Texas Health and Human Services Commission
Effective: March 1, 2013
STAR+PLUS Waiver Program Services
7100 Adult Foster Care
Adult Foster Care (AFC) provides a 24-hour living arrangement in a Department of Aging and Disability Services (DADS) contracted foster home for persons who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes. Services may include meal preparation, housekeeping, personal care, nursing tasks, supervision, companion services, daily living assistance and provision of, or arrangement for, transportation.
The HCBS STAR+PLUS Waiver (SPW) AFC member must reside in an SPW AFC home. Providers of AFC must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. The individual enrolled to provide AFC must be the primary caregiver. Providers may serve up to three adult members in a DADS-enrolled AFC home without licensure as a personal care home. Up to four residents may be served in a foster home, though there are limitations as to the number of members at each level who may reside in one home.
The delegation of nursing tasks by a registered nurse to the AFC provider is required based on the provider's abilities and the needs of the member. The three levels of participation for AFC are explained in Section 7133, Classification Levels of Adult Foster Care Members.
SPW members are required to pay for their own room and board costs, and contribute to the cost of their care, if able, through a copayment to the AFC provider.
AFC providers must be licensed by DADS, pass inspections for fire safety and health conditions, receive all required training and meet all applicable requirements in the Licensing Standards for Assisted Living Facilities Handbook.
The Adult Foster Care (AFC) provider must provide 24-hour care in a home licensed by the Department of Aging and Disability Services. Services may include, but are not limited to:
Personal care — Help with activities related to the care of the member's physical health that includes but is not limited to bathing, dressing, preparing meals, feeding, exercising, grooming (routine hair and skin care), toileting and transferring/ambulating.
Nursing tasks requiring delegation — Certain nursing tasks delegated by a registered nurse in accordance with the rules promulgated by the Texas Board of Nurse Examiners.
Transportation — Arrangement of and/or direct transport of members to meet their basic needs for food, clothing, toiletries, medications, medical care and necessary therapy.
Supervision — Periodic checks or visits by the provider to the member throughout the 24-hour period to assure the member is well and safe. For some members with more intensive medical needs or behavior problems, more supervision is required.
Meal preparation — Preparation or provision of meals adequate to meet the needs of the member.
Housekeeping — Activities related to housekeeping that are essential to the member's health and comfort, such as changing bed linens, housecleaning, laundry, shopping, arranging furniture, washing dishes and storing purchased items.
AFC services, with the exception of 24-hour supervision that is provided to all HCBS STAR+PLUS Waiver (SPW) members in AFC, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. SPW members may not require assistance with medication, for example, or need help with transportation, but the services are available to all SPW members in AFC homes. Personal care tasks must be provided as identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The AFC provider may provide more services for the member than are authorized, but not fewer.
SPW members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to scheduling medical transportation is available locally to members.
7112 Other Services Available to Adult Foster Care Members
Adaptive Aids and Medical Supplies — The HCBS STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) member is eligible to receive needed adaptive aids and medical supplies under the SPW program. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live.
Nursing Services — Services available through the SPW program provide ongoing nursing intervention for Level I and Level II members with chronic medical conditions and include activities related to the delegation of specific nursing tasks to the AFC providers or designated substitute providers.
If the nurse assessment determines a need for nursing tasks that can be delegated to an AFC provider, these nursing tasks are initially provided by the registered nurse until the decision is made to delegate. If delegation of nursing tasks to the AFC provider is not possible, the managed care organization (MCO) discusses options available to the SPW member.
Minor Home Modifications — Services that assess the need, arrange for, and provide modifications and/or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the individual service plan (ISP).
The SPW AFC provider must agree to have modifications made to the home if the member requires the minor home modifications be made so that the home meets the member's needs. If the provider is the lessee of the home, the owner must be contacted and apprised of the needed modifications. Permission to make the modifications must be obtained from the home owner in writing and kept with Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services.
When the provider and member meet to interview each other and complete Form 2327, Individual/Member and Provider Agreement, the minor home modifications must be listed in "Miscellaneous Arrangements." Both the member and the provider must sign the form agreeing to all included information and stipulations.
To save the member from spending his/her allocation for minor home modifications unnecessarily, a minimum grace period of one calendar month must be allowed for the individual to adjust to the AFC placement before any modifications are begun.
If health and/or safety of the member is jeopardized without the necessary modifications upon entry into the AFC home, a waiver of the one calendar month period can be made based on the recommendations of the interdisciplinary team and approved by the MCO.
Minor home modifications remain in an SPW AFC home even if the member for whom the modifications were made permanently leaves the home.
Dental Services — Services provided by a licensed dentist to preserve teeth and meet the medical need of the member.
Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. Services consist of the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist and within the scope of his/her state licensure.
Physical Therapy — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Services consist of the full range of activities provided by a physical therapist or a licensed physical therapist assistant under the direction of a licensed physical therapist and within the scope of his/her state licensure.
Speech Pathology Services — The evaluation and treatment of impairments, disorders or deficiencies related to a memberís speech and language. Services include the full range of activities provided by a speech and language pathologist under the scope of the pathologist's state licensure.
Each of the above services is provided according to the needs of the member as identified on the ISP. The MCO makes referrals for the services and coordinates delivery.
An SPW AFC member may not receive SPW personal assistance services while a resident in a SPW AFC home. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed by the MCO to determine the needed tasks for completion by the AFC provider. Non-waiver services may be considered in the development of the ISP.
7120 Four-Bed Adult Foster Care Homes
A Type C Assisted Living (AL) license is obtained if the Adult Foster Care (AFC) provider wants to serve four members. The home cannot be approved for the fourth member until the provider has applied for and received the Type C license. The provider may apply for a Type C license from the Department of Aging and Disability Services Regulatory Services division. The license must be renewed yearly and requires an annual fee. A single facility could be both licensed as an AL facility and as an AFC home.
Settings of one to three beds do not require licensure. Refer to the Licensing Standards for Assisted Living Facilities Handbook for specific information about contracting, qualifications and enrollment requirements.
7121 Small Group Homes
Adult Foster Care (AFC) may also be provided in a small group home licensed by the Department of Aging and Disability Services (DADS) as Assisted Living (AL) Type A, Small, under the Minimum Licensing Standards for Assisted Living. The provider must submit a copy of the AL license to the managed care organization (MCO) before being credentialed and upon renewal thereafter. The provider must report to the MCO any problem(s) identified by DADS Regulatory Services. Providers must meet all applicable requirements in the minimum standards for AFC. Providers must serve no more than eight adult members in a small group home.
AFC provided in small group homes is subject to two sets of regulations: DADS minimum standards for AFC and Licensing Standards for Assisted Living Facilities. The stricter requirements apply when requirements conflict; therefore, an AFC home licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of members currently residing in the facility.
7122 MCO Responsibilities
The managed care organization (MCO) is responsible for all requirements for Adult Foster Care (AFC) applicants and members. The MCOís responsibilities include:
- completing the AFC assessment process using Form 2330, Assessment and Service Plan Approval for Adult Foster Care;
- assessing the applicant and provider to determine whether an appropriate environment can be provided;
- providing information to interested applicants about potential AFC homes and arranging visits to the homes;
- developing a service plan;
- acting as coordinator of the interdisciplinary team;
- authorizing AFC services;
- monitoring the member;
- notifying the applicant/member of room and board and copayment amounts;
- processing changes and conducting annual reassessments of the member;
- recruiting AFC homes;
- processing AFC applications;
- orienting and training the AFC provider;
- approving private pay members;
- conducting administrative reviews; and
- processing payments.
7130 Adult Foster Care Eligibility
To be eligible for Adult Foster Care (AFC), applicants and members must meet basic eligibility requirements for HCBS STAR+PLUS Waiver (SPW) services as well as specific requirements related to AFC. Basic eligibility requirements for SPW can be found in Section 3230, Financial Eligibility, and Section 3240, Waiver Requirements. In addition, applicants/members will be classified for level of service based on their assessed needs for care. Refer to Section 7133, Classification Levels of Adult Foster Care Members.
7131 AFC Intake, Assessment and Response to Request for Services
Adult Foster Care (AFC) is appropriate for individuals who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes and who need and desire the support and security of family living. AFC is also appropriate for individuals who do not need institutional care but are unable to resume independent living or have no friends or relatives who are able to provide a home.
Upon receipt of an intake for HCBS STAR+PLUS Waiver (SPW) AFC, the managed care organization (MCO) must explain the room and board requirements in AFC and ensure the applicant understands that he or she must pay a portion of his or her monthly income for room and board. The MCO must explain that some AFC members are required to contribute to the cost of their care by paying a copayment.
7132 Assessing Potential Adult Foster Care Homes
If the applicant appears to meet eligibility criteria, the managed care organization (MCO) provides information about potential Adult Foster Care (AFC) homes. The MCO can arrange visits to appropriate AFC homes or, if the applicant is capable or has family/supports available, the applicant/family may make the arrangements to visit potential AFC homes. In some situations, the MCO may need to assist the applicant in making the visit(s).
The purpose of the visits to potential AFC homes is to let the applicant assess the home and let the AFC provider assess if the applicant will be appropriate in the AFC home. The MCO may contact the provider and share information about the applicant, including the applicant's particular needs and problems, to ensure the potential provider is fully aware of the responsibilities involved in caring for the applicant and to prevent a potential mismatch of the applicant and the provider.
The MCO also shares information on nursing care, home modifications or adaptive aids that may be necessary. In choosing a home, consideration should be given to the providerís willingness and capability to perform nursing tasks. The MCO must also inform the AFC provider if the applicant can be left alone for up to three hours, based on the MCO nurseís assessment, documented on Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services. If the applicant cannot be left alone, the AFC provider will be responsible for providing or arranging for 24-hour supervision.
To guide the applicant in the selection of the AFC home, the MCO relies on the recommendation of the registered nurse completing the pre-enrollment assessment regarding the appropriate level (I, II or III) of AFC. Refer to Section 7133 below.
7133 Classification Levels of Adult Foster Care Members
Classification of Adult Foster Care (AFC) members is based on their assessed needs for care as follows.
Level I AFC Member
Certain tasks provided in Level I AFC homes may require the delegation and supervision of a registered nurse (RN) under applicable rules of the Board of Nurse Examiners in 22 Texas Administrative Code (TAC), Chapter 225. The members need less complex assistance with tasks or supervision than those of Level II or Level III. Level I nursing facility members may require assistance with personal care tasks or one or more of the following nursing tasks, which may require delegation by an RN:
- collecting, reporting and documenting data, including but not limited to:
- vital signs, weight, intake and output, clinitest and hemetest;
- changes from baseline data established by the RN; or
- behaviors related to the plan of care;
- reinforcement of health teaching planned and/or provided by the RN;
- non-invasive and non-sterile treatment/procedures; and
Level II AFC Member
Certain skilled tasks in Level II AFC homes may require the delegation and supervision of a RN under applicable rules by the Board of Nurse Examiners in 22 TAC, Chapter 225. These members can require the same personal care tasks or delegated nursing tasks as in Level I with the same or increasing complexity and have, in addition, medical conditions requiring at least one of the following more skilled tasks:
- direct administration of oral medications or administration of medications through permanently placed feeding tubes, or sublingually, including eye, ear and nose drops, and vaginal or rectal suppositories;
- elimination procedures to include vaginal irrigations, cleansing enemas and intermittent catheterizations;
- positioning and turning;
- feedings via permanently placed gastrostomy tube;
- non-sterile procedures, such as dressing or cleansing penetrating wounds and deep burns;
- care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment;
- sterile procedures involving a wound or an anatomical site that could potentially become infected;
- invasive procedures, such as inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube (excluding a permanently placed gastrostomy tube); and
- members who are determined by the RN to exhibit confusion, disorientation and behavior problems, as validated on the Medical Necessity and Level of Care (MN/LOC) Assessment.
