shoes if there is a documented medical need and a physician order for the shoes. MCO nurse approval is required for requests for diabetic slippers or socks.

Gloves

Gloves may be purchased through SPW for family use in the care of the incontinent member, if the member has an active infectious disease that is transmitted through urine (if incontinent of urine) or stool (if incontinent of stool). Examples of active infectious diseases that qualify are Methicillin-Resistant Staphylococcus Aureus (MRSA) and hepatitis. Gloves may be purchased for family use to provide wound care to protect the member. Documentation by the MCO-contracted provider must support the need of gloves to be left at the residence and for family use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his/her approval.

SPW does not purchase gloves for universal precautions. Gloves for use by an Adult Foster Care (AFC) provider or any contracted provider staff should not be purchased with SPW funds. AFC rates take into account the higher level of care provided in the AFC home.

Other Medical Supplies

Toiletry items such as toothpaste, mouth swabs, waterless soap, shampoo, lotions, powders, deodorant, etc., are personal hygiene items and are not covered under the waiver.

Vitamins cannot be purchased as a medical supply.

Enemas may be approved if not available through Medicaid or other third-party resources.

Blood pressure monitors, including wrist monitors, may be approved if medically necessary.

6420  Approval of Adaptive Aids and Medical Supplies

In the initial pre-enrollment assessment, the managed care organization (MCO) nurse identifies the basic needs of the member for adaptive aids andHCBS STAR+PLUS Waiver medical supplies along with the estimated costs on Form H1700-1, Individual Service Plan — SPW (Pg. 1). The nurse must provide documentation supporting the medical necessity for all adaptive aids and medical supplies. The documentation must be provided by the physician, physician assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist or speech pathologist. Use of Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services, is optional as long as the required documentation as specified on Form H1700-A is provided.

Adaptive aids and medical supplies are approved for purchase as a waiver service by the MCO only if the documentation supports the requested item(s) as being necessary and related to the member's disability or medical condition.

The MCO determines if the documentation submitted is adequate, and makes the decision as to whether an adaptive aid or medical supply is needed and related to the member's condition. The MCO makes the final decision if the purchase is necessary and will be authorized on the individual service plan (ISP).

If the member's request for a particular adaptive aid or medical supply is denied as part of the initial approval of HCBS STAR+PLUS Waiver (SPW) enrollment, at reassessment, or during the ISP year (even though eligible for SPW services), the member must receive written notification of the denial of the specific item following the requirements outlined in the Uniform Managed Care Manual, Chapter 3.21.

If the member requests an item the MCO deems is not medically necessary or related to the member's disability or medical condition, the MCO sends an adverse determination notice to the member.

For situations in which the member requests an adaptive aid or medical supply, and the item(s) are documented by the nurse or other medical professional to be medically necessary, the MCO has the option of approving the item(s). If not approved, the MCO sends the adverse determination notice to the member.

The member may appeal the denial by filing an appeal with the MCO. The member does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP. The cost of the item is reflected in the ISP in effect at the time of the appeal.

Service plans should be individualized to the member. All items must be related to the member's disability or medical condition.

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive SPW services. On existing cases, the provider must deliver medical supplies within five business days of being authorized to purchase the supplies. The member's current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot deliver the adaptive aids by the appropriate time frames, the provider must notify the MCO via Form 2067, Case Information, and include the reasons the adaptive aid will be late. The MCO reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the MCO to discuss the reasons for the delayed delivery with the member and provider staff.

If the adaptive aid requested will not be delivered in the current ISP, the item must be transferred to the new ISP. If the authorization on the new ISP causes the service plan to exceed the annual cost limit, the nurse may authorize it using the date the item was ordered by the provider as the date of service delivery and the provider may bill against the previous ISP.

6421  Lift Chair Approvals

Lift chairs may be authorized as adaptive aids as part of the HCBS STAR+PLUS Waiver (SPW) service array. Use the following procedures if attempting to purchase the lift chair using Medicare funding.

Once the managed care organization (MCO) determines a lift chair may be needed or is requested by the member, the MCO assesses the individual to determine if the individual meets all of the following criteria required for Medicare to pay for the lift mechanism:

• The individual must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
• The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the individual's condition.
• The individual must be completely incapable of standing up from any chair in his/her home. Once standing, the individual must have the ability to ambulate.

Individual Does Not Meet All Criteria

If the individual does not meet all of the Medicare criteria, the MCO completes Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services. The MCO should state the following on Form H1700-A, Section 4, "Lift Chair: Plus Mechanism." The MCO is not required to submit Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, showing Medicare denial. Along with Form H1700-A, the MCO must obtain a:

• prescription or statement signed by the physician certifying the need for the lift chair, specifically stating the individual has difficulty or is incapable of getting up from a chair; and
• statement by the physician or provider specifically stating that once standing, the individual has the ability to ambulate or transfer with or without assistance.

