4110 Adult Foster Care Introduction

Revision 19-13; Effective November 5, 2019

Adult foster care (AFC) provides 24-hour living arrangements and personal care services (PCS) and supports for persons who, because of physical or behavioral conditions, are unable to live independently. Services and supports may include assistance and/or supervision with daily living, including meal preparation, housekeeping, companion services, personal care, nursing tasks and the provision of, or arrangement for, transportation. The STAR+PLUS Home and Community Based Services (HCBS) program applicant or member who chooses AFC must reside with a contracted STAR+PLUS HCBS program AFC home provider that meets the minimum standards and licensure requirements found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

AFC home providers must be contracted either directly with the member’s managed care organization (MCO) or with an AFC provider agency contracted with the member’s MCO. The individual qualified to provide AFC (AFC home provider) must be the primary caregiver. AFC home providers must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. AFC home providers may serve up to three adult residents in a qualified AFC home without being licensed as a personal care home or assisted living facility (ALF), and may be the AFC home provider’s home or the STAR+PLUS HCBS program member’s home. AFC home providers with four or more residents, which are also contracted with the Texas Health and Human Services Commission (HHSC), are required to have a Type C Personal Care Home license. AFC homes with four to eight AFC residents must be licensed as an ALF, with limitations on the number of residents at each level who may reside in the home. The three levels of eligibility for AFC are explained in Section 4133, Adult Foster Care Classification Levels. ALF licensure requirements are found in Title 26 Texas Administrative Code (TAC) Chapter 553, §553.41.

Any reference to “resident” includes members receiving services in the STAR+PLUS HCBS program AFC or private pay individuals. AFC home providers may serve a combination of STAR+PLUS HCBS program members and private pay individuals in a qualified or licensed AFC home as long as the AFC home provider continues to meet the minimum standards specified in Appendix XXIV, and additional other standards may be specified by the MCO.

When the AFC home provider moves in with the STAR+PLUS HCBS program member receiving AFC in the member’s home, the AFC home enrollment requirements indicated with an asterisk in Appendix XXIV may be waived at the discretion of the MCO or the MCO-contracted AFC provider agency, as appropriate. Other minimum standards, excluding home safety requirements, may be waived at the discretion of the MCO, or upon the recommendation by the MCO-contracted AFC provider agency if the MCO-contracted AFC provider agency has completed a home assessment and concluded the member’s needs can be appropriately met through the STAR+PLUS HCBS program and AFC specific services. Such conclusions must be documented by the MCO-contracted AFC provider agency and approved by the MCO.

The MCO is responsible for ensuring the AFC member receives all necessary AFC services, including the authorization of other needed services and nursing tasks.

STAR+PLUS HCBS program AFC members are required to pay for their own room and board (R&B) charges and, if able, contribute to the cost of AFC services through a copayment to the AFC home provider. The only time the R&B charge is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home. R&B arrangements must be documented in the member’s case file by the MCO or by the MCO-contracted AFC provider agency.

If an AFC home is contracted with HHSC to provide services to a member receiving AFC through HHSC, the MCO or the MCO-contracted provider agency may request a copy of the AFC home and AFC home provider qualification documents from HHSC, if applicable. These documents contain HHSC findings regarding the qualifications of the AFC home and AFC home provider.

4111 Adult Foster Care Purpose

Revision 19-13; Effective November 5, 2019

The purpose of the STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) is to promote the availability of appropriate services in a home-like environment for members who are aging and who have disabilities to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of a member.

The STAR+PLUS HCBS program requires each AFC member to have enough living space to guarantee his or her privacy, dignity and independence.

4112 Reserved for Future Use

Revision 24-1; Effective Feb. 22, 2024

4113 Adult Foster Care Services

Revision 19-13; Effective November 5, 2019

The adult foster care (AFC) home provider must provide services, supports and supervision, as needed, around the clock in an AFC home that has either been qualified based on the minimum standards or licensed by the Texas Health and Human Services Commission (HHSC) (for homes serving four or more residents). Services may include personal assistance services (PAS).

A STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) member may not receive STAR+PLUS HCBS program PAS while the member is a resident in a STAR+PLUS HCBS program AFC home. Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and any addendums to Form H2060, are completed by the managed care organization (MCO) to determine the needed tasks for completion by the AFC home provider. The MCO must provide a copy of the required PAS tasks to the AFC home provider and to the MCO-contracted AFC provider agency, if applicable:

• transportation;
• supervision;
• meal preparation; and
• housekeeping.

AFC services, except for 24-hour supervision that is provided to all STAR+PLUS HCBS program AFC members, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. For example, STAR+PLUS HCBS program AFC members may not need assistance with medication or help with transportation, but the services are available to all STAR+PLUS HCBS program members in AFC homes. PAS tasks must be provided, as identified on Form H6516, Form H2060 and any addendums to Form H2060. The AFC home provider may provide more services for the member than are authorized, as the changing needs of the member may warrant, but may not reduce or discontinue services without prior consultation with the MCO.

STAR+PLUS HCBS program members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to non-emergency medical transportation is available to members through the Medical Transportation Program (MTP).

4120 Minimum Standards for All AFC Homes and Providers

Revision 19-13; Effective November 5, 2019

All adult foster care (AFC) homes and AFC home providers must be qualified initially and annually thereafter in accordance with the minimum standards outlined in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

4121 AFC Homes with Four or More Residents and Members

Revision 19-13; Effective November 5, 2019

An adult foster care (AFC) home provider must obtain an assisted living (AL) license if the AFC home provider wants to serve four or more private pay residents and/or members. The AFC home provider may apply for an AL license from the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The license must be renewed annually and requires an annual fee. Licensing standards for various types of AL facilities are found in Title 26 Texas Administrative Code (TAC) Chapter 553, §553.41.

The AFC home provider must submit a copy of the AL license to the managed care organization (MCO) or MCO-contracted AFC provider agency before being credentialed and upon renewal. The AFC home provider must report to the MCO or MCO-contracted AFC provider agency any problem(s) identified by the HHSC Regulatory Services Division. AFC home providers must meet all applicable requirements in the minimum standards for AFC. AFC home providers with an AL license must serve no more than a total of eight adult residents in a small group home.

AFC homes of four or more residents, without an HHSC contract, are also subject to the following two sets of regulations:

• Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers; and
• Licensing Standards for Assisted Living Facilities, found in Title 26 TAC, Chapter 553, §553.41.

The stricter requirements apply when requirements of the two sets of regulations conflict. For example, 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.

If the MCO uses a contracted AFC provider agency, the contracted AFC provider agency must provide copies of any licenses for AFC homes of four or more residents when the MCO requests them.

4122 Small Homes for One to Three Residents and Members

Revision 19-13; Effective November 5, 2019

An adult foster care (AFC) home provider who serves up to three residents, including STAR+PLUS Home and Community Based Services (HCBS) program members, may be a member's relative, excluding the spouse. While these small homes do not require licensure, AFC homes and AFC home providers must meet the standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers. As outlined in Section 4110, Adult Foster Care Introduction, if the AFC home provider moves into the AFC member's home, AFC home requirements in Appendix XXIV may be waived at the discretion of the managed care organization (MCO) or MCO-contracted AFC provider agency.