Level III AFC Members
Skilled tasks in Level III AFC must be provided by a licensed RN, licensed vocational nurse (LVN) or substitute RN or substitute LVN. These members have a medical disorder, diseases or both with a related impairment being so complex or of such sufficient seriousness that their needs exceed the care which may be delegated to an unlicensed person. These members require timely assessment, planning and intervention by a licensed nurse on a 24-hour basis.
The level of each HCBS STAR+PLUS Waiver (SPW) AFC home is determined at the time of provider enrollment or reassessment, based on the level of the provider's experience and training. Once enrolled, the AFC provider is notified by letter of any change in the level of members the provider may accept. A copy of the letter becomes part of the contract file kept by Health Plan Management.
Although an SPW AFC provider may be designated a Level I or Level II, the provider may not perform delegated nursing tasks until the provider has demonstrated the ability to perform such tasks to the satisfaction of the supervising RN. A licensed nurse who operates a Level I or Level II AFC home must provide the nursing care directly to the member. The licensed nurse would be paid at the member's level, either Level I or II. The licensed nurse of the AFC home determines if the level of the member is Level III.
7134 Adult Protective Services and Adult Foster Care
7134.1 Placement of Adult Protective Services Clients in Adult Foster Care
In some areas, Adult Protective Services (APS) may use Adult Foster Care (AFC) as a resource for placement of APS clients. Approval by the managed care organization (MCO) is required before an APS client moves into a Department of Aging and Disability Services-enrolled AFC household. The purpose of the approval is to determine the:
- appropriateness of the member's characteristics;
- capacity of the foster home to meet the member's needs; and
- compatibility of service delivery to the APS member and the delivery of services to the existing AFC members.
If it is determined by the MCO that placement in foster care is inappropriate, the APS worker and the MCO help the member make other living arrangements.
7134.2 Adult Protective Services Investigations of Adult Foster Care Providers
Any time managed care organization (MCO) staff suspect abuse, neglect or exploitation of an Adult Foster Care (AFC) member in a foster home, a report must be made immediately to Adult Protective Services (APS).
If reports are made to APS from outside sources, MCO staff may not be notified of member allegations against a service provider until after the allegations have been validated. However, APS staff may ask the MCO to assist with the delivery of services during the course of the investigation if the alleged mistreatment poses an immediate threat to the safety of AFC residents.
The MCO handles disenrollment and corrective actions against the foster home, as appropriate. If the MCO is unable to find a suitable residence for the member, the member is referred to APS for assistance in moving from the foster home.
A member who has the capacity to consent may decide not to move from the foster home, even though the allegation has been validated and the situation is likely to recur. In such an instance, the member's AFC services will be denied and payments to the home will terminate. However, the member may continue to reside in the home by making private pay arrangements with the provider.
If a member who does not appear to have the capacity to consent refuses to move from a home operated by an individual identified as the perpetrator in a case of validated abuse, neglect or exploitation, the MCO must make a referral to APS.
7135 Private Pay Members in Adult Foster Care
Some Adult Foster Care (AFC) providers may wish to take private pay members. Approval by the managed care organization (MCO) is required before the private pay member is accepted in the home. The AFC provider must contact the MCO when considering the admission of a private pay individual. The MCO furnishes Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to the AFC provider. The AFC provider must complete Form 2330 and return it to the MCO to approve or disapprove the private pay individual. The purpose of the approval is to determine the:
- appropriateness of the member based on the applicant's/member's condition and behavior;
- capacity of the foster home to meet the member's needs; and
- compatibility of service delivery to the private pay member and the delivery of services to the certified AFC members.
If the MCO determines placement in foster care is inappropriate, the AFC provider cannot accept the member.
Any issues regarding placements must be resolved by the MCO.
7140 Adult Foster Care Managed Care Organization Procedures
7141 Eligibility Determination
To determine eligibility for Adult Foster Care (AFC), the managed care organization (MCO) must certify the applicant meets all criteria for the HCBS STAR+PLUS Waiver (SPW) program. The MCO must determine the applicant has an agreement with an enrolled AFC home to potentially move into the home. The MCO must also ensure the AFC member is placed in the appropriate level (I, II or III) of AFC, as determined by the memberís classification. Refer to Section 7133, Classification Levels of Adult Foster Care Members.
7142 Service Planning
The final care and monitoring plan for the member must address functional, medical, social and emotional needs and how the needs might be met in the selected Adult Foster Care (AFC) home. The managed care organization (MCO) must assess whether other resources in the community should be used to meet specialized needs of the member. Use of those resources must be documented in the care plan.
Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, is completed by the MCO to document the specific personal care tasks with which the AFC provider must assist the member. The AFC provider may provide more tasks, but not less than those listed on Form 2060.
Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the foster home setting beyond the scheduled monitoring. If needed, a monitoring schedule is developed and documented in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.
The MCO contacts the member and the AFC provider to arrange for the initial visit and a negotiated move-in date for the member. If there are health concerns regarding the member, the MCO nurse may be consulted and a recommendation may be made for the member to have a physical/medical exam before moving into the AFC home.
The MCO coordinates with the interdisciplinary team regarding the AFC memberís care.
7150 Finalizing the Care Plan
On or before the date the member moves into the Adult Foster Care (AFC) home, a face-to-face meeting with the member and the AFC provider is required to discuss the member's care plan and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team, including the member's family members or responsible person, may be included in the meeting. The meeting should preferably take place in the AFC home.
Discuss the member's care plan with the member and family members/responsible party and reach understanding with them about how the foster care provider will meet his/her needs. This discussion should ensure that the member, family/responsible party and the foster care provider are adequately prepared for a new member in the home and that adjustments occur smoothly. Document the care plan and any special needs of the member or special agreements between the member and provider on Form 2327.
If the member is already residing in the AFC home, Form 2327 must be completed face-to-face with the member and AFC provider before certification or recertification of AFC services.
7151 Member and Provider Agreement
During the initial home visit, the managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.
The MCO reviews all of the information on the agreement with the member, family and/or responsible person, and the provider. All conditions of the agreement and the following topics must be covered in the discussion:
- A full description of the care needs of the member and services needed, including the schedule of care
- The need for 24-hour supervision or care delegated to the Adult Foster Care (AFC) provider by a licensed registered nurse
- The beginning and ending date of the agreement
- A detailed description of the rights and responsibilities of the member and the provider
- An explanation of the member's and provider's right to privacy and confidentiality
- The monthly dollar amount the member agrees to pay the provider for room and board, as documented on Form 2327 and Form 2065-D, Notification of STAR+PLUS Program Services
- The arrangements for a trust fund if the HCBS STAR+PLUS Waiver (SPW) member requests such service from the AFC provider
- An inventory of personal belongings
- The names, addresses and telephone numbers of the persons to be notified in an emergency, including the member's physician, family members and/or responsible person
- Any special habits and needs of the member and any special arrangements or agreements between the member and the provider
- Any additional training needs of the provider and methods to obtain that training
- The rights and responsibilities of both the member and the provider for notifying the MCO and Health Plan Management of problems, such as illnesses, medication reactions, hospitalizations, acts of violence, accidents or complaints about abuse, neglect or exploitation
- Other conditions that reflect changes in the member's condition that might affect the appropriateness of the foster home placement
The MCO must fully discuss with the AFC provider the likelihood of problems arising after the member moves into the home, notification procedures, and suitable actions that should be taken to resolve problems. Also, discuss with the provider the impact of a new member on members of the foster care family and other members in the home. Anticipate problems that might arise and how they should be handled. Outline the schedule of monitoring visits that has been planned for the member. Form 2327 (see Miscellaneous Arrangements, No. 1) is used to document special monitoring schedules and other resources used in the plan of care.
The member and the provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Form 2327 must be completed and signed before authorizing and reauthorizing AFC. Any changes or incidents must be reported to the MCO within 24 hours of the occurrence.
7152 Copayment and Room and Board Requirements
Copayment and room and board are applicable to Adult Foster Care (AFC) members as described in Section 3236, Copayment and Room and Board, and Appendix VI, Calculation of Copayment and Room and Board for SPW Members.
If copayment is applicable, the AFC member's copayment amount is listed on Form 2065-D, Notification of STAR+PLUS Program Services. Form 2065-D is used to report to the member the amount of his copayment for the first month of authorized service and subsequent months. The HCBS STAR+PLUS Waiver (SPW) AFC provider also receives a copy of Form 2065-D.
The room and board amount is entered on Form 2065-D and Form 2327, Individual/Member and Provider Agreement. The managed care organization (MCO) must ensure the member and AFC provider understand that the room and board arrangement with the provider is separate from the MCO payment for services. The member pays the provider the room and board amount listed on Form 2327 and Form 2065-D. If the member is moving into the AFC home mid-month, prorate the amount of room and board for the month and advise the member and provider of the prorated amount.
When the copayment and/or room and board amounts change, the MCO must notify the provider and the member of the new amount before the change. The member must pay his/her copayment and room and board charge by the eighth day of the month. If the member does not pay the required fees, he/she may not be eligible for SPW AFC services.
The SPW AFC provider must collect the copayment from the member. The provider must keep receipts for all copayments collected. The provider must deduct the copayment amount authorized on Form 2065-D from reimbursement claims submitted to the MCO. If an SPW AFC member does not pay his/her copayment and/or room and board, the MCO must investigate the member's failure to pay. The MCO contacts the member to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the member's income check has not been received by the eighth day of the month, the member is still under obligation to pay the fees. Grievances between the member and the AFC provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of Health Plan Management and the MCO.
If the member simply refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO writes a letter to the member or the member's responsible party explaining the consequences of continued refusal to pay. If the member does not pay his/her required fees within 30 days of the due date, the MCO can terminate AFC services to the member. The member can then be evicted from the home, according to local eviction ordinances and procedures.
7153 Trust Funds
The managed care organization (MCO) must offer money management assistance by the Adult Foster Care (AFC) provider to the applicant/member and document that the applicant/member either accepted or refused the assistance. If the applicant/member expresses an interest in money management, the MCO documents the expressed interest on Form 2067, Case Information, and sends the form to the AFC provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.
