8100, Home and Community Based Services

8110 Program Overview

Revision 21-2; Effective March 10, 2021

 

8111 Service Introduction

Revision 21-2; Effective March 10, 2021

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

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities (ALFs) and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 8113, General Requirements for MCOs, and in accordance with the ISP.

8112 Service Locations for STAR+PLUS HCBS Program

Revision 21-2; Effective March 10, 2021

All services through the STAR+PLUS Home and Community Based Services (HCBS) program, except minor home modifications (MHMs), can be provided to members in locations of their choice. Nursing and therapy services, adaptive aids (including dental) and medical supplies may be provided to a STAR+PLUS HCBS program member residing in an assisted living facility (ALF) contracted to provide STAR+PLUS HCBS program services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, §441.530(a)(2), the following locations are excluded from STAR+PLUS HCBS program service locations, with the exception of out-of-home respite care:

  • nursing facilities (NFs);
  • psychiatric hospitals;
  • intermediate care facilities for individuals with intellectual disabilities or related conditions (ICF/IIDs);
  • hospitals providing long term care (LTC); and
  • locations that have the qualities of an institution (e.g., rehabilitation facility, prisons, jails, behavioral health facility).

8113 General Requirements for MCOs

Revision 21-2; Effective March 10, 2021

The managed care organization (MCO) must coordinate and authorize the array of services in accordance with Form H1700-1, Individual Service Plan (Pg. 1). Services include:

  • personal assistance services (PAS);
  • nursing services;
  • physical therapy (PT);
  • occupational therapy (OT);
  • speech therapy (ST);
  • cognitive rehabilitation therapy (CRT);
  • adaptive aids;
  • medical supplies;
  • minor home modifications (MHMs);
  • Emergency Response Services (ERS);
  • assisted living (AL);
  • adult foster care (AFC);
  • home delivered meals (HDM);
  • dental services;
  • transition assistance services (TAS);
  • respite care;
  • employment assistance (EA); and
  • supported employment (SE).

The MCO must identify, coordinate and when applicable, authorize available Medicaid services, Medicare and other third-party resources (TPRs) before authorizing those services on the member's individual service plan (ISP). Refer to specific service descriptions for exceptions or limitations.

8114 Individual Service Plan

Revision 23-2; Effective May 15, 2023

The managed care organization (MCO) must authorize all services identified on the individual service plan (ISP). The ISP is composed of the following documents:

  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum;
  • Form H6516, Community First Choice Assessment; or
  • Other forms and assessments related to the services provided.

The MCO must upload Form H1700-1 to TxMedCentral if the MCO manually generates Form H1700-1. The MCO is not required to upload Form H1700-1 to TxMedCentral if the MCO electronically generates Form H1700-1 through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The MCO maintains all other forms in the member case file.

8115 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8116 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8117 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8118 Personal Assistance Services

Revision 23-2; Effective May 15, 2023

Personal assistance services (PAS) assist members perform activities of daily living (ADLs) based on the member’s needs. PAS includes assistance with the performance of the ADLs and instrumental activities of daily living (IADLs) necessary to maintain the home in a clean, sanitary and safe environment.

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service. Federal and state rules prohibit a spouse from being the paid PAS provider.

8118.1 Description of Personal Assistance Services

Revision 21-2; Effective March 10, 2021

Personal assistance services (PAS) include the following:

  • assistance with the basic self-care tasks known as activities of daily living (ADLs). These include, but are not limited to, self-feeding, dressing, bathing, personal hygiene and grooming, transferring and going to the toilet;
  • assistance with instrumental activities of daily living (IADLs).  These are activities that allow an individual to live independently in the community, such as cleaning and maintaining the house, preparing meals, shopping for groceries and taking prescribed medications (this is not an all-inclusive list);
  • providing extension of therapy services;
  • providing assistance with ambulation and balance;
  • assisting with medications that are normally self-administered;
  • performing health maintenance activities, as defined by the Texas Board of Nursing (BON);
  • performing nursing tasks delegated and supervised by a registered nurse (RN), in accordance with the Texas BON rules;
  • escorting the member on trips to obtain medical diagnosis, treatment or both; and
  • providing protective supervision.

The managed care organization (MCO) must authorize and ensure the provision of PAS, as identified on Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum, and authorize PAS, as applicable, to members living in their own homes or other community settings.