4123 MCO Responsibilities

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) responsibilities include:

• providing information to interested applicants about potential adult foster care (AFC) homes and coordinating visits to the homes;
• developing an individual service plan (ISP);
• acting as coordinator of the interdisciplinary team (IDT);
• authorizing AFC services;
• evaluating and coordinating services for the member;
• notifying the member, AFC home provider and AFC provider agency, if applicable, of room and board (R&B) charges and copayment amounts, as outlined in Section 3236, Copayment and Room and Board;
• processing changes and conducting annual reassessments for the member;
• completing an assessment to ensure the potential or existing member’s needs can be met in a particular home;
• recruiting, contracting and credentialing AFC homes and home providers;
• processing AFC home and home provider applications;
• orienting and training AFC home providers;
• approving private pay residents;
• ensuring initial and ongoing compliance with AFC minimum standards;
• conducting annual requalification reviews of the AFC home and home provider;
• conducting administrative reviews; and
• processing AFC provider payments.

An MCO may also choose to contract with an AFC provider agency to facilitate AFC home and home provider management on behalf of the MCO. When this occurs, the contracted AFC provider agency is responsible for provisions stipulated in its contract with the MCO. However, the MCO retains overall responsibility for all requirements related to AFC service delivery and oversight of the MCO contracted AFC provider agency and the member.

4130 Adult Foster Care Eligibility

Revision 19-13; Effective November 5, 2019

To be eligible for adult foster care (AFC), applicants and members must meet basic eligibility requirements for STAR+PLUS Home and Community Based Services (HCBS) program services as well as specific requirements related to AFC. Basic eligibility requirements for the STAR+PLUS HCBS program can be found in Section 3230, Financial Eligibility, and Section 3240, STAR+PLUS HCBS Program Requirements. AFC applicants or members are identified for STAR+PLUS HCBS program AFC based on their assessed needs for care. Refer to Section 4133, Adult Foster Care Classification Levels, for additional information.

4131 AFC Intake, Assessment and Response to Request for Services

Revision 19-13; Effective November 5, 2019

Adult foster care (AFC) is appropriate for individuals who, because of physical, mental or behavioral conditions, are unable to live independently and who need and desire the support and security of family living. AFC may be appropriate for individuals who are:

• seeking alternatives to facility-based care; or
• interested in leaving institutional care but are unable to resume independent living.

When discussing AFC as an option for applicants or members, the managed care organization (MCO) or MCO-contracted AFC provider must explain the room and board (R&B) requirements and ensure the applicant or member understands that he or she must pay a portion of the monthly income for R&B. If the AFC home provider moves into the member’s home, payment for R&B charges does not apply. The MCO must also explain that some members residing in an AFC home are additionally required to contribute to the cost of their AFC services by paying a copayment, regardless of whether the AFC home is the member's home. Refer to Section 4152, Room and Board and Copayment Requirements, for additional information.

4132 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

4133 Adult Foster Care Classification Levels

Revision 19-13; Effective November 5, 2019

Classification (payment levels) for adult foster care (AFC) members are used for identification of potential AFC applicant or member appropriateness and are based on the member’s assessed needs for care, as determined through the required face-to-face assessments for STAR+PLUS Home and Community Based Services (HCBS) program services and the individual service plan (ISP) completed by the managed care organization (MCO) service coordinator. Determine and document whether an applicant or member is appropriate for AFC based on the applicant’s or member’s condition and behavior. Develop an ISP appropriate to the applicant’s or member’s needs and specific to a given AFC home provider, taking into consideration the AFC home provider’s capabilities. The MCO-contracted AFC provider agency, if applicable, would be involved in a determination of AFC home provider capabilities.

4133.1 Levels of Adult Foster Care Members

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) will use the Medical Necessity and Level of Care (MN/LOC) Assessment, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums. The MCO service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) (transferring, walking, dressing, eating, toileting, bathing), and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member.

Below are the classification levels of a member’s daily assistance or supervision requirements.

Level I AFC Member

A member who needs assistance with identified needs including a minimum of:

• one ADL and behavior(s) that occur at least once a week; or
• two ADLs.

Level II AFC Member

A member who needs assistance with identified needs including a minimum of:

• two ADLs and behavior(s) that occur at least once a week; or
• three ADLs.

Level III AFC Members

A member who needs assistance with identified needs including a minimum of:

• three ADLs and behavior(s) that occur at least once a week; or
• four ADLs.

4133.2 AFC Homes Corresponding to AFC Member Levels

Revision 19-13; Effective November 5, 2019

The adult foster care (AFC) home provider must be able to meet the member’s needs in the AFC setting in conjunction with the STAR+PLUS Home and Community Based Services (HCBS) program and other available supports. If the member’s needs for care exceed the capability of the AFC home provider, the managed care organization (MCO) service coordinator must reassess the member and offer alternate care options.

The AFC home provider who is a licensed registered nurse (RN) and the AFC home provider RN substitute must provide proof of current licensure to the MCO or contracted provider agency (if applicable) initially and annually thereafter.

The MCO RN service coordinator will complete the Medical Necessity and Level of Care (MN/LOC) Assessment, both initially and annually. AFC home providers with STAR+PLUS HCBS program members may not care for more than one totally dependent AFC resident. The MCO RN service coordinator must respond to a request for a change in services within the individual service plan (ISP) year.

Health maintenance activities (HMAs) are tasks which may be exempt from RN delegation based on the MCO RN assessment. HMAs may enable the member to remain in an independent living environment and go beyond activities of daily living (ADLs) because of the higher skill level required to perform them (as found in the Texas Board of Nursing (BON) rules in Title 22 Texas Administrative Code (TAC) §225.4(8)).

For members residing in Level I, Level II and Level III AFC homes not operated by an RN, the skilled nursing needs must be:

• identified by the MCO service coordinator as HMAs;
• purchased as nursing services on the ISP;
• provided by Medicare, Medicaid home health or other resource;
• met by a nurse at a Day Activity and Health Services (DAHS) facility; or
• a combination of the above options.

For members residing in Level I, Level II and Level III AFC homes operated by an RN, the skilled nursing needs must be:

• identified by the MCO service coordinator as HMAs;
• met by the AFC home provider nurse or nurse substitute;
• provided by Medicare, Medicaid home health or other resource; or
• a combination of the above options.

AFC members receiving nursing services and residing with an RN who is the AFC home provider are not eligible to receive DAHS.

4134 Adult Protective Services and Adult Foster Care

Revision 19-13; Effective November 5, 2019

This section provides details regarding when Adult Protective Services (APS) staff request adult foster care (AFC) as a resource for individuals who may benefit from AFC.

4134.1 Placement of APS Clients in AFC

Revision 19-13; Effective November 5, 2019

Adult Protective Services (APS) may want to move an adult foster care (AFC) individual into an AFC home where a STAR+PLUS Home and Community Based Services (HCBS) program member resides. The managed care organization (MCO) must approve and ensure the APS individual is appropriate and document this in the MCO case record. This includes determining the:

• APS individual's medical and behavioral health needs are met;
• capacity of the AFC home provider to meet the APS individual's needs; and
• compatibility of service delivery to the APS individual with the delivery of services to existing AFC members who may reside in the AFC home.

If the MCO determines the APS individual's placement is not appropriate, the APS individual may not move into the AFC home and the APS worker must make other living arrangements.