The HCBS STAR+PLUS Waiver (SPW) AFC provider must maintain trust fund records. The AFC provider must:
- have written permission from the member to handle his personal financial affairs;
- keep member trust accounts separate from the provider's operating accounts. The separate account must be identified "Trustee (name of the SPW AFC provider), Member's Trust Fund Account." If the AFC provider maintains a trust fund, the provider must:
- deposit the member's monthly income into the account; and
- write a check for the copayment and the room and board payment out of the trust fund account into the provider's operating account. Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account;
- make the member trust fund records available for review by the MCO during work hours without prior notice;
- not charge the member for services the provider is expected to provide for the member;
- not charge the member for banking service costs if the member trust fund is in a pooled account;
- obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the provider is handling. The provider must include at least the following in the records:
- member's name;
- identification of member's representative payee or responsible party;
- admission date;
- member's earned interest; and
- transactions – the provider may choose one of the following options:
- maintain records of the date and amount of each deposit and withdrawal, the name of the person who accepted the withdrawn funds and the balance after each transaction. Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his/her trust funds, the transactions or receipt must be signed by a witness; or
- maintain signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his/her name, a witness must sign the transaction, or receipt; and
- distribute the interest earned on any pooled interest banking account in one of the following options:
- prorated to each member on an actual interest earned basis; or
- prorated to each member on the basis of his/her end-of-quarter balance.
The following information must be included on the receipt for all money that is received or deposited in the memberís trust fund:
- member's name;
- date the money was received;
- source of the money;
- amount received; and
- amount returned to the member, if any.
All records pertaining to the member's trust fund must be kept in the manner designated above, and available for monitoring without notice.
7154 Hospital Leave
To reserve his/her space during hospital stays, the HCBS STAR+PLUS Waiver (SPW) member must pay his/her daily bedhold charge, which is his/her room and board rate. The SPW Adult Foster Care provider does not bill the managed care organization for the days the SPW member is hospitalized. The member's room and board charge constitutes the entire payment to the provider when a member is hospitalized.
During the initial home visit, the managed care organization reviews the information regarding the member's responsibility to pay a bedhold charge when away from the home.
7155 Authorization of Adult Foster Care
After all HCBS STAR+PLUS Waiver (SPW) eligibility is established and all additional Adult Foster Care (AFC) procedures are completed, the STAR+PLUS Support Unit (SPSU) sends the member Form 2065-D, Notification of STAR+PLUS Program Services. The managed care organization (MCO) authorizes AFC on Form H1700-1, Individual Service Plan — SPW (Pg. 1). The SPSU registers the Individual Service Plan (ISP) in the Service Authorization System.
The MCO sends to the AFC provider:
- a copy of Form H1700-1;
- additional applicable ISP forms: 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 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
- Form 2327, Individual/Member and Provider Agreement.
7156 Adult Foster Care and Day Activity and Health Services
Title XIX, Day Activities and Health Services (DAHS), may be authorized for HCBS STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) members residing in Level I and Level II homes. DAHS must not be authorized for SPW members residing in AFC Level III homes.
SPW members residing in AFC Level I and Level II homes may receive up to 10 units of DAHS per week.
7160 Monitoring Quality of Care
The quality of care provided to waiver members residing in Adult Foster Care (AFC) homes will be monitored by the managed care organization (MCO). The MCO registered nurse monitors the performance of nursing tasks in the nurseís delegation/treatment plan in accordance with applicable rules by the Board of Nurse Examiners in Texas Administrative Code 22, Chapter 225.
Regular monitoring visits by the MCO service coordinator must assess the member's needs and whether the provider is addressing and meeting those needs. The service coordinator must contact the MCO management if the AFC provider is not addressing or meeting the needs of the member. The member's physical and medical condition must be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness.
Form 2327, Individual/Member and Provider Agreement (see No. 1 under Miscellaneous Arrangements), is used to document special monitoring schedules and other resources used in the plan of care.
7170 Significant Changes
It is the responsibility of the managed care organization (MCO) and the Adult Foster Care (AFC) provider to ensure the AFC member is in an appropriate setting to meet his/her needs. When the AFC member has a change in functional need, health problems or changes in behavior, it is the responsibility of the AFC provider to notify the MCO. The MCO must follow up with the member and provider to determine if changes to the care arrangement are needed.
The MCO must give particular attention to members who reflect dramatic changes in functional need, medical problems or behaviors that are inappropriate for foster care. Family members and/or the responsible party or guardian must be alerted to the situation. Discuss with them and the member the potential for the member to remain in the AFC home. A guardian appointed by the court acts on the member's behalf. If the member has had a decline in his/her medical condition or functional ability, consult the MCO nurse to determine if a visit should be made to assess the memberís medical status.
Long-range care plans must be discussed frankly with the member, family members and the AFC provider to ensure that all are aware of the capabilities and limitations of AFC services for members with deteriorating medical or functional conditions. Members who become inappropriate for foster care must be advised of other available options. Assistance must be provided to members and their family members in this decision process and with transfer activities when necessary. If the provider decides the member is not appropriate for care in his/her home, the provider contacts the MCO to request the member be transferred to another placement. The MCO is responsible for preparing the member for transition when the member becomes inappropriate for a particular AFC home or AFC services.
7171 Termination of Adult Foster Care Services
During the course of a member's stay in an Adult Foster Care (AFC) home, the member may experience changes in his/her condition or the care required. If the member begins to need services that cannot be provided by the AFC provider, it is necessary for the managed care organization (MCO) to consult with the provider regarding the delivery of delegated nursing tasks to the member to assure the necessary care is obtained. A provider may deliver skilled care in the AFC home for stabilization or rehabilitation.
If the short-term services provided in the home by the provider are not sufficient and other services are not available to support the member in that AFC arrangement, the MCO, in conjunction with other members of the interdisciplinary team (IDT), should explore alternatives. More long-term chronic changes in service needs will likely require the member to move to another setting that provides more skilled intervention, such as a Level II or Level III AFC home or nursing facility.
Physical restraints, such as leg restraints or lap belts intended to restrain a person in a chair, may be used in AFC settings only on an emergency basis. On an emergency basis, restraints may be used if written approval is obtained from the member's physician and family, and only if the restraints are for a short, limited period of time.
The AFC provider is expected to take actions necessary if the member's condition has deteriorated and/or the member has threatened the health and safety of himself/herself or others. The provider is required to notify the MCO of actions taken on the same day of awareness. The MCO must follow the procedures identified in Section 7172, Discharge and Termination Due to Health and Safety.
HCBS STAR+PLUS Waiver (SPW) AFC providers cannot terminate AFC services to members without the prior approval of the MCO and must follow procedures for providing a 30-day written notice, with an exception for a member whose behavior or condition threatens the health or safety of himself/herself or others. During the 30 days after written notice is served to the member to vacate the AFC home, the MCO is responsible for working with the member to assure alternative services are available.
Once a member is identified as inappropriate for AFC, the MCO must negotiate a time frame with the member, family/responsible party and the AFC provider for the member to move. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the member has been a threat to the health and safety of other(s) or has exhibited inappropriate behaviors so that the provider is asking the member to move immediately, the MCO must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the member, the MCO must refer the member to Adult Protective Services (APS) to assist in locating appropriate placement.
If there is resistance to the move from the member, family or the provider, an additional staffing with the IDT may be required to resolve the problem. The MCO advises the member and AFC provider that AFC services will terminate on the date specified on Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. If the member transfers to another AFC home or SPW living arrangement, the MCO notifies the STAR+PLUS coordinator to send the member Form 2065-B. If the member does not transfer to another AFC or SPW living arrangement and all SPW services are terminated, the MCO informs the STAR+PLUS coordinator to send the member Form 2065-C. The provider has the right to begin eviction proceedings as specified in the provider's resident rights and responsibilities. Ensure that the member and responsible party understand the consequences of eviction. If the provider must use eviction procedures and the member has refused to make other living arrangements, refer the member to APS.
If the member and provider decide that the member will remain in the home as a private pay member, the MCO must give approval. The MCO must also ensure the member and AFC provider understand that there are no case management services or payment arrangements from the MCO for a private pay member.
Refer to Section 7172 below for more details on how to handle situations in which the AFC member threatens the health and/or safety of himself/herself or others in the AFC home.
7172 Discharge and Termination Due to Health and Safety
Any member whose medical condition or behavior threatens the health and/or safety of himself/herself or others is subject to discharge without notice from an HCBS STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) home.
The AFC provider must take appropriate action if the member's medical condition has deteriorated and he/she requires more skilled intervention to ensure his/her health and safety. Depending on the member's condition, appropriate action could include calling emergency medical services, the member's physician or the managed care organization (MCO) service coordinator working with the member. If some action is taken by the AFC provider, the provider must inform the MCO on the same day the provider becomes aware of the member's condition.
The MCO must work with the provider, should another level of SPW AFC home be appropriate, or with providers of other services to arrange alternate placement where the member's needs can be met.
The SPW AFC provider must take appropriate action if the member's behavior has deteriorated and he/she threatens the health and safety of himself/herself or others. Depending on the member's behavior, appropriate action could be calling the police or sheriff's department, or the member's physician and MCO service coordinator. The member must be removed from the home as soon as possible if he/she becomes a threat to the health or safety of himself/herself or others. In some instances, the MCO may call Adult Protective Services (APS) if hospitalization for psychiatric observation seems warranted.
The MCO must mail or give a completed Form 2065-B, Notification of Waiver Services, to the member within three days of receiving information regarding the incident. The effective date on Form 2065-B is the date the form is dated and mailed/given to the member, even if the decision is appealed. Though the member may not be denied all services through SPW, the member has a right to appeal the decision of removal from the SPW AFC home.
The member may not remain in the SPW AFC home during the appeal process. The MCO must work with APS or providers of other SPW services to arrange alternate placement for the member.
7180 Annual Reassessment
The managed care organization completes the annual reassessment of the HCBS STAR+PLUS Waiver (SPW) Adult Foster Care (AFC) member. Additional tasks include the completion of:
7200 Assisted Living Services
This section applies to the HCBS STAR+PLUS Waiver (SPW) program. Assisted Living (AL) services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Department of Aging and Disability Services (DADS). SPW participants are responsible for their room and board costs and, if applicable, copayment for AL.
The purpose of AL services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision making ability of the participant. The personal care facility must provide each participant a separate living unit to guarantee their privacy, dignity and independence.
7211 Housing Options in Licensed Personal Care Facilities
The Assisted Living (AL) apartment may be an efficiency or one or two bedroom apartment, and each apartment must have a private bath and cooking facilities. An AL non-apartment setting is defined as a Licensed Personal Care facility which has living units that do not meet the definition of an AL apartment, may be double occupancy, and must be:
- freestanding; and
- licensed for 16 or fewer beds.
HCBS STAR+PLUS Waiver (SPW) AL contracts specify whether the facility has contracted to provide services under the housing options of AL or AL Non-Apartment. The provider may not deliver SPW services in a housing option for which he/she does not have a contract to deliver services. If a provider wishes to maintain both AL (single occupancy) and AL apartments (double occupancy) in one facility, his/her contract must specify that information.
If the AL provider wishes to limit the types of apartments in the facility available to SPW participants, the provider must specify these limitations in their contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications as specified in this section. If there are no such specifications in the contract, all types of apartments in the facility must be available to SPW participants.