Activities purchased under PAS are limited to the member’s personal space and solely for the member’s personal needs. The following examples of services not reimbursable under the STAR+PLUS Home and Community Based Services (HCBS) program are:

  • taking care of household non-service related pets;
  • ironing;
  • moving furniture;
  • cleaning windows; and
  • performing yard work other than yard hazard removal.

Shopping

Shopping is intended for the purchase of groceries, medications or other items that support the health, safety and well-being of a member. This may be done by the attendant on behalf of the member or to accompany the member to assist with this task. Neither the provider nor the attendant can charge the member for transportation costs incurred in the performance of this task.

Ambulation

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

To facilitate safe member ambulation or movement, the attendant may need to ensure safe pathways throughout the home for the member. Examples include those who use wheelchairs, walkers or crutches, or for members with visual impairment. The attendant care provider or member (or member's authorized representative (AR)) addresses this activity during orientation and on an ongoing basis for an attendant who provides services to a member needing assistance.

The member’s primary care provider (PCP) may request specific ambulation orders. If ambulation is authorized as a nursing task, the MCO service coordinator must not authorize ambulation as a non-skilled task on Form H6516, Form H2060 and any addendums to Form H2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form H2060 and any addendums to Form H2060, the MCO service coordinator must consider the member’s need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the MCO service coordinator must document in the case record why and how the member requires both. The MCO service coordinator can approve both if there is no duplication.

Escort

Escorting is for health care-related appointments and does not include the direct transportation of the member, or the receipt or exchange of health information by the attendant. Escort services may be provided for safety needs, to enter or exit a building, or to remain safe during the wait time while attending medical appointments. Transportation for Medicaid members to Medicaid appointments is available in every county through the Medical Transportation Program (MTP). Transportation is not included as an activity in the escort task.

Protective Supervision

The purpose of protective supervision is to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness. Protective supervision is authorized by the MCO and assures supervision of the member during instances in which the member’s informal support is unavailable.

Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to his or her cognitive or memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn himself or herself, or try to walk and then fall. Protective supervision is not routinely authorized for members who can safely live on their own, nor is it intended to provide 24-hour care. Protective supervision is not a benefit of Community First Choice (CFC) and can be on a member’s individual service plan (ISP), even if the member receives CFC.

Exercise

A member may request, or a physician may order, assistance with walking as a form of exercise. A member must be ambulatory for exercise to be an authorized PAS activity.

Therapy Extension

Licensed therapists may choose to instruct the PAS attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance or support provides reinforcement of instruction and aids in the rehabilitative process. Therapy extension is documented on Form H2060-A.

8118.2 Personal Assistance Services Attendants

Revision 21-2; Effective March 10, 2021

Personal assistance services (PAS) are performed by personal care attendants who:

  • are not themselves recipients of PAS;
  • are employed by a managed care organization (MCO) contracted provider or employed by the member or the employer of record under the Consumer Directed Services (CDS) option;
  • are not the spouse of member;
  • perform all of the services available within his or her scope of competency;
  • may serve as backup attendants to initiate services, prevent a break in service and provide ongoing service;  
  • are required to provide services that meet a member’s health and safety needs; and
  • if applicable, meet additional eligibility requirements under the CDS option.

8300, Therapy Services

Revision 21-2; Effective March 10, 2021

Therapy services purchased through the STAR+PLUS Home and Community Based Services (HCBS) program are long-term services and supports (LTSS) and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional, cognitive, speech and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of the therapist’s state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic. If therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing his or her own transportation or accessing the Medicaid Medical Transportation Program (MTP).

If therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. If a member resides in an adult foster care (AFC) or an assisted living (AL) setting and therapy is provided in an outpatient center or clinic (refer to Section 8112, Service Locations for STAR+PLUS HCBS Program), the AL or AFC provider is responsible for arranging the transport or directly transporting the member.

Occupational therapy (OT), physical therapy (PT), speech therapy (ST) and cognitive rehabilitative therapy (CRT) services are covered by the STAR+PLUS HCBS program only after the member has exhausted his or her therapy benefit under Medicare, Medicaid or other third-party resources (TPR). Providers contracted with the managed care organization (MCO) must provide the OT, PT, ST and CRT services as identified on the member's individual service plan (ISP). Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider, or through the Consumer Directed Services (CDS) option.

PT is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed PT assistant directly supervised by a licensed physical therapist. PT is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents including, but not limited to, mechanical devices, heat, cold, air, light, water, electricity and sound in the aid of diagnosis or treatment.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist.