The MCO approves the cost of the lift chair plus the mechanism if the request meets all criteria and the above documentation is received.

For instances in which the MCO cannot obtain or provide the required documentation because the member does not meet the requirements, the MCO must complete Form H1700-A, Section 4, stating that the lift chair is not medically necessary. The MCO denies the request for the lift chair.

Individual Meets All Criteria

If the MCO determines the individual meets all of the criteria for Medicare to pay for the lift mechanism, the MCO:

• approves the cost of the lift chair minus the mechanism;
• authorizes the durable medical equipment provider to deliver the lift chair and bill Medicare for the mechanism; and
• must state the following on Form H1700-A, Section 4, "Lift Chair: No Mechanism."

If a request for a lift chair minus the mechanism is approved by the MCO, but the provider later requests additional funds for the mechanism denied by Medicare, the MCO may approve the request if it meets all HCBS STAR+PLUS Waiver (SPW) criteria, and Form 3672 or other documentation is received stating the lift mechanism was denied by Medicare. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

6422  Nutritional Supplement Approvals

The following procedures must be used when authorizing nutritional supplements in the HCBS STAR+PLUS Waiver (SPW) program:

• All requests for nutritional supplements must be approved by the managed care organization (MCO).
• Products such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, bottled water, nutrition bars, protein bars and breakfast cereals are not covered by SPW.

Liquid nutritional supplements are covered by SPW when they are medically necessary and have either a therapeutic or a diagnostic benefit specific to the individual's diagnosis that is necessary to carry out the individual service plan (ISP). Ensure, Boost, Resource, Jevity, Glucerna (which is used primarily by individuals with diabetes), Pulmocare (which is used primarily by individuals with pulmonary disease) and Arginaid (which is used primarily by individuals with burns or wound care) are examples of covered nutritional supplements. Medical necessity does not include situations in which an individual chooses a nutritional supplement in place of eating a meal for reasons of personal preference or convenience. Nutritional supplements, if approved, are authorized and billed as medical supplies.

Nutrition bars, protein bars and breakfast cereals, including those marketed to individuals with specific medical conditions, such as Glucerna cereal and Glucerna snack bars (marketed to individuals with diabetes), do not require medical supervision and are not covered by the programs. Products such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin-enhanced water and bottled water are available to individuals for overall health benefits and convenience. These products do not require medical supervision and are not covered by SPW.

All requests for nutritional supplements must be approved by the MCO nurse. This includes initial requests for nutritional supplements, requests to increase the quantity/amount of supplements an individual is already receiving, and ongoing requests for supplements when a new ISP is being developed. The MCO nurse determines if the nutritional supplement will be approved on the ISP.

The nurse must complete:

• Form H1700-1, Individual Service Plan — SPW (Pg. 1);
• Form H1700-2, Individual Service Plan — SPW (Pg. 2);
• Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services;
• the most current Medical Necessity and Level of Care (MN and LOC) Assessment;
• Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report, or a statement indicating the item(s) are not covered by Medicare, Medicaid or other third-party resource; and
• any additional documentation submitted by the provider, such as a physician's order.

The MCO reviews the information, determines if the nutritional supplement will be approved or denied, and documents the determination. This process does not extend the 14-day time frame the MCO has to respond to service plan changes.

6430  Effects of Changing MCOs on Adaptive Aids Procurements

If a member changes to another managed care organization (MCO) while an adaptive aid remains on order or in the process of being delivered, the losing MCO is responsible for payment and delivery of the adaptive aid.

6440  Time Frames for Adaptive Aids/Medical Supplies

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) form or the date the form is received, whichever is later.

The MCO must notify the member and service coordinator in writing of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization.

Form H1700-1, Individual Service Plan — SPW (Pg. 1), authorizing the purchase of the requested adaptive aid, must be date stamped upon receipt. The MCO has 14 or 30 business days counting from either the effective date entered on Form H1700-1 or the date the form is received, whichever is later, to purchase and deliver the adaptive aid.

If there will be a delay in the delivery, the MCO must provide written notice to the member of the expected delay in the delivery and provide notification of the new proposed delivery date prior to the date the adaptive aid should have been delivered. Written notification must be mailed by the date the adaptive aid is required to be delivered.