If the provider limits the type of apartment available for SPW members and there is no apartment of that size available, they can refuse to accept any SPW member, based on not having space available. This would apply both for a member wanting to move into the facility from the outside, or to a private pay member currently in the facility who is becoming an SPW member. The member would then have the option of reviewing other available AL facilities in the area or Adult Foster Care homes.
"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At minimum, a covered walkway between buildings is required for physical connection.
At the member's request, portable kitchen units may be removed from the living area.
7211.1 Single Occupancy Apartments
An Assisted Living apartment setting is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom and adequate storage space, as specified in the following:
- The apartment must have a minimum of 220 square feet, not including the bathroom. Apartments in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.
- The kitchen is an area equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.
- The bathroom must be a separate room in the individual's living area with a toilet, sink and an accessible bath.
- The bedroom must be single occupancy except when double occupancy is requested by the participant.
7211.2 Double Occupancy Apartments
An Assisted Living apartment must be a double occupancy apartment with a connected bedroom, kitchen and bathroom area that provides a minimum of 350 square feet of space per participant, and meet the following specifications:
- Indoor common areas used by waiver participants may be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.
- The kitchen must be equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.
7220 Description of Services
The Assisted Living (AL) facility must provide 24-hour care in a personal care facility licensed by the Department of Aging and Disability Services. Services include, but are not limited to:
- Home management — Assisting with activities related to housekeeping that are essential to the member's health and comfort, including changing bed linens, housecleaning, laundering, shopping, storing purchased items and washing dishes.
- Transportation and escort — Providing and/or arranging for transportation to:
- local community shopping areas where a member may purchase items to meet his/her personal needs;
- recreational activities, field/community trips; and
- the nearest available provider that can provide medical care which may include medical appointments, therapies and other medical care, unless arrangements are made to transport the member to the medical care provider of the member's choice. Licensure as a personal care facility requires the facility to provide soap and toilet tissue at all times for member use. Other personal items must be purchased by the member. STAR+PLUS Waiver (SPW) members receiving AL are entitled to receive medical transportation services through Medicaid for Medicaid-covered medical appointments. The AL facility personnel are responsible for scheduling the transportation according to medical transportation procedure. If the SPW member wishes to attend an activity outside the facility, which is not a group activity sponsored by the facility, he/she is responsible for paying for his/her own transportation.
- 24-Hour supervision — Periodic checks or visits to a member during each eight-hour shift to ensure that the member is safe and well.
- Meal services that include:
- planning, cooking and serving three meals per day that are essential to the member's health and well-being. The meals must:
- be suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of special needs members; and
- supply 100% of the recommended daily dietary allowance for adults, as recommended by the United States Department of Agriculture;
- providing special diets, as required by the member's service plan;
- offering dietary counseling and nutrition education for the member;
- assisting the member with his/her meals, if necessary, which includes food texture modification, including grinding meats and mashing vegetables for members having trouble chewing; and
- food management, including assistance with spoon feeding in instances when the member is temporarily ill, bread buttering, and milk opening for members with hand deformities, paralysis or hand tremors.
- planning, cooking and serving three meals per day that are essential to the member's health and well-being. The meals must:
- Social and recreational activities that include:
- organizing activities that require group and member-initiated activities;
- providing opportunities to interact with other people;
- providing interaction, cultural enrichment, educational or recreational activities, and other social activities on site or in the community in a planned program to meet the social needs and interests of the members;
- providing four scheduled social activities per week; and
- posting a monthly social/activity calendar at least one week in advance.
Personal care tasks must be provided, as identified in Section III, Form 3050, Day Activity and Health Services Health Assessment/Individual Service Plan. A registered nurse must perform the medication administration assessment part of Form 3050.
The AL provider is responsible through its licensure requirements for providing the administration of medications, which is the direct administration of all medications, or the assistance with or supervision of medication. This includes injections, if needed. Only a licensed nurse can give injections. The personal care facility may provide more services for the member than are identified on Form 3050, but not fewer services.
7221 Requirements Related to Assisted Living
STAR+PLUS Waiver (SPW) members who wish to reside in a personal care facility must reside in a licensed Assisted Living (AL) facility which is contracted with the managed care organization (MCO) to provide SPW services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services to four or more persons who are unrelated to the owner. The member is required to pay room and board, and possibly a copayment based on income in the AL setting. See Section 3230, Financial Eligibility, for detailed information.
7222 Initial Responsibilities for Members Residing in AL Facilities
The managed care organization (MCO) is responsible for helping the applicant or member select an Assisted Living (AL) facility that can meet his/her needs. The MCO sends an authorization to the AL facility that the member selects.
The AL facility must explain the copayment requirement and room and board charges, described in Section 3236, Copayment and Room and Board, and Appendix VI, Calculation of Copayment and Room and Board for SPW Members, to the applicant/member. Room and board must be paid by every STAR+PLUS Waiver (SPW) AL member. A copayment is not required of Supplemental Security Income recipients. A copayment is required from those AL members whose financial eligibility was determined under the special institutional criteria. The MCO must:
- determine the member's room and board and copayment amounts, based on the copayment worksheet received from the STAR+PLUS Support Unit (SPSU), for the initial month of service and ongoing copayment amount for subsequent months;
- document the amounts on Form H1700-1, Individual Service Plan — SPW (Pg. 1) (ISP);
- verbally notify the member;
- send a copy of Form 2065-D, Notification of STAR+PLUS Program Services, to the provider as notification of the amounts to be collected; and
- assist the member and provider in resolving problems related to collection of the member's copayment and room and board contributions.
As described Section 3236, the SPSU may have to estimate the initial and ongoing copayment amounts for the initial ISP development. If the Medicaid for the Elderly and People with Disabilities (MEPD) specialist is unable to provide an estimate on the amount available for copayment prior to the Medicaid eligibility determination, the SPSU estimates the copayments based on the applicant's self-reported income from Form H1200, Application for Assistance – Your Texas Benefits. The estimated copayments are necessary in order to compute an ISP for AL residents. When the accurate amount available for copayment is received from the MEPD specialist, SPSU recalculates the copayment amounts. The MCO must explain to the member that failure to pay his/her room and board charges or copayment will result in termination of his/her SPW services.
7223 Admission to Facility
Before admission, the managed care organization faxes or mails to the Assisted Living (AL) facility:
- Form H1700-1, Individual Service Plan — SPW (Pg. 1);
- Form H1700-2, Individual Service Plan — SPW (Pg. 2);
- Form 8598, Non-Waiver Services, and all attachments; and
- Form 2065-D, Notification of STAR+PLUS Program Services.
The STAR+PLUS Waiver (SPW) AL provider is expected to provide to the new member a tour of the facility, including staff and resident introductions. Members are encouraged to bring basic furnishings for bedroom areas with them.
In the event the member does not provide his own furnishings, the facility must provide for each member:
- a bed with mattress;
- table or dresser;
- drawer space; and
- enclosed closet space for clothing and personal belongings.
Furnishings provided by the facility must be maintained in good repair.
7224 Personal Care 3
STAR+PLUS Waiver (SPW) applicants/members with heavy personal care needs who choose to reside in Assisted Living (AL) non-apartment settings may be approved for Personal Care 3 level services. Classification of an SPW applicant/member at the Personal Care 3 level is based on the applicant's/member's assessed needs, as evidenced by a value of two or greater in one or more of the activities of daily living of transferring, eating or toileting, as assessed on the Medical Necessity and Level of Care (MN/LOC) Assessment, Section G, Physical Functioning and Structural Problems, Column A, Self Performance.
During the initial pre-enrollment assessment and annual reassessment, the managed care organization (MCO) nurse completes the MN/LOC Assessment and uses the information recorded for transferring, eating or toileting to make a recommendation regarding the applicant's/member's need for the Personal Care 3 level. The recommendation is recorded on Form H1700-1, Individual Service Plan — SPW (Pg. 1).
At the initial certification and each annual reassessment, the MCO must check Form H1700-1 to determine if the applicant/member who chooses to reside in an AL non-apartment setting is identified as meeting the Personal Care 3 level. If the provider nurse does not provide a recommendation for Personal Care 3 level, the MCO must contact the nurse to obtain a Personal Care 3 level. The MCO documents the nurse's recommendation in the case record. The MCO must inform the applicant/member that he/she meets the Personal Care 3 level, and ensure the applicant/member is aware of all facilities contracted to provide care at the Personal Care 3 level by presenting a choice list of AL facilities that specifically identifies the Personal Care 3 facilities. The MCO authorizes the Personal Care 3 reimbursement rate if the applicant/member meets the Personal Care 3 level and chooses to reside in a contracted Personal Care 3 facility.
Changes may occur in an SPW member's health during the individual service plan year that may cause the member to require a greater level of care in an AL facility, or move to an AL setting from a community setting. The MCO must review the most current MN/LOC Assessment to determine the provider nurse's recommendation regarding the member's Personal Care 3 level and ensure the member is presented with a choice of AL facilities that are contracted at the Personal Care 3 level to provide a higher level of care.
Designation of an AL facility as a Personal Care 3 facility is determined in the contracting process. To qualify as a Personal Care 3 facility, the AL facility must meet the following requirements:
- be a personal care facility licensed for four to 16 beds in a non-apartment setting;
- provide 60 percent or more of its SPW members with a single occupancy bedroom;
- maintain a minimum staffing ratio of one direct care staff member for every four members during the day and evening shifts, and a minimum of one direct care staff member for every eight members during the night shift; and
- at least 60 percent of the total members served each month must require a minimum of one-to-one staff assistance as evidenced by a value of three or greater in one or more of the activities of daily living of transferring, eating or toileting, as assessed on the MN/LOC Assessment.
7230 Other Services Available to Members
Each of the following services are provided according to the needs of the member, as authorized on the individual service plan (ISP), as a STAR+PLUS Waiver (SPW) service and not included in the Assisted Living (AL) daily rate. The managed care organization (MCO) makes referrals for the services and coordinates delivery.
Adaptive Aids and Medical Supplies — The SPW AL member is eligible to receive needed adaptive aids and medical supplies under SPW. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care that enable individuals to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live. See Section 6410, List of Adaptive Aids and Medical Supplies, for a list of adaptive aids and supplies that can be purchased through SPW.
Minor Home Modifications — Services that assess the need, arrange for and provide modifications, and/or improvements to an individual's residence to enable the individual to reside in the community and ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the ISP and apply to Type A facilities only. (See Texas Administrative Code §92.3, Types of Assisted Living Facilities.)
Occupational Therapy — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. Occupational therapy services consist of the full range of activities provided by a licensed occupational therapist or a licensed occupational therapy assistant, if under the direction of a licensed occupational therapist, within the scope of state licensure.
Physical Therapy — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Physical therapy services consist of the full range of activities provided by a licensed physical therapist or a licensed physical therapy assistant, under the direction of a licensed physical therapist and within the scope of state licensure.
Hearing and Language Therapy — The evaluation and treatment of impairments, disorders or deficiencies related to a member's speech and language. Services include the full range of activities provided by licensed speech and language pathologists under the scope of the pathologist's state licensure.