ST is defined as the evaluation and treatment of impairments, disorders or deficiencies related to an individual's speech and language. The scope of speech, hearing and language therapy services offered to STAR+PLUS HCBS program participants exceeds the Texas state plan as the service in this context is available to adults. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist.

8310 Cognitive Rehabilitation Therapy

Revision 21-2; Effective March 10, 2021

Cognitive rehabilitative therapy (CRT) is a service that assists a member in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells or chemistry in order to enable the member to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. CRT is provided in accordance with the individual service plan (ISP) developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Qualified providers include:

  • Psychologists licensed under Texas Occupations Code, Title 3, Chapter 501;
  • Speech and language pathologists licensed under Texas Occupations Code, Title 3, Subtitle G, Chapter 401; or
  • Occupational therapists licensed under Texas Occupations Code, Title 3, Subtitle H, Chapter 454. 

8320 Initiation of Assessment and Therapy

Revision 21-2; Effective March 10, 2021

A therapy assessment is initiated upon member request, recommendation from the member’s primary care provider (PCP) or managed care organization (MCO) service coordinator. The MCO service coordinator must coordinate with the member to select a provider for the assessment. The Medical Necessity and Level of Care (MN/LOC) Assessment must be submitted by the provider for the MCO service coordinator to authorize service hours based on physician orders and MN review. Any therapy for the management of a chronic condition must be included on the individual service plan (ISP).

8330 Responsibilities of Licensed Therapists in STAR+PLUS HCBS Program

Revision 21-2; Effective March 10, 2021

Responsibilities of the licensed therapists include the following:

  • assessing the member's need for therapy, adaptive aids and minor home modifications (MHMs);
  • delivering direct therapy as authorized in the individual service plan (ISP);
  • supervising delivery of therapy rendered by the therapy assistant as authorized in the ISP;
  • informing the physician and other team members of changes in the member's health status requiring an ISP change;
  • training the member’s attendant or caregiver to extend therapeutic interventions;
  • training the member to use adaptive aids; and
  • participating in interdisciplinary team meetings, when appropriate and requested by the MCO.  

8400, Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their ability to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which the member lives. Adaptive aids and medical supplies are reimbursed with STAR+PLUS Home and Community Based Services (HCBS) program funds, when specified in the individual service plan (ISP), with the goal of providing the individual a safe alternative to nursing facility (NF) placement.

Adaptive aids and medical supplies may also include items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items, and durable and non-durable medical equipment not available under the Texas state plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

The annual cost limit of this service is $10,000 per ISP year. The managed care organization (MCO) may exceed the $10,000 cost limit; however, the MCO must not include any costs over the $10,000 on any cost reports, claims, encounters or financial statistical reports (FSR).

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member’s provider for this service if the relative or legal guardian meets the requirements for this type of service.

Adaptive aids and medical supplies are limited to the most cost-effective items that:

  • meet the member's needs;
  • directly aid the member to avoid premature NF placement; and
  • provide NF residents an opportunity to return to the community.

8410 List of Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted Texas state plan benefits and any third-party resources (TPRs) including product warranties, Medicare and Medicaid the member is eligible to receive.

If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, the managed care organization (MCO) contracted provider must:

  • obtain a written evaluation by an experienced mechanic to ensure the sound mechanical condition of all major components of the vehicle;
  • document the experience of the mechanic doing the evaluation; and
  • include the actual cost of the written evaluation as part of the invoice cost not to exceed $150.

Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of, but are not limited to, the following:

