Case Worker Community Care for Aged and Disabled Handbook

 

CW-CCAD, Section 1000, Program Description

Revision 17-1; Effective March 15, 2017

 

 

1100 Program Introduction

Revision 17-1; Effective March 15, 2017

 

 

1110 Legal Base

Revision 17-1; Effective March 15, 2017

 

Community Care for Aged and Disabled (CCAD) is a group of services purchased by the Texas Health and Human Services Commission (HHSC) in response to recommendations of the Texas Legislature. CCAD provides services in a person's own home or community for aged or disabled Texans who are not self-sufficient, and who might otherwise be subject to premature institutionalization or to abuse, neglect or exploitation. CCAD includes the following direct services for eligible individuals (detailed descriptions of the services are in Section 4000, Specific CCAD Services):

HHSC also provides CCAD case management, information and referral (I&R) to other service resources. Case management is direct assistance to eligible individuals in managing the services that have been mutually planned and that use the individuals’ own resources as well as community resources. These services are planned to enable individuals to carry out activities of daily living and to continue living in the community. (For details see Section 2000, Case Management.)

See also Appendix XXIV, Legal Basis for Community Care Programs.

 

1120 Program Goals

Revision 17-1; Effective March 15, 2017

 

CCAD goals are:

 

1130 Definitions

Revision 17-1; Effective March 15, 2017

 

Definitions are located in 40 Texas Administrative Code (TAC) §48.1201.

 

1140 Disclosure of Information

Revision 17-1; Effective March 15, 2017

 

 

1141 Confidential Nature of the Case Record

Revision 17-1; Effective March 15, 2017

 

Information that is collected in determining initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about individuals. HHSC may disclose general information about policies, procedures, or other methods of determining eligibility, and any other information that is not about or does not specifically identify an individual.

An individual may review all information in the case record and in HHSC handbooks that contributed to the decision about his eligibility.

 

1141.1 Confidential Information on Notifications

Revision 17-1; Effective March 15, 2017

 

HHSC is committed to protecting all confidential information supplied by the applicant or individual during the eligibility determination process. This covers inclusion of confidential information by HHSC staff to third parties who receive a copy of a notification of eligibility form. Staff must ensure they do not include confidential information on the eligibility notice that should not be shared with the service provider or another third party. For example:

An individual is being denied Family Care due to an increase in income. It is a violation of confidentiality to record on Form 2065-A, Notification of Community Care Services, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "Your income exceeds the eligibility limit."

Another applicant is being denied Primary Home Care services because he does not meet the medical diagnosis criterion. It is a violation of confidentiality to record on Form 2065-A, "Your diagnosis of Schizophrenia does not meet the medical diagnosis criterion for eligibility for the Primary Home Care Program." The comment should simply state, "You do not have a medical diagnosis resulting in a functional limitation, as required for eligibility."

In the examples above, revealing the amount of the individual's income or his diagnosis is a violation of his right to confidentiality. In all cases, HHSC staff must assess any information provided by the individual to determine if its release would be a confidentiality violation.

 

1142 Establishing Identity for Contact Outside the Interview Process

Revision 17-1; Effective March 15, 2017

 

Keep all information HHSC has about an individual or any individual on the individual's case confidential. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing information about an individual or any individual on the individual's case, take steps to be reasonably sure the individual receiving the confidential information is either the individual or a person the individual has authorized to receive confidential information (for example, an attorney or personal representative).

 

1142.1 Telephone Contact

Revision 17-1; Effective March 15, 2017

 

Establish the identity of an individual who identifies himself as an individual using his knowledge of the individual's:

  • Social Security number (SSN),
  • date of birth,
  • other identifying information, or
  • call back to the individual.

Establish the identity of a personal representative by using the individual's knowledge of the individual's:

  • SSN,
  • date of birth,
  • other identifying information,
  • call back to the individual, or
  • the knowledge of the same information about the individual's representative.

Establish the identity of attorneys or legal representatives by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the individual.

Establish the identity of legislators or their staff by following regional procedures.

 

1142.2 In-Person Contact

Revision 17-1; Effective March 15, 2017

 

Establish the identity of the individual who presents himself as an individual or individual's representative at an HHSC office by using sources such as:

  • driver's license,
  • date of birth,
  • Social Security number, or
  • other identifying information.

Establish the identity of other HHSC staff, federal agency staff, researchers, or contractors by using sources such as:

  • employee badge, or
  • government-issued identification card with a photograph.

Identify the need for other HHSC staff, federal staff, research staff, or contractors to access confidential information through:

  • official correspondence or a telephone call from a state or regional office.
  • contact with regional attorney.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers, or other HHSC staff come to the office without prior notification or adequate identification and request permission to access HHSC records.

 

1142.3 Verification and Documentation

Revision 17-1; Effective March 15, 2017

 

If disclosing individually identifiable health information, document how the identity of the person was verified when contact is outside the interview.

Verify the identity of the person who requests disclosure of individually identifiable health information using sources such as:

  • valid driver's license or Department of Public Safety ID card,
  • birth certificate,
  • hospital or birth record,
  • adoption papers or records,
  • work or school ID card,
  • voter registration card,
  • wage stubs, and
  • U.S. passport.

 

1143 Custody of Records

Revision 17-1; Effective March 15, 2017

 

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain, except as provided by HHSC regulations.

"Reasonable diligence" for employees responsible for records includes:

  • keeping records in a locked office when the building is closed;
  • keeping records properly filed during office hours; and
  • keeping records in the office at all times, except when authorized to remove or transfer them.

 

1144 Disposal of Records

Revision 17-1; Effective March 15, 2017

 

To dispose of documents with individual-specific information, follow the HHSC procedures for destruction of confidential data in the Records Management Manual.

 

1145 When and What Information May Be Disclosed

Revision 17-1; Effective March 15, 2017

 

Reasonable efforts must be made to limit the use, request, or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an individual authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the individual.

Give individual addresses or other case information only to a person who has written permission from the individual to obtain the information. The individual authorizes the release of information by completing and signing:

  • Form 1826-D, Case Information Release; or
  • a document containing all of the following information:
    • the applicant/individual's full name (including middle initial) and case number, or full name (including middle initial) and either his date of birth or Social Security number;
    • a description of the information to be released. If a general release is authorized, provide the information that can be disclosed to the individual. Withhold confidential information from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
    • a statement specifically authorizing HHSC to release the information;
    • the name of the person or entity where the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the individual, the purpose of the release, or an expiration date of the release;
    • a statement about whether refusal to sign the release affects eligibility for delivery of services;
    • a statement describing the applicant's or individual's right to revoke the authorization to release information;
    • the date the document is signed; and
    • the signature of the applicant, individual or legally authorized representative (LAR).

If the case information to be released includes individually identifiable health information, the document must also tell the applicant or individual that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally requests for information from the case records of deceased individuals are received. In these instances, protect the confidentiality of the former individuals and their survivors.

The Office of the General Counsel handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to the Office of the General Counsel, State Office, W-615. Regional staff should direct questions and problems to the regional attorney.

Note: See Section 1146, Confidential Nature of Medical Information – HIPAA, for restrictions on the release of an individual's protected health information under Health Insurance Portability and Accountability Act regulations.

 

1145.1 Request for Release of Information Related to a Deceased Individual

Revision 17-1; Effective March 15, 2017

 

This section provides guidance for handling requests for release of information related to a deceased applicant/individual. A request for such information is likely to occur in relation to the Medicaid Estate Recovery Program. HHSC does not provide a form to document when someone requests information. In lieu of a form, the following methods are acceptable for documenting the request for this type of release of information to the requestor:

  • A release form or statement signed by the applicant/individual prior to death, and not revoked by the applicant/individual, authorizing release of information to the specific person requesting the information.
  • A copy of an order from a probate court appointing the requestor as estate administrator or guardian.
  • A copy of another type of order from a court authorizing the requestor to administer the affairs of the deceased.
  • Documentation demonstrating the requestor has authority under Texas law to act for the deceased.

A person who has authority under Texas law to act on behalf of a deceased applicant/individual or the deceased's estate includes a surviving spouse, an adult child, a parent or an heir.

Regional staff should first ask the requestor for any available document (noted above). If a document is not available, staff must determine and document if the requestor has authority under Texas law to act for the deceased applicant/individual. Regional staff may release information to the requestor if one of the documentation requirements above is met and filed/recorded in the case record.

 

1146 Confidential Nature of Medical Information – HIPAA

Revision 17-1; Effective March 15, 2017

 

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:

  • past, present, or future physical or mental health or condition of the individual;
  • provision of health care to the individual; or
  • past, present, or future payment for the provision of health care to the individual.

 

1147 Privacy Notice

Revision 17-1; Effective March 15, 2017

 

HHSC staff must send each individual the HHS Agencies Notice of Privacy Practices, upon certification. The HHS Agencies Notice of Privacy Practices is available in both English and Spanish as printable PDF documents:

Link to printable English PDF

Link to printable Spanish PDF

This form tells the individual about:

  • his privacy rights;
  • the duties of HHSC to protect health information; and
  • how HHSC may use or disclose health information without his authorization. (Examples of use or disclosure include: health care operations (for example, Medicaid), public health purposes, reporting victims of abuse, law enforcement purposes, sharing with HHSC contractors, and coordinating government programs that provide benefits.)

 

1148 Individual Authorization

Revision 17-1; Effective March 15, 2017

 

The individual may authorize the release of his health information from HHSC records by using a valid authorization form. Form 1826-D, Case Information Release, includes all the authorization elements required by HIPAA privacy regulations.

 

1149 Minimum Necessary

Revision 17-1; Effective March 15, 2017

 

Reasonable efforts must be made to limit the use, request, or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from HHSC records must be limited to the minimum necessary to accomplish the requested disclosure. Example: If an individual authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the individual.

 

1150 Personal Representatives

Revision 17-1; Effective March 15, 2017

 

Only the individual or the individual's personal representative can exercise the individual's rights with respect to individually identifiable health information. Therefore, only the individual or individual's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of an individual.

Exception: HHSC is not required to disclose the information to the personal representative if the individual is subjected to domestic violence, abuse, or neglect by the personal representative. Consult the regional attorney if it is believed that health information should not be released to the personal representative.

Note: A responsible party is not automatically a personal representative.

 

1151 Adults and Emancipated Minors

Revision 17-1; Effective March 15, 2017

 

If the individual is an adult or emancipated minor, including married minors, the individual's personal representative is a person who has the authority to make health care decisions about the individual and includes a:

  • person the individual has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
  • court-appointed guardian for the individual; or
  • person designated by law to make health care decisions when the individual is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication. Follow regional procedures to contact the regional attorney for approval.

 

1152 Unemancipated Minors

Revision 17-1; Effective March 15, 2017

 

A parent is the personal representative for a minor child except when:

  • the minor child can consent to medical treatment by him or herself. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment by him or herself when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 or older, lives separately from the parents, and manages his own financial affairs;
    • consent involves diagnosis and treatment of disease that must be reported to local health officer or state health services;
    • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
    • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency, or use at a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
    • consent involves examination and treatment for drug or chemical addiction, dependency, or use by a physician or counselor at a location other than a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
    • minor is unmarried, is the parent of a child, has actual custody of the child, and consents to treatment for the child; or
    • consent involves suicide prevention or sexual, physical, or emotional abuse.
  • a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about the health care decisions not made by the parent.

 

1153 Deceased Individuals

Revision 17-1; Effective March 15, 2017

 

The personal representative for a deceased individual is an executor, administrator, or other person with authority to act on behalf of the individual or the individual's estate. These include:

  • an executor, including an independent executor;
  • an administrator, including a temporary administrator;
  • a surviving spouse;
  • a child;
  • a parent; and
  • an heir.

Consult the regional attorney if there are questions about whether a particular person is the personal representative of an applicant or individual.

 

1160 Correcting Information

Revision 17-1; Effective March 15, 2017

 

An individual has a right to correct any information that HHSC has about the individual and any other individual on the individual's case.

A request for correction must be in writing and:

  • identify the individual asking for the correction;
  • identify the disputed information about the individual;
  • state why the information is wrong;
  • include any proof that shows the information is wrong;
  • state what correction is requested; and
  • include a return address, telephone number, or email address at which HHSC can contact the individual.

If HHSC agrees to change individually identifiable health information, the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the individual's request.

Notify the individual in writing within 60 days (using current HHSC letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the individual if HHSC needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC makes a correction to individually identifiable health information, ask the individual for permission before sharing with third parties. HHSC will make a reasonable effort to share the correct information with persons who received the incorrect information from HHSC if they may have relied or could rely on it to the disadvantage of the individual. Follow regional procedures to contact the HHSC Privacy Officer for a record of disclosures.

Note: Do not follow above procedures when the accuracy of information provided by an individual is determined by another review process, such as a:

  • fair hearing,
  • civil rights hearing, or
  • other appeal process.

The decision in that review process is the decision on the request to correct information.

 

1170 Alternate Means of Communication

Revision 17-1; Effective March 15, 2017

 

HHSC must accommodate an individual's reasonable requests to receive communications by alternative means or at alternate locations.

The individual must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the individual.

 

CW-CCAD, Section 2000, Case Management

Revision 17-11; Effective November 20, 2017

2100 Case Management

Revision 17-1; Effective March 15, 2017

2110 Description of Case Management

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2917 — Clients must meet the eligibility criteria for CCAD services, but they do not have to receive services to receive case management. Ineligible applicants receiving only information and referral are not eligible for case management.

Case management is a set of actions taken by a Texas Health and Human Services Commission (HHSC) case worker to determine:

Case management also includes:

Nine is the lowest score an individual can have and still qualify for a Community Care for Aged and Disabled service on the basis of his score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. An individual must score at least nine on Form 2060 to be eligible for case management only.

2120 Case Management Process

Revision 17-1; Effective March 15, 2017

Case management involves six individual functions.

  1. Intake — Requests for service or information are made by an individual, or someone on the individual's behalf, by telephone, letter or in person. Texas Health and Human Services Commission (HHSC) intake staff:
    • determine exactly what is being requested;
    • record certain information given by the requester;
    • give the requester certain information;
    • determine whether an immediate, expedited or routine response is necessary; and
    • refer the request to the appropriate unit for further action.

For detailed intake procedures, see Section 2200, Intake Procedures.

  1. Assessment — HHSC case workers respond to intake by visiting the person at home or other setting to conduct a face-to-face assessment of eligibility and needs. The assessment process includes:
    • determining financial eligibility;
    • determining functional eligibility relative to performance of activities of daily living;
    • assessing the individual's home, social/environmental supports and resources;
    • determining services the individual needs and whether those needs are currently being met by family or community resources; and
    • assessing the individual's physical condition and determining whether that condition, in combination with the environment, poses any degree of risk.

For detailed assessment procedures, see Section 2400, Assessment Process.

  1. Service planning — After completing the assessment, case workers develop a service plan with each eligible individual. Service planning includes:
    • determining what services and environmental adaptations are required to satisfy the individual's personal unmet needs, health and safety;
    • determining and specifying what services will be secured from whom or from where, how much will be provided and on what schedule;
    • specifying how often the case worker will monitor the provision of services and individual satisfaction; and
    • obtaining the individual's concurrence with the service plan.

For detailed service planning procedures, see Section 2500, Service Planning.

  1. Service authorization
    1. Non-Medicaid services — If non-Medicaid HHSC services are to be purchased as part of the service plan, the case worker:
      • authorizes the services according to program policies and procedures;
      • sends the service plan and individual referral information to the provider selected by the individual; and
      • discusses the plan with the potential provider, as necessary.
    2. Medicaid services — If Medicaid services are to be purchased as part of the service plan, the case worker:
      • designates the services according to Medicaid program policies and procedures;
      • obtains, if necessary, consultation from the regional nurse regarding medical need for services;
      • sends the service plan and individual referral information to the provider selected by the individual;
      • discusses the plan with the provider supervisor, if requested; and
      • discusses the plan with the regional nurse, as necessary.

For detailed service authorization procedures, see Section 2600, Authorizing and Reassessing Services.

  1. Service monitoring and evaluation — The case worker:
    • contacts each individual after service referral, according to case management requirements, to ensure that services were initiated as scheduled and to determine the individual's satisfaction with the service;
    • contacts and visits each individual according to the individualized case management plan or upon request by the individual or others;
    • accompanies regional nurses on utilization review home visits, when requested;
    • evaluates the individual's condition, needs and service provision on an ongoing basis, according to HHSC procedures and individual requirements;
    • requests consultation and joint home visits with the regional nurse or provider nurse, or both, when indicated because of the individual's health condition or risk status;
    • receives information from providers about the individual's ongoing needs and conditions; and
    • reassesses individual's needs and reviews and reauthorizes service plans according to required schedules.

For detailed procedures concerning service monitoring, see Section 2700, Service Monitoring, Changes and Transfers.

  1. The case worker is also responsible for assisting individuals who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. For detailed procedures, see Section 2130, Your Texas Benefits Medicaid Card and Replacement.

2130 Your Texas Benefits Medicaid Card and Replacement

Revision 17-1; Effective March 15, 2017

Form H3087, Medicaid Identification, is no longer issued and has been replaced by the Your Texas Benefits (YTB) Medicaid card.

The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services as the card is not proof of ongoing Medicaid eligibility. Medicaid recipients must take the card to doctor or dental appointments and to the pharmacy. This card is expected to be for permanent use and the Texas Health and Human Services Commission (HHSC) will only issue a new card if the card is lost or if the information printed on the card changes.

The individual may call 1-855-827-3748 if the card is lost and the individual needs a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line, so even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the individual later regains eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form, not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services Forms website for completion of the form. Designated HHSC staff may continue to assist individuals in the following situations:

Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time services are requested. The recipient may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage if he is not sure of his eligibility status.

More information about the new card is available at: www.yourtexasbenefits.com.

2200 Intake Procedures

Revision 17-1; Effective March 15, 2017

For interest list procedures involving managed care, see the STAR+PLUS Handbook.

2210 Requests for Services

Revision 17-1; Effective March 15, 2017

A request for services may begin with

2211 Applications and Referrals Routed from the Austin Document Processing Center

Revision 17-1; Effective March 15, 2017

When the Austin Document Processing Center (DPC) receives an application in which a request for an HHSC referral exists, the DPC will fax the first three pages of the application and a cover sheet to the HHSC local office. Upon receipt of the application, HHSC staff will review each of the referrals and contact the individual to determine if the individual is interested in HHSC services and take the following actions:

The document processing center address is:
 
Document Processing Center
P.O. Box 149024
Austin, TX 78714-9024
Fax Number: 877-236-4123

2220 Response to Requests for Service

Revision 17-7; Effective July 1, 2017

When a request for service is received by telephone, written referral or in person, the HHSC staff who conducts intake for community care services or who receives a request for service gives the requester information about HHSC CCAD services and determines what service is being requested and whether HHSC provides that service.

Upon receipt of a written/faxed referral, the applicant or responsible party may be contacted by intake staff or the referral may be accepted, entered in the Intake (NTK) system and assigned to a case worker. The case worker would then make the initial contact, provide information about HHSC and screen for appropriate services.

The intake staff or case worker who conducts intake for community care services or who receives a request for service:

If the requester does not want to apply for CCAD services, the requester is transferred to appropriate staff for requests for HHSC services other than community care services or referred to other appropriate resources. See Appendix XV, Services Available from Other State Agencies, and Section 2530, Other Resource Services. The information is not entered into NTK and an intake is not completed. This information is recorded in an Information and Referral Log.

If the individual wishes to apply for CCAD services, the intake person:

For all individuals who currently do not receive Supplemental Security Income (SSI) or SSI-related Medicaid and are requesting personal attendant services (PAS), the intake screener must assign the intake to a case worker as an application for Community Attendant Services (CAS). Intake screeners must not screen applicants for a specific service or determine if an applicant should only be assigned for Family Care or placed on the interest list for Family Care services. The intake screener does not place the individual on the Family Care interest list. The case worker determines whether the individual will be placed on the interest list, as described below.