Nursing Services — Services provided by a licensed registered nurse or licensed vocational nurse within the scope of state licensure. Nursing services can be brought into the personal care facility for the member. If the projected cost of the member's services exceeds the annual cost limit, the MCO meets with the member to discuss the options for care, such as other living arrangements in Adult Foster Care or Title XIX Day Activity and Health Services. The member's choice for service delivery is given first priority as long as the cost for the service does not exceed the annual cost limit. STAR+PLUS services are also explored by the MCO for the delivery of all waiver services.
The use of self-administered oxygen is allowed in an SPW AL facility. Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.
7240 Room and Board and Copayment Requirements
The member must pay the required fees to be eligible for Assisted Living (AL) services. Refusal to pay the required fees can result in termination of services.
The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied. The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first business day thereafter.
7241 Room and Board Requirements
All members must pay the room and board charges to be eligible for Assisted Living (AL). Room and board cannot be waived, but an AL facility may choose to accept an individual for a lower amount. STAR+PLUS Waiver (SPW) policy does not direct the facility to accept or reject the individual. The room and board charge is based on the Supplemental Security Income federal benefit rate (FBR), minus a personal needs allowance of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on January 1. The room and board charge is adjusted accordingly based on that change. For the initial month of entry, the monthly rate is divided by the number of days in that month, then multiplied by the number of days the member is in the facility. See Appendix VI, Calculation of Copayment and Room and Board for SPW Members, for calculations. The member must be notified of the initial amount of room and board to pay and the ongoing amount of room and board to pay.
7241.1 Copayment Requirements
The amount of copayment the member is required to pay is determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff through use of the MEPD copayment worksheet. The MEPD specialist makes the determination of the amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.
The STAR+PLUS Support Unit coordinator sends Form 2065-D, Notification of STAR+PLUS Program Services, to the member. Once received, the MCO sends a copy to the assisted living facility, detailing the first month's copayment amount and the subsequent months' amounts.
7242 Personal Leave
The member is entitled to 14 days of personal leave from the facility each calendar year. The member is responsible for the room and board charge and copayment for personal leave days.
A day of personal leave is defined as 24 continuous hours. STAR+PLUS Waiver assisted living members must sign out when leaving the facility and sign in upon returning. The sign-in log must have at minimum the following information:
- name of the person;
- time and date of departure;
- emergency contact; and
- type of leave (for example, personal leave or hospital leave).
7243 Nursing Services for AL Members
If a member is residing in an Assisted Living (AL) setting, all of the administration of his/her medications, including injections, are provided by the nurse. It is possible that a member residing in an AL setting does not need any nursing tasks that are to be delivered by STAR+PLUS Waiver. Examples of when this may occur include when the member's only nursing need is for medication administration that is provided by the nurse or when the member is receiving nursing services through Medicare.
7244 Response to AL Member Condition Change
If the member experiences a change in health or conditions related to the amount and type of care he/she requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member/legal representative may explore other means to serve the member adequately in his/her current setting. The use of Day Activity and Health Services for daily nursing tasks or the direct provision of nursing by provider nurses may be explored as alternatives that would avoid disrupting the member's living arrangement. Nursing tasks cannot be delegated in Assisted Living (AL) settings.
If a member exhibits behavior that threatens the health or safety of himself or others, or his needs exceed the licensed capacity of the facility, the AL provider must take appropriate action and notify the MCO verbally by the next business day. The provider must confirm his verbal report in writing within seven calendar days. The MCO must take appropriate actions based on the verbal notification to assess the member's continued eligibility for STAR+PLUS Waiver (SPW). See Section 7251, Facility Reporting and Notification Requirements.
If an SPW member living in an AL apartment becomes a safety hazard to himself or others due to his operation of the stove or cooking unit in the apartment, the AL provider can disconnect the unit and must notify the MCO by the next business day. The MCO must investigate the situation and document any recent or previous incident which indicates a threat to the health or safety of the member or others. The MCO, in cooperation with the IDT, the AL provider, and the member's family or responsible party, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The decision is documented on Form 2067, Case Information, which is sent to the AL provider within three business days of the IDT meeting.
7245 Hospital and Nursing Facility Stays
To reserve his space during hospital stays, the member must pay his daily room and board charge.
The facility's bedhold charge or the negotiated bedhold charge for reserving a member's space during hospital stays may not exceed the maximum amount established by the managed care organization (MCO).
The facility does not bill the MCO for days the member is hospitalized. The member's room and board charge, used as a bedhold charge, constitutes the entire payment to the facility when a member is hospitalized.
The facility must notify the MCO via Form 2067, Case Information, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every calendar month up to four calendar months to determine if the stay will become permanent. If the member stays in the hospital longer than four calendar months, the member is systemically disenrolled.
A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.
Nursing Facility Stays
For issues related to nursing facility payment see the Medicaid for the Elderly and People with Disabilities Handbook, Section H-1700, Deduction for Home Maintenance.
The MCO must follow the Uniform Managed Care Contract, Attachment B.1, Section 18.104.22.168, Nursing Facilities, related to nursing facility stays.
7246 Termination Due to Failure to Pay the Required Contribution to the Cost of Care
If the member or the member's representative fails to pay the entire copayment and room and board by the facility's due date, the facility must notify the member or the member's representative and the managed care organization (MCO) in writing that payment was not received. The facility must make an oral notification no later than the first business day after the due date. The facility follows up in writing within five calendar days of when the member or the member's representative fails to pay the required payments.
Upon receipt of the written notice, the MCO:
- coordinates with the facility to convene a meeting of the interdisciplinary team (IDT) within five business days of receipt of the written notification. The IDT must include the member, a facility representative, the MCO and the member's authorized representative(s), if applicable;
- explores with the member and IDT if there are new circumstances preventing the member from making the required payment. Circumstances to consider are:
- the member has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
- circumstances indicate that the member is being exploited by another person; and
- other situations exist in which the member and facility can work out an agreement for the member to pay the required payments;
- makes every effort to resolve the problem with the member and the facility;
- advises the member of the consequences that result from refusal to make the required payments to the Assisted Living (AL) facility, including:
- termination of eligibility;
- eviction; and
- being placed at the end of the interest list if the member reapplies for services in the future; and
- asks the member to read and sign Form 2119, Residential Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the member continues to refuse to pay the required payments. The form states that he/she refuses to pay the required payments and understands the consequences of not meeting this eligibility requirement. If the member refuses to sign, document the refusal on the form and have a witness sign. Leave the member a copy of the form and retain the original copy with the signature in the member's case record. Advise the member that he/she will receive a notice to terminate services. Also advise the member that he/she will not be allowed to move to another AL facility while he/she has an outstanding balance at the current facility, and the current facility may evict the member for refusal to pay.
After the IDT meeting, the MCO:
- makes any appropriate referrals to adjust countable income;
- refers to Adult Protective Services, if exploitation is suspected; or
- coordinates the notice of termination with the facility and the STAR+PLUS Support Unit (SPSU) by sending written notification within five calendar days of the IDT meeting.
If the situation cannot be resolved and the member refuses to pay for any reason, within three business days of the MCO's notification, the SPSU:
- sends the member Form 2065-D, Notification of STAR+PLUS Program Services, giving the member notice that services will be terminated effective the end of the month following the end of the 30 day notification period, as indicated on Form 2065-D unless the member pays the required payments. In the comments section of the form, advise the member that services will end and the facility may evict the member if payment is not made by date indicated on Form 2065-D;
- sends the facility and Medicaid for the Elderly and People with Disabilities (MEPD) a copy of Form 2065-D;
- posts to TxMedCentral in the XXXSPW folder, using the appropriate naming convention and a copy of Form 2065-D; and
- emails Managed Care Operations (HMCO) a copy of Form 2065-D.
If the member does not appeal:
- the facility may initiates eviction proceedings by giving the member an eviction notice in writing stating eviction will be effective the date indicated on the Form 2065-D.
- and the member has not made other living arrangements by the denial date the facility makes a referral to Adult Protective Services.
- and the facility is in compliance with the provisions of its license and contract regarding the eviction of members, the facility evicts the member on the date provided on the written eviction notice.
If the member does appeal within the 10-day adverse action period, SPSU notifies the MCO, MEPD and Health Plan Operations. The member may receive other services, but remains ineligible for AL until all outstanding payments are made.
7250 Standards for Operation
Assisted Living (AL) facilities must:
- provide each member the choice of a private or semi-private room;
- reserve space for up to three days from the agreed-upon entry date for each referred member before requesting another referral;
- designate a separate bedroom area for members in dual facilities where nursing home members are co-housed in the facility; and
- accept all managed care organization (MCO) referrals if space is available.
The only reason a STAR+PLUS Waiver (SPW) AL provider could refuse to accept a referral is if the member's condition makes the member inappropriate for the facility according to the facility's personal care licensure.
Having a communicable disease does not necessarily make a member inappropriate for placement in an AL setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have Infection Control Policy and Procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases, and contagious conditions. If transmission of the condition or disease cannot be controlled, the member cannot be placed in an SPW AL setting.
To receive AL services under SPW, the applicant must first be determined eligible for SPW. The STAR+PLUS Support Unit (SPSU) coordinates with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, where applicable, to complete the Medicaid eligibility determination.
The MCO discusses residential options with the member, allowing him/her to choose his/her preference. If AL is chosen, a verbal referral is made to the provider as an alert that space is needed. The starting date for services is a negotiated date between the MCO, the member and the AL provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan — SPW (Pg. 1), and applicable attachments are sent as follow-up, along with a copy of Form 2065-D, Notification of STAR+PLUS Program Services, which authorizes the provider to deliver SPW services, and Form 2067, Case Information, confirming the negotiated service initiation date.
In addition, AL facilities must:
- conduct a health assessment with the member within three calendar days of admission to the facility;
- provide each member with training in the emergency/disaster procedures and evacuation plan within three days from the date of service initiation. The training must be documented in the member's record. The facility must also document all training and orientation provided to members and facility staff;
- provide services according to the member's health assessment/individual service plan;
- document the member's daily activity and service delivery on the daily census record;
- obtain written approval from the MCO before discharging a member, except when MCO staff cannot be reached and the member threatens the health or safety of others or himself/herself;
- help the member to prepare for transfer or discharge;
- provide a minimum of four social and recreational activities per week;
- collect payment from the member according to copayment and room and board policies. If payment is not made by the 10th day of the month, the facility must send notice to the member by the 11th day of the same month;
- allow the member to manage his finances and/or trust funds. The facility must provide assistance to the member in managing his finances only if the member requests assistance in writing;
- refund, within five business days after the member has been discharged, the full balance of the member's personal funds that the facility deposited in an account. This applies to copayments and trust funds; and
- inform the member verbally and in writing, before or at the time of admission, of bedhold policies for hospital/nursing facility stays, personal leave, eviction procedures, all available services in the facility, and charges for services not paid by the MCO and/or not included in the facility's basic daily rate.
Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of others or himself/herself. If a stove or cooking unit needs to be disconnected, the service coordinator, in cooperation with the IDT, makes this decision. The IDT must also include the MCO, the AL provider and the member's family or responsible party, if any.