  • lifts:
    • wheelchair porch lifts;
    • hydraulic, manual or other electronic lifts;
    • stairway lifts;
    • bathtub seat lifts;
    • ceiling lifts with tracks;
    • transfer bench;
  • mobility aids, including batteries and chargers:
    • manual or electric wheelchairs and necessary accessories;
    • customized wheelchair with documentation of cost effectiveness;
    • three- or four-wheel scooters;
    • mobility bases for customized chairs;
    • braces, crutches, walkers and canes;
    • forearm platform attachments for walkers and motorized or electric wheelchairs;
    • prescribed prosthetic devices;
    • prescribed orthotic devices, orthopedic shoes and other prescribed footwear, including diabetic shoes if the member does not have Medicare and there is a documented medical need and a physician order for the shoes;
    • diabetic slippers or socks;
    • prescribed exercise equipment and therapy aids;
    • portable ramps;
  • respiratory aids:
    • ventilators or respirators;
    • back-up generators;
    • oxygen containers or concentrators, and related supplies;
    • continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines, including headgear;
    • nebulizers;
    • portable air purifiers and filters for a member with chronic respiratory diagnosis such as asthma, Chronic Obstructive Pulmonary Disease (COPD), bronchitis or emphysema;
    • suction pumps;
    • incentive spirometers and peak flow meters;
  • positioning devices:
    • standing boards, frames and customized seating systems;
    • electric or manual hospital beds, tilt frame beds and necessary accessories;
    • hospital beds, including electric controls, manual cranks or other items related to the use of the bed (Medicare or Medicaid can cover hospital beds, specialty mattresses and specialty hospital bed sheets for skin breakdown);
    • replacement mattresses;
    • egg crate mattresses, sheepskin and other medically related padding;
    • wheelchair cushions;
    • elbow, knee and heel protectors and hand rolls for positioning;
    • arm slings, arm braces and wrist splints;
    • abdominal binders;
    • trapeze bars;
  • communication aids (including repair, maintenance and batteries):
    • augmentative communication devices:
      • direct selection communicators;
      • alphanumeric communicators;
      • scanning communicators;
      • encoding communicators;
      • speaker and cordless telephones for persons who cannot use conventional telephones;
    • speech amplifiers, aids and assistive devices;
    • interpreters;
  • control switches- or pneumatic switches and devices:
    • sip and puff controls;
    • adaptive switches or devices;
  • environmental control units:
    • locks;
    • electronic devices;
    • voice-activated, light-activated and motion-activated devices;
  • medically necessary durable medical equipment (DME) not covered in the state plan for the Texas Medicaid Program;
  • temporary lease or rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment;
  • payment of premium deductibles and co-insurance (for items covered under the STAR+PLUS HCBS program), including rentals for Medicare or TPR, if not covered under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
  • modifications or additions to primary transportation vehicles:
    • van lifts;
    • driving controls:
      • brake or accelerator hand controls;
      • dimmer relays or switches;
      • horn buttons;
      • wrist supports;
      • hand extensions;
      • left-foot gas pedals;
      • right turn levers;
      • gear shift levers;
      • steering spinners;
    • medically necessary air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature;
    • removal or placement of seats to accommodate a wheelchair;
    • installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle;
    • raising the roof of the vehicle, lowering the floor or modifying the suspension of the vehicle to accommodate an individual riding in a wheelchair;
    • installation of frames, carriers, lifts for transporting mobility aids;
    • installation of trailer hitches for trailers used to transport wheelchairs or scooters;

Note: If the adaptive aid is a vehicle modification, the program provider must obtain written approval from the vehicle’s owner before making the modification. The owner must sign and date the approval. The MCO must maintain documentation that the contracted provider ensured the specifications for a vehicle modification included information on the vehicle to be modified, including:

  • the year and model of the vehicle;
    • a determination that the vehicle is the member’s primary vehicle;
    • proof of ownership of the vehicle;
    • current state inspection and registration for the vehicle;
    • any required state insurance for the vehicle;
    • mileage of the vehicle;
    • an itemized list of parts and accessories, including prices;
    • an itemized list of required labor, including labor charges; and
    • warranty coverage;
  • sensory adaptations:
    • corrective lenses including eyeglasses not covered by the Texas state plan;
    • hearing aids not covered by the state plan;
    • auditory adaptations to mobility devices; and
  • adaptive equipment for activities of daily living (ADLs):
    • assistive devices:
      • reachers;
      • stabilizing devices;
      • weighted equipment;
      • holders;
      • feeding devices, including:
        • electric self-feeders; and
        • food processors and blenders – only for members with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances;
    • variations of everyday utensils:
      • shaped, bent, built-up utensils;
      • long-handled equipment;
      • addition of friction covering;
      • coated feeding equipment;
    • medication reminder systems, including those for the visually disabled;
    • walking belts and physical fitness aids;
    • specially adapted kitchen appliances;
    • toilet seat reducer rings unless member resides in an assisted living facility (ALF);
    • bedside commodes;
    • hand-held shower sprays unless member resides in an ALF;
    • shower chairs unless member resides in ALF or residential care facility;
    • electric razors;
    • electric toothbrushes;
    • water picks;
    • service animals and maintenance including veterinary expenses;
    • over-bed tray tables unless member resides in an ALF;
    • safety devices, such as:
      • safety padding;
      • helmets;
      • elbow and knee pads;
      • visual alert systems;
    • medically necessary heating and cooling equipment for members with respiratory or cardiac problems, people who cannot regulate temperature or people who have conditions affected by temperature;
    • one window or portable air conditioner, including wiring, for a member’s main living area, such as a bedroom;
    • medical supplies necessary for therapeutic or diagnostic benefits for:
      • tracheostomy care;
      • decubitus care;
      • ostomy care;
      • pulmonary, respirator or ventilator care; and
      • catheterization.