All individuals who are not currently receiving Medicaid and wish to apply for PAS must be seen by a case worker and assessed for CAS. During the initial interview, the case worker screens all applicants for potential eligibility for CAS and determines whether or not the applicant will be referred to MEPD for CAS.

Certain services require special intake procedures. For details, see Section 4000, Specific CCAD Services.

2221 Requests for Services in STAR+PLUS Areas

Revision 17-1; Effective March 15, 2017

When the Texas Health and Human Services Commission (HHSC) receives a request for services, staff must assess whether the request for services should be forwarded for processing to the:

Refer to the charts in the STAR+PLUS Handbook for additional information.

Individuals awaiting managed care enrollment may be assessed for interim services from HHSC.

HHSC will enroll individuals into Primary Home Care (PHC) who meet the PHC immediate or expedited criteria, as described in Section 2310, Criteria for Immediate or Expedited Responses to Service Requests, when they are listed in the Texas Integrated Eligibility Redesign System (TIERS) as a candidate for STAR+PLUS enrollment. However, mandatory STAR+PLUS individuals who are not yet enrolled with an MCO, and do not meet immediate or expedited criteria, will be referred to the Enrollment Broker. Individuals who are already enrolled with an MCO and request PHC or Day Activity and Health Services (DAHS) from HHSC must be advised to contact their MCO.

HHSC will not enroll individuals in DAHS when they are listed in TIERS as a candidate for STAR+PLUS enrollment. Since there are no immediate or expedited criteria for DAHS enrollment, individuals seeking these services will be available upon enrollment into the STAR+PLUS program. DAHS facility initiated referrals which take place for individuals pending STAR+PLUS enrollment will not be reimbursed by HHSC.

2222 Reinstatement Procedures for Individuals Reapplying for Services After Loss of Financial Eligibility

Revision 17-1; Effective March 15, 2017

If an individual has lost categorical or financial eligibility creating a gap in service, the following procedures are applicable.

If financial or categorical eligibility is re-established within 60 days of the denial date and the individual reapplies for services, the case worker may use the information currently on file to determine eligibility. A new Form 2110, Community Care Intake, must be completed. The case worker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date. See Section 3441.2, Reinstatement Procedures After Denial, for complete procedures.

2223 Caregiver Support Assessment Initiative

Revision 17-1; Effective March 15, 2017

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Texas Health and Human Services Commission (HHSC) staff to:

SB 271 requires HHSC to use the information collected to refer informal caregivers to available support services and to:

The Caregiver Status Questionnaire (CSQ) is designed to meet the requirements of SB 271. The information collected will be analyzed and included in the HHSC report to the governor and the Legislative Budget Board. HHSC is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

Completion of the CSQ

The CSQ is available in the Long Term Care Services Intake (NTK) System and is completed at the time of the intake contact, when possible. The CSQ and a script for the interview are available in English and Spanish in Appendix XXXVIII, Caregiver Support Assessment Initiative. If not feasible, one additional contact with the caregiver must be attempted within five business days. (In situations where it is necessary to go beyond the five-business-day period, document the reason in the comments section of the CSQ.) When a follow-up contact is made, enter the date on the top right corner of the CSQ, just under the NTK menu bar. Check the appropriate box to indicate if the attempt to contact failed or if the caregiver declined to participate.

Staff should always assume there is no assessment and proceed as usual. If the caller states he has completed the caregiver assessment in the past, staff should not ask him to complete the assessment again. Staff may exit the caregiver screen by selecting "yes" at the top of the page to the question: "Caregiver declined to answer?", In the comments section at the bottom of the page, document that an assessment has already been conducted for that caregiver.

The purpose of the CSQ is to collect the information described above. This information is not being used to determine if the unmet need criteria for Community Care services has been met, and will not be forwarded to the case worker.

Question Sensitivity

Some staff may find it awkward to ask some of the questions on the CSQ. While understandable, all the questions must be asked and a response recorded for each. It is not acceptable to skip a question. If an individual seems resistant to answer any of the questions, do not insist on a response. Simply document the individual refuses to answer and continue to the next question.

Caregiver Employment

Check boxes have been provided as a means to record the ways caregiving responsibilities have affected the caregiver's employment. After asking the open-ended question, listen to the caregiver's comments and check all of the boxes that apply. You are not expected to read aloud each possible response to the employment question; however, the list can be used as a prompt if the responder is unsure how to answer. If the individual seems uncertain, you may read aloud the response category headings. Example: "Has caregiving affected your employment schedule, pay, leave, performance or work relationships?" If further clarification is necessary, you may ask, "For example, have you had to take extra leave or change your work schedule to meet your caregiver responsibilities?"

Referral to the Area Agency on Aging (AAA)

If the individual meets one of the following criteria, he may qualify for services from the AAA. If so, and if the individual indicates he would like assistance, make the referral according to regional procedures.

AAA Eligibility Screening Criteria

The individual may qualify for services from AAA if the individual is:

Accessing the CSQ

The manual copy of the CSQ should be used when the automated system is unavailable; however, all information must be entered in the automated system as soon as possible. The version of the CSQ, which includes a script and instructions on recording responses, may be useful for staff completing the CSQ for the first few times. Follow the instructions below to complete the CSQ.

  1. Conduct intake per usual procedures using the NTK system.
  2. At the Client Information screen, document whether the individual requesting services has a caregiver. If there is a caregiver, the CSQ must be completed at the end of the intake process if the caregiver is available. If the caregiver is not available, document the caregiver contact information. At least one follow-up attempt must be made to contact the caregiver at a later date.
  3. Select the "Caregiver" tab on the NTK section selection menu.
  4. Enter the information on the Caregiver screens, as requested.
  5. If, at the end of the CSQ, it appears the individual requesting services may qualify for services from the AAA, make a referral following regional procedures.

Collection of legislatively mandated information will enable the state to refer caregivers to available support services and to develop additional services to meet caregiver needs.

2230 Interest List Procedures

Revision 17-1; Effective March 15, 2017

Individuals who express interest in a Community Services program which has an interest list will be registered on the Community Services Interest List (CSIL), regardless of the program’s enrollment status. CSIL will record the date and time of the expressed interest. If the individual is first on the list and the region is releasing and enrolling for that program, the individual may be immediately released and assigned for the enrollment process.

If all service authorization slots are filled, consult with the individual to decide whether his needs can be met through other services. If the individual agrees, add the individual’s name to the appropriate interest lists by entering the information in the CSIL system if no other service is available or suitable. Individuals who request placement on an interest list must reside in the state of Texas. An out-of-state address can be used as a contact if the power of attorney/guardian or legally authorized representative is residing out of state. Additional exceptions may be made for individuals who have been placed on an interest list while residing in Texas, and who then move temporarily out of the state because of military assignments.

Individuals on military assignments who are temporarily out of state include:

Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted when an individual is released from the interest list.

When an individual on an interest list transfers from one region to another, he must be added to the receiving region's list using the original intake date for the service as documented by the losing region. The staff person who first becomes aware that the individual has transferred to another region (whether losing or gaining) is responsible for notifying the other region. This ensures that both regions' lists are accurate.

When an individual is released from the interest list, the case worker must contact the individual to determine his continued interest in services and if interested, schedule a home visit if required by the service. If the individual is no longer interested in services and voluntarily withdraws, the case worker enters the appropriate CSIL closure code in the CSIL system. No entries in the Service Authorization System (SAS) are required and Form 2065-A, Notification of Community Care Services, is not sent.

During routine interest list contacts, individuals on the interest list who do not reside in Texas should be removed from the list and informed they must be a resident of Texas to be on an interest list. Exceptions may be made for individuals on military assignments who are temporarily residing out of state.

If the individual is interested in services, the case will be processed as a routine intake.

For more information regarding the CSIL system, refer to:

Note: The Area Agencies on Aging (AAA) can refer individuals to available services. Service needs, resources and available service providers vary across the state; not all of the services identified by AAA may be available in every area. The applicant/individual should contact the local AAA to determine whether a specific service is available. To find the telephone number for the local AAA, call 1-800-252-9240.

When the Texas Health and Human Services Commission (HHSC) intake staff determine a request for Home and Community-based Services STAR+PLUS Waiver (HCBS SPW) services, the request should be forwarded to the Program Support Unit (PSU) for processing. Staff must submit the request to the PSU mailbox designated for referrals to this program at StarPlusWaiverInterestList@hhsc.state.tx.us.

The email should contain the following data elements:

2230.1 Adding Individual's Name Back to CSIL

Revision 17-1; Effective March 15, 2017

An individual's name may be added back to the Community Services Interest List (CSIL) at any time within 90 days after the CSIL service has been closed if the individual contacts the Texas Health and Human Services Commission (HHSC):

If a CSIL closure occurred during "release" or "assigned" status and the individual is added back to the interest list, the name may be released for eligibility determination, as needed, to ensure the region is fully utilizing its slot allocation.

Any exceptions for adding names back to CSIL with the original date after a 90-day period must be approved by the state office CSIL manager.

When an applicant or individual has been denied for a service, the earliest date the applicant/individual may be added back to CSIL for the same program is the date the applicant/individual is determined to be ineligible or is no longer eligible for the program.

If the individual's name is added back to CSIL prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System (SAS) will cause the name to be removed from the interest list for that program. Example: An individual's Family Care (FC) services are denied and end on Aug. 13, 2015. The first date the individual can be added back to the FC interest list is Aug. 14, 2015. If the individual is already on the Home-Delivered Meals (HDM) interest list, the denial date for FC services would not impact the individual's original date on the HDM interest list.

2231 Community Services Interest List Bypass Criteria

Revision 17-1; Effective March 15, 2017

 

Under certain circumstances, individuals are allowed to bypass the interest list to start the enrollment process. The bypass must meet specific criteria and be approved by the regional director.

2231.1 Individuals Who May Receive Title XX Services with Regional Director Approval

Revision 17-1; Effective March 15, 2017

In the following circumstances, an individual may be given a bypass code to be placed at the top of the interest list. The regional director makes the decision if the individual may bypass the interest list and begin the enrollment process.

Personal Attendant Services (PAS)

Individuals who meet criteria for immediate or expedited intakes and need immediate service initiation may be given a bypass code and go to the top of the interest list. Individuals in the following programs may be considered for the criteria:

The criteria are:

All individuals meeting bypass criteria will be placed at the top of the specific program interest list. Additionally, the bypass criteria will now apply to individuals meeting the criteria who are no longer eligible for STAR+PLUS or STAR+PLUS Waiver services or individuals denied financial eligibility for CAS. The Regional Director will make the decision whether an individual can be released immediately or will remain on the interest list until the next slot is available. The decision must be documented in the case record.

2231.2 Bypass Criteria for Additional Services

Revision 17-1; Effective March 15, 2017

Individuals in the following circumstances may be given a bypass code and placed at the top of an interest list. The regional director makes the decision whether the individual can be released immediately or will remain on the interest list until the next slot is available. The decision must be documented in the case record.

Individuals authorized for any Title XX service that transfer to a new region will be allowed to continue receiving that service.

2231.3 Individuals Who May Not Bypass the Interest List

Revision 17-1; Effective March 15, 2017

An individual who has been denied Primary Home Care (PHC) because he does not need assistance with a personal care task should be placed on the Family Care (FC) interest list using the date of the PHC denial. He may not bypass the FC interest list.

Individuals leaving a nursing facility are not eligible to bypass the interest list unless they meet the criteria for immediate or expedited as listed in Section 2231.1, Individuals Who May Receive Services with Regional Director Approval.

For individuals who have a temporary loss of categorical status or financial eligibility, follow the procedures in Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 3441.1, Procedures Pending Reinstatement.

2231.4 Bypass Approval

Revision 17-1; Effective March 15, 2017

The final decision on whether an individual is approved to bypass the interest list will be made by the regional director or his designee, rather than the regional budget officer or the contract manager. Releasing a name from the interest list and offering services to an individual still remains subject to available regional funds and slots.

2232 The Community Services Interest List System

Revision 17-1; Effective March 15, 2017

Interest lists for community care services are registered on the Community Services Interest List (CSIL) system.

Initial requests for services are documented using Form 2110, Community Care Intake, or the Long Term Care Service Intake (NTK) system, regardless of whether slots for the requested service exist. If the individual needs a service that is currently unavailable, use the interface on the NTK system or enter the individual on the CSIL. Complete and send the individual:

Only individuals who reside in the state of Texas may be placed on an interest list for Texas Health and Human Services Commission (HHSC) community services. An out-of-state address can be used as a contact if the power of attorney/guardian or legally authorized representative is residing out of state.

Information provided by the individual for the interest list must include a Texas address as the contact location for the individual requesting services. Exceptions may be made for individuals who are temporarily out of the state due to military assignments.

Exceptions involving military members and military family members, as described in Section 2230, Interest List Procedures, apply when:            

If the case worker is making a home visit to assess the individual for other services, it is preferable for the case worker to assist in completing appropriate application forms at that time. If not, this task may be accomplished by mail. If Form 2111 and Appendix XXXV are mailed, they must be sent within two workdays of intake. Forms being filled out in person at the time of the home visit must be completed within the time frames as indicated in Section 2320, Case Worker Response, as determined by intake priority.

Within five workdays of intake, staff enter all relevant data into the CSIL. Staff may choose to use Form 2113, Community Services Interest List Registration and Follow-Up, to manually record interest list information to be data entered. Although use of Form 2113 is not mandatory, regional staff are responsible for entering all applicable data fields it contains into the CSIL.

Staff may not perform functional or financial determinations at the time the individual is being added to the interest list, even if staff are not using the determination to screen the applicant off the interest list. If an individual insists that he be assessed for eligibility immediately, even though staff have assured him that no slot is currently available, staff are required to do so. This action is considered an application, not an interest list case; all notification and civil rights procedures apply.

Individuals on an interest list are contacted annually to confirm that they wish to remain on the list. Form 2247, Interest List Contact Letter, is mailed to the individual.

If an individual does not respond and no update is made to the annual contact date in CSIL within 120 days past the annual contact due date, CSIL will automatically update the individual’s record as inactive. An annual contact is no longer required for individuals in an inactive status. An individual with a status of inactive will not lose his place on the interest list. If/when the CSIL individual record is updated with a current contact date, the record will automatically go back into an active status.

Staff are reminded the CSIL must also be updated within five workdays of the case worker’s determination and the date that a completed Form 2065-A, Notification of Community Care Services, is mailed/given to the individual. Within five workdays of the case action, the case worker records whether the case was certified, application denied or closed without application. If the case was closed or denied, the reason for closure/denial must be indicated.

See Appendix XXV, Community Services Interest List (CSIL) Closure Code User's Guide, or the CSIL User’s Guide found on the intranet (for staff use only).

2240 Regional Procedures

Revision 17-1; Effective March 15, 2017

2241 Supervisor Responsibilities

Revision 17-1; Effective March 15, 2017

CCAD unit supervisors ensure that their units have procedures for

2242 Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

CCAD case workers are responsible for:

2243 Conflicts of Interest

Revision 17-1; Effective March 15, 2017

Texas Health and Human Services Commission (HHSC) staff control and direct significant amounts of public funds and must avoid the appearance of impropriety or conflict of interest. This applies to the awarding of Community Care for Aged and Disabled (CCAD) benefits and in determining how these benefits are to be provided.

Staff must not work on or review an ongoing CCAD case, nor assist an applicant or individual to receive CCAD benefits, if the applicant or individual is a relative (by blood or marriage), roommate, dating companion, supervisor or someone under the individual's supervision. Staff may not determine eligibility, need for CCAD services nor the amount of service they may receive. HHSC staff may provide anyone with an application for services and inform them how and where to apply. It is also permissible to help any person gather documents needed to verify eligibility and the need for services. Staff must not perform any other role in determining eligibility for CCAD services.

Case workers must consult with their supervisors if the applicant or individual is a friend or an acquaintance. Generally, staff should not work on cases or applications involving these individuals, but the degree and nature of the relationship should be taken into account.

If staff have a relative (by blood or marriage), roommate, dating companion or close friend who owns or is employed by a provider that contracts with HHSC to provide CCAD services, he must not demonstrate any special consideration toward that provider. Referrals of individuals to a provider must be based strictly on individual preference and the individual's need for the service provided. In addition, instructions (or lack of instructions) to the provider concerning the delivery of service must be based solely on the individual's needs and HHSC policy.

If a staff member suspects that a conflict exists, use Form 2115, Conflict of Interest Notification, to notify the supervisor that a conflict of interest may exist that could result in an unethical or biased business relationship. The supervisor will record on the Supervisory Response section what action, if any, may be necessary and return the signed/dated form to the sender.

All CCAD staff are required to complete Form 2115 regardless of potential conflict of interest when:

The form is also used to notify the first-line supervisor whether or not a potential conflict of interest exists that involves provider employees, applicants or individuals, even if staff are not involved in the eligibility determination for the applicant or individual. Staff must complete Form 2115 if the potential conflict involves an individual who is:

2300 Responding to Requests for Service

Revision 17-1; Effective March 15, 2017

2310 Criteria for Immediate or Expedited Responses to Service Requests

Revision 17-1; Effective March 15, 2017

An individual requires an immediate response to his service request if he has no available caregiver, he has personal care needs which are not now being met, and he is unable to do without personal care services for a full day.

The following examples of situations requiring immediate response are just that — examples. This list, and other lists within this section, are not intended to be all inclusive.

The individual:

An individual requires an expedited response to his service request if he needs personal care, he has no available caregiver, and his need for services has increased during the five days prior to the service request, or will increase during the five days following the service request. For example, the individual:

All persons with AIDS or HIV infection requesting CCAD services should be carefully screened to determine if an immediate or expedited response is needed. CCAD regional nurses can provide consultation if needed. Persons with AIDS or HIV infection are often very ill and may need services initiated as soon as possible. It is essential that intake screeners and CCAD case workers follow the procedures for immediate or expedited responses, for all persons with AIDS or HIV infection who meet the criteria.

2320 Case Worker Response

Revision 17-1; Effective March 15, 2017

Respond to requests for Community Care for Aged and Disabled (CCAD) services according to the following program standards:

If Applicant Requires . . . Then . . .
an immediate response, Program Standard: The case worker to whom the case is assigned visits the applicant within 24 hours of the case assignment to the case worker. (Example: The case worker must respond to a case assignment received at 4 p.m. Tuesday no later than 4 p.m. Wednesday, or must respond to a case assignment received at 11 a.m. Friday no later than 11 a.m. Saturday).
an expedited response, Program Standard: The case worker to whom the case is assigned visits the applicant within five calendar days of the date of the case assignment to the case worker. (Example: A response to a case assignment received on Wednesday must be made no later than Monday, or a response to a case assignment received on Monday must be made no later than Saturday.)
a routine response, Program Standard: The case worker to whom the case is assigned visits the applicant within 14 calendar days of the date of the case assignment to the case worker. (Example: A response to a case assignment on April 1 must be made no later than April 15.)

If the person with AIDS or HIV infection does not need an immediate or expedited response at intake, the case worker should closely monitor the situation during the routine referral process.

If the applicant's health condition suddenly deteriorates, make every effort to obtain services for the individual as quickly as possible.

After talking with the applicant or family, the case worker may alter the urgency of the request, as long as the change is made before the deadline for the intake priority. The case worker may contact the applicant after the period specified above if the:

If the case worker contacts the applicant to schedule an appointment and the applicant refuses and states he does not want services, the case worker must close the intake in the Intake (NTK) system. The case worker may use the denial codes from the Community Services Interest List (CSIL) system in the comments in NTK. No entries in the Service Authorization System (SAS) are required and Form 2065-A, Notification of Community Care Services, is not sent.

