Habilitation Coordination Billing Guidelines

1000, Introduction

Revision 19-0; Effective July 7, 2019

Habilitation coordination is defined in 26 Texas Administrative Code (TAC) Chapter 303, §303.102 of rules governing Preadmission Screening and Resident Review (PASRR). Habilitation coordination funded by Medicaid provides assistance for an individual to access appropriate specialized services necessary to achieve a quality of life and level of community participation which is acceptable to the individual and legally authorized representative (LAR) on the individual’s behalf.

2000, Definitions

Revision 19-0; Effective July 7, 2019

The following words and terms, when used in this manual, have the following meanings unless the context clearly indicates otherwise:

CLO or community living options — A process by which the LIDDA provides information to an individual and legally authorized representative (LAR) about the range of community living services, supports and programs the individual may be eligible for, and discusses services and supports the individual will need to live in the community, as well as individual preferences and barriers to community living.

Collateral contact — A person who is knowledgeable about the individual seeking admission to an NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.

Habilitation coordination — Assistance for an individual residing in a nursing facility to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the individual and LAR on the individual’s behalf.

Habilitation Coordinator — An employee of a local intellectual and developmental disability authority (LIDDA) who provides habilitation coordination.

HHSC — The Texas Health and Human Services Commission.

HSP or Habilitation Service Plan — A plan developed by the service planning team (SPT) while an individual is residing in an NF that:

  1. is individualized and developed through a person-centered approach;
  2. identifies the individual’s:
    1. strengths;
    2. preferences;
    3. desired outcomes; and
    4. psychiatric, behavioral, nutritional management, and support needs as described in the comprehensive care plan or Minimum Date Set (MDS) assessment; and
  3. identifies the specialized services that will accomplish the desired outcomes of the individual, or the LAR’s on behalf of the individual, including amount, frequency and duration for each service.

ID or intellectual disability — Defined in 42 Code of Federal Regulations (CFR) §483.102(b)(3)(i).

IDD habilitative specialized services — The following specialized services that are available to an individual:

  1. habilitation coordination;
  2. day habilitation;
  3. independent living skills training;
  4. behavioral support;
  5. employment assistance; and
  6. supported employment.

IDT or interdisciplinary team — A team consisting of:

  1. a resident with MI, ID or DD;
  2. the resident's LAR, if any;
  3. a registered nurse from the NF with responsibility for the resident;
  4. a representative of:
    1. the LIDDA, if the resident has ID or DD;
    2. the LMHA or LBHA, if the resident has MI; or
    3. the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and
  5. others as follows:
    1. a concerned person whose inclusion is requested by the resident or LAR;
    2. a person specified by the resident, LAR, NF, LIDDA, LMHA or LBHA, as applicable, who is professionally qualified, certified, or licensed with special training and experience in the diagnosis, management, needs, and treatment of people with MI, ID or DD; and
    3. a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.

Individual — A person:

  1. whose active PASRR evaluation (PE) or resident review is positive for ID or DD;
  2. who is 21 years of age or older; and
  3. who is a Medicaid recipient.

LAR or legally authorized representative — A person authorized by law to act on behalf of an individual seeking admission to an NF or resident about a matter described by this chapter, and who may be the parent of a minor child, the legal guardian or the surrogate decision maker. (See limitations on authority of surrogate decision maker in the definition of “surrogate decision maker.”

LIDDA or local intellectual and developmental disability authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.

LMHA or local mental health authority — An entity designated to provide mental health services in accordance with Texas Health and Safety Code §533.035(a).

LBHA or local behavioral health authority — An entity designated to provide mental health and chemical dependency services in accordance with Texas Health and Safety Code §533.0356(a).

Nursing facility (NF) — A Medicaid-certified facility that is licensed in accordance with Texas Health and Safety Code, Chapter 242.

Nursing facility specialized services — The following NF specialized services that are available to an individual:

  1. therapy services;
  2. customized manual wheelchair; and
  3. durable medical equipment.

PASRR or Preadmission Screening and Resident Review — required by 42 CFR 483.100-138.

PASRR Level II Evaluation (PE) — A face-to-face evaluation:

  1. of an individual seeking admission to an NF who is suspected of having MI, ID or DD; and
  2. performed by a LIDDA, LHMA or LBHA to determine if the individual has MI, ID or DD and, if so, to:
    1. assess the individual's need for care in a nursing facility;
    2. assess the individual's need for specialized services; and
    3. identify alternate placement options.

PASRR Level 1 (PL1) — The process of screening an individual seeking admission to an NF to identify whether the person is suspected of having MI, ID or DD.

QIDP or qualified intellectual disability professional — A person who meets the qualifications described in 42 CFR §483.430(a).

Service coordination — Assistance in accessing medical, social, educational and other appropriate services and supports, including alternate placement assistance that will help a person achieve a quality of life and community participation acceptable to the person and LAR on the person's behalf.

Service coordinator — An employee of a LIDDA who provides service coordination.