4134.2 APS Investigations of AFC Providers

Revision 19-13; Effective November 5, 2019

Any time managed care organization (MCO) staff of an MCO-contracted adult foster care (AFC) provider agency suspect abuse, neglect or exploitation (ANE) of an AFC member in an unlicensed AFC home, the staff must report it immediately to Adult Protective Services (APS). Reports of ANE in a licensed AFC home must be made to the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The MCO-contracted AFC provider agency must also notify the MCO.

If reports of ANE taking place in an unlicensed AFC home are made to APS by other parties, the MCO or MCO-contracted AFC provider agency staff may not be notified of member allegations against an AFC provider until after the allegations have been validated. However, APS staff may ask the MCO or MCO-contracted provider agency to assist with the delivery of alternative services during the investigation if the alleged mistreatment poses an immediate threat to the safety of the member or other AFC residents.

The MCO handles disenrollment and corrective actions against the AFC home provider, as appropriate. HHSC takes necessary licensure actions for licensed AFC homes. If HHSC terminates the licensure of an AFC home and the MCO is unable to find a suitable alternative residence for the member, the member is referred to APS for assistance in moving from the AFC home.

A member in an unlicensed AFC home who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated. In this instance, the member's AFC services will be denied, payments to the home will terminate and an MCO-contracted provider agency will withdraw from supporting ongoing management of the home. However, the member may continue to reside in the unlicensed AFC home by making private pay arrangements at that home.

If a member residing in an unlicensed AFC home, who does not appear to have the capacity to consent, refuses to move from an unlicensed AFC home in which an individual identified as the perpetrator in a case of validated ANE lives and is in a state of ANE, the MCO must make a referral to APS. The MCO-contracted AFC provider agency staff must send a referral to the MCO and APS if the agency staff identify this situation.

If the substantiated allegation of ANE is in a licensed AFC home, the perpetrator must be removed from the AFC home and the license holder must submit to HHSC a plan for the protection of the health and safety of all residents. The resident will not be required to move.

4135 Private Pay Individuals in AFC

Revision 19-13; Effective November 5, 2019

Some adult foster care (AFC) home providers may wish to take private pay individuals. The AFC home provider must contact the managed care organization (MCO) when considering the admission of a private pay individual before he or she is accepted in the AFC home. The purpose of the approval is to determine the:

• appropriateness of AFC for the private pay individual based on the individual’s condition and behavior;
• capacity of the AFC home to meet the private pay individual’s needs; and
• compatibility of service delivery to the private pay individual and the delivery of services to AFC members.

If the MCO determines placement in an AFC home is inappropriate, the AFC home provider cannot accept the private pay individual. Any issues regarding placements must be resolved by the MCO.

4140 AFC MCO Procedures

Revision 19-13; Effective November 5, 2019

This section provides details for a managed care organization (MCO) when determining an applicant's eligibility for adult foster care (AFC) and for developing the applicant’s or member’s individual service plan (ISP).

4141 Eligibility Determination

Revision 19-13; Effective November 5, 2019

To determine eligibility for Adult Foster Care (AFC), the managed care organization (MCO) must determine the applicant or member meets all criteria for the STAR+PLUS Home and Community Based Services (HCBS) program and completes an assessment to determine the applicant’s or member’s classification level. If the AFC placement is with an individual AFC home provider contracted with the MCO, the MCO must also ensure the applicant or member has an agreement with an enrolled AFC home provider, and the applicant or member and AFC home or home provider are appropriately matched per the classification and needs of the applicant or member before the MCO pays for AFC services. If an MCO contracts with an AFC provider agency to perform AFC management services, the MCO-contracted provider agency may perform activities related to the qualification of the home and the home provider before the MCO pays for AFC services. Refer to Section 4133, Adult Foster Care Classification Levels, for additional information.

4142 Service Planning

Revision 19-13; Effective November 5, 2019

The member’s plan of care (POC) must address functional, medical, social and emotional needs and how the needs will be met by the adult foster care (AFC) home provider. 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 member’s POC.

The MCO must complete Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, to document the specific personal assistance tasks with which the AFC home provider must assist the member. The AFC home provider may provide more services for the member than are identified on Form H2060 as the changing needs of the member may warrant but may not reduce or discontinue services without consultation with the MCO or MCO-contracted AFC provider agency.

Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the AFC home. The MCO must document any special needs or interventions 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 or MCO-contracted AFC provider agency contacts the member and the AFC home provider to arrange for the initial visit and a negotiated move-in date for the member or AFC home provider. 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 or medical exam before moving into the AFC home. The MCO coordinates with the interdisciplinary team (IDT) and the MCO-contracted AFC home provider, if applicable, regarding the AFC member’s care.

4150 Finalizing the Member’s Plan of Care

Revision 19-13; Effective November 5, 2019

On or before the date the member begins to receive adult foster care (AFC) services, a face-to-face meeting with the member and the AFC home provider is required to discuss the member's plan of care (POC) and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team (IDT), including the staff of the managed care organization (MCO)-contracted AFC provider, as applicable, and the member's family, authorized representative (AR) or guardian may be included in the meeting. The meeting should preferably take place in the AFC home.

The MCO must discuss the member's POC with the member and family, AR or guardian and reach understanding with them about how the AFC home provider will meet the member’s needs. This discussion should ensure the member and family, AR or guardian that the AFC home provider is adequately prepared to provide services to the member and that adjustments occur smoothly. The MCO must document the POC and any special needs of the member or special agreements between the member and AFC home provider on Form 2327.

If the applicant or member is already residing in the AFC home, Form 2327 must be completed by the MCO service coordinator face-to-face with the applicant or member and AFC home provider or provider agency, if applicable, before the MCO pays for AFC services initially and upon annual reassessment.

4151 Member and AFC Home Provider Agreement

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment (R&B) charge on Form 2327, Individual/Member and Provider Agreement.

The MCO or the MCO-contracted adult foster care (AFC) provider agency reviews all of the information on the agreement with the member, family, authorized representative (AR) or guardian and the AFC home 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 frequency of services needed.
• The need for, and frequency of, supervision.
• The beginning and ending date on Form 2327.
• A detailed description of the rights and responsibilities of the member and the AFC home provider.
• An explanation of the member's and AFC home provider's right to privacy and confidentiality.
• The monthly dollar amount the member agrees to pay the AFC home provider for R&B, as documented on Form 2327.
• The arrangements for a trust fund if the STAR+PLUS Home and Community Based Services (HCBS) program member requests such service from the AFC home provider.
• An inventory of the AFC member’s 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 AR or guardian.
• Any special habits and needs of the member and any special arrangements or agreements between the member and the AFC home provider.
• Any additional training needs of the AFC home provider and methods to obtain that training.
• The rights and responsibilities of both the member and the AFC home provider for notifying the MCO, MCO-contracted AFC provider agency, as applicable, of problems such as illnesses, adverse medication reactions, hospitalizations, acts of violence, accidents or complaints about abuse, neglect or exploitation (ANE). The Texas Health and Human Services Commission (HHSC) Managed Care Compliance and Operations (MCCO) Unit staff must be notified if the member, MCO-contracted provider agency or AFC home provider have a complaint or issue regarding the health and safety of the member.
• Other conditions that reflect changes in the member's condition that might affect the appropriateness of AFC services.