The case worker should make every effort to ensure that the initial visit is conducted as close as possible to the date of the case assignment to the case worker. For service control purposes, this standard should be measured by comparing the date/time of the case assignment on Form 2110, Community Care Intake, to that on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Use the date of the initial assessment contact for Day Activity and Health Services (DAHS)-only cases. If the intake priority (for all except DAHS) is not checked (or information indicating priority level is not contained in case documentation), it is assumed to be immediate.

Although 14 days are allowed for a routine referral, timelines cannot be used as a justification to delay contact with the individual. If the two attempted contacts both occur near the end of the 14-day period, the case worker or supervisor may choose to call a timeliness error if a justifiable reason for delay is not documented in the case record.

Example: A case assignment for services is received March 1. The case worker makes the first attempted contact on March 11, and the second on March 14. In order to meet the program standard relating to timeliness of initial contact, the case worker must document why the delay could not have been avoided.

2330 Scheduling the Initial Interview

Revision 17-4; Effective May 23, 2017

40 Texas Administrative Code §48.3901(b) — The applicant is entitled to a face-to-face interview during the department's determination of his eligibility for CCAD services.

Determining eligibility for Community Care for Aged and Disabled (CCAD) services normally begins with a face-to-face assessment of the person, preferably in the home. Home visits are required for all CCAD applications, except for applications requesting Emergency Response Services, Home-Delivered Meals, or Day Activity and Health Services. Initial home visits for any one of these three services are required only at the applicant's request. A face-to-face home visit is required if, during the telephone interview, it is determined attendant care is needed or requested, as indicated in Section 2431, Form 2060, Part A, Functional Assessment, and Section 4651, Assessing the Individual’s Needs.

When feasible, ask the person's current caregiver to be present during the assessment. Home visits must be scheduled for a time that is convenient to the applicant. Schedule the appointment by telephone or in writing using Form 2068, Application/Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for any reason, the applicant or authorized representative must be notified in advance that the appointment will have to be rescheduled. Do not visit the applicant without informing the person in advance of the visit.

If a case worker contacts an applicant to schedule a home visit and the applicant states he has a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker should schedule a future date for the visit when the applicant thinks he will be better. If unable to schedule the visit for a future date, the case worker must contact the applicant at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

Although a face-to-face visit with a person in a nursing home, hospital, prison or jail facility is acceptable, this visit does not allow the case worker to assess the person in the home environment or to assess family resources and how they function at home. If the initial visit and eligibility determination must be done in a location other than the person's home and in-home services are subsequently initiated, conduct a home visit within 30 days after service initiation and make any necessary revisions to the service plan according to Section 2663, Reassessment of Functional Need. Document the home visit on Form 2059, Summary of Client's Need for Service (Item 4 or 8), or in the case narrative.

A person who is already receiving services from the Texas Health and Human Services Commission (HHSC), or for whom the Social Security Administration has already verified that the individual is financially eligible for Supplemental Security Income (SSI), is not required to submit an application form.

A person who is not receiving services from HHSC, not receiving SSI, or who needs a financial eligibility determination from Medicaid for the Elderly and People with Disabilities (MEPD) must complete an Application for Assistance. The preferred form is Form H1200-EZ, Application for Assistance – Aged and Disabled. If an applicant has completed Form H1200, Application for Assistance – Your Texas Benefits, the case worker may accept those forms and send to MEPD.

The form may be mailed if the applicant is capable of completing the form or has assistance available. If the applicant is not capable of completing the form, it is the case worker's responsibility to provide the form and assist the applicant with completing the form at the initial interview. If the form has been mailed to the applicant, it is the case worker's responsibility at the initial interview to review the form for completion and assist the applicant in completing the form, if necessary.

The official date of application is the date HHSC staff receive a completed, signed and dated Application for Assistance. The application date on the Service Authorization System screen is the date of:

2331 Information and Referral (I&R)

Revision 17-1; Effective March 15, 2017

If, during the initial interview it is determined that the individual could use services from other agencies in the community, refer him to the appropriate agency or community resource. Fully discuss the referral with him and his family, if they are present. Give complete information about Community Care for Aged and Disabled (CCAD) services and about any other Texas Health and Human Services Commission (HHSC) services (for example, the Supplemental Nutrition Assistance Program (SNAP) or the Qualified Medicare Beneficiary program) that might be helpful. See Appendix XV, Services Available from Other State Agencies.

Always refer an applicant or individual to the Social Security Administration if the individual appears eligible for Supplemental Security Income (SSI) but does not receive SSI. Consult with Medicaid for the Elderly and People with Disabilities (MEPD) staff if there are questions about SSI eligibility.

When referring an individual to other agencies or other HHSC services, fully inform him about where he must go to apply. Help set up his appointment, if necessary. Provide the office address, telephone number, name of the correct person to contact, and the appointment date and time (if known).

Provide I&R services to individuals without regard to their incomes. Do not register with the Service Authorization System (SAS) persons who receive only I&R services. Document I&R services as required by regional policy.

2332 Requests for Services from Individuals Under Age 21

Revision 17-1; Effective March 15, 2017

Children who have a medical need and meet other eligibility requirements may receive Community Attendant Services (CAS). The age requirements that apply to other community care programs do not apply to CAS. However, the applicant under age 21 must meet all other eligibility criteria, including medical, financial, functional and unmet need.

Upon receipt of a request for services from an individual under age 21, the case worker must contact the regional nurse and arrange for a joint visit for the initial home visit assessment. The regional nurse will assist in the screening of the individual for medical need, determine if there are skilled tasks that cannot be performed by a personal attendant, and determine whether the caregiver must be present in the home to perform skilled tasks or react to emergency medical situations while the personal attendant is in the home.

See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information.

2333 Applications

Revision 17-4; Effective May 23, 2017

An application for services has been made if any one of the following occurs:

The preferred form for the Application for Assistance is Form H1200-EZ, Application for Assistance – Aged and Disabled. If an applicant has completed Form H1200, Application for Assistance – Your Texas Benefits, the case worker may accept those forms.

Once an application has begun, the case worker must record the disposition of the application in the Service Authorization System (SAS).

Examples:

Example 1 (Request for Services Only): A hospital social worker contacts HHSC on behalf of a patient who is being discharged the following day. The social worker notes that the patient lives alone and believes the patient's condition will result in a need for personal attendant services (PAS). In response to the social worker's call, an intake specialist contacts the individual and he states that his daughter will be living with him during the weeks following release from the hospital and will be able to provide all his needs. He states that he will call HHSC if PAS is needed at a later time.

This is not an intake but is an example of a request for services that is appropriately screened and determined CCAD services are not needed at this time. Although the intake specialist contacted the individual and some information may have been recorded, Form 2110, Community Care Intake, was not completed in the Intake (NTK) system and a case worker was not assigned to the case. There is no need to send Form 2065-A, Notification of Community Care Services. No entries in SAS are required.

Example 2 (Intake Only): An individual contacts HHSC requesting Home-Delivered Meals (HDM). The intake specialist completes Form 2110 and assigns the intake to a case worker. When the case worker calls to set up an appointment, the applicant states that he has changed his mind and does not want HHSC services. The case worker records the correct denial code (from the Community Services Interest List (CSIL) denial codes) for voluntary withdrawal in the NTK system comments section. There is no need to send Form 2065-A. No entries in SAS are required.

Example 3 (Application): An individual contacts HHSC and requests Primary Home Care. The case worker schedules the home visit and upon arriving at the individual's home, the applicant states he is moving out of state and he does not need services. Because a home visit was made, this is considered an application and must be entered in SAS and Form 2065-A sent to the applicant.

2333.1 Required SAS Entries for Applications Withdrawn Early in the Process

Revision 17-1; Effective March 15, 2017

All applications must be entered in the Service Authorization System (SAS) within 30 calendar days of the home visit date or receipt of the application. See Section 2611, Processing Time Frames, for additional information. This includes situations such as the one described in Example 3 in Section 2333, Applications, where very little information has been gathered. The type of SAS entries required depends on the type and amount of information collected by the case worker.

2340 The Initial Interview and Application Process

Revision 17-1; Effective March 15, 2017

During the initial home visit interview, the case worker:

If the applicant is only able to sign documents with an "X," the case worker may make the required documentation and then date and initial the entry.

The case worker also must be alert for indications of abuse, neglect or exploitation when assessing CCAD individuals. Anyone who has reason to believe an elderly person or an individual with a disability is being abused, neglected or exploited must report this information to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS) (Title 2, §48.306 of the Texas Resources Code). Immediately notify APS of any reports received that indicate an elderly person or individual with a disability has been abused, neglected or exploited.

If a CCAD individual has been referred to APS in the past and it is possible another referral may be needed now for the same problems, contact APS to discuss the situation before a formal referral is made. Document the APS response in the CCAD case record. See Appendix XV-E, Department of Family and Protective Services (DFPS), for more information.

2341 Financial Application Process

Revision 17-10; Effective October 6, 2017

40 Texas Administrative Code (TAC) §48.3901(c) — Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form. Non-Medicaid applicants or their representatives applying for retroactive reimbursement for Medicaid-covered attendant services must also sign an application for assistance form. The date of application is the date the department receives the signed application. Applicants must provide accurate information about income and resources.

40 TAC §48.3901(e) — Non-Medicaid applicants or their representatives applying for Medicaid-covered attendant services may be reimbursed for services provided up to three months prior to the month of receipt of a completed, signed, and dated application.

If an application is denied for any reason, the previously completed application form is valid for 90 days following the date of denial. A written, dated and signed statement of request to reapply must be obtained from the applicant or authorized representative. The statement must be sent to Medicaid for the Elderly and People with Disabilities by the close of business the second business day. Documentation in the case record must indicate whether any changes have occurred since the original application date.

The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked “Application.” The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for Community Attendant Services. The case worker includes all identifying information on Form H1746-A, and any additional information that will help identify the original application, and faxes Form H1746-A and documentation to the Austin Document Processing Center.

The case worker will also be able to use Form H1200-EZ, Application for Assistance – Aged and Disabled, on file for up to 90 days following the denial date of Form 2065-A, Notification of Community Care Services. The case worker may also use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the additional forms signed at the initial home visit, and verifications on file. The case worker does not need to make an additional home visit, but must review Form H1200-EZ and Form 2060 with the applicant and document any changes which have occurred since the initial visit. The case worker will need to follow appropriate time frames for annual reassessments as the annual reassessment will still be due within 12 months of the initial home visit.

2341.1 Application for Assistance Form

Revision 17-4; Effective May 23, 2017

Individuals applying for services without categorical eligibility status apply for Community Care for Aged and Disabled (CCAD) services by completing Form H1200-EZ, Application for Assistance – Aged and Disabled.

Use Form H1200-EZ for individuals who are:

Although Form H1200-EZ is the preferred form, a completed Form H1200, Application for Assistance – Your Texas Benefits, should not be refused.

An application is incomplete until it contains the individual's signature. If unable to sign, it is acceptable to allow the individual to make an "X," along with two witnesses' signatures. Unless no other option is available, the case worker should not be one of the witnesses.

If Form H1200 or Form H1200-EZ is being sent to Medicaid for the Elderly and People with Disabilities (MEPD), the signature must be on the form. Unsigned applications will be returned to the sender. HHSC staff must ensure applications are signed prior to referring to MEPD. If MEPD receives an unsigned application from HHSC with either Form H1746-A, MEPD Referral Cover Sheet, or Form 2067, Case Information, MEPD will return the application to HHSC with an annotation on the cover form (Form 2067 or Form H1746-A) that the application is unsigned and must be signed before HHSC can establish a file date. Once HHSC staff receive an unsigned application from MEPD, it is their responsibility to coordinate with the individual in getting the application signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to individuals.

2341.2 Application for Assistance Form Completion and Receipt Date

Revision 17-6; Effective June 28, 2017

The Application for Assistance form may be mailed if the applicant is capable of completing the form or has assistance available. If the applicant is not capable of completing the form, it is the case worker's responsibility to provide the form and assist the applicant with completing the form at the initial interview.

If the Application for Assistance form has been mailed to the applicant, it is the case worker's responsibility at the initial interview to review the form for completion and assist the applicant in completing the form, if necessary.

Ensure that the person completes the entire application, signs and dates it, and understands the penalties for fraud in the event the person deliberately gives false information. Do not make any changes to the Application for Assistance form after the applicant has signed it. Document any changed or additional information on Form 2064, Eligibility Worksheet.

For applicants or individuals requiring a Medical Assistance Only (MAO) determination to be sent to Medicaid for the Elderly and People with Disabilities (MEPD), the case worker must assist the applicant/individual with completion of the application form and provide the most complete packet possible to MEPD. The case worker should ensure the following items are included to facilitate the financial eligibility process:

While it may not be possible to obtain everything on the list, the case worker should gather whatever information is available, as it will prevent the applicant from a delay in certification. The case worker should explain to the applicant that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

When a signed and dated Application for Assistance form is received by the case worker at the home visit, or is mailed or hand delivered to a Texas Health and Human Services Commission (HHSC) office, the date of receipt becomes the official date of application.

If Form H1200-EZ, Application for Assistance – Aged and Disabled, has not been returned by the 30th day from the initial home visit, the case worker may deny the application. The case worker sends Form 2065-A, Notification of Community Care Services, with Rule Reference 40 Texas Administrative Code §48.3901(c): “Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form.” In the comments section, the case worker enters: “HHSC is unable to make an eligibility decision within 30 days due to your failure to furnish information.” The case worker must document all contact in the case record.

When an income eligible individual is receiving services and the individual's spouse subsequently applies, the individual's form (if it is less than one year old) may be used for the spouse. Review the Application for Assistance form to ensure the information is still valid, have the spouse sign and date it for the current application, and complete a new eligibility determination.

2341.3 Categorical Eligibility

Revision 17-1; Effective March 15, 2017

If a financial determination has already been made for the applicant by Social Security or another program within the Texas Health and Human Services Commission (HHSC), then the applicant may be considered categorically eligible. The applicant is categorically eligible if receiving:

*Note: Medicaid Buy-In benefits provide categorical eligibility only for the following programs:

Completion of the Application for Assistance form is not required for a categorically eligible applicant. The date of the initial home visit with the person is considered the date of application.

See Section 7110, TIERS Inquiries, for complete information on how existing coverage affects eligibility for CCAD services.

2341.3.1 Effect of QI Benefits on Eligibility for Community Care Services

Revision 17-1; Effective March 15, 2017

The Qualifying Individuals (QI) program was created by Public Law 105-33, as part of the Balanced Budget Act of 1997. The legislation specifies that QI recipients cannot be eligible under any other Title XIX-funded program and simultaneously receive QI benefits. Therefore, applicants and individuals receiving QI benefits are not eligible for Primary Home Care (PHC), Community Attendant Services (CAS) or Title XIX Day Activity and Health Services (DAHS). QI recipients are eligible to receive Title XX Family Care (FC) or Title XX DAHS, or both, provided all other eligibility criteria are met.

Identification of QI Coverage

At the time of application for Title XIX services and at each subsequent annual reassessment, case workers must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is receiving QI services. TIERS designates QI coverage as Type Program (TP) of Assistance TP-26.

Procedure for Applicants

If an applicant specifically requests PHC, CAS or DAHS, explain that individuals may not receive QI while receiving any other Title XIX-funded service. Inform the individual that there is no prohibition against receiving Title XX FC or DAHS at the same service levels. Applicants requesting DAHS must be certified for Title XX DAHS. Receipt of QI services does not preclude applicants from being placed on any existing interest list.

Procedure for Ongoing Individuals

When it is discovered that an individual receiving a Title XIX Community Care for Aged and Disabled (CCAD) service (CAS, PHC or Title XIX DAHS) has been certified for QI benefits, the case worker must first determine if enrollment in Title XX FC/ DAHS is open or if an interest list exists for the desired service. If no interest list exists, process the request for the desired service. If it is determined that the individual will have to be placed on a Title XX FC/ DAHS interest list, the case worker must contact the individual to give him the choice of service he wants to continue (QI or Title XIX CCAD service).

The case worker's next actions will depend on the individual's decision:

2341.4 Refusal to Cooperate with the Application Process

Revision 17-1; Effective March 15, 2017

If the applicant refuses to sign Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, or otherwise refuses to participate in the assessment process, do not proceed with the application process. Advise the applicant that he will receive a notice of ineligibility in the mail. Send the applicant Form 2065-A, Notification of Community Care Services. Use Code 17, "You failed to provide the necessary information."

2341.5 Retroactive Payment Process

Revision 17-1; Effective March 15, 2017

The retroactive payment process is an option that an individual and/or the provider may use if the individual has an immediate need for assistance with personal care task(s) pending the Texas Health and Human Services Commission's eligibility decision for Medicaid eligibility. See Section 2348, Retroactive Payments.

2342 Screening for Primary Home Care and Community Attendant Services

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must screen all applicants and individuals for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC) or continuing with an authorization for FC. If appropriate, the case worker makes a referral for PHC eligibility or services.

40 Texas Administrative Code §48.2911(d) — To be eligible for family care, the individual must not be eligible to receive attendant care services funded through Medicaid.

Screening Applicants

During the initial interview, determine if the applicant is currently receiving Medicaid or is potentially eligible for CAS. If the applicant is receiving Medicaid, use the additional screening criteria to determine if a referral to PHC is appropriate.

If the individual's income and resources appear to be within the Supplemental Security Income (SSI) limits (refer to Appendix XI, Monthly Income/Resource Limits), and the individual appears to have a medical need for assistance with personal care, refer the individual to the Social Security Administration for an SSI application. However, the individual should not be denied services for refusing to apply for SSI.

If the applicant is not receiving Medicaid and his income and resources are above SSI limits, complete an Application for Assistance form during the interview or review the application form mailed to the applicant for completion. Assist the applicant in the completion of the form and obtain all required verifications that are available.

If the applicant cannot complete the application form during the interview, explain to the applicant the importance of returning the form and requested verifications as soon as possible since his eligibility for services cannot be determined until the form is received.

Forward the completed Application for Assistance form promptly to the local Medicaid for the Elderly and People with Disabilities (MEPD) office, as specified in Section 2342.2, Timely Referral to MEPD.

Screening Ongoing Family Care Cases

At each financial recertification of FC cases (or whenever the individual's circumstances change), review the individual's situation to determine if he is potentially eligible for:

Minor changes in the individual's situation do not require a referral to MEPD if it obviously will not affect the individual's eligibility. If any doubt exists, make the referral to MEPD.

2342.1 Receipt Date of the Application Form

Revision 17-1; Effective March 15, 2017

The date of the official application is the day the application form is received by the case worker at a home visit, or received by mail or hand delivered to a Texas Health and Human Services Commission office.

See Section 2333, Applications, for a list of acceptable applications.

If the case worker receives the application form during the home visit, the case worker enters the date in the "Date Form Received" box at the top of the form.

2342.2 Timely Referral to MEPD

Revision 17-1; Effective March 15, 2017

All new Medicaid for the Elderly and People with Disabilities (MEPD) applications statewide must be processed using the Texas Integrated Eligibility Redesign System (TIERS). A new application is defined as "an individual not currently authorized services in TIERS."

All communication to MEPD must include Form H1746-A, MEPD Referral Cover Sheet. Form 2067, Case Information, is not an acceptable means of communication to MEPD staff.

Prior to the home visit, the case worker must check TIERS to determine if a prior application has ever been completed for the applicant. If there is no active record, then the application is considered a "new" application.

The date of receipt of the application form is considered as day zero.

New Applications

No later than the close of business on the second business day after receipt of the completed application form, the case worker must:

Prior Applications

If a record of the applicant is found in TIERS, including current individuals requesting a program transfer, then no later than the close of business on the second business day after receipt of the completed application form, the case worker must fax the completed application and verification documents to the Austin DPC, using Form H1746-A as a cover sheet. The case worker retains the original Form H1200 or Form H1200-EZ with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

Transmittal

If Form H1746-A is not completed correctly, an incorrect assignment to MEPD staff could result.