Other types of supplies include:

  • incontinence supplies, including diapers, disposable or washable bed pads, briefs, protective liners, pull ups, wipes, moisture protective mattress covers, moisture barrier cream, regular or antiseptic wipes (if a medical need is documented), sheets, towels and washcloths (if medically necessary);
  • nutritional supplements;
  • enteral feeding formulas and supplies;
  • mouth swabs and toothettes;
  • diabetic supplies (strips, lancelets and syringes);
  • Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs;
  • stethoscopes, blood pressure monitors and thermometers for home use;
  • blood glucose monitors;
  • medical alert bracelets;
  • sharps or biohazard containers;
  • anti-embolism hose or stockings, such as thromboembolic disease hose; and
  • approved enemas, if not available through the state plan or other TPR.

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare or Medicaid can cover hospital beds and specialty mattresses. Specialty sheets, such as hospital bed sheets, may be covered.

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

Gloves

Gloves may be purchased through the STAR+PLUS HCBS program for family or caregiver use in the care of a member with incontinence or if the member has an active infectious disease that is transmitted through body fluids. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis. Gloves may be purchased for family or caregiver use to provide wound care to protect the member. Documentation by the MCO contracted provider must support the need of gloves to be left at the residence and for family or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using STAR+PLUS HCBS program funds. These items include, but are not limited to:

  • hot water heater;
  • combination heater, light and exhaust fan;
  • heating and cooling system filters;
  • non-adapted appliances, such as refrigerators, stoves, dryers, washing machines and vacuum cleaners;
  • water filtration systems;
  • central air conditioning and heating;
  • multiple air conditioning units to cover an individual's residence;
  • non-adapted home furnishings to include (except as allowed through transition assistance services (TAS) or Supplemental Transition Support):
    • cooking utensils;
    • non-hospital bed mattresses and springs, including Adjustamatic, Craftmatic, Tempur-Pedic®, Posturepedic and Sleep Number® beds;
    • pillows (excluding neck pillows and support wedge pillows);
  • electrical heating elements (heating pads, electric blankets);
  • recreational items, equipment and supplies including:
    • bicycles and tricycles (two, three or four wheels);
    • helmets for recreational purposes;
    • trampolines;
    • swing sets;
    • bowling and fishing gear;
    • karaoke machines;
    • entertainment systems;
    • off-road recreational vehicles;
  • memberships to gyms, spas, health clubs, or other exercise facilities;
  • communication items, including:
    • telephones (standard, cordless or cellular);
    • pagers;
    • pre-paid minute cards;
    • monthly service fees;
  • computers for the following justifications:
    • educational purposes;
    • self-improvement/employment purposes;
    • improvement of general computer skills;
    • internet and email access;
    • games and fun/craft activities;
  • office equipment and supplies to include:
    • fax machines;
    • printers or copiers;
    • scanners;
    • internet and email services;

Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

  • gloves for universal precautions, or gloves that are used by MCO contracted provider, an adult foster care (AFC) provider or any contracted provider staff;
  • personal items for activities of daily living (ADLs), such as hygiene products including soap, waterless soap, toothbrush, toothpaste, deodorant, powder, shampoo, lotions (except moisture barrier products), feminine products (except when documented for use as an incontinent supply), manual razors, washcloths, towels, bibs and first-aid supplies;
  • clothing items;
  • food;
  • bottled water (for drinking and cooking);
  • nutritional drinks and products, such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, nutrition and protein bars, breakfast cereals;
  • vitamins, minerals and herbal supplements and over-the-counter drugs;
  • title, license and registration for trailers or vehicles;
  • wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports;
  • vehicle repairs, as part of normal maintenance; repairs are part of normal vehicle maintenance and cannot be covered. Installation of heavy-duty shocks as required by a lift installation may be included as part of the vehicle modification; trailers (including taxes) for transporting wheelchairs or scooters;
  • experimental medical treatment and therapies, such as equestrian therapy; and
  • installation of gas or propane lines.