Specialized services — The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID or DD: a. NF specialized services; b. IDD habilitative specialized services; and c. MI specialized services.

SPT or service planning team — A team convened by a LIDDA staff member that develops, reviews and revises the HSP and the Transition Plan for an individual.

  1. The team must include:
    1. the individual;
    2. the individual’s LAR, if any;
    3. the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the individual is transitioning to the community;
    4. the managed care organization (MCO) service coordinator, if the individual does not object;
    5. while the individual is in a nursing facility:
      1. a nursing facility staff member familiar with the individual’s needs; and
      2. a person providing a specialized service to the individual or a representative of a provider agency that is providing specialized services for the individual;
    6. if the individual is transitioning to the community:
      1. a representative from the community program provider, if one has been selected; and
      2. a relocation specialist; and (vii) a representative from the LMHA/LBHA, if the individual has MI.
  2. Other participants on the SPT may include:
    1. a concerned person whose inclusion is requested by the individual or the LAR; and
    2. at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.

Transition Plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in assisting an individual to transition from residing in a nursing facility to living in the community.

3000, References in Law, Rule and Policy

Revision 19-0; Effective July 7, 2019

The provision of habilitation coordination is also governed by the following:

  • Medicaid Provider Agreement
  • Current LIDDA Performance Contract
  • 1 TAC §355.315 Subchapter C (Reimbursement Methodology for Preadmission Screening and Resident Review (PASRR) Specialized Services)
  • 26 TAC, Chapter 303, PASRR

4100, Habilitation Coordination Service Authorization Revision

Revision 19-0; Effective July 7, 2019

The habilitation coordinator must send a request for habilitation coordination service units from HHSC. To be paid for participating in the initial IDT meeting, a request must be sent using designated Form 2358, Habilitation Coordination Authorization Request, and faxed to the HHSC Provider Claims section at 512-438-2301 within three business days of the initial IDT for processing. If the IDT agrees to the provision of habilitation coordination for the individual, the LIDDA requests habilitation coordination for 12 months effective the date of the IDT meeting.

Service authorizations may take five to seven business days to appear on Medicaid Eligibility and Service Authorization Verification (MESAV).

4110 Habilitation Coordination Service Authorization Requests

Revision 19-0; Effective July 7, 2019

There are six habilitation coordination authorization requests that the habilitation coordinator will identify on Form 2358, Habilitation Coordination Authorization Request, that will be processed by HHSC staff:

  • Initial — LIDDA requests initial authorization for habilitation coordination for 12 units for one year if the individual accepts a recommendation for habilitation coordination.
  • Refusal — LIDDA requests one unit to cover the initial IDT if the individual refuses habilitation coordination.
  • Renewal — LIDDA requests renewal of authorization for habilitation coordination (12 service units) for the next year.
  • CLO — LIDDA requests one additional unit of habilitation coordination to provide CLO in accordance Section 5810.1 of the IDD PASRR Handbook for an individual who has refused habilitation coordination.
  • Revision — LIDDA requests additional units of habilitation coordination. This usually occurs when an individual requests habilitation coordination after an initial refusal.
  • Termination —There are two types of termination:
    • Voluntary: When an individual, or LAR on his or her behalf, requests an end to habilitation coordination.
    • Involuntary: The second type is to request an end to an authorization for habilitation coordination for an individual who has transferred to an NF in the service area of another LIDDA.

4120 Termination Codes

Revision 19-0; Effective July 7, 2019

For all terminations submitted by the habilitation coordinator, an accompanying code will need to be used to reflect what type of termination is being submitted. Below are the codes:

Code Description
1 Client Leaves the LIDDA’s catchment area
2 Death of Client
5 Client Requests Service Termination
23 Transferred to Another Service
29 Discharged from Facility (Assumed to Home)
32 Hospitalized over 30 days
39 Other

4200, Units of Service

Revision 19-1; Effective September 19, 2019

A billable unit of service is the method for calculating the amount the habilitation coordinator may bill HHSC. HHSC established the habilitation coordination rate based on an assumption of a caseload of 26 individuals served within any given calendar month. For the first year of implementation, HHSC will not be imposing a contractual requirement that LIDDAs maintain a caseload of 26 individuals. HHSC encourages and expects that LIDDAs will maintain manageable caseloads that continue to support the integrity and quality of habilitation coordination that PASRR residents receive. Rate information is published by procedure code in the applicable Texas Medicaid Fee Schedule located on the Texas Medicaid website (see Fee Schedules).

Service Procedure Code Modifier Rate Unit Effective
Habilitation Coordination S0311 96 $208.23 Monthly 7/7/2019

The number of habilitation coordination units needed by the individual are determined by the IT or SPT and documented on the HSP. The monthly habilitation coordination fee may only be billed during a month when a billable activity has occurred. Habilitation coordination progress notes must include the following elements:

  • the date of habilitation coordination encounter;
  • description of the service provided (e.g., assessment, service planning and coordination, monitoring, or crisis prevention and management);
  • place of encounter;
  • actual begin time and duration of encounter;
  • detailed description of the encounter;
  • the person with whom the contact occurred; and
  • the habilitation coordinator who provided the contact including name and title.