The case worker must follow the guidelines below to ensure a correct assignment is made:

Do not fax and mail the same documents. This will cause duplication in the system. Use two-sided faxing when possible.

If unusual circumstances exist in which the original must be mailed to MEPD after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 or Form H1200-EZ and sending by electronic mail is prohibited. The time frames for submission of the form and all other requirements remain the same.

The case worker must keep a copy of the application form, any verifications and Form H1746-A in the case record.

Any applications received by HHSC or MEPD for Medical Assistance Only (MAO) programs must be retained. Applications are part of the Code of Federal Regulations (CFR) maintenance of record requirements and must be added to the MEPD case record (original or copy, if faxed), even if the individual is already on Medicaid or has not determined which, if any, services he is requesting. In these circumstances, clearly document the situation on Form H1746-A. The best practice is to perform an inquiry to determine if the individual already has Medicaid coverage prior to the contact, thus avoiding unnecessary completion of an application.

Part 413 Subpart A – Code of Federal Regulations §431.17, Maintenance of records.

(b) Content of records. A State plan must provide that the Medicaid agency will maintain or supervise the maintenance of the records necessary for the proper and efficient operation of the plan. The records must include –

(1) Individual records on each applicant and recipient that contain information on –

  1. Date of application;
  2. Date of and basis for disposition;
  3. Facts essential to determination of initial and continuing eligibility;
  4. Provision of medical assistance;
  5. Basis for discontinuing assistance;
  6. The disposition of income and eligibility verification information received under Social Security Part 413 Subpart A - Code of Federal Regulations §435.940 through §435.960 of this subchapter;

Refer to Appendix XXXII, Medicaid Program Actions, for additional information. This chart provides instructions for sending Form H1746-A to MEPD when a case action is needed and indicates when a new Form H1200 needs to be attached to the cover sheet.

For program transfers, Appendix XLV of the Office of Social Services MEPD Website, provides a guide to determine when Form H1200, along with Form H1746-A, are needed by the MEPD specialist to complete the program transfer.

Refer to Appendix XXVII, HHSC Benefits Portal and TIERS Inquiry Desk Guide, for instructions on how to complete the inquiries described in this memorandum, as well as other types of inquiries through the Portal and TIERS.

2342.3 Exception Criteria for Referrals to PHC or CAS

Revision 17-10; Effective October 6, 2017

The case worker must screen all applicants for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC). The case worker applies the following exception criteria to determine if the applicant has a reason not to be referred for CAS, or if on Medicaid, would not be eligible for PHC.

To determine if the applicant is not appropriate for a referral to PHC or CAS, screen the applicant for the following criteria:

Other Criteria:

If the applicant answers “Yes” to all other criteria, then a referral for PHC or CAS is made. If the applicant answers “No” to any one of the other criteria, then the individual is referred for FC or placed on the FC interest list and is not referred for PHC or CAS.

Placement on the FC Interest List

Within five workdays of screening for CAS or PHC, using the original date of the request for services, assigned staff must enter all relevant data into the Community Services Interest List (CSIL) if:

The original date of the request for services is the date the applicant called in requesting services, listed on Form 2110, Community Services Intake.

FC Services Pending the CAS Eligibility Decision

If FC enrollment is open in a region, the case worker assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending from Medicaid for the Elderly and People with Disabilities (MEPD). If an individual placed on the FC interest list is released from the interest list, the case worker must screen the individual for CAS and refer to MEPD, if screening criteria are met. The case worker also assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending.

If the individual is determined eligible for CAS, the case worker follows the policy in Section 4652.3, Initial Referrals for Community Attendant Services, and negotiates a transfer from FC to CAS. The case worker sends Form 2065-A, Notification of Community Care Services, noting the transfer of services. If the individual is not eligible for CAS, the case worker continues FC services, unless the individual was denied CAS for refusal to cooperate.

Refusal to Cooperate with MEPD

If the individual is denied for refusal to cooperate with the financial eligibility determination process, including refusal to furnish information or withdrawing the CAS application, the case worker must follow up with the individual to explore why the individual did not cooperate. If the individual states he is unwilling to cooperate with the financial eligibility determination process, then the case worker must advise the individual his application for services is denied and if he reapplies in the future, he will be referred for CAS again. The case worker documents all contacts in the case record and sends Form 2065-A to the individual citing rule reference 40 Texas Administrative Code §48.2911 (a)(3). In the Comments section, the case worker includes the following statement: “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. Medicaid for the Elderly and People with Disabilities has notified HHSC you failed to provide the necessary information to determine eligibility for Medicaid-funded services.” If the individual requests to be placed on the FC interest list, the individual may be placed on the list, but he must be informed that he will be referred to CAS when his name is released from the list.

If the individual is receiving FC services pending the MEPD eligibility decision and the individual refuses to cooperate with the financial eligibility determination process as described above, the case worker must deny FC services. The case worker documents all contacts in the case record and sends Form 2065-A to the individual citing rule reference 40 Texas Administrative Code §48.2911 (a)(3). In the Comments section, the case worker includes the following statement: “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. You failed to provide the necessary information to determine eligibility for Medicaid-funded services.”

If the individual states that he cooperated and thought he submitted all requested information, the case worker may check the Comments section in the Texas Integrated Eligibility Redesign System (TIERS). The case worker may need to assist the individual in obtaining any missing requested documentation.

The individual can reapply for CAS for up to 90 days from the date of the MEPD denial without completing a new Form H1200-EZ, Application for Assistance – Aged and Disabled. The case worker must obtain a written, dated and signed statement of request to reapply from the applicant or authorized representative to establish the date of application. The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked “Application.” The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for CAS. The case worker includes all identifying information on Form H1746-A, and any additional information that will help identify the original application. Fax Form H1746-A and documentation to the Austin Document Processing Center.

Applications Denied by MEPD

If a referral is sent to MEPD and the individual is denied CAS eligibility for reasons other than refusal to cooperate with the financial eligibility determination process, then the individual remains eligible for FC or is placed on the FC interest list. The assigned staff enter the information into the CSIL using the original request date for services when placing the individual on the interest list.

If the individual who was denied CAS eligibility for reasons other than refusal to cooperate is released from the FC interest list within 90 days of the application date, the case worker may use Form H1200-EZ, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the additional forms signed at the initial home visit, and verifications on file to determine eligibility for FC. The case worker must review all the information provided and note any changes on Form 2064, Eligibility Worksheet. The case worker must establish that the individual meets all financial eligibility requirements for Title XX services. The case worker does not need to do an additional home visit, but must review Form H1200-EZ and Form 2060 with the applicant and document any changes which have occurred since the initial visit. The case worker will need to follow appropriate time frames for annual reassessments as the annual reassessment will still be due within 12 months of the initial home visit.

FC Annual Reassessments

See Section 4447, Reassessment, for FC reassessment procedures.

2342.4 Spouse Attendant in Family Care Services

Revision 17-1; Effective March 15, 2017

If an individual states he will accept care only from his spouse, then the individual may be assessed for Family Care services or placed on the Family Care interest list and not referred to Primary Home Care (PHC) or Community Attendant Services (CAS).

Individuals on Medicaid may elect to receive Family Care services to have a spouse attendant. The policy that states, “"To be eligible for Family Care, the individual must not be eligible to receive attendant care services funded through Medicaid",” does not apply if the individual elects to have a spouse attendant. Even though these individuals meet the criteria to be referred to CAS, they may elect to receive Family Care services and not be screened or referred to Medicaid for the Elderly and People with Disabilities (MEPD) for a financial determination.

Unmet need policy applies and the case worker must carefully evaluate tasks provided and tasks not currently provided by the spouse to determine the service plan purchased through Family Care services. See Section 2513, Caregiver as the Paid Attendant, and Section 2514, Who Cannot Be Hired as the Paid Attendant, for additional information. The policy must be followed and the spouse assessed as any other caregiver. One exception to the policy is that on Form 2101, Authorization for Community Care Services, the case worker must note the individual is requesting the spouse as the paid attendant.

If the arrangement for the spouse as the attendant ends, then the individual must be referred for the appropriate Medicaid funded service.

2342.5 Disability Determination for Individuals Under Age 65 Applying for CAS

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker is required to assist certain individuals under age 65 to complete the forms required by HHSC for a disability determination. Individuals age 65 or over may qualify for Medicaid or Medicaid-funded programs, such as Community Attendant Services (CAS), without a disability determination.

The case worker must review an individual's disability status by using the State On-Line Query (SOLQ) or Wire Third Party Query (WTPY) systems. An individual has a disability established by Social Security if there is a disability onset date on the SOLQ or WTPY systems. If the individual under age 65 does not have a Social Security established disability, the case worker must assist the individual with completing Form H1200-EZ, Application for Assistance – Aged and Disabled, Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact when assessing eligibility.

To determine a disability, HHSC must review evidence, signed by the individual's treating physician (that may include medical reports), detailing the degree and history of the individual's diagnosis. The case worker must inform the individual when scheduling the initial face-to-face contact that the case worker will need the required evidence at the initial contact with the individual. If the case worker schedules the face-to-face contact at least seven calendar days in advance, the case worker must send Form 2423, Request for Medical Evidence, to the individual on the same day of the telephone contact to advise the individual of the evidence requirement. If the case worker schedules the face-to-face contact less than seven calendar days in advance, the case worker must present Form 2423 at the face-to-face contact. The case worker must not delay the face-to-face contact for the purpose of allowing the individual time to obtain the medical evidence.

The case worker should include the completed Form H3034, Form H3035 and any evidence obtained at the initial face-to-face contact with Form H1200-EZ following current transmittal procedures to Medicaid for the Elderly and People with Disabilities (MEPD). If evidence was not available at the initial face-to-face contact, the case worker documents "No evidence was obtained" in the Section I, Comments about your disability, on Form H3034 prior to submitting to HHSC for a disability determination.

2343 Confidentiality

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(a) — Information collected to determine eligibility for services, whether collected by DHS staff or provider agencies, is confidential.

Information concerning Texas Health and Human Services Commission (HHSC) applicants and individuals is confidential and can only be used for purposes directly connected to administration of HHSC services. HHSC routinely shares confidential information with providers because the information shared is directly connected with service administration.

Information can also be shared with other entities if it is determined that the purpose is directly tied to the administration of services. Consult the unit supervisor before making the decision to share information with individuals other than the providers.

Code of Federal Regulations, Title 42, Part 431, Subpart F – Safeguarding Information of Applicants and Recipients – (a) Section 1902(a) (7) of the Act requires that a state plan must provide safeguards that restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan.

Refer to Section 1140, Disclosure of Information, regarding national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2344 Individual Rights and Responsibilities

Revision 17-1; Effective March 15, 2017

During the initial visit with the applicant and, as appropriate, the responsible person (RP), discuss the information contained in Form 2307, Rights and Responsibilities. Ensure the applicant understands the significance of his rights and responsibilities.

If the applicant appears unable to understand this information or the complaint process, it is important to give the RP a copy of Form 2307. Sharing the applicant's rights and responsibilities with the RP is particularly important if it appears the applicant may not be able to fully understand his rights and responsibilities. An RP may be a guardian, family member or other individual who assists in the development of the care plan and/or who maintains regular communication with the applicant or department regarding the applicant's well-being.

The applicant must:

Rights and Responsibilities Documentation Requirements

At Application

At the initial home visit, the case worker must clearly and fully explain the information in the following forms with the applicant. Maintain copies in the case record and review with the applicant/RP as indicated in the instructions for each form.

Individuals must receive the following forms:

If the applicant selects the Consumer Directed Services (CDS) option on Form 1584, he must also receive:

If the applicant selected the Service Responsibility Option on Form 1584, he must also receive:

See Section 6000, Service Delivery Options, for complete information and requirements on CDS and SRO.

Individuals applying for Family Care, Community Attendant Services or Primary Home Care, Emergency Response Services (ERS) and Adult Foster Care (AFC) services must be given the following forms for the requested service:

All applicants must receive Form 2065-A, Notification of Community Care Services, notifying them of the eligibility decision.

Annual Reassessments and Changes

See Appendix IX, Notification/Effective Date of Decision, for additional details or exceptions.

2345 Registering to Vote

Revision 17-1; Effective March 15, 2017

The National Voter Registration Act (NVRA) of 1993 requires that the Texas Health and Human Services Commission (HHSC)  offer each individual applying for HHSC services the opportunity to register to vote, to record the individual's decision on Form 1019, Opportunity to Register to Vote/Declination, and to file it in the case record. Additionally, HHSC case workers must also offer the individual an opportunity to register to vote at annual reassessments and when notified of a change of address.

The HHSC case worker must provide the same degree of assistance, including bilingual assistance, to help the individual complete the voter registration forms as is provided with the completion of any HHSC forms.

The case worker may not make a determination about an individual's eligibility for voter registration other than a determination of whether the person is of voting age, which is 18 years of age, or is a U.S. citizen. An individual's age or citizenship may be verified by the case worker if the age or citizenship can be readily determined from information filed with HHSC for purposes other than voter registration. An individual must be offered voter registration assistance as provided by the NVRA if the individual's age or citizenship cannot be determined.

At the time an individual applies for services, at annual reassessments or when changing addresses, he must be given the opportunity to:

If the individual wishes to complete Form 0030 during the interview, the case worker must review the form for completeness in the presence of the individual. If the form does not contain all the required information, including the required signature, the case worker returns it to the individual for completion. If the individual requests the case worker to mail the form, Form 0030 must be sent to the appropriate county voter registrar within five working days of signature by the individual.

When HHSC staff offer individuals the opportunity to register to vote, as required by the National Voter Registration Act, they must also inform individuals of the option of requesting a ballot by mail. Individuals may request a ballot by mail if they are:

He or she can print an application for a ballot by mail (PDF) from the Texas Secretary of State website and mail it to the Early Voting Clerk. HHSC staff must also provide assistance in completing any form while an individual is registering to vote as prescribed in current voter registration policy.

Declining to Register

If the individual does not wish to complete Form 0030, he must complete and sign Form 1019. If the individual refuses to sign Form 1019, the case worker must document the refusal on the form. The case worker must keep each declination form in the case record for at least 22 months after the date of signing.

Annual Reassessments Conducted by Telephone

If the individual receiving services wishes to register to vote during an annual reassessment that is conducted by telephone, the case worker must mail Form 0030 to the individual within three working days after the date of the phone call. If the individual does not wish to register to vote, the case worker must ask the individual to complete and sign Form 1019. The case worker must mail him Form 1019 within three working days after the date of the phone call. The case worker must inform the individual that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the individual refuses to sign the declination form, or the case worker does not receive the form within 30 calendar days after the date of the phone call with the individual, the case worker must enter on Form 1019 that the individual refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the individual's case record for at least 22 months after the date of signing.

Change of Address

The case worker must contact the individual by phone within five working days after receiving notification of a change of address and offer the opportunity to register to vote. If the individual does not have a phone, the case worker must mail Form 0030 and Form 1019 within five working days after being notified of a change in address. If the case worker does not receive either Form 0030 or Form 1019 within 30 days of mailing the forms to the individual, the case worker must complete Form 1019 indicating that the individual failed to return Form 1019.

If the individual wishes to register to vote, the case worker must mail Form 0030 to the individual within three working days after the date of the phone call. If the individual does not wish to register to vote, the case worker must ask the individual to complete and sign Form 1019. The case worker must mail him Form 1019 within three working days after the date of the phone call. The case worker must inform the individual that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the individual refuses to sign the declination form, or the case worker does not receive the form within 30 days after the date of the phone call with the individual, the case worker must enter on Form 1019 that the individual refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the individual's case record for at least 22 months after the date of signing.

Additional Guidelines

The case worker must not:

If the individual has any questions regarding the voter registration process that the case worker cannot answer, the case worker must:

2346 Service Delivery Options

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) offers applicants and individuals three options for the delivery of personal attendant services (PAS). It is the case worker's responsibility to present information on all available service delivery options to the applicant at the initial interview and to ongoing individuals at the annual review, or whenever requested.

The service delivery options include the:

If the applicant/individual chooses an option other than the AO, the case worker will conduct special casework procedures including, but not limited to:

Once the applicant/individual has made a choice, the case worker asks the applicant/individual to sign Form 1584, Consumer Participation Choice, to document the choice of option. Additional casework procedures are detailed in:

2347 Texas Medicaid Estate Recovery Program (MERP)

Revision 17-1; Effective March 15, 2017

2347.1 Introduction

Revision 17-1; Effective March 15, 2017

On March 1, 2005, Texas implemented the Medicaid Estate Recovery Program (MERP) in compliance with federal Medicaid laws. The Texas Health and Human Services Commission (HHSC) manages the program.

Under this program, the state may file a claim against the estate of a deceased Medicaid recipient, age 55 and older, who applied for certain long-term care services on or after March 1, 2005. Claims include the cost of services, hospital care and prescription drugs supported by Medicaid under the following programs:

In addition to information provided in this handbook, staff may also consult the MERP website at https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program.

2347.2 Presentation of Information to Community Attendant Services Applicants

Revision 17-9; Effective September 15, 2017

Medicaid Estate Recovery Program (MERP) information must be shared with all Community Attendant Services (CAS) applicants and, in some cases, ongoing individuals, regardless of age, unless the applicant or individual is determined to have "grandfathered" status. (See Section 2347.3, Determining Grandfathered Status).

For all CAS applications received on or after March 1, 2005, the case worker is responsible for presenting MERP information to the applicant and authorized representatives.

1 Texas Administrative Code §373.301, Notice Upon Application

(a) Written notice of the MERP provisions will be provided to:

(2) Individuals for Medicaid-covered Home and Community-Based Services (§1915(c), Social Security Act) and Community Attendant Services (§1929(b), Social Security Act):

(A) prior to an individual's signing an election statement for Home and Community-Based Services, as an alternative to institutionalization; or

(B) at the initial home visit for Community Attendant Services.

MERP information is shared at the initial home visit or face-to-face contact. MERP information must be presented in person, not over the phone. Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, must not be mailed with the application packet.

Questions about MERP received before the face-to-face contact with the applicant should be promptly addressed; however, applicants expressing concern about the estate recovery program should be encouraged to allow an in-person contact in order to have a more extensive discussion of the policy, including the exemption and the undue hardship provisions.

At the initial home visit for a CAS applicant, the Texas Health and Human Services Commission (HHSC) case worker must present the MERP script in Appendix XXI, Medicaid Estate Recovery Program (MERP) Script and Cover Sheet. Staff will follow the MERP script to present MERP information and to request the individual to sign Form 8001. The script also provides guidance on how to handle questions or the individual's refusal to sign Form 8001.

Staff are not required to follow the script if the individual chooses to sign Form 8001 after a brief overview of MERP.

During the interview, the case worker will ask if the individual would like to read Form 8001. If the individual chooses to read the form, the case worker allows time for the individual to read the form. The case worker must clearly state that Form 8001 is informational material only. After MERP and Form 8001 are shared, the case worker asks the individual to sign Form 8001 to acknowledge MERP information was shared. If the individual refuses to sign the form, the case worker documents the individual's refusal by checking the box on the bottom of Form 8001. The case worker explains to the individual that refusal to sign Form 8001 does not exempt the individual from estate recovery.

Also during the interview, the case worker must obtain and document executor information. Executor information must be recorded in the Service Authorization System (SAS) by creating an "Executor" address type. If the individual has already identified an executor and this information has been recorded in SAS, confirm with the individual that this information is correct. If the individual does not have a will and executor, the case worker asks for the name of the person whom the state should contact after the individual's death to determine whether recovery is appropriate. The order of preference for contacts after executor is: (1) legal guardian, (2) power of attorney (POA) or (3) other family members who have acted on behalf of the individual. A space is provided on the MERP script to record two names and addresses of the persons the individual identifies. If the individual does not have an executor, the case worker enters the information about the first preferred contact in SAS "Executor" address record. The case worker files the page from the MERP script that lists the contact information in the case record.