The MCO or MCO-contracted provider agency must fully discuss with the AFC home provider the potential for transition issues arising after the member moves into the AFC home or when the AFC home provider moves into the member’s home. The discussion should include notification procedures and suitable actions to be taken to address issues and resolve problems, and the impact of a new living situation on family and other residents in the home.

The member and the AFC home 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 significant changes to the terms of the agreement must be reported by the AFC home provider within five business days. Any incidents, as referenced in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, must be reported by the AFC home provider to the MCO service coordinator assigned to the member, and the MCO-contracted AFC provider agency, as applicable, within 24 hours of the occurrence.

4152 Room and Board Charges and Copayment Requirements

Revision 19-13; Effective November 5, 2019

Room and board (R&B) charges and copayment are applicable to adult foster care (AFC) members as described in Section 3236, Copayment and Room and Board. If the AFC service is provided in the member’s own home, the member is not required to pay R&B charges. It is the responsibility of the managed care organization (MCO) to ensure the member and the MCO-contracted AFC provider agency, as applicable, are notified in writing on Form 2327, Individual/Member and Provider Agreement, when the R&B charge is waived. It is the MCO-contracted AFC provider agency’s responsibility to notify the AFC home provider when the R&B charge is waived. The copayment amount, if applicable to the member, may be waived.

The R&B charge, as applicable, is entered on Form H2065-D, Notification of Managed Care Program Services, and Form 2327. The member does not pay R&B if the AFC home provider moves in with the member into the member’s home. The MCO or MCO-contracted AFC provider agency must ensure the member and AFC home provider understand that the R&B arrangement with the AFC home provider is separate from the MCO payment for AFC services. The member pays the AFC home provider the R&B charge listed on Form 2327 and Form H2065-D. If the member is moving into the AFC home mid-month, the amount of R&B for the month is prorated and the member and AFC home provider will be advised of the prorated amount.

If a copayment is applicable, the AFC member's copayment amount is listed on Form H2065-D, which is sent to the member by Program Support Unit (PSU) staff and uploaded to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Form H2065-D is used to report to the member the amount of his or her copayment for the first month of authorized service and subsequent months. The MCO furnishes a copy of Form H2065-D to the AFC home provider.

When the R&B amounts and/or copayment change, the MCO must notify the AFC home provider and the member of the new amount before the change, as described in Section 3239, Copayment Changes. The member must pay the R&B charge and copayment amount by the eighth day of the month. If the member does not pay the required fees, he or she may not be eligible for STAR+PLUS Home and Community Based Services (HCBS) program AFC services.

The STAR+PLUS HCBS program AFC home provider must collect the copayment amount from the member. The AFC home provider must keep receipts for all copayments collected. The AFC home provider must deduct the copayment amount authorized on Form H2065-D from reimbursement claims submitted to the MCO or advise the MCO-contracted AFC provider agency of the amount collected. If a STAR+PLUS HCBS program AFC member does not pay the R&B or copayment amount, the MCO or MCO-contracted AFC provider agency must investigate the member's failure to pay, including contacting 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 home provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of Texas Health and Human Services Commission (HHSC) Managed Care Compliance and Operations (MCCO) Unit staff and the MCO.

If the member refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO shall write a letter to the member or authorized representative (AR) explaining the consequences of continued refusal to pay. If the member does not pay his or her required fees within 30 days of the due date, the MCO can terminate AFC services to the member. If STAR+PLUS HCBS program AFC is being delivered in the AFC home provider’s residence, the member can then be evicted from the home, according to local eviction ordinances and procedures.

4153 Trust Funds

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) must offer money management assistance by the adult foster care (AFC) home provider to the member and document when the member either accepted or refused the assistance. If the member expresses an interest in money management, the MCO documents the expressed interest on Form H2067-MC, Managed Care Programs Communication, and sends the form to the AFC home provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The AFC home provider must maintain trust fund records. The AFC home provider must:

• have written permission from the member, his or her guardian, power of attorney or applicable individual to handle the member’s personal financial affairs;
• keep member trust accounts separate from the AFC home provider's operating accounts. The separate account must be identified "Trustee (name of the STAR+PLUS Home and Community Based Services (HCBS) program AFC home provider), Member's Trust Fund Account." If the AFC home provider maintains a trust fund, the AFC home provider must:
  • deposit the member's monthly income into the account; and
  • write a check for the room and board (R&B) charge and copayment amount out of the trust fund account into the AFC home provider's operating account. Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and R&B allowance into the trust fund account;
• make the member trust fund records available for review by the MCO or AFC home provider agency during work hours without prior notice;
• not charge the member for services the AFC home provider is expected to provide for the member;
• not charge 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 AFC home provider is handling. The AFC home 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 AFC home 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. The member must sign each withdrawal. If the member is unable to sign when funds are being withdrawn from his or her trust funds, the transactions or receipt must be signed by a witness other than the AFC home provider or employee or contractor of the provider; 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 or her name, a witness other than the AFC home provider or employee or contractor of the provider 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 based on his or her end-of-quarter balance.

The following information must be included on the receipt for all money that is received or deposited in the member’s 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.

4154 Hospital Leave

Revision 19-13; Effective November 5, 2019

If a member is receiving adult foster care (AFC) services in an AFC home which is not the member’s home, the member may be required to reserve his or her space during hospital stays by paying the daily bedhold charge, if the provider requires such a charge, which is the negotiated daily rate the managed care organization (MCO) pays the AFC home provider or MCO-contracted provider agency. The AFC home provider does not bill the MCO for the days the STAR+PLUS Home and Community Based Services (HCBS) program AFC member is hospitalized. The AFC member's bedhold charge constitutes the entire payment to the AFC home provider or MCO-contracted AFC provider agency when an AFC member is hospitalized.

During the initial home visit, the MCO or MCO-contracted AFC provider agency review the information regarding the AFC member's responsibility to pay a bedhold charge when away from the home and document this on Form 2327, Individual/Member and Provider Agreement. Hospital leave does not apply when the AFC home provider moves into the member’s home.

4160 Monitoring Quality of Care

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) service coordinator will monitor the quality of care and services provided to meet the needs of the STAR+PLUS Home and Community Based Services (HCBS) program members receiving adult foster care (AFC) services. The MCO service coordinator will appropriately address any issues identified to protect the health and safety of the member.

During regular monitoring visits, the MCO service coordinator must contact the MCO management and MCO-contracted AFC provider agency, if applicable, if the AFC home provider is not meeting the member's needs or the home provider requires additional support or training to meet the member’s needs. The AFC 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 (POC). When the AFC home provider moves in with the AFC member, it is the MCO's responsibility to ensure the AFC member's needs are being met, and there are no health and safety concerns. If concerns are reported or identified, the AFC member's rights must be protected and adjustments to the POC made accordingly.

4170 Reserved for Future Use

Revision 24-1; Effective Feb. 22, 2023

4180 Annual Reassessment of the AFC Member

Revision 19-13; Effective November 5, 2019

In addition to the regular reassessment for the STAR+PLUS Home and Community Based Services (HCBS) program, which includes the managed care organization (MCO) service coordinator completing the Medical Necessity and Level of Care (MN/LOC) Assessment, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums, and the individual service plan (ISP) documents, the MCO or MCO-contracted adult foster care (AFC) provider agency must also continue to meet all eligibility requirements and complete Form 2327, Individual/Member and Provider Agreement.