For medical supplies, the MCO is responsible for assuring the purchase and delivery of any authorized medical supply within five business days of the waiver service initiation date. On existing cases, the MCO must deliver medical supplies within five business days of being authorized to purchase the supplies, counting from the effective date of the ISP form or the date the form is received, whichever is later.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit the case information form to the MCO before the fifth day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time.

Stockpiling of medical supplies must not occur. Supplies, such as incontinence and wound care supplies not covered through Medicaid Home Health and needed on an ongoing basis, should be delivered so there is no more than a three-month supply in the member's home at a time.

6450  Co-Insurance and Deductibles

Reimbursement for the cost of co-insurance for the purchase or rental of adaptive aids or the purchase of medical supplies reimbursed by Medicare or private health insurance is available if the following conditions are met:

• the member does not have coverage under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
• the adaptive aid or medical supply is listed in the service definition of this handbook or has been prior authorized by managed care organization management; and
• documentation submitted supports the necessity of the item(s) for the individual's disability or medical condition.

Reimbursement for the co-insurance amount to Medicare or private health insurance for therapy services or the rental of any adaptive aids is a cost-effective way to utilize third-party resources. The cost of any co-insurance payment must be billed under adaptive aids.

For instances in which a member is not covered under the QMB or MQMB programs and cannot pay his/her premium deductible under a third-party resource for items covered under the waiver, the deductible can be listed under adaptive aids on Form H1700-1, Individual Service Plan — SPW (Pg. 1), for payment.

6451  Temporary Lease and Equipment Rental

Rental of equipment allows for repair, purchase or replacement of the essential equipment, or temporary usage of the equipment. The length of time for rental of equipment must be based on the individual circumstances of the member. If the medical professional and/or the member is not certain the medical equipment will be useful, the equipment should be rented for a trial or short-term period before purchasing the equipment.

When renting equipment, the cost of rental versus purchase may be explored. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment may be considered in the decision to rent or purchase. It may be more cost-effective, after renting for a period of time, to purchase the equipment instead of continuing to rent.

Used adaptive aids can be purchased if the member prefers to buy used equipment and documentation verifies the equipment is appropriate, functions properly and is the choice of the individual.

6452  Bulk Purchase of Medical Supplies

The managed care organization may choose to buy medical supplies in bulk. The cost of storing supplies can be reported on the annual cost report as an allowable expense. The medical supply is billed at the unit rate based on the invoice cost of the bulk purchase divided by the number of units purchased.

6460  Reserved

6470  Reserved

6480  Reserved

6490  Dental Services

Effective Feb. 1, 2011, dental services will be available as an HCBS STAR+PLUS Waiver (SPW) service. Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership. The managed care organization coordinates the needed dental services for SPW members with licensed dentists.

6491  Allowable Dental Services

Dental services are those services provided by a licensed dentist to preserve teeth and meet the medical needs of the HCBS STAR+PLUS Waiver (SPW) member. Allowable dental services include:

• emergency dental treatment procedures necessary to control bleeding, relieve pain and eliminate acute infection;
• preventative procedures required to prevent the imminent loss of teeth;
• treatment of injuries to the teeth or supporting structures;
• dentures and the cost of fitting and preparing for dentures, including extractions, molds, etc.; and
• routine and preventative dental treatment.

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by SPW when no other financial resource for such services is available and when all other available resources have been used. MCOs must not authorize dental services for cosmetic treatments.

6492  Documentation of Dental Services by a Dentist

The managed care organization (MCO) must ensure all requests for dental treatments include documentation by a professional dentist of the need for dental services. A dentist must determine the medical necessity for dental treatment and submit a detailed treatment plan to the MCO to document the medical necessity and all specific dental procedures to be completed. The dentist may not bill the HCBS STAR+PLUS Waiver (SPW) member for the remainder of the cost over the approved amount.

Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services, must be completed by the MCO to document the medical need for requested SPW items/services. Medical necessity for dental services is completed by the dental professional, as described above. Form H1700-A may be submitted in lieu the process described above, if the information is sufficient to describe the medical need for the dental services.

6493  Responsibilities Pertaining to Dental Services

Dental services are approved for purchase as a waiver service by the managed care organization (MCO) only if the documentation supports the requested dental services as being necessary to preserve teeth and meet the medical needs of the member. The MCO must discuss with the HCBS STAR+PLUS Waiver (SPW) member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through SPW.

6494  Responsibilities Pertaining to Minor Home Modifications

In order to ensure cost-effectiveness in the purchase of minor home modifications (MHMs), it is recommended that the managed care organization (MCO):

• determine and document the needs and preferences of the member for the MHM; and
• document the necessity for the MHM.

The MCOs have their own policies and procedures in regards to bidding, awarding contracts, doing inspections and completing MHMs.