The case worker explains program requirements related to sharing MERP information, but does not make recommendations about MERP or speculate whether MERP will be applicable upon the individual's death, if the individual has this type question. The case worker provides to the individual additional sources for MERP information, including:

Along with Form 8001, the case worker must share a copy of the MERP brochure, Your Guide to the Medicaid Estate Recovery Program.

Applicants or family members with access to the Internet can obtain information about MERP at https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program.

Regional and local staff can obtain information about MERP procedures and estate recovery policy information at https://hhs.texas.gov/medicaid-estate-recovery-program-faqs.

2347.3 Determining Grandfathered Status

Revision 17-1; Effective March 15, 2017

An individual's estate is not subject to the Medicaid Estate Recovery Program (MERP) if the individual applied for one of the following programs/services subject to MERP prior to March 1, 2005. An individual who meets these criteria is considered to be "grandfathered" (or protected) from MERP. The services are:

Form 1575, Medicaid Estate Recovery Program Worksheet, and instructions, have been developed to document verification of an applicant's or individual's grandfathered status. The case worker completes Form 1575 for CAS applicants or individuals to document whether the applicant or individual is considered to have grandfathered status. This form is completed at the initial home visit for applicants or at the next annual reassessment for ongoing individuals if there is not a Form 1575 in the case record. The following procedures apply:

Form 1575 and Form 8001 must be filed and kept in the most current volume of the case record. The information documented on Form 1575 includes the:

The case worker must provide Form 2061, Notification of Medicaid Estate Recovery Program Status, to individuals who meet grandfathered status to alleviate concerns and to confirm the applicant's/individual's MERP status. Form 2061 must only be provided if the applicant's/individual's grandfathered status has been researched, verified and documented on Form 1575. A copy of Form 2061 must be placed in the case record along with Form 1575.

2347.3.1 Determining the Application Date for MERP Grandfathered Status

Revision 17-4; Effective May 23, 2017

This section provides guidelines on the program application dates that may be used to determine if individuals have Medicaid Estate Recovery Program (MERP) grandfathered status.

An individual's estate is not subject to MERP if the individual applied for programs/services subject to MERP prior to March 1, 2005. An individual who meets this criteria is considered to be "grandfathered" (or protected) from MERP. The application date used to determine if an individual has grandfathered status is based on specific program/service application dates, and must clearly indicate the application process for the program/service that was initiated on that date.

For Community Attendant Services (CAS), the application date is when:

In CAS, home visits or completion of the application are more clearly documented events; however, if case documentation (prior to March 1, 2005) clearly shows the case worker began the application process by completing or starting to complete Form 2060 (by phone) prior to the home visit or completion of the application for assistance, this documented date can be used to designate the individual as grandfathered status. This scenario should be rare.

The earliest verified and confirmed program/service application date can be used to determine the individual's grandfathered status.

There could be scenarios when Form H1200 was mailed to the individual requesting CAS but Form H1200 was mailed back to Medicaid for the Elderly and People with Disabilities (MEPD). The case worker uses the earliest date of receipt, by MEPD or the Texas Health and Human Services Commission (HHSC), as the application date. Applying for Qualified Medicare Beneficiary (QMB) and Specified Low-income Medicare Beneficiary (SLMB) prior to applying for a MERP service does not automatically constitute an application for a MERP service. The case worker must confirm the application date used to determine that an individual has grandfathered status is clearly related to the initiation of the application process for the MERP service.

Note: All application dates must be verified, confirmed and documented on Form 1575, Medicaid Estate Recovery Program Worksheet. If there is no clear verification of the application date, the individual must not be designated as grandfathered status.

2347.4 Medicaid Estate Recovery Program Exemptions

Revision 17-1; Effective March 15, 2017

Undue Hardship Waivers

The Medicaid Estate Recovery Program (MERP) does not recover costs from estates when it would result in undue hardship. An undue hardship waiver request form is provided as part of the MERP Notice of Intent to File a Claim form. The state considers a full or partial waiver of recovery when:

A waiver request specific to the descendant's homestead will be considered when one or more siblings or lineal heirs have gross family income less than 300 percent of the federal poverty level. The waiver will be proportionate to each qualifying heir's share.

Waivers based on hardship are evaluated at the time of death, not at the time of application for services. Exception: Estates of individuals who applied for services through programs subject to MERP before March 1, 2005, are permanently exempt from recovery.

Grandfathering Exemptions

How individuals qualify for Medicaid (Supplemental Security Income (SSI) or Medical Assistance Only (MAO)) is irrelevant to evaluating MERP exemption status. The determining factor is the program in which the individual is enrolled. The MERP-covered programs are:

See Section 2347.3, Determining Grandfathered Status.

2347.5 MERP Claims and the Filing Process

Revision 17-1; Effective March 15, 2017

Medicaid Estate Recovery Program (MERP) claims will not be filed when it is not cost-effective. Claims that are not considered cost-effective are those where the:

The acceptance of Medicaid medical assistance provides a basis for a Class 7 probate claim, as defined in §322 of the Texas Probate Code. The MERP files claims in accordance with the requirements contained in §298 and §301 of the Texas Probate Code. Additionally, a claim may not be filed under MERP if there is:

MERP claims are filed within 70 days after MERP receives notice of the death of a Medicaid recipient, age 55 and older, and who after March 1, 2005, applied for certain Medicaid long-term care services. A MERP Notice of Intent to File a Claim form is sent to the contacts on file in the Texas Integrated Eligibility Redesign System (TIERS) and the Service Authorization System (SAS) within 30 days of notification of the death of a Medicaid recipient. The notice includes a program overview, an estate questionnaire regarding possible exemptions and information on the estate property. An undue hardship waiver request form is also included.

An heir has up to 60 days from the date of the notice to submit an undue hardship waiver request. Determination of an undue hardship waiver is evaluated on a case-by-case basis and is completed within 40 days of receipt of the request and supporting documentation. Should an undue hardship waiver be denied, the heir may submit a written appeal. Both the application and written appeal, when applicable, should be sent to:

Texas Health and Human Services Commission
Accounts Receivable – Mail Code E-411
P.O. Box 149030
Austin, TX 78714-9030

An appeal of denial must be submitted within 60 days of the date of the decision letter.

If no exemptions or full waivers apply, the lesser of the claim amount or estate value will be recovered after higher priority estate debts are paid. §322 of the Texas Probate Code contains the classification and priority of claims from a decedent's estate. The acceptance of certain Medicaid long-term care services provides a basis for a Class 7 claim after:

An estate, according to the Texas Probate Code, is the real and personal property of an individual, such as a home or car. It typically does not include insurance policy proceeds; retirement accounts (such as IRAs), pension plans, financial institution accounts, mutual funds or deferred compensation plans when there is a designated beneficiary. MERP may compromise, settle or waive any claim upon good cause shown.

2347.6 Allowable Claim Deductions

Revision 17-1; Effective March 15, 2017

Under the Medicaid Estate Recovery Program (MERP), certain deductions from the claim amount are considered. These include necessary and reasonable expenses for home maintenance, including real estate taxes; real estate insurance, excluding liability; utility bills; home repairs and other maintenance expenses such as lawn care. Additionally, deductions from the claim amount may be considered for necessary and reasonable expenses for the direct payment of the costs of care (including payment of personal attendant care) provided for the Medicaid recipient that enabled the recipient to remain at home, thereby delaying the need for institutionalization.

The estate representative must provide supporting documentation for the requested deductions within 60 days following the date of the notice of intent to file a claim to recover Medicaid costs.

See Section 2347.5, Claim Filing Process, for additional information.

2347.7 Transfer of Assets

Revision 17-1; Effective March 15, 2017

Giving away assets without compensation may result in non-payment of nursing facility, intermediate care facilities for individuals with an intellectual disability or related conditions and 1915(c) waiver services. Assets transferred up to 60 months before application for long-term care or institutional services may affect an individual's entitlement to payment of services. There may be no transfer penalty if a recipient transfers a home to a:

Questions regarding the transfer of assets policy should be referred to the eligibility specialist at the local Medicaid for the Elderly and People with Disabilities office.

2347.8 Documenting Executor Information in SAS for CAS Individuals

Revision 17-1; Effective March 15, 2017

Within thirty days of notification of the death of a Medicaid recipient, the Texas Health and Human Services Commission (HHSC) sends notice of intent to file a claim to the executor or other estate representative of the Medicaid recipient. To facilitate this notification process, the case worker enters in the Service Authorization System (SAS) the name, address and telephone number of all Community Attendant Services (CAS) individuals' executors or estate representatives, if the individuals have them. Executor information is entered in the Address folder as follows:

Other information, such as directions, comments or executor's relationship to the individual must not be entered.

2347.9 Additional MERP Information

Revision 17-1; Effective March 15, 2017

If applicants or their family members with access to the internet would like more information about the Medicaid Estate Recovery Program (MERP), direct them to: https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program

Additional information about MERP can also be obtained by calling the MERP hotline at 1-800-641-9356 or by calling the Legal hotline for Texans at 1-800-622-2520 (available to persons age 60 and over; Medicare beneficiaries, regardless of age; and victims of violent crime).

2348 Retroactive Payments

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §47.85 (c)(1) — The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS's Application for Assistance – Aged and Disabled form is received:

(A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and

(B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

If an application is received for retroactive attendant care services, the following actions apply. Upon receipt of a completed, signed and dated application or request for services, send Form H1236, Notification of Receipt of Application, to the provider currently serving the applicant. The notice advises the provider that its individual:

The case worker must send the completed application to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) or Community Care for Aged and Disabled (CCAD) regional staff so that a decision can be made regarding the applicant's financial eligibility.

Note: An individual who may complete or sign an application for an applicant or individual may not be on the list of people to whom HHSC can release the applicant's individually identifiable health information. See Section 1150, Personal Representatives, for individuals who may receive or authorize the release of individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

A Medicaid-eligible or categorically eligible individual does not have to complete an application when requesting services. Also, an individual who requests facility-initiated Day Activity and Health Services (DAHS) does not have to complete an application if he has stopped receiving services by the time he is contacted. The DAHS facility can be reimbursed for facility-initiated DAHS provided to an individual who was Medicaid eligible when service was received, even if the individual does not complete an application.

The following applies to individuals receiving Primary Home Care (PHC) or DAHS through provider or facility-initiated services.

If a request for DAHS is received from a Medicaid-eligible individual who is not required to complete a written application and is receiving DAHS services, then the individual must allow staff to process the initial paperwork if the individual plans to continue receiving services.

If the individual refuses to participate or allow staff to process the initial paperwork:

For situations listed above, deny DAHS or PHC individuals on Form 2101, Authorization for Community Care Services, with a reason for withdrawal of services.

See Section 4640, Retroactive Payments, for complete procedures relating to retroactive payments.

2349 Procedures for Applicants Aging Out of PCS to PHC

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) has an agreement with the Texas Department of State Health Services (DSHS) for individuals receiving Personal Care Services (PCS) to be referred for Primary Home Care (PHC) two months prior to the individual's 21st birthday. See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information and a listing of DSHS offices.

This time frame has been set to ensure there will not be a gap in services. The DSHS case worker will make the referral for intake 60 days prior to the individual's 21st birthday. Referrals from DSHS must be accepted, Form 2110, Community Care Intake, must be completed and the intake assigned to a case worker. Regional staff must also check the quarterly Age Out list, in case the referral from DSHS is not timely.

Since there are differences in PCS and PHC services, the HHSC case worker will thoroughly explain the allowable PHC services at the time of the initial PHC assessment. PHC may not offer some of the services provided through the PCS program.

The applicant must meet all PHC eligibility criteria, including medical, functional and unmet need. If the applicant is eligible, PHC services are negotiated to begin on the individual's 21st birthday. PCS services should end at midnight on the day before the individual's birthday. Coordinate the transition with the PCS case worker and applicant to ensure there are no gaps in services.

All time frames are applicable and processing of the intake must not be delayed. The case worker must make the home visit within 14 calendar days and send a referral Form 2101, Authorization for Community Care Services, to the selected provider within five business days. Currently, the Service Authorization System (SAS) will not allow the processing of referral Form 2101 due to the age edit in the system. Therefore, Form 2101 must be completed manually. This edit will be modified in the future to allow completion of the case prior to the individual's 21st birthday.

Upon receipt of Form 3052, Practitioner's Statement of Medical Need, and final eligibility determination, the case worker negotiates the start of care date for the individual's 21st birthday, completes a manual authorization Form 2101, and sends it to the provider. Form 2065-A, Notification of Community Care Services, is sent within two business days of sending authorization Form 2101. Since SAS entry cannot be completed until the individual's 21st birthday, the case worker is allowed up to five business days after the 21st birthday to complete the data entry.

If the PCS Individual Is Ineligible for PHC

If the individual is not eligible for PHC due to a low score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, requests voluntary withdrawal or has no unmet need, the denial code must be entered in SAS. These cases are tracked for reporting purposes.

PCS Caregiver as the Paid Attendant

Refer to Section 2422.5, Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program, for special procedures regarding caregivers as paid attendants in PCS cases. If a parent or other caregiver has been the paid attendant through PCS, he may meet the criteria to continue to be the paid attendant and would not be listed as "Do Not Hire." Caregiver support may also be appropriate in some cases.

2400 Assessment Process

Revision 17-1; Effective March 15, 2017

2410 Overview of the Assessment Process

Revision 17-1; Effective March 15, 2017

The purpose of the assessment process is to determine whether the applicant meets all eligibility requirements, including:

The assessment process should produce a case record that clearly documents the results of the case worker's determination. All processes that can be performed in the Service Authorization System (SAS) Wizards must be performed in the system to consider that action complete, including:

Lack of case record documentation in the following areas is considered inadequate, unless the case is being denied for an unrelated reason.

Example: The case worker conducts a home visit in response to an intake request. After completing the Form 2060 assessment, it is determined that the individual's score is too low to qualify for any of the requested services. Since the individual has already been determined functionally ineligible, it is not necessary to evaluate financial eligibility. If an Application for Assistance form has been completed, the form must be retained in the case record.

2411 Required Documentation

Revision 17-1; Effective March 15, 2017

The following must be documented in the case record:

In some areas of Texas, the Area Agency on Aging may submit a completed Form 2060 based on the assessment for services it provides. If a completed Form 2060 is received, it must be reviewed for information as part of the assessment process.

Note: For detailed explanations of financial eligibility assessment and determination procedures, see Section 3000, Eligibility for Services.

2420 Assessing the Applicant's Needs

Revision 17-1; Effective March 15, 2017

During the initial home visit, as required in Section 2300, Responding to Requests for Service, the case worker completes the following assessment procedures.

2421 Review of the Community Care Intake Form

Revision 17-1; Effective March 15, 2017

Review Form 2110, Community Care Intake, for all relevant information. Make sure the practitioner is the applicant's current practitioner and the name, address and telephone number listed are correct. If the applicant provided a rural route address, ask for the updated street address. If the individual states he does not have a new address, continue to use the address provided. Take no action if the street-style address is not provided. Ask the individual to update his information with the Texas Health and Human Services Commission if he is notified by the U.S. Postal Service of a new address.

Verify that the responsible party is the primary contact for the applicant and the name, address and telephone number are correct. On Form 2110, list any other family members or informal supports who can be contacted if the applicant cannot be reached. Review the requested services and address those during the interview and in documentation.

2422 Form 2059, Summary of Client's Need for Service

Revision 17-1; Effective March 15, 2017

The purpose of Form 2059, Summary of Client's Need for Service, is to document the applicant's:

Record all information reported by the applicant or informal supports during the home visit on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into the Service Authorization System Wizards (SASW) and will generate Form 2059.

Carefully observe and use interviewing skills during the initial home visit and throughout the assessment process. This is necessary to collect critical information about the individual's functional and mental abilities, and community and family resources. Individuals may demonstrate functional abilities while responding to questions about their home and living environment or medical problems. They may reveal information about family resources while responding to questions about financial eligibility. They may reveal intellectual and developmental disabilities or lack of mental clarity in the way they respond to questioning throughout the interview. During the interview, be alert for any indications of abuse, neglect or exploitation. If any of these conditions are present, refer the individual to the Texas Department of Family and Protective Services (DFPS), Adult Protective Services.

2422.1 Medical Diagnosis and Functional Limitations

Revision 17-1; Effective March 15, 2017

Ask the applicant for information regarding his medical diagnosis and physical and functional limitations. Record this information on Form 2059-W, Summary of Individual's Need for Service Worksheet.

2422.2 Home Environment

Revision 17-1; Effective March 15, 2017

The individual's functional status is always relative to the home circumstances in which the individual performs the activities of daily living. For example, the individual may have physical limitations that would not affect his abilities to perform certain personal care tasks if he lived in a home complete with all modern conveniences. If, however, his home contains only minimal household equipment, his inability to perform his personal care tasks could be compounded. Always assess an individual's functional capacity in relation to the home environment in which the tasks are performed daily. Service plans are developed to be carried out in specific home environments and each plan should relate specifically to a functional assessment done in that particular environment.

Observe and ask questions about the individual's home and immediate environment to assess his ability to perform activities of daily living. Determine whether the environment affects the individual's ability to perform these activities or otherwise affects his health and safety.

Guidelines for Assessing the Home Environment

Using the following guidelines, assess the home environment and document the results on Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered in the Service Authorization System Wizards (SASW). When observing the individual's home and immediate environment, assess the following:

Home Arrangement

Is the individual the owner of his home or does he reside in an apartment or live with friends or relatives? The individual may pay rent, own the home or live cost free.

Is the individual homeless and no friend or relative is available to provide a home? If the individual has insufficient income to rent a suitable home, he may be living in a public shelter or an exposed setting. Refer the individual to Adult Foster Care (AFC), Residential Care (RC), public housing or other community living resources. A referral to Adult Protective Services (APS) may be needed.

Home Condition

Is the individual's home:

2422.3 Living Arrangement

Revision 17-1; Effective March 15, 2017

The case worker documents on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 4, if the applicant lives alone, with a spouse, with family or friends, or if he is in adult foster care or a residential care facility. In Item 5, list the name and relationship of all household members and indicate with a "Y" that they are in the household. Note if any of the household members receive services or are applying for services.

 

2422.4 Documentation of Caregivers

Revision 17-1; Effective March 15, 2017

Ask the individual if he receives assistance with his activities of daily living and list the name and relationship of all caregivers. These people may be family members, friends or neighbors. List the tasks performed by each caregiver on Form 2059-W, Summary of Individual's Need for Service Worksheet. Under Caregiver Status, indicate if there is a reason the caregiver cannot meet all of the individual's needs, such as working full time, ill health, needing caregiver support or providing continual care. For household members who are not performing any caregiver tasks, leave the caregiver status blank. If a household member states he is unwilling to assist the individual with any tasks, note this in the Caregiver Status on Form 2059-W.

The caregiver will be assessed during the functional assessment. See Section 2433.1, Assessment of the Caregiver.

Determine if the caregiver needs caregiver support as defined in Section 2512, Caregiver Support, and develop the service plan accordingly.

2422.5 Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program

Revision 17-1; Effective March 15, 2017

For individuals applying for Community Care for Aged and Disabled (CCAD) personal attendant services (PAS) and the caregiver has been the paid attendant in that program, the following guidelines must be applied to individuals who are transitioning from the following programs:

The applicant must meet the unmet need criteria like any other applicant, but the current circumstances will be considered.

During the initial interview, if the caregiver has been the ongoing paid attendant and would like to continue as the paid attendant, the case worker will ask the caregiver the following question: "Would you continue to provide care if you are not being paid to provide the care?"

If the response is "No," determine the tasks for which the caregiver has been paid in the previous program and whether the individual still needs assistance with those tasks. Determine which tasks will continue as caregiver tasks and develop the service plan accordingly. Document the caregiver's response and send Form 2067, Case Information, along with the referral packet, to the provider advising that the caregiver had previously been the paid attendant and is eligible to be the paid attendant.