4210 Assisted Living Services Introduction

Revision 19-13; Effective November 5, 2019

This section applies to the STAR+PLUS Home and Community Based Services (HCBS) 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 Texas Health and Human Services Commission (HHSC). STAR+PLUS HCBS program members are responsible for their room and board (R&B) charges and, if applicable, copayments 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 member. The personal care facility must provide each member a separate living unit to guarantee their privacy, dignity and independence.

4211 Housing Options in Licensed Personal Care Facilities

Revision 19-13; Effective November 5, 2019

An 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.

STAR+PLUS Home and Community Based Services (HCBS) program 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 STAR+PLUS HCBS program services in a housing option for which the provider 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, the member’s contract must specify that information.

If the AL provider wishes to limit the types of apartments in the facility available to STAR+PLUS HCBS program members, the provider must specify these limitations in the 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 STAR+PLUS HCBS program members.

If the provider limits the type of apartment available for STAR+PLUS HCBS program members and there is no apartment of that size available, they can refuse to accept any STAR+PLUS HCBS program 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 a STAR+PLUS HCBS program member. The member would then have the option of reviewing other available assisted living facilities (ALFs) in the area or adult foster care (AFC) 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 a 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.

4211.1 Single Occupancy Apartments

Revision 19-13; Effective November 5, 2019

An assisted living (AL) 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 individual.

4211.2 Double Occupancy Apartments

Revision 19-13; Effective November 5, 2019

An assisted living (AL) 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 individual, and meets the following specifications:

• Indoor common areas used by STAR+PLUS Home and Community Based Services (HCBS) program members 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.

4220 Description of Services

Revision 19-13; Effective November 5, 2019

The assisted living facility (ALF) must provide 24-hour care in a personal care facility licensed by the Texas Health and Human Services Commission (HHSC). Services include:

• home management;
• transportation and escort;
• 24-hour supervision;
• meal services; and
• social and recreational activities.

Personal care tasks must be provided on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, as identified on the individual service plan (ISP) and approved by the MCO. A registered nurse (RN) must perform the medication administration assessment.

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 RN can give injections. The personal care facility may provide more services for the member than are identified in the ISP, but not fewer services.

4221 Requirements Related to Assisted Living Facility

Revision 19-13; Effective November 5, 2019

STAR+PLUS Home and Community Based Services (HCBS) program members who wish to reside in a personal care facility must reside in a licensed assisted living facility (ALF) which is contracted with the managed care organization (MCO) to provide STAR+PLUS HCBS program services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services (PCS) to four or more persons who are unrelated to the owner. The member is required to pay room and board (R&B) charges, and possibly a copayment amount based on income in the ALF setting. Refer to Section 3230, Financial Eligibility, for detailed information.

4222 Reserved for Future Use

Revision 23-2; Effective May 15, 2023
 

4223 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

4224 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

4230 Other Services Available to Members

Revision 19-13; Effective November 5, 2019

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 Home and Community Based Services (HCBS) program service and not included in the assisted living facility (ALF) daily rate:

• adaptive aids and medical supplies;
• minor home modifications (MHMs);
• occupational therapy (OT);
• physical therapy (PT);
• speech therapy (ST); or
• nursing services.

The managed care organization (MCO) makes referrals for the services and coordinates delivery.

The use of self-administered oxygen is allowed in a STAR+PLUS HCBS program ALF. 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.

4240 Copayment and Room and Board Requirements

Revision 19-13; Effective November 5, 2019

The member must pay the required fees to be eligible for assisted living facility (ALF) services. Refusal to pay the required fees can result in termination of services.

The facility must designate a due date for room and board (R&B) charges and the copayment amount in writing. The due date must be during the same month the R&B charges and copayment amount are applied. The facility must collect the entire R&B charges and copayment amount on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire R&B charge and copayment amount on or before the first business day thereafter.

4240.1 Room and Board Charges Requirements

Revision 19-13; Effective November 5, 2019

All members must pay the room and board (R&B) charges to be eligible for assisted living (AL). R&B charges cannot be waived, but an assisted living facility (ALF) may choose to accept an applicant or member for a lower amount. STAR+PLUS Home and Community Based Services (HCBS) program policy does not direct the facility to accept or reject the applicant or member. The R&B charge is based on the Supplemental Security Income (SSI) 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 R&B 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 ALF. The managed care organization (MCO) must notify the applicant or member of the initial amount of R&B charge to pay and the ongoing amount of R&B charge to pay.

4240.2 Copayment Requirements

Revision 19-13; Effective November 5, 2019

The amount of copayment the member is required to pay is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist through use of the MEPD copayment worksheet. The MEPD specialist makes the determination of the copayment amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.

Program Support Unit (PSU) staff mail Form H2065-D, Notification of Managed Care Program Services, to the member and upload a copy of Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Once received through TxMedCentral, the MCO sends a copy to the assisted living facility (ALF), detailing the first month's copayment amount and the subsequent months' amounts.

4241 Personal Leave

Revision 19-13; Effective November 5, 2019

The member is entitled to 14 days of personal leave from the assisted living facility (ALF) each year. The member is responsible for the room and board (R&B) charge and copayment amount for personal leave days.

A day of personal leave is defined as 24 continuous hours. STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) 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;
• destination;
• emergency contact; and
• type of leave (for example, personal leave or hospital leave).

4242 Nursing Services for Members in an ALF

Revision 19-13; Effective November 5, 2019

If a member is residing in an assisted living facility (ALF), all the administration of medications, including injections, is provided by the nurse. It is possible that a member residing in an ALF does not need any nursing tasks that are to be delivered by the STAR+PLUS Home and Community Based Services (HCBS) program. 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.

4243 Response to ALF Member Condition Change

Revision 19-13; Effective November 5, 2019

If the member experiences a change in health or condition related to the amount and type of care the member requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member or authorized representative (AR) may explore other means to serve the member adequately in his or her current setting. The use of Day Activity and Health Services (DAHS) 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 an assisted living facility (ALF).

If a member exhibits behavior or degradation of mental health that threatens the health or safety of himself or herself or other residents in the facility, or the member’s needs exceed the licensed capacity of the facility, the ALF provider must take appropriate action and notify the MCO orally by the next business day. The provider must confirm the verbal report in writing within seven days. The MCO must take appropriate actions based on the oral notification to assess the member's continued eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program. Refer to Section 4251, Facility Reporting and Notification Requirements.

If a STAR+PLUS HCBS program member living in an assisted living (AL) apartment becomes a safety hazard to himself or herself or others due to the member’s 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 and safety of the member or other residents in the facility. The MCO, in cooperation with the IDT, the AL provider, and the member's family or AR, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The MCO’s decision is documented on Form H2067-MC, Managed Care Programs Communication, which is sent to the AL provider within three business days of the IDT meeting.

4244 Hospital and Nursing Facility Stays

Revision 19-13; Effective November 5, 2019

Hospital Stays

To reserve bedhold during hospital stays, the member must pay the daily room and board (R&B) 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 R&B charge, used as a bedhold charge, constitutes the entire payment to the facility when a member is hospitalized.