8420 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8430 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8440 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

 

8451 Time Frames for Adaptive Aids

Revision 21-2; Effective March 10, 2021

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized (except for vehicle modifications) to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) on Form H1700-1, Individual Service Plan (Pg. 1), or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO ISP folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, documenting the reason for the delay.

The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered. The MCO must authorize a vehicle modification on the effective date of the member’s ISP. The MCO must coordinate with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

8452 Time Frames for Medical Supplies

Revision 21-2; Effective March 10, 2021

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Home and Community Based Services (HCBS) program services. The provider must deliver medical supplies within five business days from the start date on the individual service plan (ISP). The member’s current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) before the fifth business day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

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

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

8500, Dental Services

Revision 21-2; Effective March 10, 2021

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.

The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through the STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.

8510 Allowable Dental Services

Revision 21-2; Effective March 10, 2021

Allowable dental services include:

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

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by the STAR+PLUS Home and Community Based Services (HCBS) program when no other financial resource for such services is available and when all other available resources are exhausted, with the exception of value-added services (VAS). VAS are not required to be used prior to STAR+PLUS HCBS program dental benefit. VAS vary by MCO.

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.

The annual cost limit of this service is $5,000 per individual service plan (ISP) year. The $5,000 cost limit may be waived by the MCO upon request of the member only when the services of an oral surgeon are required.

8600, Minor Home Modifications

Revision 21-2; Effective March 10, 2021

Minor home modifications (MHMs) are those physical adaptations to a member’s home, required by the individual service plan (ISP), that are necessary to ensure the member's health, welfare and safety or that enable the member to function with greater independence in the home. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities or installation of specialized electric and plumbing systems that are needed to accommodate the medical equipment and supplies necessary for the member’s welfare. Excluded are those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the member, such as carpeting, roof repair, central air conditioning, etc. Adaptations that add to the total square footage of the home are excluded from this benefit.

All services are provided in accordance with applicable state or local building codes. Modifications are not made to settings that are leased, owned or controlled by providers contracted with the managed care organization (MCO). The Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service.

8610 Responsibilities Pertaining to Minor Home Modifications

Revision 21-2; Effective March 10, 2021

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

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

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

8620 List of Minor Home Modifications

Revision 21-2; Effective March 10, 2021

The following minor home modifications (MHMs) include the installation, maintenance and repair of approved items not covered by warranty:

  • Purchase of wheelchair ramps;
    • protective awnings over ramps;
  • Modifications or additions for accessible bathroom facilities;
    • wheelchair accessible showers;
    • sink modifications;
    • bathtub modifications;
    • toilet modifications;
    • water faucet controls;
    • floor urinal and bidet adaptations;
    • plumbing modifications and additions to existing structures necessary for accessibility adaptations;
    • turnaround space modifications;
  • Modifications or additions for accessible kitchen facilities;
    • sink modifications;
    • sink cut-outs;
    • turnaround space modifications;
    • water faucet controls;
    • plumbing modifications or additions to existing structures necessary for accessibility adaptations;
    • worktable, work surface adjustments or additions;
    • cabinet adjustments or additions;
  • Specialized accessibility, safety adaptations or additions, including repair and maintenance;
    • door widening;
    • electrical wiring;
    • grab bars and handrails;
    • automatic door openers, doorbells, door scopes, and adaptive wall switches;
    • fire safety adaptations and alarms;
    • medically necessary air filtering devices;
    • light alarms, doorbells for the hearing and visually impaired;
    • floor leveling, only when the installation of a ramp is not possible;
    • vinyl flooring or industrial grade carpet necessary to ensure the safety of the member, prevent falling, improve mobility, and adapt a living space occupied by a member who is unable to safely use existing floor surface;
    • medically necessary steam cleaning of walls, carpet, support equipment and upholstery;
    • widening or enlargement of garage and/or carport to accommodate primary transportation vehicle and to allow persons using wheelchairs to enter and exit their vehicles safely;
    • installation of sidewalk for access from non-connected garage and/or driveway to residence, when existing surface condition is a safety hazard for the person with a disability;
    • porch or patio leveling, only when the installation of a ramp is not possible;
    • safety glass, safety alarms, security door locks, fire safety approved window locks, and security window screens; for example, for persons with severe behavioral problems;
    • security fencing for residence, for those persons with cognitive impairment or persons whose safety would be compromised if they wandered;
    • protective padding and corner guards for walls for members with impaired vision and mobility;
    • recessed lighting with mesh covering and metal dome light covers to compensate for violent aggressive behavior; for example, for persons with autism or mental illness;
    • noise abatement renovations to provide increased sound proofing; for example, for persons with autism or mental illness;
    • door replacement for accessibility only;
    • motion sensory lighting;
    • intercom systems for individuals with impaired mobility; and
    • lever door handles.