The AL provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of others or himself. He must inform the service coordinator of the disconnection by the next business day after it occurs. The MCO investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the member or others. If the decision is made to approve a disconnection, the service coordinator documents it on Form 2067 that is sent to the AL provider within three calendar days.
Note: The facility must make oral notification no later than the first business day after the due date. Within five business days of the MCO receiving notification from the provider that the member has failed to pay the copayment or room and board, the MCO posts Form 2067 to TxMedCentral in the XXXSPW folder using the appropriate naming convention. Form 2067 serves as notification to SPSU of the member's failure to pay the copayment or room and board. Within three business days, SPSU must send the member Form 2065-D stating services will be terminated if the member fails to pay his copayment/room and board within 30 calendar days of the date on Form 2065-D.
If an SPW member does not pay his copayment and/or room and board within 30 calendar days of the date on Form 2065-D, the MCO contacts the member to learn the reason the fees were not paid. Even if there is a legitimate reason (such as the member's income check has not been received by the 10th day of the month) for the non-payment of the required fees, the member is still under obligation to pay the fees.
If the member simply refuses to pay the fees, or there is no legitimate reason for his/her failing to pay, the MCO writes a letter to the member, with copies to the facility manager and to the member's responsible party, if applicable, explaining the possible consequences of continued refusal to pay.
The MCO is responsible for working with the member during this time period to assure alternative services will be available. If the member refuses to leave the facility when his/her services are terminated, the facility must follow its written eviction procedures.
Examples of charges not paid by the MCO could be the destruction of facility property or any additional charges, such as pet deposits. Items not required to be provided by the AL provider through the AL facility licensing standards (for example, returned check fees, service deposits) may be charged to the member if listed in the admission agreement. The MCO may contact Regional Regulatory Services regarding any questionable items charged to the member.
7251 Facility Reporting and Notification Requirements
The facility must verbally report to the managed care organization (MCO) the following occurrences pertinent to member services by the next business day after they occur. These occurrences must be followed up in writing within five business days after they occur and may lead to MCO intervention and/or termination of services, including but not limited to:
- significant changes in the member's health and/or condition, such as:
- the member enters a hospital, nursing home, state school or state hospital;
- death of a member; or
- serious occurrences or emergencies involving the member or facility staff; and
- changes based on member actions, such as the member:
- is discharged because he/she threatens the health or safety of himself/herself or other members in the facility;
- leaves the state;
- requests that services end;
- refuses to comply with the service plan;
- fails to pay the copayment;
- exceeds personal leave days; and
- requests to move to another facility.
If a member exhibits behavior that threatens the health or safety of others or himself, or his needs exceed the licensed capability of the facility, the provider's written notice must explain the situation and the reasons the member is no longer appropriate for the services. With the concurrence of the MCO, discharge can be as soon as practical when:
- the health or safety of individuals in the facility would be endangered if the member would remain in the facility; or
- the member's medical needs escalate beyond the capability of the facility to meet his/her needs. For example, the member's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.
7252 Member Documentation
The facility must maintain records for each member that include at least the following information:
- health assessment;
- serious occurrences or emergencies involving members or facility staff;
- incidents when a member threatens the health or safety of himself/herself or other residents in the facility;
- documentation when the member has used 10 personal leave days during the member's current individual service plan effective period;
- documentation when the member's needs exceed the licensed capability of the personal care facility;
- termination of services to a member;
- hospitalization of a member;
- death of a member; and
- documentation when a member requests to move to another facility.
7260 Staffing and Training Requirements
The facility must provide all staff with training in the fire, disaster and evacuation procedures within three business days of employment. The training must be documented in the facility records.
7270 Copayment and Trust Fund Records
The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form 2065-D, Notification of STAR+PLUS Program Services.
The facility must maintain a current member copayment ledger system that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances; it must be maintained in accordance with generally accepted accounting principles. If a member copayment is paid from a trust fund, the facility still must prepare a receipt.
The ledger must also reflect room and board charges and payments, and the member must be given a receipt for the room and board payments.
7272 Trust Fund Records/Written Receipts
The facility must maintain trust fund records based on recognized fiscal and accounting principles, and have written permission from the member to handle his/her personal financial affairs.
Members must be informed that:
- funds will be commingled with the funds of other members if the facility will handle the member's trust fund; and
- the facility may review trust fund records of all members whose funds are commingled.
If the member is unable to sign or initial the transaction, or if he/she signs his/her name with a mark (x), the transaction must be signed by a witness. The facility must:
- keep the member's trust fund accounts separate from the facility's operating accounts. The separate account must be identified "Trustee, (name of facility), Member's Trust Fund Account";
- make the member's trust records available for review by the facility during work hours without prior notice;
- not charge the member for services that the facility is expected to provide for the member;
- refrain from charging the member for banking service costs if the member's trust fund is in a pooled account;
- obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the facility is handling; and
- include at least the following in the trust fund records:
- member's name;
- identification of member's representative payee or responsible party;
- transactions; and
- member's earned interest.
The facility may choose one of the following options:
- records of the date and amount of each deposit and withdrawal;
- the name of the person who accepted the withdrawn funds; and
- the balance after each transaction.
Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his/her trust fund, the transaction or receipt must be signed by a witness or signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his/her name, a witness must sign the transaction or receipt.
- distribute the interest earned on any pooled interest banking account in one of the following options:
- prorated to each member on an actual interest earned basis;
- prorated to each member on the basis of his/her end-of-quarter balance; or
- prorated to each member's account monthly if interest is paid on a monthly basis.
If the facility earns interest on any pooled interest account, the interest earned must be prorated to each member's account. Deposit entries should be documented as "interest" in the member's ledger. All transactions must be posted by the middle of the following month. The facility may:
- keep a running balance; or
- compute a balance at the end of the month.
If the facility maintains a trust fund, the facility staff must:
- give the member a receipt for the money deposited into the trust fund;
- deposit the member's monthly income into the account; and
- write a check for the copayment and the room and board payment out of the trust fund account into the facility operating account.
Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account. If the member writes a check to be deposited into his/her trust fund account and there are insufficient funds to cover the check, the facility can charge the member only the actual insufficient funds fee charged by the bank.
There is no requirement that the deposit into the trust fund be made on the same date the money is received. However, the facility must ensure that the deposit slip/bank statement reflects the same amount recorded on the receipt.
7273 Records and Receipts
The facility must ensure that records include written receipts for all purchases made by or for members. A receipt is a written or computer-generated, signed record of payment prepared at the time of payment. If the payment is in person, the written or computer-generated receipt must be signed and contemporaneous with the payment. If the payment is by mail, a statement at the end of the month satisfies the requirement for a written receipt and a bill for the next month. If a single receipt is written for different items, the receipt must clearly describe what the receipt covers.
The record or receipt must include the:
- name of member;
- date the money was received;
- coverage period;
- purpose of payment;
- amount received;
- source of the money;
- amount returned, if any; and
- signature of the facility representative.
The facility is required to have both a trust fund ledger and a copayment ledger. A current member copayment ledger system must be maintained that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances, and be maintained in accordance with generally accepted accounting principles.
The facility must maintain both receipts for monies received from members and bank deposit slips showing the money deposited. These amounts must correspond to amounts recorded in the individual member's trust fund ledger. This system must be maintained in accordance with generally accepted accounting principles.
Vendor withdrawal records must be maintained, regardless of how facility staff account for trust fund transactions (withdrawals on a ledger, cash envelope or individual checkbook register). They must retain receipts for any payment out of a trust fund account that is more than $1.00. The receipt, cash register tape or sales statement is documentation of who actually received the money that was withdrawn from the trust fund account, and that the money was spent as authorized. Any unused money returned to the trust fund custodian must be redeposited to the member's trust fund account and appropriately documented. The prerequisites that allow withdrawal from the member's trust fund are:
- the purchase must be authorized by and for the benefit of the member;
- the cost must be reasonable; and
- facility staff do not profit from the transaction. For example, purchasing items in bulk and selling them at a higher price; or the member authorized the purchase of a TV, stereo, refrigerator, and staff are using it.
7274 Vendor Receipts
The following information must be included on all trust fund vendor receipts (other than long-term payments):
- name of the member;
- date the receipt was written;
- store name;
- amount of money spent or received; and
- item purchased.
7275 Group Purchases
Often, a single purchase is made for goods to be distributed among specific members (for example, cigarettes). In such a case, the invoice or receipt should show the:
- names of the members for whom the purchase was made; and
- portion of the total price charged to each individual account.
Group purchases are only allowable if they can be traced to the individual member.
7276 Payment of Copayment and Room and Board from Trust Fund
It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the copayment and room and board from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the copayment and room and board is paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.
For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on his/her behalf. Examples of long-term payments include insurance premiums, church tithe and cable TV. If the facility:
- has a signed statement from the member authorizing the facility to pay long-term payments on his/her behalf, they do not need a monthly receipt from the vendor; or
- does not obtain a signed statement from the member/responsible party authorizing it to pay the monthly payment on the member's behalf, the facility must have a vendor receipt that includes all items previously identified.
Daily Withdrawals for Minor Purchases or Petty Cash Withdrawals
Members usually require small amounts of money to meet their daily needs for items such as soft drinks, snacks, etc. It is often difficult to keep supporting documents for all such minor purchases.
The member's signature or authorization for a cash withdrawal must be on the individual member ledger, the cash envelope or on a receipt.
Bulk purchase of the same items may be made by the facility. In this case, the member's signature and the amount of the purchase must be on the individual member ledger or a receipt.
7277 Member Authorization
If the member is unable to sign or initial the transaction, or if he/she signs his/her name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than the:
- facility employee who is responsible for managing the trust fund accounts;
- supervisor of the employee who manages the trust fund account; or
- person who is receiving payment for services to the member.
7278 Refunds to Discharged or Deceased Members
The facility must refund the full balance of the member's monies deposited in his/her trust fund account within five days after the member is discharged. If the member dies, there should be no payment from his/her trust fund account other than the refund to the responsible party. No funds may be dispensed to reimburse the facility for damages caused by the member to an Assisted Living apartment. If there is a responsible party, the facility may request voluntary reimbursement prior to the refund, but the responsible party is not obligated to agree.
Maintenance to the facility is included in the cost report as an allowance expense.
The two types of refunds are listed below:
Check — If the refund was made by check, the cancelled check or a copy of the receipt must be signed by the member or responsible party.
Cash — If the refund was made by cash, the receipt must be signed by the member or responsible party.
7300 Respite Care
Respite Services in the HCBS STAR+PLUS Waiver (SPW) are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for an SPW member unable to care for himself/herself.
7310 Service Coordination Duties Related to Respite Care
To be eligible for Respite Services, the member must live in his/her own home or with relatives or other individuals. The member may not live in an Adult Foster Care (AFC) or Assisted Living (AL) setting.