The facility must notify the MCO on Form H2067-MC, Managed Care Programs Communication, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every month up to four months to determine if the stay will become permanent. The MCO will notify Program Support Unit (PSU) staff by uploading Form H2067-MC to TxMedCentral in the MCOs SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. If the member stays in the hospital longer than four 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 (NF) 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 (UMCC), Attachment B.1, Section 8.3.2.6, Nursing Facilities, related to NF stays.

4245 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

4250 Standards for Operation

Revision 19-13; Effective November 5, 2019

Assisted living facilities (ALFs) 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 facility (NF) 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 Home and Community Based Services (HCBS) program ALF 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 ALF 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 a STAR+PLUS HCBS program ALF setting.

To receive ALF services under the STAR+PLUS HCBS program, the applicant must first be determined eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff will fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, to complete the Medicaid eligibility determination.

The MCO discusses residential options with the member, allowing the member to choose his or her preference. If an ALF is chosen, a verbal referral is made to the provider as an alert that bedhold is needed. The starting date for services is a negotiated date between the MCO, the member and the ALF provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan (Pg. 1), and applicable attachments are sent as follow-up, along with a copy of Form H2065-D, Notification of Managed Care Program Services, which authorizes the provider to deliver STAR+PLUS HCBS program services, and Form H2067-MC, Managed Care Programs Communication, confirming the negotiated service initiation date.

Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of himself or herself or other residents in the facility. If a stove or cooking unit needs to be disconnected, the MCO service coordinator, in cooperation with the interdisciplinary team (IDT), makes this decision. The IDT must also include the MCO, the ALF provider and the member's family or authorized representative (AR), if any.

The ALF provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of himself or herself or other residents in the facility. The ALF must inform the MCO 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 other residents in the facility. If the decision is made to approve a disconnection, the MCO service coordinator documents actions on Form H2067-MC that is sent to the ALF provider within three days.

Note: The ALF 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 room and board (R&B) charge or copayment amount, the MCO uploads Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Form H2067-MC serves as notification to PSU staff of the member's failure to pay the R&B charge and copayment amount. Within three business days, PSU staff must mail the member Form H2065-D stating services will be terminated if the member fails to pay the R&B charge and/or copayment amount within 30 days of the date on Form H2065-D.

If a STAR+PLUS HCBS program member does not pay the R&B charge and copayment within 30 days of the date on Form H2065-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 or her failing to pay, the MCO writes a letter to the member, with copies to the ALF manager and to the member's AR, 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 or her services are terminated, the ALF must follow its written eviction procedures.

In addition, ALFs must:

• conduct a health assessment with the member within three days of admission to the facility;
• provide each member with training in the emergency or 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 or individual service plan (ISP);
• 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 himself or herself or other residents in the facility;
• 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 R&B and copayment 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 or her finances and/or trust funds. The facility must provide assistance to the member in managing his or her 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 copayment amounts and trust funds; and
• inform the member verbally and in writing, before or at the time of admission, of bedhold policies for hospital or nursing facility (NF) 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.

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 ALF provider through the ALF 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 the Texas Health and Human Services Commission (HHSC) Regulatory Services Division regarding any questionable items charged to the member.

4251 Facility Reporting and Notification Requirements

Revision 19-13; Effective November 5, 2019

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 facility (NF), 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 or she threatens the health or safety of himself or herself or other residents in the facility;
  • leaves the state;
  • requests that services end;
  • refuses to comply with the individual service plan (ISP);
  • fails to pay the copayment amount;
  • exceeds personal leave days; and
  • requests to move to another facility.

If a member exhibits behavior that threatens the health or safety of himself or herself or other residents in the facility, or the member’s 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 and safety of residents 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 or her needs. For example, the member's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.

4252 Member Documentation

Revision 19-13; Effective November 5, 2019

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 and safety of himself or 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.

4260 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

4270 Copayment and Trust Fund Records

Revision 19-13; Effective November 5, 2019

4271 Copayment

Revision 19-13; Effective November 5, 2019

The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form H2065-D, Notification of Managed Care 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’s copayment amount is paid from a trust fund, the facility still must prepare a receipt.

The ledger must also reflect room and board (R&B) charges and payments, and the member must be given a receipt for the R&B payments.

4272 Trust Fund Records or Written Receipts

Revision 19-13; Effective November 5, 2019

The facility must maintain trust fund records based on recognized fiscal and accounting principles and have written permission from the member to handle his or 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 the member signs his or 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 or 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 or 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 based on his or 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 room and board (R&B) charges and copayment amounts out of the trust fund account into the facility operating account.

Facility staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and R&B allowance into the trust fund account. If the member writes a check to be deposited into his or 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 or bank statement reflects the same amount recorded on the receipt.

4273 Records and Receipts

Revision 19-13; Effective November 5, 2019

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 the member;
• date the money was received;
• coverage period;
• purpose of the 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 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 or refrigerator and staff are using it.

4274 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

4275 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

4276 Payment of Copayment and Room and Board from Trust Fund

Revision 19-13; Effective November 5, 2019

It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the room and board (R&B) charge and copayment amount from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the R&B charge and copayment amount are paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.

Long-term Payments

For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on the member’s 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 the member’s behalf, they do not need a monthly receipt from the vendor; or
• does not obtain a signed statement from the member, responsible party or authorized representative (AR) 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 member ledger, the cash envelope or on a receipt.

Bulk Purchases

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 member ledger or a receipt.

4277 Member Authorization

Revision 19-13; Effective November 5, 2019

If the member is unable to sign or initial the transaction, or if the member signs his or 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.

Revision 19-13; Effective November 5, 2019

Respite care services in the STAR+PLUS Home and Community Based Services (HCBS) program are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for a STAR+PLUS HCBS program member unable to care for himself or herself.

4310 Service Coordination Duties Related to Respite Care

Revision 19-13; Effective November 5, 2019

To be eligible for respite care services, the member must live in his or 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 care provider must not be a primary caregiver, whether or not the respite care provider is related to the member and must not live with the STAR+PLUS Home and Community Based Services (HCBS) program member for whom respite care is needed. If the member's primary caregiver is the paid attendant who also provides uncompensated care, in-home respite care may be provided only during those hours the primary caregiver would be providing uncompensated care to the member. If the primary caregiver is the paid attendant and will be absent during hours for which the primary caregiver is normally paid, it is the employer of record who has the obligation to provide a substitute attendant during this period.

Respite care services are intended to relieve the primary caregiver during emergency or planned short-term periods. Respite care services must be authorized on the individual service plan (ISP) before the services can be delivered. The respite care rate for out-of-home settings includes payment for room and board (R&B) charges. There are no member R&B charges or copayment amounts for respite care services in out-of-home settings.

The managed care organization (MCO) service coordinator is responsible for documenting the respite care services needed by the member. For example, a member needs respite care services every Friday afternoon so the primary caregiver can attend class, or a member's primary caregiver has three four-day trips planned during the ISP year, or a primary caregiver has a history of emergency hospitalizations. The MCO service coordinator’s documentation must also support that the member meets the eligibility criteria for respite care. The MCO service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested or authorized. Respite care cannot be authorized retroactively. For STAR+PLUS HCBS program members who have an emergency need for respite care and respite care is not authorized on the ISP, the provider must contact the MCO for authorization prior to delivery of respite care services.