If the response is "Yes," evaluate if there is any unmet need or if caregiver support is required. If services continue, the caregiver cannot be hired. If there is no need for caregiver support or no unmet need, the applicant is denied services.

The case worker must follow this policy for individuals applying for HHSC Primary Home Care (PHC), Community Attendant Services (CAS) or Family Care (FC) who are transitioning from one of the programs listed above.

2422.6 Common Household Tasks, Duplicate Services and Services Provided to Other Family Members

Revision 17-1; Effective March 15, 2017

If an individual lives with others, do not purchase services that duplicate services normally provided as part of the household routine. For example, meal preparation, shopping, laundry and housekeeping for the individual are performed daily as part of the family routine. Unless the individual has unique needs, these tasks will not be purchased.

If an individual lives with others, determine whether he has needs for unique tasks that are performed apart from the household's tasks and whether performing these tasks imposes additional burdens of time and responsibility on the household members. Unique tasks are attributable to the individual's problems. Examples include incontinence, a need for a special diet, food preparation, extra shopping or special housecleaning caused by the individual's behavior. Allowable tasks also include cleaning up after personal care tasks, cleaning the individual's room and the bathroom used by the individual. If it is determined the individual's needs impose special and extra activities on the household members, document these needs on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Services Provided to Other Family Members

Identify whether services are being provided to any other family member by the Texas Health and Human Services Commission (HHSC) or another agency. If services are being provided, assess whether they meet some of the individual's needs and would affect his service plan.

Example: An individual's spouse receives Community Care for Aged and Disabled Family Care services and an attendant performs housecleaning, laundry and meal preparation as part of that service plan. Some of those services also benefit the individual or duplicate services that he needs. In this case, divide the time for common tasks between the individuals and authorize the task for both individuals. Refer to the maximum times listed on Form 2060 for companion cases.

Refer to Section 4400, Family Care Services, and Section 4600, Primary Home Care and Community Attendant Services, for specific information about situations in which two persons in the same household receive attendant services.

2422.7 Assessment of Social and Community Resources

Revision 17-1; Effective March 15, 2017

Assess the individual's community and social network resources, such as churches, civic clubs and voluntary affiliations to determine whether any of these entities provide services or would be able to do so. Also, identify available service agencies that serve the elderly and disabled and might be able to provide a service needed by the individual. Always determine whether any of these sources can help the individual before services from the Texas Health and Human Services Commission (HHSC) are authorized. See Appendix XV, Services Available from Other State Agencies, for assistance in identifying alternate sources of assistance. When possible, refer to local resource directories for information about services in an individual's community. Document the use of or referral to other service agencies on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7.

All other services available to the individual must be considered and used before HHSC services are authorized.

2423 Guardianship

Revision 17-1; Effective March 15, 2017

A Community Care for Aged and Disabled individual may need a guardian if he:

If the individual's incompetence or incapacity results in his being in a state of abuse, neglect or exploitation, the case worker must make a referral to Adult Protective Services (APS). Unless ordered by a court to do so, the case worker must not file a petition for guardianship or assume guardianship of the person or the estate of a Texas Health and Human Services Commission (HHSC) individual.

If the court intends to appoint the case worker as guardian, the case worker must advise the court that serving in that capacity will violate HHSC policy. If the case worker is appointed guardian by the court, the supervisor and regional attorney must be notified immediately. If a referral to APS, Texas Department of Family and Protective Services, has not already been made, one should be made at this time.

2430 Functional Assessment

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2907(a) — The Client Needs Assessment Questionnaire is used to determine an individual's functional need for CCAD services.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is used to make several determinations regarding the individual's eligibility. The completed form will determine:

An individual's functional level is based on:

The age of the individual being assessed for services should not be considered when determining the level of functional need. For example, the applicant is a 3-month-old infant whose mother is applying for Community Attendant Services (CAS) for the child. Obviously, the infant will need help with most of the activities of daily living and would, therefore, score a "3" on those tasks. The fact that the functional need is the direct result of the individual's age should not be taken into consideration when assigning a score for the particular task.

If the person appears to be eligible for Community Care for Aged and Disabled services on the basis of age, income and resources, and he requests services beyond Information and Referral, complete Form 2060, Part A, to determine the functional eligibility for services. This assessment helps determine whether the person has functional needs, what kinds of functional limitations he experiences, which tasks he needs help with and whether his mental clarity contributes to his need for help.

2431 Form 2060, Part A, Functional Assessment

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must score each item on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Assessment, and then accurately compute the total score to determine whether the individual is eligible for Community Care for Aged and Disabled services. Use the spaces under each item, as needed, to explain the person's limitations or his accommodations for his disability. For detailed information about scoring Form 2060, Part A, refer to the form instructions. Appendix XVII, Service/Score Code Guide, indicates the score requirement for each service.

During a face-to-face interview, ask the individual each question on Form 2060, Part A, as the question is stated on the form. Then, ask further questions to gain a more complete understanding about the degree of the individual's ability or inability to carry out activities of daily living. Careful assessment of the individual reveals what he can do for himself, what he should continue to do for himself to maintain his current level of self-sufficiency, and what he cannot do for himself because of physical limitations and/or mental limitations. When conducting an assessment, use the following scale of disability and follow the detailed definitions of impairment levels found in the instructions for Form 2060, Part A.

0 = No impairment. The individual is able to conduct activities without difficulty and has no need for assistance.
1 = Minimal/mild impairment. The individual is able to conduct activities with minimal difficulty and needs minimal assistance.
2 = Extensive/severe impairment. The individual has extensive difficulty carrying out activities and needs extensive assistance.
3 = Total impairment. The individual is completely unable to carry out any part of the activity.

To determine the severity of the individual's impairment, consider the following factors:

  1. Individual's Perception of the Impairment — Does the individual view the impairment as a major or minor problem?
  2. Congruence — Is the individual's response to a particular question consistent with the individual's response to other questions and also consistent with what has been observed?
  3. Individual History — Probe for an understanding of the individual's history as it relates to the current situation and the individual's attitude about the severity of the impairment. For example, has the individual always kept a messy house and is not, therefore, concerned because he is unable to perform housekeeping tasks? Has the individual always eaten only one meal a day and is not, therefore, interested in eating more often? How has the impairment changed the individual's lifestyle?
  4. Individual's Right to Self-Determination versus Danger to Self — Consider the consequence to the individual if he chooses not to take medications, bathe, adhere to a special diet, etc.
  5. Lack of Facilities — Absence of facilities for bathing, laundry, telephone calls or meal preparation may indicate an impairment. The impairment and its degree will depend on the individual's accessibility to the facility, ability to use the facility and ability to make satisfactory accommodations in the absence of the facility.
  6. Adaptation — If the individual has adapted his physical environment or clothing to the extent that he is able to function without assistance, the degree of impairment will be lessened, but the individual will still have an impairment.
    Note: Medication is not considered an adaptation to the individual's functioning in the same way a walker would be. The individual is not considered to have an impairment if the medication is working. The individual is rated on how he is functioning at the time of the interview, regardless of the status of taking medication.

The following chart provides a general guide for assessment. Whether the individual is taking medication, forgetting or refusing medication, or taking medication incorrectly, he is still assessed on his current level of functional ability.

Situation: The individual has problems with dizziness and balance, which could affect scoring on the transfer/ambulation and balance questions.

If the individual: then:
is taking medication and has no problems with dizziness, score 0 on impairment.
is taking medication but still has occasional episodes of dizziness, score 1 on impairment.
is taking medication, but still has major problems with dizziness and balance, score 2 on impairment.
has a prescribed medication, but is forgetting to take the medication or is taking the medication incorrectly, the individual is still assessed based on his current level of functioning.

The case worker must clearly document the reason in situations where the task score on Form 2060 is clearly inconsistent with the amount of time allotted for that task. For example, a case reader may decide to rate Standard 10 unmet if an individual scores 1 on all Form 2060 tasks, yet the maximum amount of hours for each are purchased and case documentation does not explain the discrepancy.

2432 Scoring Persons Who Cannot Respond

Revision 17-1; Effective March 15, 2017

On some occasions, the case worker may need to assess small children, infants or individuals who are comatose or otherwise non-responsive. Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to conduct these assessments, even though the instrument may not seem to apply. Allow the caregiver to respond if the individual cannot do so. In scoring each item, use the caregiver's response, the case worker's observations and any knowledge the case worker may have about the individual from other sources.

 

2433 Determining Unmet Need in the Service Arrangement Column

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2907(b) — Regardless of a client's functional eligibility as determined by his score on the client needs assessment questionnaire he receives CCAD services only if he has an unmet need for those services.

Unmet need is defined as a requirement for assistance with activities of daily living that cannot be adequately met on an ongoing basis by friends, relatives, volunteers or other service agencies.

For any task listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the Service Arrangement Column will determine if the individual has an unmet need in order to determine the individual's overall eligibility based on unmet need. Review questions 1 through 15 and ask the individual the following additional questions.

If the impairment score is "1" – Ask the individual if he is able to perform the task by himself, even though it may be difficult for him.

If the impairment score is "2" or "3" – Ask the individual if he receives help with this task.

If the individual states he receives some help from others but it does not meet all of his needs for a specific task, enter "P/C." Document the part of the task performed by the caregiver in the "Tasks Performed" section on Form 2059-W.

2433.1 Assessment of the Caregiver

Revision 17-1; Effective March 15, 2017

For each task marked "C" on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, assess the capability, dependability, availability and willingness of the caregiver. Consider and discuss family and job responsibilities, as well as the physical demands of caregiving. For each task, determine by observation and by asking the applicant or caregiver the following questions:

  1. Is the caregiver physically and mentally able to perform the task?
  2. Is the caregiver dependable in performing the task on the required schedule?
  3. Is the caregiver available at the time the individual needs the task performed (either scheduled or on demand)?
  4. Is the caregiver willing to perform the task on a regular and ongoing basis?

It may be necessary to talk with the applicant's current caregiver in order to accurately assess his contribution to the applicant's care needs. If the caregiver cannot join the applicant for the initial face-to-face visit, get as much information as possible from the applicant and contact the caregiver by telephone to verify that the caregiver is willing to provide the tasks. Do not delay service initiation if the caregiver cannot be reached.

If, for any task, it appears the caregiver is not able to adequately meet the applicant's needs, discuss with the applicant if some or all of the task should be purchased. If the applicant states the caregiver is currently performing the task, but it is apparent from case worker observation that the task is not being adequately performed, discuss if the task should be purchased.

Be sensitive to any indications of abusive or neglectful behavior on the part of the caregiver and make a referral to Adult Protective Services, if necessary.

2433.2 Exploring Other Resources for Meeting the Applicant's Needs

Revision 17-1; Effective March 15, 2017

Explore other possibilities for resources with the individual. Ask if family members pay someone to help the individual and if the current assistance is adequate. Use observations about the caregiving arrangement to determine whether needed tasks are being adequately performed. If an individual's need for help with a particular task is being adequately met and the assistance can reasonably be expected to continue, do not authorize purchased services for that task. If the need for help with a particular task is not being met or is only partially met, ask the individual and family if there is anyone who would voluntarily provide the needed help. Explore the use of any identified volunteers. If voluntary help cannot be obtained, explore the use of community resources and consider service options from other groups or agencies. See Section 2535, Involvement of Volunteer Resources, and Section 2530, Other Resource Services, for possible resources to meet the individual's needs. If the individual's need for help cannot be met in any other way, enter "P" for the task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. If Home Delivered Meals is the only service being purchased, complete the service arrangement column and do not allocate time on Form 2060.

If an individual's needs for help are now being met and the individual or family determines the present care arrangements cannot be continued, inform the individual or family that the individual may reapply for services when the current arrangement is discontinued. If, during the initial interview, the individual or his family knows the present care arrangements will discontinue within 30 calendar days, proceed with the application process.

Examples:

If someone who has been paying for care intends to discontinue the arrangement on a specific date within 30 days, proceed with the application. Otherwise, offer to take an application at the time the care arrangement is discontinued. If someone will continue to purchase some of the care, determine if the applicant has an unmet need for any additional care. If someone is willing to pay for services only while the individual is on an interest list, this does not affect the individual's unmet need for services purchased by the Texas Health and Human Services Commission (HHSC). However, if someone is willing to pay for services after the individual comes off the interest list, there is no unmet need.

In some situations, a caregiver may quit employment to stay home and provide care for the applicant and is requesting to be the paid attendant. In this situation, the case worker must obtain verification that the individual quit employment within 30 days before or after the application date. The caregiver may be considered as a potential attendant. In the Service Arrangement column of Form 2060, note the tasks that the caregiver will voluntarily provide and those tasks that will be purchased. See Section 2513, Caregiver as the Paid Attendant, for additional information.

This policy also applies for ongoing cases in which a caregiver has been working full time and quits employment to stay home and provide care for the individual. The case worker must obtain verification that the individual quit employment within 30 days of the request for the change.

When the Service Arrangement Column of Form 2060 is completed, review the results to determine if the individual has an unmet need. If all responses are "S," "C" or "A," the individual has no unmet need and is not eligible for services. Advise the individual he is not eligible at this time and may reapply if his circumstances change. Be sure to adequately document this information in the Service Authorization System Wizards with the appropriate denial code and send the applicant Form 2065-A, Notification of Community Care Services.

If there are tasks marked "P" on Form 2060, continue to the Task/Hour Guide section.

2434 Support Score and Establishing Priority

Revision 17-1; Effective March 15, 2017

If an applicant for Primary Home Care (PHC), Family Care (FC) or Community Attendant Services (CAS) has a functional score of "3" and the service arrangement for a priority task (feeding, toileting, transfer, meal preparation) is a "P," then a support score must be entered for these tasks on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Determine the likelihood of that task being done if the attendant does not show up during a normally scheduled service shift. Using the following scale, enter the score in the Form 2060 Support Score box by the appropriate item.

1 = It is very likely that the task would be done even if the attendant does not show up.
2 = The task will probably be done if the attendant does not show up.
3 = The task will probably not be done if the attendant does not show up.
4 = It is very unlikely that the task will be done if the attendant does not show up.

In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the individual's home if the attendant was not there. Do not enter a support score for an item if either the task is not purchased or the individual's score for that task is not "3."

If the support score is "4" on any of the priority tasks, then the individual will be designated as a priority individual. See Section 2540, Priority Status Individuals, for further information.

2440 Use of Form 2060, Part B, Task/Hour Guide, and Part C, Task/Minute and Subtask Guide

Revision 17-1; Effective March 15, 2017

For all personal attendant services (PAS) cases, the case worker uses Part B and Part C of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to determine the quantity of purchased services needed by an individual.

The Part C, Task/Minute and Subtask Guide, provides a uniform approach in the authorization of services based on a minute range per task and impairment score. Each impairment score for each task has a minimum and maximum time that can be allotted. It is mandatory to follow the minute guideline and check the subtasks for each task as a way of documenting the type of assistance needed and to support the time allocated for that task. See the Form 2060 Instructions for complete directions for completing the form.

Form 2060, Pages 1-5, must be manually completed during the home visit initial assessment for an applicant who will receive PAS. Review the Task/Minute and Subtask Guide at each reassessment and initial the form. When there is a change in hours, either complete a new Form 2060 manually or update the current Part B and Part C.

Refer to Form 2060, Part C, for guidelines on the number of minutes to be allowed per task. The amount of time allowed for any particular task should be determined by taking into account:

Discuss fully with the individual each service task to determine whether he needs assistance with that task, how much time is required to perform each task, and how often each week the task must be performed. The total time allowed for each task must be within the minimum and maximum time limits for the impairment score, as indicated on Form 2060.

Negotiate service authorizations with individuals to reach an agreement about:

All appropriate subtasks must be checked to indicate the specific tasks the individual needs. An individual scoring a 2 or 3 may need all subtasks under the impairment score for 1 and additional subtasks under the impairment score of 2. The time allotted must be within the range for the impairment score.

Time outside the minute range (either above or below) may not be allotted without documented supervisory approval.

2440.1 Requesting Supervisory Approval for Time Outside the Minute Range

Revision 17-1; Effective March 15, 2017

In situations in which the individual has extenuating circumstances and requires a deviation in the time range, the case worker may request supervisory approval to authorize time above or below the minute range for the task and impairment score. The case worker must document the reason why the individual requires minutes outside the range for the task/impairment score level. The documentation is sent to the supervisor in writing or electronic mail (email) and the supervisor must approve or disapprove in writing or by email. The documentation and the supervisor's response must be filed in the case record.

2441 Circumstances When Supervisory Approval is Not Required

Revision 17-1; Effective March 15, 2017

In some situations, the individual may have extenuating circumstances and a compelling reason that require subtasks in a lesser impairment score to be authorized for a task. The two situations in which the case worker may allot time for subtasks in a lesser impairment score without supervisory approval are:

The case worker documents the individual's extenuating circumstances and the reason tasks in a lesser impairment score are authorized, or documents the part of the task the caregiver or other agency provides.

2441.1 Exception for a Compelling Reason

Revision 17-1; Effective March 15, 2017

In some situations, an individual may request tasks not be performed for him even though he has an impairment and may not be able to perform the task for himself.

If an individual has a compelling reason for not wanting any of the subtasks under the appropriate impairment score, but only wants subtasks listed in a lower impairment score, the case worker must document the individual's request and allocate minutes in the minute range for the subtasks selected. The case worker must document the reason, and no supervisory approval is required.

Example: The individual scores a 2 on bathing. She needs assistance with drying. However, when discussing subtasks, she states she would like standby assistance for safety and drawing of water, all under the impairment score of 1. She states her skin is very sensitive and she would not allow help with drying as she is afraid it would hurt her. The subtasks checked are all under the impairment score of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.

See Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Instructions, for additional information.

2441.2 Exception for Assistance from a Caregiver or Other Agency

Revision 17-1; Effective March 15, 2017

If an individual has a caregiver or other agency performing part of a task and only subtasks in a lower impairment score are needed, the case worker must document the individual's request and allocate minutes in the minute range for the subtasks selected. The case worker must document the reason and the part of the task the caregiver or other agency performs. No supervisory approval is required.

Example: The individual scores a 2 for bathing, but only wants assistance with laying out supplies and drawing water because her daughter provides all hands-on assistance with the bathing task. The task is marked P/C. The subtasks under the impairment score of 1 are checked and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance.

2441.3 Time Allocation for Companion Cases

Revision 17-1; Effective March 15, 2017

For companion cases, time allocated for general household tasks, including cleaning, shopping and meal preparation, is based on the companion minute range on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, rather than the individual range. Time is assigned per individual based on the individual's impairment score. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation and/or shopping to indicate that time is authorized for these tasks to the companion case. In situations where there are more than two companions in the household, assign time based on the individual's impairment score using the companion minute ranges.

In situations where there are more than two individuals in the household, the case worker continues to use the companion minute range based on the individual's impairment score.

Example: On cleaning, Mr. Jones scores a 3 and Mrs. Jones scores a 1. Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under impairment score 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score 3 in the companion range.

See Form 2060 Instructions for additional examples and guidance on companion cases.

2442 Calculation of Time to be Authorized

Revision 17-1; Effective March 15, 2017

Use the following procedures to calculate the total amount of time needed each week.

  1. Multiply the number of minutes needed to conduct each task by the number of times the task will be conducted each day to reach a daily total of minutes for each task. Times must be shown in five-minute increments. If necessary, round the time up to the next five-minute increment.