The respite provider must not be a primary caregiver, whether or not he/she is related to the member, and must not live with the HCBS STAR+PLUS Waiver (SPW) member for whom respite is needed. If the member's caregiver is the paid attendant who also provides uncompensated care, in-home respite may be provided only during those hours the caregiver would be providing uncompensated care to the member. If the caregiver is the paid attendant and will be absent during hours for which he/she is normally paid, it is the provider's obligation to provide a substitute attendant during this period.
Respite Services is intended to relieve the caregiver during emergency or planned short-term periods. Respite must be authorized on the individual service plan (ISP) before it can be delivered. The respite rate for out-of-home settings includes payment for room and board. There are no member copayment or room and board charges for respite in out-of-home settings.
The service coordinator is responsible for documenting the Respite Care Services needed by the member. For example, a member needs respite every Friday afternoon so the caregiver can attend class, or a member's caregiver has three four-day trips planned during the ISP year, or a caregiver has a history of emergency hospitalizations. Documentation must also support that the member meets the eligibility criteria for respite. The service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested/authorized. Respite cannot be authorized retroactively. For SPW members who have an emergency need for respite and respite is not authorized on the ISP, the provider must contact the managed care organization (MCO) for authorization prior to delivery of Respite Services.
The member must be given the opportunity to choose from the contracted providers that are appropriate considering his/her needs and the licensed capabilities of the provider. In-home respite is provided by licensed providers contracting with the MCO and/or a Home and Community Support Services Agency (HCSSA) that is contracted with the MCO to provide services. Out-of-home respite is provided by licensed nursing facilities, licensed personal care facilities and licensed AFC homes.
The provider who delivers in-home respite is responsible for providing the personal assistance services authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite and the attendant providing the personal care is not the same attendant to whom the nursing tasks were delegated, the nurse may directly provide the nursing care. It is necessary for the MCO to modify the ISP to include the increased direct nursing based on information provided by the provider. Other services (for example, physical therapy or minor home modifications) may continue to be delivered at the same time as the in-home respite.
Respite Services can be authorized as often as needed for caregiver relief or emergency absences of the caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. Respite must be authorized on Form H1700-1, Individual Service Plan — SPW (Pg. 1), in daily units. For example, if two hours of respite are to be used per week, the ISP authorization is for five units. The calculation is two hours per week times 52 weeks = 104 hours divided by 24 hours = 4.33 units, rounded to next higher unit, or 5. The annual limit on Respite Services is 30 days, equivalent to 720 hours (30 days times 24 hours per day), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of SPW services, must keep track of the units a member has used. The provider may use Form 2067, Case Information, to notify the MCO of the dates and duration of Respite Services delivered so the MCO can track the number of respite days used.
7311 Requesting MCO Approval to Exceed the Respite Service Cap
To request approval to exceed the annual individual service plan (ISP) 30-day limit on Respite Services, the provider must send a written request to the managed care organization (MCO) documenting the:
- need for additional respite units;
- number of additional units needed;
- cost estimate considering the location(s) in which the Respite Services will be delivered;
- overall service plan is within the member's ISP cost limit; and
- service plan is adequate and meets the individual's needs in the community.
The provider includes his/her telephone number and address in the written request. The MCO provides written approval or disapproval of the request.
In reviewing requests to exceed the respite limit, the MCO must consider the intent of Respite Services to relieve the caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:
- members whose caregivers become ill, hospitalized or have a family emergency;
- extenuating circumstances that cause care to be required beyond routine or periodic respite relief; or
- a breakdown in member and/or family support, causing an increased risk of institutionalization because of the physical burden and emotional stress of providing continuous support and care to a dependent person.
7320 In-Home Respite Care
In-home respite care offers services provided by managed care organization (MCO) contracted providers, on a short-term basis, to members unable to care for themselves because of the absence or need of relief for their unpaid caregiver.
In-home respite care is provided in the member's own home, as authorized on the member's Form H1700-1, Individual Service Plan — SPW (Pg. 1), when the unpaid caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2060-MC, 1915(c) STAR+PLUS Waiver Addendum to Form 2060, during the time he/she is receiving in-home respite care.
The provider must document in the member's clinical record:
- the in-home Respite Services provider was given a briefing on the member's status, needs and preferences prior to delivering services; and
- dates and duration of the services delivered.
In-home Respite Care helps prevent member and/or family support breakdown and the consequent institutionalization, which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.
The in-home Respite Services provider must deliver the personal assistance services. The MCO may allow the in-home Respite Services provider's registered nurse the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home Respite Services provider.
In-home respite is not intended to be used when the caregiver needs to be out of the house for short periods of time (for example, to go to the pharmacy or grocery store to pick up medications or grocery items). The caregiver should be encouraged to be out of the house for brief respite when the attendant is providing the personal assistance services.
7330 Out-of-Home Respite Services
Out-of-home Respite Services provide a 24-hour living arrangement in an Adult Foster Care (AFC) home, a licensed personal care facility or a licensed nursing facility for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living, supervision, and the provision or arrangement of transportation.
Nursing tasks may be directly provided by licensed nurses in out-of-home Respite Services or may be delegated as determined by the professional judgment of the provider's registered nurse, unless facility licensure prohibits delegation.
7331 Member Eligibility
The Respite Services applicant or member must:
- meet all eligibility criteria, as specified in Section 3200, Eligibility;
- reside in his/her own home;
- have a caregiver who needs relief either on an emergency or planned short-term basis; and
- not reside in Adult Foster Care (AFC) or a personal care facility.
The applicant for HCBS STAR+PLUS Waiver (SPW) Respite Services must complete the same eligibility determination process as other SPW applicants.
7332 Provider Qualifications
Out-of-home Respite Services providers must be a:
- licensed nursing facility;
- licensed personal care facility; or
- Department of Aging and Disability Services licensed Adult Foster Care home.
In order to deliver HCBS STAR+PLUS Waiver (SPW) out-of-home Respite Services, the provider must complete and sign a contract with the managed care organization (MCO). The contract must be signed by both the provider and MCO prior to the provider serving members.
7333 Description of Services
The HCBS STAR+PLUS Waiver (SPW) member may receive out-of-home Respite Services in a nursing facility, a personal care facility or a Department of Aging and Disability Services licensed Adult Foster Care home, with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The SPW member may take any adaptive aids he/she is using to the out-of-home respite setting.
The managed care organization provides the out-of-home respite provider with the ISP attachments pertinent to the services the member will receive while in the facility/home. The provider must deliver services as identified on the member's ISP attachments.
7334 Respite Services in a Personal Care Facility or AFC Home
The HCBS STAR+PLUS Waiver (SPW) member receiving Respite Services in a personal care facility or Adult Foster Care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite setting. The member's need for any service must be authorized on his/her individual service plan before he/she receives the service.
The SPW member receiving Respite Services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.
Nursing services provided in a Level I or Level II AFC home may be delegated, according to the professional judgment of the provider's registered nurse. Personal care facility licensure prohibits delegation of nursing tasks. In Assisted Living out-of-home respite settings, nursing services must be provided directly by licensed nurses.
7335 Respite Services in a Nursing Facility
The HCBS STAR+PLUS Waiver (SPW) member receiving Respite Services in a nursing facility may receive therapy services from outside providers. The member's need for any service must be authorized on his/her individual service plan before receiving the service. The nursing facility is responsible for providing the needed nursing services to the member.
7340 Room and Board
Room and board charges are not allowable charges to the HCBS STAR+PLUS Waiver (SPW) member receiving out-of-home Respite Services. Room and board charges are included in the rates for the services.
7400 Emergency Response Services
7410 Introduction to ERS
Emergency Response Services (ERS) are provided through an electronic monitoring system and are used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure the appropriate person or service provider responds to an alarm call from a member.
7420 ERS Program Purpose
The purpose of Emergency Response Services under the HCBS STAR+PLUS Waiver (SPW) is to:
- enable aged and disabled persons to maintain dignity, independence, individuality, privacy, choice and decision-making ability; and
- prevent or reduce inappropriate institutional care by providing home-based care and other forms of less intensive care.
7430 Member Eligibility
In order to be eligible for Emergency Response Services (ERS) through the HCBS STAR+PLUS Waiver (SPW), a member must:
- have been determined eligible for SPW;
- be mentally alert enough to operate the equipment properly, in the judgment of the managed care organization service coordinator;
- have a telephone with a private line, if the system requires a private line to function properly;
- be willing to sign a release statement that allows the responder to make a forced entry into the member's home if he/she is asked to respond to an activated alarm call and has no other means of entering the home to respond; and
- live in a place other than an Assisted Living or Adult Foster Care setting, institution or any other setting where 24-hour supervision is available.
STAR+PLUS services members are not eligible to receive ERS through the STAR+PLUS program.
7440 Referral and Selection of Providers
If the member is considered eligible for Emergency Response Services (ERS), the managed care organization (MCO) shares its contracted list of all ERS providers with the member, who selects a provider from the list. The member can request a provider change; however, the member must contact his service coordinator to request the change.
The MCO follows the procedures in Section 3600, Ongoing Service Coordination, and gives members an explanation of the service and requirements.
7450 Duties Related to ERS
If the member wants and appears to be in need of Emergency Response Services (ERS), the service coordinator determines if the member meets the general criteria for participating in ERS, as described in Section 7430, Member Eligibility. The managed care organization (MCO) may involve other members of the interdisciplinary team in the decision regarding the member's physical and mental ability to participate in the ERS program. ERS may be authorized through the HCBS STAR+PLUS Waiver (SPW) when it appears the member may need the capability to notify a respondent of an emergency. ERS services are limited to those individuals who:
- live alone;
- are alone for significant parts of the day;
- have no regular caregiver for extended periods of time and who would otherwise require extensive supervision; or
- live with someone who is too incapacitated to call for help should the need arise.
During the course of the services, the MCO and the provider have the joint responsibility of keeping each other informed of changes or problems.
7460 Provider Duties
Managed care organization contracted providers' duties specific to Emergency Response Services are described in Texas Administrative Code, Part 1, Chapter 52, Subchapter D.
7500 Home-Delivered Meals
Home-Delivered Meals provides hot, nutritious meals that are served in the member's home. Meals provided by contracted agencies are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics or food service management.
7520 Provider Responsibilities
Home-delivered meals are delivered to the memberís home as authorized by the managed care organization (MCO). The individual delivering the meal reports any member illnesses, potential threats to his/her safety or observable changes in the memberís condition to the provider. The provider must notify the service coordinator about the report within 24 hours.
The provider also informs the service coordinator whenever:
- the home-delivered meal is found uneaten or untouched and the member cannot be found; or
- the meals are repeatedly found to be uneaten or untouched.
This report must also reach the MCO within 24 hours of the event.
The MCO must notify the provider on the day that meals services are suspended. The MCO must suspend services in any of the following situations:
- The member moves out of the STAR+PLUS service area.
- The member enters an institution.
- The member requests that services be suspended or terminated.
- The member dies.
- The service coordinator directs the provider to suspend services.
Unless the interruption is the result of one of the above situations, the provider must obtain the service coordinator's approval for service interruptions of more than two consecutive days. When the member requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the service coordinator.