The member must be given the opportunity to choose from the contracted providers that are appropriate considering the member’s needs and the licensed capabilities of the provider. In-home respite care 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 care services is provided by licensed nursing facilities (NFs), licensed personal care facilities and licensed AFC homes.

The provider who delivers in-home respite care services is responsible for providing the personal assistance services (PAS) authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite care 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 (PT) or minor home modifications (MHMs)) may continue to be delivered at the same time as the in-home respite care service.

Respite care services can be authorized as often as needed for primary caregiver relief or emergency absences of the primary caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. Respite care services must be authorized on Form H1700-1, Individual Service Plan (Pg. 1). For example, if two hours of respite care are to be used per week, the ISP authorization is for eight 15-minute units. The calculation is two hours per week times 52 weeks = 104 hours divided by four 15-minute units. The annual limit on respite care services is 30 days, equivalent to 720 hours, which equals 2,880 units (30 days times 24 hours per day; 720 hours = 2,880 15-minute increments), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of STAR+PLUS HCBS program services, must keep track of the units a member has used. The provider may use Form H2067-MC, Managed Care Programs Communication, to notify the MCO of the dates and duration of respite care services delivered. The MCO can track the number of respite care days used.

4311 MCO Approval to Exceed the Respite Care Service Cap

Revision 19-13; Effective November 5, 2019

To request approval to exceed the annual individual service plan (ISP) cost limit on respite care services, the provider must send a written request to the managed care organization (MCO) documenting the:

• need for additional respite care units;
• number of additional units needed;
• cost estimate considering the location(s) in which the respite care services will be delivered;
• overall service plan is within the member's individual service plan (ISP) cost limit; and
• ISP is adequate and meets the individual's needs in the community.

The provider includes his or 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 care service limit, the MCO must consider the intent of respite care services to relieve the primary caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:

• members whose primary caregivers become ill, hospitalized or have a family emergency;
• extenuating circumstances that cause care to be required beyond routine or periodic respite care relief; or
• a breakdown in member 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.

4320 In-Home Respite Care Services

Revision 19-13; Effective November 5, 2019

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 primary 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 (Pg. 1), when the unpaid primary caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, during the time the member is receiving in-home respite care.

The provider must document in the member's clinical record:

• the in-home respite care 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 services help prevent member 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 care services provider must deliver the personal assistance services (PAS). The MCO may allow the in-home respite care services provider's registered nurse (RN) the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home respite care services provider.

In-home respite care services are not intended to be used when the primary 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 primary caregiver should be encouraged to be out of the house for brief respite care when the attendant is providing the PAS.

4330 Out-of-Home Respite Care Services

Revision 19-13; Effective November 5, 2019

Out-of-home respite care services provide a 24-hour living arrangement in a licensed personal care facility, an adult foster care (AFC) home or a licensed nursing facility (NF) 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 (ADLs), supervision, and the provision or arrangement of transportation.

Nursing tasks may be directly provided by licensed nurses in out-of-home respite care services or may be delegated as determined by the professional judgment of the provider's registered nurse (RN), unless facility licensure prohibits delegation.

4331 Member Eligibility

Revision 19-13; Effective November 5, 2019

The respite care services member must:

• meet all eligibility criteria, as specified in Section 3200, Eligibility;
• reside in his or her own home;
• have a primary caregiver who needs relief either on an emergency or planned short-term basis; and
• not reside in a personal care facility or adult foster care (AFC).

The applicant for STAR+PLUS Home and Community Based Services (HCBS) program respite care services must complete the same eligibility determination process as other STAR+PLUS HCBS program applicants.

4332 Provider Qualifications

Revision 19-13; Effective November 5, 2019

Out-of-home respite care services providers must be a:

• licensed personal care facility nursing facility (NF);
• Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home; or
• licensed nursing facility (NF).

To deliver STAR+PLUS Home and Community Based Services (HCBS) program out-of-home respite care 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.

4333 Description of Services

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member may receive out-of-home respite care services in a licensed personal care facility, a Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home or licensed nursing facility (NF), with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The STAR+PLUS HCBS program member may take any adaptive aids he or she is using to the out-of-home respite care setting.

The managed care organization (MCO) provides the out-of-home respite care provider with the assessments and ISP attachments pertinent to the services the member will receive while in the facility or home. The provider must deliver services as identified on the member's ISP attachments.

4334 Respite Care Services in a Personal Care Facility or AFC Home

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care 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 care setting. The member's need for any service must be authorized on his or her individual service plan (ISP) before he or she receives the service.

The STAR+PLUS HCBS program member receiving respite care 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 (RN). Personal care facility licensure prohibits delegation of nursing tasks. In assisted living out-of-home respite care settings, nursing services must be provided directly by licensed nurses.

4335 Respite Care Services in a Nursing Facility

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a nursing facility (NF) may receive therapy services from outside providers. The member's need for any service must be authorized on the individual service plan (ISP) before receiving the service. The NF is responsible for providing the needed nursing services to the member.

4340 Room and Board Charges

Revision 19-13; Effective November 5, 2019

Room and board (R&B) charges are not allowable charges to the STAR+PLUS Home and Community Based Services (HCBS) program member receiving out-of-home respite care services. R&B charges are included in the rates for the respite care services.

4410 ERS Introduction

Revision 19-13; Effective November 5, 2019

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-days-a-week monitoring capability, helps to ensure the appropriate person or service provider responds to an alarm call from a member.

4420 ERS Program Purpose

Revision 19-13; Effective November 5, 2019

The purpose of Emergency Response Services (ERS) under the STAR+PLUS Home and Community Based Services (HCBS) program 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.

4430 ERS Member Eligibility

Revision 23-2; Effective May 15, 2023

A member must meet the following criteria to be eligible for Emergency Response Services (ERS) through the STAR+PLUS Home and Community Based Services (HCBS) program:

• have been determined eligible for the STAR+PLUS HCBS program;
• be mentally alert enough to operate the equipment properly, in the judgment of the managed care organization (MCO) service coordinator;
• have a phone 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 or 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 adult foster care (AFC), assisted living facility (ALF), institution or any other setting where 24-hour supervision is available.

4440 ERS Referral and Selection of Providers

Revision 19-13; Effective November 5, 2019

If the member is considered eligible for Emergency Response Services (ERS), the managed care organization (MCO) shares a 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 or her MCO service coordinator to request the change.

The MCO follows the procedures in Section 3600, Ongoing Service Coordination, and gives the member an explanation of the service and requirements.

4450 ERS Duties

Revision 19-13; Effective November 5, 2019

If the member wants and appears to be in need of Emergency Response Services (ERS), the managed care organization (MCO) service coordinator determines if the member meets the general criteria for participating in ERS, as described in Section 4430, ERS Member Eligibility. The MCO may involve other members of the interdisciplinary team (IDT) in the decision regarding the member's physical and mental ability to participate in the ERS program. ERS may be authorized through the STAR+PLUS Home and Community Based Services (HCBS) program when it appears the member may need the capability to notify a respondent of an emergency. ERS services are limited to members who:

• live alone;
• are alone for significant parts of the day;
• have no regular primary 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.

4460 Provider Duties

Revision 19-13; Effective November 5, 2019

Managed care organization (MCO) contracted providers' duties specific to Emergency Response Services (ERS) are described in Title 40 Texas Administrative Code (TAC) Part 1, Chapter 52, Subchapter D.