Ramps may be installed for improved mobility for use with scooters, walkers, canes, etc., or for members with impaired ambulation, as well as for wheelchair mobility. In some instances and according to supporting documentation, multiple modifications may be needed for accessibility and mobility, such as ramps and hand rails for members with impaired ambulation. There is no limit to the number of wheelchair ramps that can be authorized, provided the total cost does not exceed the cost limit. Documentation must support the justification for additional ramps as related to medical need or health and safety of the member.

Carbon monoxide detectors cannot be purchased under STAR+PLUS Home and Community Based Services (HCBS) program as a "fire safety adaptation and alarm."

Requests for items (or repair of items) or service calls that are considered routine home maintenance and upkeep cannot be approved.

Items that cannot be approved by the managed care organization (MCO) service coordinator include:

  • carpeting (other than industrial grade);
  • newly constructed carports, porches, patios, garages, porticos or decks;
  • electric fences;
  • landscaping and yard work or supplies;
  • roof repair or replacement;
  • gutters;
  • leaky faucet repair;
  • elevators;
  • house painting;
  • electrical upgrades and/or electrical outlets, unless needed to power adapted equipment or a safety hazard exists;
  • air duct cleaning and maintenance; and
  • pest exterminations.

Heating and cooling equipment may be approved as an adaptive aid. Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms are considered as an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as an MHM.

Flooring applications, including vinyl and industrial carpet, may not be authorized for adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the member.

8630 Minor Home Modification Service Cost Lifetime Limit

Revision 21-2; Effective March 10, 2021

There is a cost lifetime limit of $7,500 per member for this service and $300 yearly for repairs. Once the $7,500 cost limit is reached, only $300 per year per member, excluding associated fees, will be allowed for repairs, replacement or additional modifications. The managed care organization (MCO) is responsible for obtaining cost effective modifications authorized on the member's individual service plan (ISP). The MCO may exceed the $7,500 cost limit; however, the MCO must not include costs over the lifetime limit on any cost reports, claims, encounters or financial statistical reports (FSRs).

If a member changes MCOs, the losing MCO must provide documentation to the gaining MCO related to any minor home modification (MHM) expenditures. Refer to Uniform Managed Care Contract (UMCC) Terms and Conditions, Section 5.06, Span of Coverage, for payment responsibilities.

8640 Landlord Approval for Minor Home Modifications

Revision 21-2; Effective March 10, 2021

When the member has a landlord or when the owner of the home is not the member, written approval prior to the initiation of any requested minor home modification (MHM) must be obtained by the managed care organization (MCO).

8700, Employment Services

8710 Employment Assistance

Revision 21-2; Effective March 10, 2021

Employment assistance (EA) is provided to a member to help the member locate paid employment in the community and includes:

  • identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with a member’s identified preferences, skills and requirements; and
  • contacting a prospective employer on behalf of a member and negotiating the member’s employment.

In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the member’s record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (United States Code (U.S.C.) Title 20, §1401 et seq.).

An EA service provider’s credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate's degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or general equivalency diploma (GED); and
  • two years of documented experience providing services to people with disabilities in a professional or personal setting.

8720 Supported Employment

Revision 21-2; Effective March 10, 2021

Supported employment (SE) is assistance provided, in order to sustain competitive employment, to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which members without disabilities are employed. SE includes adaptations, supervision, training related to a member’s assessed needs and earning at least minimum wage (if not self-employed). In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the member’s record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (United States Code (U.S.C.) Title 20, §1401 et seq.).

An SE service provider’s credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate's degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or general equivalency diploma (GED); and
  • two years of documented experience providing services to people with disabilities in a professional or a personal setting.