Elements noted above do not necessarily have to be contained within the narrative describing the encounter as long as they are contained within the progress note that also contains the narrative (e.g., billing strip).

4210 SASO Codes

Revision 19-0; Effective July 7, 2019

A service authorization for habilitation coordination is created in the Service Authorization System Online (SASO) by designated HHSC staff for one unit per month requested, for up to 12 months, with effective the date of the IDT or the date that the habilitation coordinator meets with the individual. The service authorization is identified as a Service Group (SG) 14 or “SG 14,” which means the LIDDA is the provider. The service code for which is associated with “habilitation coordination” is 10H provided by a LIDDA.

4300, Service Claim Requirements

Revision 19-0; Effective July 7, 2019

For habilitation coordination services to be reimbursed, there must be at least one face-to-face meeting with an individual delivered by a qualified provider employed by the LIDDA. A LIDDA must submit an electronic service claim for habilitation coordination that meets the requirements specified by Texas Medicaid & Healthcare Partnership (TMHP).

5000, Billable Activities

Revision 19-0; Effective July 7, 2019

The monthly rate for habilitation coordination covers all habilitation coordination activities provided to the individual in one month. One contact must be face-to-face, and include one or more of the following activities:

  • assessing and reassessing habilitative service needs by gathering information from the individual through observation and/or other appropriate sources to determine habilitative needs and the specialized services that will address those needs;
  • facilitating an SPT meeting;
  • monitoring and providing follow-up activities through observation of:
    • the initiation and delivery of all specialized services agreed upon in an IDT or SPT meeting and following up when delays occur;
    • the individual’s satisfaction with all specialized services;
    • the individual’s progress or lack of progress toward achieving goals and outcomes identified in the HSP; and
  • offering educational opportunities and information activities about community living options and addressing concerns about community living.

6000, Non-Claimable Activities

Revision 19-0; Effective July 7, 2019

HHSC does not authorize the monthly habilitation coordination fee for activities that are not one of the habilitation coordination activities defined in Section 5000 of the IDD PASRR Handbook.

6100, Non-Claimable Activities Related to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

The following are activities that are included in the rate of habilitation coordination, but can’t be billed exclusively without a face-to-face meeting and an activity discussed in Section 5000:

  • phone calls, letters, emails or meetings with HHSC or non-habilitation coordination resources when the activity does not benefit a specific individual;
  • collateral contact;
  • leaving a phone message on a recorder; and
  • direct contact with the individual or LAR by a habilitation coordinator when contact is about coordination of transition services.

6200, Non-Claimable Activities Related to Administration

Revision 19-0; Effective July 7, 2019

The following are examples of non-billable administrative activities and not required for habilitation coordination but maybe required by a LIDDA:

  • administrative meetings or staff meetings;
  • in-service training, continuing education or conferences;
  • employee conferences or evaluations;
  • filing claims for services;
  • traveling to and from the individual's nursing facility;
  • travel time spent by staff related to habilitation coordination services;
  • "down-time" such as illness, holidays or vacation time; and
  • processing paperwork including documentation.

7000, Data Reporting Requirements

Revision 19-0; Effective July 7, 2019

The following reporting requirements for the Mental Health and ID Business Objects Warehouse (MBOW) must be followed:

  • Appropriate Encounter Services and Grid Codes – Refer to the HHSC LIDDA Performance Contract. Applicable grid code 361 is Habilitation Coordination for an individual, and grid code 0362 is refuse Habilitation Coordination.
  • Critical Encounter Fields – Enc Type Cd must be F, Face to Face, T, Telephone, or E, Telemedicine. An Encounter Type value T is not sufficient on its own to produce or support an RO1H assignment. Recipient Cds 1-7 will be allowed for valid encounters. Values 2, collateral, Not Specified, 5, collateral, family member or LAR only, or 7, collateral, waiver provider only are not sufficient on their own to produce or support an RO1H assignment.

8000, Billing and Payment Reviews

Revision 19-0; Effective July 7, 2019

A LIDDA must provide any documentation related to habilitation coordination that is requested by HHSC in the time frame specified by HHSC.

Forms

ES = Spanish version available.

Form Title  
2358 Habilitation Coordination Authorization Request  

19-1, Section 4200 Changes and Appendix Deleted

Effective Sept. 19, 2019

The following change(s) were made:

Section Title Change
4200 Units of Service Revises the requirement to have a 26-person cap on a habilitation coordinator's caseload.
Appendix I LIDDA Habilitation Coordinator (HC) Maximum Caseload Size Deletes the appendix.

19-0, New Handbook

Effective July 7, 2019

The Habilitation Coordination Billing Guidelines informs local intellectual and developmental disability authorities about billing and system reporting requirements regarding habilitation coordination provided through the Preadmission Screening and Resident Review program.