4510 Home-Delivered Meals Description

Revision 19-13; Effective November 5, 2019

The home-delivered meals (HDMs) benefit 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.

4520 Provider Responsibilities

Revision 19-13; Effective November 5, 2019

Home-delivered meals (HDMs) are delivered to the member’s home as authorized by the managed care organization (MCO). The individual delivering the meal reports any member illnesses, potential threats to his or her safety, or observable changes in the member’s condition to the provider. The provider must notify the MCO service coordinator about the report within 24 hours.

The provider also informs the MCO service coordinator whenever:

• the HDM 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:

• Member enters an institution.
• Member requests that services be suspended or terminated.
• Member dies.
• MCO 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 MCO 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 MCO service coordinator.

4520.1 Frozen or Shelf-Stable Meals

Revision 19-13; Effective November 5, 2019

A provider that contracts with the managed care organization (MCO) to provide home-delivered meals (HDMs) 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 HDMs 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 provider’s 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.

4610 Transition Assistance Services Introduction

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) is a STAR+PLUS Home and Community Based Services (HCBS) program service designed to assist Medicaid members who are transitioning from a nursing facility (NF) to the community. An NF resident discharged from the NF into a waiver program is eligible to receive up to $2,500 in TAS for assistance with setting up a household. TAS is available on a one-time only basis and is not available to residents moving from an NF who are approved for any of the following waiver services:

• adult foster care (AFC) services; or
• assisted living facility (ALF) services.

4611 Transition Assistance Services Service Description

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for members transitioning from nursing facilities (NFs) to a home in the community. TAS is a benefit to cover basic and essential household items. Allowable expenses are those necessary to enable the member 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, bath linens, cleaning supplies and toiletries;
• 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 member 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.

4620 Transition Assistance Services Procedures at the Initial Interview

Revision 19-13; Effective November 5, 2019

All STAR+PLUS Home and Community Based Services (HCBS) program 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.

Within 14 business days of learning of a request to move to the community, the managed care organization (MCO) service coordinator discusses the applicant’s or member’s available living arrangements in the community and asks the applicant or member where he or she intends to live upon discharge from the NF.

TAS may be considered when the applicant or member:

• 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 or her 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.

4630 Identification of Needed Items and Services

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) conducts the interview with the applicant and/or authorized representative (AR) to identify the applicant's needs and determines if other resources are available to meet the needs. The MCO service coordinator 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.

The applicant selects a TAS agency from the list of contracted agencies.

4640 Items and Services Included Under TAS

Revision 19-13; Effective November 5, 2019

Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.

4640.1 Deposits

Revision 19-13; Effective November 5, 2019

Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant’s or member’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 member’s home is connected and has a supply of butane or propane.

4640.2 Household Needs

Revision 19-13; Effective November 5, 2019

Household needs include basic furniture or appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, cleaning supplies and toiletries, etc.

An applicant or member may request a specific brand or type of appliance, furniture or other Transition Assistance Services (TAS) item if the applicant’s or member’s needs are met within the cost limit.

TAS items may be placed in a home other than the applicant’s or member’s only when furnishings are not available and are necessary for the applicant or member 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 or essential item creates a barrier keeping the member from returning to the community, the item is considered a need.

4640.3 Housewares

Revision 19-13; Effective November 5, 2019

Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.

4640.4 Small Appliances

Revision 19-13; Effective November 5, 2019

Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.

4640.5 Cleaning Supplies

Revision 19-13; Effective November 5, 2019

Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.

4640.6 Other Items Not Listed

Revision 19-13; Effective November 5, 2019

Any special requests from the applicant or member not covered in the general list that meet the criteria as basic essential items to move to the community may be considered.

4641 Services and Items Not Included in TAS

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) does not include any items or services that are included under STAR+PLUS Home and Community Based Services (HCBS) program services such as adaptive aids, minor home modifications (MHMs), medical supplies or medications.

TAS does not include any recreational items or 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 or expansion on the member’s dwelling. TAS is not used for remodeling or renovation, upgrading of existing items or purchasing non-essential items.

TAS funds cannot be used for food. The managed care organization (MCO) may refer the member to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources.

The room and board (R&B) charge is not an allowable TAS expense.

TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.

4642 Site Preparation

Revision 19-13; Effective November 5, 2019

Site preparation can include the following services:

• moving expenses, which include the cost of moving the applicant’s or member’s items from another location, or delivery charges on large purchased items;
• pest eradication, if the applicant’s or member’s place of residence has been unattended and some type of extermination is needed;
• allergen control, if the applicant’s or member’s place of residence has been unattended or the applicant or member is moving into a place that poses a respiratory health problem; or
• one-time cleaning, if the applicant’s or member’s place of residence has been unattended or the applicant or member 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 (TAS) cannot pay for septic systems.

4650 Estimated Cost of Items and Services

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) 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 MCO 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 member, which will assist the TAS agency in meeting the member’s needs.

4651 Totaling the Estimated Cost and Authorization of TAS

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) 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 or member must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he or she agrees that the TAS agency selected is authorized to make the purchases for him or her.

The applicant or member selects a TAS agency from the list of contracted agencies.

The MCO service coordinator must explain to the applicant that the service will not be authorized until the applicant is determined eligible for STAR+PLUS Home and Community Based Services (HCBS) program services and notified in writing that he or she is eligible. The MCO service coordinator must contact the applicant or authorized representative (AR) before certification to verify the applicant has made arrangements for relocating to the community and has finalized a projected discharge date.

The MCO service coordinator includes TAS on Form H1700-1, Individual Service Plan (Pg. 1). The MCO 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 business days before the projected nursing facility (NF) 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 MCO service coordinator must contact the TAS agency and negotiate an earlier date. The MCO service coordinator will code those items as delivered prior to the arrival date.

Additional applicant information to the TAS agency may be included on Form 8604 or Form H2067-MC, Managed Care Programs Communication. Form 8604 is mailed after the applicant or member is determined eligible for STAR+PLUS HCBS program services.

The TAS agency may only obtain items or services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items or services that the applicant or member may need, the TAS agency must obtain prior approval from the MCO. Refer to Section 4652, Changes to the Authorization, below.

4652 Changes to the Authorization

Revision 19-13; Effective November 5, 2019

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 or service.

The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items or 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 service coordinator must update Form H1700-1, Individual Service Plan (Pg. 1), to reflect the change in the amount for funds authorized.

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.

4660 Transition Assistance Services Agency Responsibilities

Revision 19-13; Effective November 5, 2019

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 or 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 authorized representative (AR), 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 AR by the completion date to confirm that all authorized TAS services were delivered.

4670 Three-Day Monitor Required

Revision 19-13; Effective November 5, 2019

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 member’s case record.

4680 Failure to Leave the Nursing Facility

Revision 19-13; Effective November 5, 2019

While the managed care organization (MCO) makes every effort to confirm that the member has definite plans to leave the nursing facility (NF), there may be situations in which the member changes his or her mind or has a change in his or her health making it impossible for the member 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 member 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 member.

• 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 member cannot be recouped, the TAS agency is entitled to the 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 members whose needs are similar to those of the member for whom the items were purchased or must be dedicated to assisting the member to 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 member is only in the community for a few days and returns to the NF, the member keeps the item(s) purchased through TAS.