    Example: If an individual needs meal preparation twice a day and the meal preparation requires the maximum amount of time, multiply 30 minutes by two to reach a daily total of 60 minutes.
  2. Multiply the daily total of minutes for each task by the number of days per week the attendant will conduct that task. Again, times must be shown in five-minute increments and rounded up to the next five-minute increment, if necessary.
  3. Add the required weekly minutes for all tasks and divide the total by 60 minutes to determine the weekly total in hours.
  4. Round the weekly number of hours to the next highest half unit to determine the number of units to be authorized. Example: If an individual needs 7 hours and 10 minutes of service each week, authorize 7.5 units of service. The number of hours must be correctly rounded up to ensure accurate authorization of services.

Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to calculate the hours of service to be purchased. The correct number of hours must be authorized on Form 2101, Authorization for Community Care Services. Write comments in the Service Authorization System (SAS) "Impairment Scoring" window in the Functional Wizard.

Tasks/services identified as needing to be purchased must be authorized on Form 2101. Tasks marked "P" in the "Service Arrangement" column of Form 2060 must also be marked on Form 2101. The meal preparation task may be marked "P" on Form 2060 and not marked on Form 2101, as long as the individual is receiving home-delivered meals. A separate Form 2101, authorizing meals, is sent to the home-delivered meals agency.

2443 Balancing Incentive Program, Level II Assessment

Revision 17-1; Effective March 15, 2017

The Balancing Incentive Program (BIP) provides additional Federal Matching Assistance Percentage (FMAP) funds to states that initiate reforms to increase nursing home diversions and access to non-institutional long-term services and supports. As part of the effort to increase access to additional federal funds and meet BIP requirements, the Texas Health and Human Services Commission (HHSC) administers the Level II Assessment to all individuals requesting or receiving Primary Home Care (PHC), Community Attendant Services (CAS) and Day Activity and Health Services (DAHS) Title XIX. The Level II Assessment consists of:

The BIP was created by the Affordable Care Act of 2010 and improves the state’s ability to serve more individuals by increasing access to non-institutional long-term services and supports. The BIP allows states to adhere to the integration mandate of the Americans with Disabilities Act (ADA), as required by the Olmstead decision.

The case worker will complete the Level II Assessment, Form 2060-B, for initial assessments, annual reassessments and for a significant change request for a new service.

For changes in services, the case worker will complete:

The following are examples of the forms that are completed when a request is made for a change in service:

Examples:

The case worker determines whether a referral is needed for HHSC services or non-HHSC services based on the information collected from Form 2060-B. The case worker discusses and obtains approval to make a referral with the individual to non-HHSC services. Referrals may include:

The case worker documents the referrals made on behalf of the individual in Section III of Form 2060-B, including any need for referrals that were identified but refused by the individual. No data entry is required in the Service Authorization System (SAS) resulting from the completion of the Form 2060-B only.

The individual retains the right to participate in the development of his service plan and the right to refuse all or part of any services and to be informed of the likely consequences of such refusal, which include referral to non-HHSC services.

Identified needs for referrals agreed to by the individual are considered as requests for information and referral. The case worker makes use of applicable existing referral policy to assist the individual with the appropriate referral located in:

Referrals for behavioral health needs identified on Form 2060-B may be made to local mental health authorities using the local phone numbers available at: https://hhs.texas.gov/services/health/mental-health-substance-abuse.

2500 Service Planning

Revision 17-1; Effective March 15, 2017

2510 Service Plan Development

Revision 17-1; Effective March 15, 2017

Program Standard: Case workers must develop service plans that accurately authorize appropriate services for individuals based on individual needs, eligibility and priority level.

After the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet need of the individual, discuss service planning with the individual and/or his family members. Consider all possible resources that may be available through Community Care for Aged and Disabled (CCAD) services or other community resources. Evaluate if the individual is interested in receiving Home-Delivered Meals, Emergency Response Services or attending Day Activity and Health Services (DAHS) or other community centers. Be sure to review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made regarding the use of those services.

To the extent of their abilities, eligible individuals must be involved in the development of their service plans. Discuss service planning with an individual or his caregivers during the initial visit to his home. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the home visit and after financial eligibility has been determined.

The discussion with the individual (and caregivers) should include the type of services that may be appropriate for purchase after unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence, allow the individual the opportunity to continue performing tasks he prefers to do himself, even though they may be difficult for him. Explain to the individual that Texas Health and Human Services Commission (HHSC) programs are not designed to replace the care that caregivers now provide or are able and willing to provide over time. At the conclusion of the initial home visit, ensure that the individual fully understands exactly what HHSC may provide, the limitations of HHSC services and the importance of the existing caregiver arrangement to the development of a service plan.

The service plan should reflect consideration of all these factors:

Document service planning information on:

 

2511 Caregiver Arrangements

Revision 17-1; Effective March 15, 2017

Discuss with the individual, and any family members or caregivers, that Community Care for Aged and Disabled (CCAD) services are not designed to replace the care family members and other caregivers now provide or are able and willing to provide over time. Explain that the existing caregiver arrangement is very important to the development of a service plan. If possible, confirm with the caregivers that they are able and willing to perform the tasks listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, that are marked "C" for caregiver. Be sure the individual and family members understand CCAD services are not intended to serve as a supplement to income. Decisions about service plans cannot be based upon the family's income or financial needs.

2512 Caregiver Support

Revision 17-1; Effective March 15, 2017

Caregiver support is defined as providing relief to a caregiver who provides the majority of the applicant's care or continual care for the applicant. This support is always provided by an attendant other than the applicant's regular caregiver. Caregiver support may be appropriate when the initial functional assessment results in no unmet need, but the caregiver needs relief. The paid attendant will provide some of the tasks that the caregiver has been performing in order to provide relief.

Examples: Caregiving responsibilities prevent the individual's caregiver from leaving the house to conduct personal business or do the family shopping or the caregiver needs time away from his caregiving duties on a regular basis due to his health needs or for periods of rest due to the continual care.

Discuss with the caregiver how many days per week and what tasks may be needed to provide relief. Mark the appropriate items on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, with a "P," and document on each task in the comments section that support care is needed. Indicate on Form 2101, Authorization for Community Care Services, that the service plan is for caregiver support and list the caregiver as someone not to be hired. Support care may be temporary; if so, authorize it only for the time needed.

Note: There are a number of services provided through the local Area Agencies on Aging designed to support caregivers. Service availability varies by region. For service availability in a particular area, provide the toll-free telephone number, 1-800-252-9240, to persons interested in potential services.

2513 Caregiver as the Paid Attendant

Revision 17-1; Effective March 15, 2017

If the caregiver expresses an interest in being the paid attendant, inform the caregiver and applicant that the case worker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Individuals who want a specific person to be the attendant should be encouraged to discuss this with provider staff. The case worker must explain to the potential attendant that he will be an employee of a home and community support services agency. He must be able to provide the tasks needed and work the complete specified schedule that will be developed by the provider and the applicant. His performance will be monitored and evaluated by the provider and the case worker.

The case worker must also explain to the applicant and the caregiver that the tasks listed as "C" (caregiver) under the service arrangement on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must remain as caregiver tasks if the caregiver is hired as the paid attendant. Those tasks may not be purchased tasks as long as this caregiver is the paid attendant. If circumstances change and the attendant can no longer perform or is no longer willing to perform either the purchased tasks or the caregiver tasks, then the provider will be requested to hire a new attendant for those tasks. The caregiver will be designated as someone not to be hired for those tasks on Form 2101, Authorization for Community Care Services.

In situations as described in Section 2433, Determining Unmet Need in the Service Arrangement Column, where the caregiver has recently quit employment to provide care, note the tasks the caregiver will continue to provide voluntarily and mark them as "C" in the service arrangement column of Form 2060. Other needed tasks may be purchased.

For ongoing cases, a caregiver who had been listed as working full time and quits a job to provide care for the individual may also be considered as a potential attendant. The case worker must obtain verification the caregiver quit employment within 30 days prior to the requested change. Any tasks previously identified as performed by the caregiver may not be purchased tasks.

2514 Who Cannot Be Hired as the Paid Attendant

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the individual's paid attendant. The only role HHSC plays in the hiring process is notifying the provider when a particular person must not be hired.

Based on the following chart, if a person is identified as someone who must not be hired as the paid attendant, the case worker documents this information in the Comments section on the initial and all subsequent submissions of Form 2101, Authorization for Community Care Services. The case worker enters "Do Not Hire" and the name of the individual on the form. The following chart lists the persons who must not be hired and must be specified as "Do Not Hire."

Do Not Hire: If the individual:
Abused, Neglected, Exploited, as Substantiated by Adult Protective Services has abused, neglected or exploited the individual or others.
Parent of a Minor Child is the legal or foster parent of the minor child receiving Community Attendant Services (CAS). There is no prohibition against hiring the parent of an adult child to be the paid attendant.
Spouse in Primary Home Care (PHC) or CAS is the spouse of the PHC or CAS individual.
Unwilling Household Member is not willing to help the individual with any of the tasks the individual needs.
Caregiver Support caregiver needs relief from providing continuous care and the authorization for purchased services is based on caregiver support.
Individual Designated is a particular person the applicant/individual does not want hired as the paid attendant.
Caregiver/Paid Attendant at Reassessment is no longer able or willing to provide tasks previously designated as caregiver tasks. The caregiver may not be hired for those tasks. (See Section 2664, Redetermination of Unmet Need.)

Beyond these limitations, the case worker will not specify who cannot be hired as the paid attendant.

2520 Freedom of Choice

Revision 17-1; Effective March 15, 2017

2521 Freedom of Choice in Living Arrangements

Revision 17-1; Effective March 15, 2017

The applicant has freedom of choice when it comes to his living arrangements. Case workers are, however, required to consider if the individual's needs can be met in the environment chosen by applicant.

Consider the individual's ability to understand whether the services the Texas Health and Human Services Commission (HHSC) can provide are adequate to meet his needs. If the individual has medical needs that cannot be addressed with personal care and housekeeping services, or if the environment poses a threat to health and safety, discuss these issues with the individual and the responsible person.

Explain the limitations of Community Care for Aged and Disabled (CCAD) services and determine how the individual's special needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the individual insists on remaining in his current residence, despite the fact that his needs may not be met in that environment, assess his mental capacity for making an informed choice and whether he understands the consequences of that choice. See Section 2550, Identifying Individuals at Risk, for additional information.

If he is capable of informed consent, respect his choice and develop a service plan accordingly. If he appears incapable of making an informed choice or if abuse, neglect or exploitation is suspected, make a referral to Adult Protective Services.

2522 Service Delivery in Alternate Locations

Revision 17-1; Effective March 15, 2017

It is acceptable to allow delivery of services intended for the home environment to be provided in alternate locations. Hours diverted to provide services to the individual in alternate locations may not be added back into the service plan. For example, an individual's service authorization includes an hour each day for feeding/eating. The individual will also need this help during a visit to his sister who lives 20 miles away, which will add an additional hour to the time needed to provide this assistance. The individual opts to divert an hour allocated for laundry to feeding/eating in order to make the visit. This hour cannot be added back into the service plan in order to provide the amount of time required to do the laundry.

Do not anticipate the need for additional hours based on delivery of services outside the home and build that time into the service plan. It is also unacceptable for additional hours to be approved because the extra time expenditure does not allow the attendant enough time to do some other task. Hours authorized will be based solely on services that are assumed to be provided within the home environment.

When individuals receive services outside the home, providers must document in the comments section of Form 3054, Service Delivery Record, the specific services provided and in which location. Documentation must also be available to substantiate the individual requested these services. The actual transportation, as well as transportation cost, is the responsibility of the individual.

2523 Freedom of Choice in Agency Selection

Revision 17-1; Effective March 15, 2017

Once it appears that the applicant will meet the eligibility criteria for Community Care for Aged and Disabled (CCAD) services, offer the applicant the choice of selecting an agency contracted to deliver the requested service in the applicant's area. Either the applicant or the responsible person may make the selection. The selection must be documented on an agency choice list or other document in the case record.

If the applicant requests time to consider his choice or to consult with family members or other resources, leave the applicant a return envelope or make arrangements to pick up the agency choice list when the decision is made.

If the applicant refuses to make a choice from all of the contracted agencies in the service area, an agency may be selected for the applicant as a last resort. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date.

2530 Other Resource Services

Revision 17-1; Effective March 15, 2017

When determining unmet need, also identify and examine other agencies' services that the individual now receives or is eligible to receive. This prevents service duplication and ensures all service resources have been pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the individual. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7. If possible, document information about other service resources in the Service Authorization System (SAS) "Support Assisting Client window". If that is not feasible, document using the WordPad function. See Section 7330, Narrative Documentation for SAS Wizards, for specific instructions.

All other services available to the individual must be considered and used before services are authorized by the Texas Health and Human Services Commission (HHSC).

2531 Veterans Affairs Aid and Attendance and Housebound Benefits

Revision 17-6; Effective June 28, 2017

Some individuals receive Aid and Attendance (A&A) or housebound benefits (HB) from Veterans Affairs (VA). These benefits must be considered the primary source of funds to pay for in-home services.

HHSC has an information sharing program between HHSC, the Texas Veterans Commission (TVC), and the Veterans Land Board (VLB) for the purposes of coordinating and collecting information about the use and analysis among state agencies of data received from the Public Assistance Reporting Information System (PARIS) VA match. The PARIS system is a federal-state partnership that provides states with detailed information and data to assist in maintaining program integrity and detecting improper payments.

This information sharing program helps identify HHSC recipients who may be eligible for veteran’s benefits. HHSC creates a file of active recipients in the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid programs. The file of active recipients is sent to the Defense Manpower Data Center (DMDC) on a quarterly basis for PARIS matching. DMDC returns a file of the matched recipients with veterans benefit information back to HHSC. This file is shared with the TVC and VLB to contact veterans who may be eligible for benefits or may be eligible for increased benefits and report those benefits back to HHSC.

HHSC will receive reports regarding A&A and HB that may affect the level of service currently authorized for personal attendant services (PAS).  HHSC will verify the information on any individuals currently receiving Community Attendant Services (CAS), Primary Home Care (PHC), Family Care (FC), Home and Community Services (HCS), Community Living Assistance and Support Services (CLASS), or the Texas Home Living (TxHmL) Program. Since financial eligibility for CAS is determined by HHSC, any changes to eligibility status will be processed by HHSC.

Actions Required Upon Receipt of the Report

When the report is received, the region must distribute the information to the assigned case workers to contact the individual and verify the change in VA benefits. For individuals receiving A&A or HB, the case worker must discuss and document how the individual is using the benefits. A list of some of the items/services that can be purchased using A&A or HB funds includes:

If all the A&A or HB funds are being used to purchase items that help the individual remain independent and in the community, the case worker documents the information and no funds are applied to the service plan.

The individual may also use the funds to purchase:

If the individual is using the funds to purchase PAS or home health aide services, this must be considered when developing the plan of care. For FC, PHC and CAS, this would be noted on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the individual is able to purchase all the services required, then there is no unmet need and the individual would not be eligible for PAS. If the individual can only purchase part of the required services, or if the funds are not used to purchase services, then the amount of the A&A or HB funds is applied to the purchase of attendant care per Form 2060 instructions.

If the funds are not used to purchase services that help the individual remain independent and in the community, apply the funds to the purchase of non-skilled attendant care. Calculate the number of hours of non-skilled attendant care that could be paid for with the individual's unused portion of A&A or HB. To do this, divide the unused portion of the monthly benefit by the maximum non-priority attendant care limit rate without regard to service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care limit rate. Subtract the resulting amount from the person's authorization. If the number of hours required by the individual's unmet need is more than the benefits he can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the individual's unmet need, even if this exceeds the maximum HHSC can purchase.

These procedures apply only to the purchase of PAS. Do not reduce the amount of other services because the individual receives VA benefits.

Example: An individual whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this individual's A&A benefits by the current maximum attendant care limit rate yields 46 hours per month.

46 ÷ 4.33 = 10.6 hours per week

20 − 10.6 = 9.4 hours per week

This individual may be authorized 9 1/2 hours per week.

Explain this procedure to the individual. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the individual and case worker should jointly decide which PAS tasks will be purchased and authorize only those tasks on Form 2101, Authorization for Community Care Services. Update the Service Arrangement Column of Form 2060 to match the tasks/hours authorized on Form 2101.

Reporting Requirements

Regional management will be required to report the amount of savings generated by the application of VA funds. For example, an individual requires 20 hours per week of PAS, but is now receiving A&A funds. The A&A funds can purchase five hours per week reducing the weekly service plan to 15 authorized hours per week. The cost of the five hours per week is reported as a savings for HHSC.

2532 Skilled Home Health Services

Revision 17-1; Effective March 15, 2017

If an individual is receiving or is eligible to receive Medicare/Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the individual when determining unmet need. SHH is ordered for an individual by his physician and is provided over a short period of time in conjunction with illness.

Use regional procedures to refer any applicant/individual who requests or appears in need of SHH services.

It is possible to authorize other Community Care for Aged and Disabled (CCAD) services, including personal attendant services (PAS), at the same time SHH attendant care is being utilized and both services may even be provided on the same day. If an individual is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCAD service that may be needed by the individual. If SHH provided attendant care on some but not all of the days of a week, PAS may be authorized to provide attendant care on the other days, if needed. If SHH is providing all the personal care needed by the individual but housekeeping services are needed, Family Care or Home-Delivered Meals may be suitable options to consider.

If SHH is providing only skilled nursing services by a registered nurse or licensed vocational nurse, the service would not be duplicated by any other CCAD service that might be authorized, and is not a consideration in determining unmet need. Consider how long SHH has been in use and how long it will continue as the CCAD service plan is developed with the individual. If duplication of tasks would occur by authorizing a CCAD service, denial and/or a later revision to the service plan may be necessary.

2533 Hospice Services

Revision 17-1; Effective March 15, 2017

When Medicaid recipients elect the Medicaid Hospice Program, they waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es). These waived services are limited to services also provided under Medicare. Recipients do not waive their rights to HHSC services unrelated to the treatment of the terminal illness(es). Therefore, participation of the individual in a hospice program does not affect eligibility for Community Care for Aged and Disabled (CCAD) programs.

If an individual chooses to receive hospice services and some of the individual's needs will not be adequately met by the hospice agency, assess the individual and authorize services for the individual's remaining needs on the same basis as any other individual.

For more detailed information about the Hospice program, see Section 2745, Individuals Who Need Hospice Services.

2534 Mutually Exclusive Services

Revision 17-1; Effective March 15, 2017

To determine unmet need for a particular Community Care for Aged and Disabled (CCAD) service, or determine if an individual can receive other HHSC services, ask the individual or family members if the individual is receiving another HHSC service. Check the Service Authorization System (SAS) and the Client Assignment and Registration (CARE) system for services and refer to Appendix XX, Mutually Exclusive Services. See Section 4000, Specific CCAD services.

2534.1 Services Through the Texas Home Living Waiver

Revision 17-8; Effective September 1, 2017

Due to the limited services provided through the Texas Home Living (TxHmL) waiver, some Community Care for Aged and Disabled (CCAD) services are not mutually exclusive and can be received at the same time as Texas Home Living (TxHmL).

The following services may be authorized with TxHmL:

Case workers must review the services received through TxHmL before authorizing CCAD services to assure there is no duplication of tasks and there is an unmet need for the service. Individuals must meet the eligibility requirements for the specific CCAD service requested. The case worker must document there is no duplication.

2534.2 Targeted Case Management and Other HHSC Services or the STAR+PLUS Program

Revision 17-6; Effective June 28, 2017

Local Authorities (LAs) provide service coordination through Targeted Case Management (TCM) to Individuals with Intellectual and Developmental Disabilities (IDD) in the HHSC LA priority population.

TCM authorizations are processed through the Service Authorization System (SAS). TCM services are identified in SAS as Service Group 14, Service Code 12A or 12C. TCM can be authorized along with Home and Community-based Services (HCS), Texas Home Living (TxHmL) or as a general revenue (GR) service.