7520.1 Frozen or Shelf-Stable Meals
A provider that contracts with the managed care organization (MCO) to provide home-delivered meals must agree to provide services:
- for a specific number of service days, with a minimum of five meals per week; and
- to all eligible members in the service area unless services are suspended or the provider is unable to provide a certain therapeutic medical diet.
Providers of home-delivered meals must submit a waiver request to the MCO if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the providerís contracted service area. Any waiver granted is effective for a period not to exceed one fiscal year. The provider must not implement the waiver for delivery of a hot meal five days a week before MCO approval of the waiver request.
7600 Transition Assistance Services
Transition Assistance Services (TAS) assists Medicaid recipients who are nursing facility residents discharged from the facility to a waiver program with setting up a household. A nursing facility resident discharged from the facility into a waiver program is eligible to receive up to $2,500 in TAS. TAS is available on a one-time only basis and is not available to residents moving from a nursing facility who are approved for any of the following waiver services:
- Assisted Living services;
- Adult Foster Care services;
- support family services;
- 24-hour residential habilitation; or
- family surrogate services.
Waiver individuals who are temporarily residing in a nursing facility may also be eligible for TAS. TAS may be used if the waiver member's living conditions are inadequate. Inadequate living conditions may include situations in which the individual has lost his residence because of moving into the nursing facility or conditions in the previous residence are so inadequate that the individual cannot return.
7611 Service Description
Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for individuals transitioning from nursing facilities to a home in the community. Allowable expenses are those necessary to enable the individual to establish a basic household and may include:
- payment of security deposits required to lease an apartment or home;
- set-up fees or deposits to establish utility services for the home, including telephone, electricity, gas and water;
- purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, food preparation items and bath linens;
- payment of moving expenses required to move into or occupy the home or apartment; and
- payment for services to ensure the health and safety of the individual in the apartment or home, such as pest eradication, allergen control or a one-time cleaning before occupancy.
TAS does not include relocation services and is not available to assist the applicant in locating a residence.
7620 Procedures at the Initial Interview
All HCBS STAR+PLUS Waiver (SPW) applicants who are in a nursing facility (NF) must be advised of the availability of Transition Assistance Services (TAS) and screened for the potential need for services.
At the initial interview with the applicant, the managed care organization service coordinator discusses the applicant's available living arrangements in the community and asks the applicant where he/she intends to live upon discharge from the nursing facility.
TAS may be considered when the applicant:
- plans to rent an unfurnished apartment;
- plans to rent an unfurnished house;
- has a home, but all the utilities have been off while in the NF;
- has a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
- needs his belongings moved to the new residence.
If these or any other situations exist in which the applicant could benefit from TAS services, continue with the screening for TAS.
7630 Assistance from Relocation Specialists
All applicants for HCBS STAR+PLUS Waiver (SPW) using the Money Follows the Person option must be referred to a relocation specialist. Relocation assistance consists of, but is not limited to:
- assessment for relocation;
- information about Medicaid waiver and non-waiver services and supports;
- information about and assistance with applying for affordable, accessible housing;
- coordination with the various state agency services for which the person is eligible;
- coordination of community services/resources that can assist in transitioning to the community;
- development of persons/family-directed transition plans and arrangements;
- support and assistance to individuals and families making the transition; and
- follow-up assessment after transition.
In addition to providing relocation assistance, some relocation specialists may also contract to provide Transition Assistance Services (TAS).
Form 1579, Referral for Relocation Services, is also used to refer an ongoing SPW member who has entered a nursing facility (NF). Form 1579 must be sent to the relocation specialist within two business days of release from the nursing facility.
Although relocation services may be available when the member is discharged back to the community after a temporary NF stay, TAS may not be available if the member previously used TAS services to move from the NF to the community and used the entire $2,500 allocation.
7640 Identification of Needed Items and Services
The managed care organization (MCO) conducts the interview with the applicant and/or authorized representative to identify the applicant's needs and determine if other resources are available to meet the needs. The MCO completes Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, by marking each identified need and writing a description of the exact need.
Example: If the applicant needs a deposit made for electricity, the MCO enters the name and address of the utility company and the amount required.
7641 Items and Services Included Under TAS
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.
Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's name.
Security deposits may be paid as long as the payment is specifically called a security deposit and not rent, the payment is for a one-time expense, and the amount of the payment is no more than the equivalent of two months rent. Transition Assistance Services (TAS) cannot pay for rent.
TAS can be used to pay for arrears on previous utilities if the account is in the member's name and the member will not be able to get the utilities unless the previous balance is paid. TAS cannot pay the first month's payment on utilities.
TAS can be used to pay for a telephone since it is a basic need, but minutes or services on the telephone are not allowable expenses.
TAS cannot pay for any charges for upgraded services beyond the basic service.
TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company has a policy that requires a minimal supply of fuel to be delivered during the initial or reconnection service call. TAS funds cannot be used to top off a tank with fuel when the individual's home is connected and has a supply of butane or propane.
TAS can pay for pet deposits only if the pet is a service animal essential to the member.
7641.2 Household Needs
Household needs include basic furniture/appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, etc.
An applicant may request a specific brand or type of appliance, furniture or other Transition Assistance Services (TAS) item as long as the applicant's needs are met within the cost limit.
TAS items may be placed in a home other than the applicantís only when furnishings are not available and are necessary for the applicant to transition to the community. TAS cannot pay for items that would only be used by the other person.
If existing items are not usable and the lack of a usable basic/essential item creates a barrier keeping the individual from returning to the community, the item is considered a need.
Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.
7641.4 Small Appliances
Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.
7641.5 Cleaning Supplies
Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.
7641.6 Other Items Not Listed
Any special requests from the applicant not covered in the general list that meet the criteria as basic essential items to move to the community may be considered.
7642 Services and Items Not Included in Transition Assistance Services
Transition Assistance Services (TAS) does not include any items or services that are included under HCBS STAR+PLUS Waiver (SPW) services such as adaptive aids, minor home modifications, medical supplies or medications.
TAS does not include any recreational items/appliances, including televisions, VCR or DVD players, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.
TAS does not cover the cost of repairs on the individual's dwelling. TAS is not used for remodeling or renovation, upgrading of existing items or purchase of non-essential items.
TAS funds cannot be used for food. The managed care organization may refer the individual to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources. Some funds are still available through the Transition to Living in the Community (TLC) Program. While funds are primarily designated for non-waiver individuals, if a waiver individual has no other resources, TLC could be used to pay for food.
Room and board are not allowable TAS expenses.
TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.
7643 Site Preparation
Site preparation can include the following services:
- moving expenses, which include the cost of moving the applicant's items from another location, or delivery charges on large purchased items;
- pest eradication, if the applicant's place of residence has been unattended and some type of extermination is needed;
- allergen control, if the applicant's place of residence has been unattended or the applicant is moving into a place that poses a respiratory health problem; or
- one-time cleaning, if the applicant's place of residence has been unattended or the applicant is moving into a private home or apartment where pre-move-in cleaning should not be expected (for example, a family friend has an empty house available, but cannot provide the cleaning).
Transition Assistance Services cannot pay for septic systems.
7650 Estimated Cost of Items and Services
The managed care organization service coordinator provides a description and estimated cost of each item identified as needed under each service category on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The actual cost of an item may be used, if known. The amounts, either actual or estimated, must be less than or equal to $2,500.
The service coordinator must be as specific as possible when describing what items are needed and the estimated cost. The description must include size, color, specific types or any other identifying information, as specified by the individual, which will assist the TAS agency in meeting the individual's needs.
7651 Totaling the Estimated Cost and Authorization of Transition Assistance Services
The service coordinator totals each section of Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and enters the amounts in the totals section to arrive at the final amount to be authorized under the TAS program. The $2,500 total amount is not entered as a flat rate.
The applicant must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he/she agrees that the TAS agency selected is authorized to make the purchases for him/her.
The applicant selects a TAS agency from the list of contracted agencies.
The service coordinator must explain to the applicant that the service will not be authorized until the applicant is determined eligible for HCBS STAR+PLUS Waiver (SPW) services, and notified in writing that he/she is eligible. The service coordinator must contact the applicant or applicant's representative before certification to verify the applicant has made arrangements for relocating to the community and has finalized a projected discharge date.
The service coordinator sends the applicant the notification of eligibility and sends the TAS agency Form 8604 and the authorization. The completion date on the authorization is two days before the projected nursing facility discharge date. Allow at least five business days between the authorization date and the completion date. The TAS agency is expected to have all services and items completed by that date. For situations in which a shorter completion date is needed, the service coordinator must contact the TAS agency and negotiate an earlier date.
Additional applicant information to the TAS agency may be included on Form 8604 or Form 2067, Case Information. Form 8604 is mailed after the applicant is determined eligible for waiver services.
The TAS agency may only obtain items/services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items/services that the individual may need, the TAS agency must obtain prior approval from the managed care organization. Refer to Section 7652 below.
7652 Changes to the Authorization
If the Transition Assistance Services (TAS) agency or the member identifies additional items required by the member after the TAS authorization has been sent, the TAS agency must obtain approval from the managed care organization (MCO) on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, prior to obtaining the item/service.
The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items/services needed is more than the total amount authorized, the TAS agency must obtain prior approval and an updated Form 8604 from the MCO.
The MCO must send an amended Form 8604 updating the authorization to the TAS agency within two business days with the additional items and amounts authorized.
MCO approval is required to authorize delivery of TAS services.
7660 Transition Assistance Services Agency Responsibilities
The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the forms carefully and contact the MCO if there are any questions regarding what has been authorized. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization form within two business days if it clarifies an item is authorized or approves a change to the authorization.
The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the dollar amount authorized by the MCO. The TAS agency contacts the member or member's authorized representative, if necessary, to coordinate service delivery.
The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.
The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.
7670 Three-Day Monitor Required
The managed care organization (MCO) monitors the member within three business days after the discharge date to assure that all services and items authorized through the Transition Assistance Services (TAS) agency have been received. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the memberís case record.
7680 Failure to Leave the Facility
While the managed care organization (MCO) makes every effort to confirm that the member has definite plans to leave the facility, there may be situations in which the member changes his/her mind or has a change in his/her health making it impossible for him/her to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.
The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual.
- If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting individuals establish a home.
- If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
- If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the costs of the service, not to exceed the authorized amount.
If the individual is only in the community for a few days and returns to the nursing facility, the individual keeps the item(s) purchased through TAS.
7690 Member Notifications and Appeals
The purpose and limitations of Transition Assistance Services (TAS) must be explained to the applicant when determining the applicant's needs. The applicant may appeal a decision regarding a needed item or service, but services should not be delayed due to the appeal.
Form 2065-D, Notification of STAR+PLUS Program Services, must be sent advising the member of the date of eligibility for the HCBS STAR+PLUS Waiver (SPW) service before the authorization of any services. If the member has finalized his/her discharge plans, Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, may be sent to the TAS provider on the same day Form 2065-B is sent to the member. If discharge plans are not finalized at the time of eligibility, Form 8604 may be sent at a later date. TAS information may be addressed in the Form 2065-D comments section.
The managed care organization notifies the applicant in writing of any changes in TAS services or items. The TAS provider is given provider authorization to deliver TAS services on Form 8604.