TCM and Other HHSC Services

Other HHSC waiver services (excluding HCS and TxHmL) are mutually exclusive with TCM. An individual receiving any of the following waiver programs cannot receive TCM at the same time:

If an individual on TCM is applying for one of these waivers, then the SAS Service Codes 40, 40A and 60, for assessments, pre-assessments and prescriptions, are the only service codes allowed to overlap with TCM service authorizations.

Since the waiver programs identified above provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The HHSC case worker must contact the LA to coordinate closing TCM for the waiver service to begin. Individuals receiving the STAR+PLUS program may receive TCM. These services are not mutually exclusive.

The Program for All-Inclusive Care for the Elderly (PACE) is not a waiver program but an all-inclusive program. PACE is mutually exclusive with all other services including TCM.

TCM and Other HHSC Services

Determining whether an individual who receives TCM services can receive other HHSC services, including Community Care for Aged and Disabled (CCAD) services, depends on whether he is receiving TCM services through HCS, TxHmL or as a GR service.

Once the case worker identifies an individual is receiving TCM, he or a regional designee must check the Client Assignment and REgistration (CARE) system to determine if the individual is receiving HCS or TxHmL. If the individual is receiving HCS or TxHmL, the case worker must refer to Appendix XX, Mutually Exclusive Services, to determine if the individual can receive other HHSC services, as some services are mutually exclusive and others are not.

If the individual is receiving HCS or TxHmL and the requested CCAD service is mutually exclusive, then the case worker will contact the individual to allow a choice of services and document the individual's choice. If the individual elects to continue receiving HCS or TxHmL, then the request for CCAD services is denied. If the individual elects to receive the CCAD service, then the case worker must contact the LA to coordinate closing services.

If the individual is not receiving HCS or TxHmL and is receiving TCM as a GR service, then he can receive other CCAD services.

2535 Involvement of Volunteer Resources

Revision 17-1; Effective March 15, 2017

Some services needed by aged and disabled individuals may be performed by volunteers. When developing an individual's service plan, consider whether volunteers from community resources might meet some of the individual's needs.

Volunteer help may include:

Some organizations may contribute group volunteer efforts to accomplish major tasks for functionally disabled individuals. These tasks might include:

Before completing a plan that includes volunteers, discuss the idea fully with the individual and his family or caregiver. If an individual is served completely through planned volunteer services, the case worker may keep the case open as "case management only" as long as the individual's condition warrants regular monitoring. In the case narrative, document all volunteer resource development and use.

2536 Program of All-Inclusive Care for the Elderly

Revision 17-1; Effective March 15, 2017

The Program of All-Inclusive Care for the Elderly (PACE) is an all-inclusive program that provides all required services for an individual enrolled in the program. PACE is only available in catchment areas and information on service locations may be found in Appendix XXXIV-F, Program of All-Inclusive Care for the Elderly.

Texas Health and Human Services Commission (HHSC) intake screeners in the catchment areas must be aware of the PACE service and referral procedures for the service. Intake screeners must provide information about PACE to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. Individuals in the PACE catchment areas may request services through the local HHSC intake office or through the PACE service site. Additional information is found in Appendix XXXIV-F, Waiver Program Descriptions Program of All-Inclusive Care for the Elderly.

Since PACE is an all-inclusive program, it is mutually exclusive with all other HHSC programs and STAR+PLUS programs.

2540 Priority Status Individuals

Revision 17-1; Effective March 15, 2017

For an individual to be assigned priority status, there must be at least one purchased priority task such that both the individual's:

The service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must be completed for each task in which the individual scores 1, 2 or 3. The support score column must be completed for each priority task (eating, toileting, transfer and meal preparation) in which the individual scores 3 and the service is being purchased.

If the attendant does not show up during a normally scheduled service shift, the individual's health, safety or well-being may or may not be jeopardized. Always assess the potential impact on the individual's health or safety when determining the effects of an attendant not providing service.

Do not designate an individual as having priority status if the failure of the attendant to report to work would not result in any risk to the individual's health, safety or well-being. If the individual appears to be at risk (scores a 3 on a priority task with little or no caregiver support), document the reason(s) why a support score of 4 was not assigned.

In determining whether health, safety or well-being is endangered, consider the worst result that might follow from the attendant not providing service. For example, an individual may have a friend who visits daily when she can, but the friend is regularly out of town on business. Determine the consequences of the attendant not showing up on a day when the individual's friend is out of town.

Consider each individual's condition and situation. One individual may be able to miss a meal during a scheduled service shift because his caregiver will be home later to prepare the meal. Another individual may not be able to miss a scheduled meal without risk to his health because of individual nutritional needs or no caregiver to prepare the meal later. Contact the regional nurse if assistance is needed in assessing the risk that would result from an attendant not working during a scheduled shift.

Priority individuals must be advised of the importance of being available in their homes during the hours designated in the service plan. Advise the individual to contact the provider in advance if the individual knows he will not be at home during a normally scheduled shift. If information is received that a priority individual will not be home, inform the provider.

Inform a priority individual that the provider may monitor the attendant's work performance by making frequent calls or home visits. If a priority individual objects to this increased monitoring of the attendant, the individual has the option of withdrawing from priority status.

For priority cases, note in the comments section of Form 2101, Authorization for Community Care Services, this is a priority case. Use verbal referral procedures for new priority individuals.

Providers may not allow a service interruption for an individual designated as priority status unless the:

The provider must notify the case worker within seven calendar days of a priority individual not receiving scheduled services. This notification is for the case worker's information only; no response is required. Do not approve or disapprove service interruptions for priority individuals.

Individuals can refuse priority status. If an individual refuses priority status, document in the case record the individual's decision and the reason for it.

Because the unit rate for priority individuals is higher than the rate for non-priority individuals, the maximum allowable service authorization is less for priority individuals. A priority individual receiving the maximum hours per week may not be able to receive another Community Care for Aged and Disabled service for which he may be eligible. This could exceed the total expenditures allowed by the average daily nursing facility rate (see Appendix II, Cost Limit for Purchased Services). A priority individual can exercise the option to receive less than the maximum hours in order to receive another needed service or he can decline priority status. The case worker must give the individual the choice and explain the options, including the advantages/disadvantages of each. Document the individual's decision in the case record.

2550 Identifying Individuals at Risk

Revision 17-1; Effective March 15, 2017

An individual whose unmet medical or functional need constitutes a potential hazard to his health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of his condition. The case worker may identify the unique problems of these individuals at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the case worker. Address these problems in the individual's service plan and document the information on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Form 2059, Summary of Client's Need for Service, in the Service Authorization System. Consult with the unit supervisor and the regional nurse about threats to the individual's health and safety and about unmet medical and functional need issues. Use a team approach to develop service and monitoring plans whenever necessary and feasible.

A "critical level of risk" exists when an individual has certain medical, physical and social characteristics that endanger his health and safety in his current living arrangement. Factors that contribute to critical risk are the individual's level of functional impairment, his medical condition, the quality and strength of his caregiver arrangement, and the physical and social conditions of his immediate environment.

The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in an individual or in his situation, the case worker must decide whether he should be handled as an individual at risk.

Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary, and in the case narrative if more space is needed.

2551 Case Worker Actions for Individuals at Risk

Revision 17-1; Effective March 15, 2017

The case worker must discuss the individual's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The case worker and unit supervisor determine whether a risk management team meeting is necessary. If necessary, the case worker will:

If the team members disagree about whether an individual is at risk, the person who first identified the critical-risk indicators should document in the case record the:

If service plan disagreements cannot be resolved through team discussions, the unit supervisor consults with the lead regional nurse and, if necessary, the program director. Any difficulties with providers that cannot be resolved through discussion should be reported to the contract manager. If the problem cannot be resolved in the discussion process, the regional director makes the final decision.

If, during the service planning process, staff become aware the individual's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the individual and his family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the individual's response in the case narrative or on Form 2084. The individual and his family decide whether he is to remain in his present living arrangement, using the available services. The individual is free to refuse any or all services offered.

2600 Authorizing and Reassessing Services

Revision 17-1; Effective March 15, 2017

2610 Application Processing and Notification

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(d) — Eligibility for CCAD services for income-eligible applicants is determined within 30 calendar days after a signed application is received. For categorically-eligible applicants, eligibility must be determined within 30 calendar days after either the consumer's assessment or face-to-face contact with the worker, whichever occurs first. If the applicant withdraws from the program before an assessment is completed or a face-to-face interview is conducted, no further action is necessary.

2611 Processing Time Frames

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker is required to determine eligibility for Community Care for Aged and Disabled (CCAD) services for income-eligible applicants as soon as possible, but within 30 calendar days after a signed application is received. The case worker must determine eligibility for categorically eligible applicants as soon as possible, but within 30 calendar days after either the individual's assessment or face-to-face contact with the case worker, whichever occurs first.

This standard is applied to all applications, except for Community Attendant Services (CAS), using the date shown in "Date Eligibility Rules Processed" on the Service Authorization System Wizards (SASW) Form 2064, Eligibility Worksheet, as the end point of measurement. The 30-day processing deadline cannot be used to unnecessarily delay a decision if all information is available before the 30th calendar day.

Proceed with the eligibility determination process if the individual fails to cooperate but has received facility-initiated Day Activity and Health Services (DAHS) as a Medicaid individual. See the procedures in Section 4231.2, Intake Response.

2611.1 Processing Time Frames for Community Attendant Services

Revision 17-1; Effective March 15, 2017

Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. Because the MEPD process can take up to 45 days for regular referrals and 90 days if a disability determination is required, this may delay Community Care for Aged and Disabled (CCAD) certification beyond the 30-day time frame.

MEPD will notify the Texas Health and Human Services Commission (HHSC) case worker of the eligibility decision through the MEPD to HHS Communication Tool. However, if a decision is not received, the HHSC case worker must check the Texas Integrated and Eligibility Redesign System (TIERS) for an MEPD eligibility decision on or before the 25th day from the application date and perform weekly checks until the eligibility decision is received. The TIERS checks must be documented in the case record.

When the eligibility decision notification is received either through TIERS or the MEPD to HHS Communication Tool, the case worker has seven business days to:

The seven business days are measured from the date HHSC receives the eligibility decision from MEPD or the date eligibility is verified through TIERS. The case worker must print a copy of the eligibility notice or TIERS screen and file it in the case record.

The HHSC case worker must advise MEPD only if the applicant is not approved for CAS (i.e., no practitioner’s statement or other circumstances preventing services delivery). In this circumstance, the case worker must send Form H1746-A,  MEPD Referral Cover Sheet, to MEPD within two business days of determining the individual is not eligible for CAS, advising that the applicant has not met the functional eligibility requirements. Form H1746-A is sent to MEPD at the same time Form 2065-A, Notification of Community Care Services, is sent to the individual notifying him of CAS ineligibility.

The case worker is not required to notify MEPD when CAS services are authorized.

See Section 4653, Referral to the Provider, and Section 4660, Service Authorization, for additional procedures for authorizing CAS services.

Case workers always have seven business days after confirmation of MEPD eligibility to send the referral to the provider. This applies even when verification of MEPD certification is received near the end of the 30-day period allowed for completing CCAD applications.

2612 Notification of Eligibility Decision

Revision 17-1; Effective March 15, 2017

An applicant/individual certified for one Community Care for Aged and Disabled (CCAD) service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the units per week he is eligible to receive services. If certified for Day Activity and Health Services (DAHS), the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

When notifying the applicant of eligibility, specify on Form 2065-A, Notification of Community Care Services:

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

See Section 2662, Redetermination of Financial Eligibility, and Section 2660, Reassessments and Recertification Procedures, for time limits that apply when eligibility is redetermined.

2613 Case Record Documentation

Revision 17-1; Effective March 15, 2017

To document the eligibility decision, the case worker places in the applicant's case record a signed and dated:

Note: Texas Health and Human Services Commission (HHSC) staff must send each individual the Health and Human Services Agencies’ Notice of Privacy Practices, https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms, upon certification.

2620 Service Authorizations

Revision 17-1; Effective March 15, 2017

Service plans may include one or more Texas Health and Human Services Commission (HHSC) purchased service. If more than one service is authorized, be sure that the tasks are not duplicative and that the service combinations do not exceed the allowable costs specified in Appendix II, Cost Limit for Purchased Services. Example: Before authorizing 10 units of Day Activity and Health Services (DAHS) per week for an individual who will also be receiving an in-home service, determine whether or not it is feasible for the individual to participate in DAHS five full days per week.

To authorize services, enter the required information in the Service Authorization System Wizards (SASW). SASW will generate Form 2101, Authorization for Community Care Services. Based on the urgency of the individual's need, negotiate with the provider for the earliest possible date that services can begin. Remember that services can and may need to begin on the weekend if an individual is discharged from a hospital or other institution on a Friday afternoon and needs services immediately. Enter the negotiated beginning date of coverage.

Use the comments section of Form 2101 to give specific instructions to the provider about the individual's service arrangement. These include the number of days the individual requests services, specific service schedules that are required or strongly preferred by the individual, specific instructions about unique individual problems or the individual's home, or information about individuals who should not be hired as the paid attendant.

Along with Form 2101, send the provider a copy of the SASW Auto Form 2060, Needs Assessment Questionnaire and the Auto Task/Hour Guide and for all personal attendant services (PAS) individuals.

Providers are expected to follow the instructions given on Form 2101. If a provider does not do so, try to resolve the problem through discussion with the provider's supervisors. If this fails, report the problem to the supervisor and follow the procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

2630 Referrals to the Provider

Revision 17-1; Effective March 15, 2017

Refer to Section 4000, Specific CCAD Services, for specific procedures for each service for sending referrals to providers. See Appendix XIII, Content of Referral Packets, for referral-packet contents sent to providers for each service.

2631 Negotiated Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: Individuals must be referred no later than the next business day after the day the individual is visited and/or it is determined that a negotiated verbal referral is necessary. Form 2101, Authorization for Community Care Services, must be sent within five business days from the date the individual was determined eligible for a negotiated verbal referral. Use the comment section of the form to document verbal referrals, dates and other relevant information. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

Regardless of the response criteria established for the applicant at intake, the case worker must reassess the individual's need for service initiation during the assessment process. In particular, assess the continued provision of any assistance with the individual's personal care needs by individuals and/or other providers.

If it is determined that the individual's unmet needs for personal care are, or will be, such that services must begin sooner than the time usually required when using the routine written referral process, contact the provider and negotiate a start date according to the individual's need for service initiation. The need for a verbal referral will vary from individual to individual. Consult with the unit supervisor if an individual's particular circumstances are such that it is uncertain whether to use the negotiated referral process.

2632 Routine Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: For applicants who do not require negotiated referrals, authorize services by sending Form 2101, Authorization for Community Care Services, within five business days from the date the applicant is determined eligible. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

If a provider is operating at capacity, or if all budgeted service slots are filled when an eligible individual is referred for services, enter the individual's name on the appropriate interest list. Individuals must be served as indicated in Section 2230, Interest List Procedures. For services other than Day Activity and Health Services (DAHS), Community Attendant Services (CAS) and Primary Home Care (PHC), the provider must return Form 2101 by the 21st calendar day from the date of the referral. If Form 2101 or some other kind of notification is not received, contact the provider to find out the reason for the delay and the status of the referral.

If the provider is unable or fails to provide services within the negotiated time, refer the individual to another provider. If another provider cannot provide the services as needed, resolve the problem through conference with the supervisor. For special referral procedures for PHC, CAS and DAHS, see Section 4000, Specific CCAD Services.

2640 Provider Requirements for Hiring a Paid Attendant

Revision 17-1; Effective March 15, 2017

Criminal background checks are required for all facilities and service providers providing care to the aged and disabled. Except in emergency situations, providers are required to obtain a criminal history check before offering permanent employment to unlicensed employees having direct contact with individuals who are receiving:

A person must be barred from employment if he has been convicted of a criminal offense for which an administrative review is not available. A person may request an administrative review for some criminal offenses that may potentially bar employment.

If asked by anyone, including the individual, about the results of the criminal history check, explain that:

2650 Changes in Service Plans

Revision 17-1; Effective March 15, 2017

2651 Disagreements about Service Plans

Revision 17-1; Effective March 15, 2017

If a disagreement arises between provider staff and Texas Health and Human Services Commission (HHSC) staff about an individual's service plan, resolve the problem through discussion and negotiation. Use an interdisciplinary meeting, if necessary. Ensure that services are not delayed unnecessarily because of these disagreements.

HHSC regional nurses make final decisions in disagreements with providers about an individual's medical need for Community Attendant Services and Day Activity and Health Services.

In all other instances, the Community Care for Aged and Disabled (CCAD) supervisor attempts to resolve the disagreement with the provider's supervisor. If supervisory staff of both providers are unable to resolve the disagreement, the CCAD program manager resolves the disagreement.

2652 Changing the Service Schedule Between Reassessments

Revision 17-1; Effective March 15, 2017

If a schedule change results in a change in hours or priority status, use the chart below to determine which specific changes must be included on Form 2101, Authorization for Community Care Services.

Type of Individual Specific Instructions
Ongoing Primary Home Care or Community Attendant Services with chronic medical conditions, and transfer individuals Specify the effective date as the beginning date of the service plan change on Form 2101, Item 4. If the change results in:

 

  • an increase in hours, the "Begin" date on Form 2101 must be at least seven days from the Form 2101 date, unless another date is negotiated; or
  • a reduction in hours, the "Begin" date on Form 2101 must be at least 12 days from the Form 2101 date. See Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services, for additional information.

    Note: For a reduction in hours, the "Begin" date on Form 2101 must match the effective date on Form 2065-A, Notification of Community Care Services.
Community Attendant Services If a change is being conducted in conjunction with an annual reassessment, enter the "Begin" date as indicated below and leave the authorization "Pending." The HHSC nurse will authorize Form 2101.

If a decrease in service is being implemented between assessment periods, the "Begin" date should be 12 days in the future to allow advance notice of the reduction in service. The "Begin" date must match the effective date on Form 2065-A.

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

Family Care and Family Care transfer case The "Begin" date should be 12 days in the future to allow advance notice of the reduction in service.

 

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

For all other changes not related to a change in hours, complete Form 2067, Case Information, for personal attendant services.

2653 Provider Flexibility

Revision 17-1; Effective March 15, 2017

Providers are, as much as possible, expected to follow instructions given on Form 2101, Authorization for Community Care Services. However, there are times when changes in tasks or schedules will be necessary in order to meet the individual's needs. In these situations, it is not necessary for the provider to notify the case worker as long as the units delivered and billed for a calendar month do not exceed 4.33 times the adjusted weekly hours identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Example – An individual who regularly receives 15 hours of service per week is sick for two days and declines services due to illness. During those two days, a total of five hours of personal care services would have been delivered had the individual been able to receive services. Because the individual may have an increased need for services following the illness, those five hours may be made up if it would be to the benefit of the individual. Because the number of hours delivered does not exceed the number of hours authorized, the provider does not need to notify the case worker.

This ongoing flexibility is intended to allow services to meet the individual's needs, considering his desires and changes in his condition. The flexibility is not intended to be for the convenience of the provider or to be applied retroactively to justify an attendant absence or interruption of services.

If a provider makes changes to tasks/schedules inappropriately or against the individual's wishes, try to resolve the problem through discussions with a provider supervisor. If this fails, report the problem to the case worker's supervisor and follow procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

2660 Reassessments and Recertification Procedures

Revision 17-1; Effective March 15, 2017

Conduct reassessments and (if applicable) referrals of individuals to Community Care for Aged and Disabled (CCAD) services within:

Annual reassessments are required for all CCAD services. See Section 2663.1, Annual Home Visit Required for Individuals Receiving PAS, and Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is required for the reassessment.

When the reassessment is conducted in the individual's home, the case worker must schedule the visit with the individual or his authorized representative at a time that is convenient to the individual. Schedule the appointment by telephone or in writing using Form 2068, Application, Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for some reason, inform the individual or his authorized representative in advance that the appointment will have to be rescheduled. Do not visit the individual without advance notice of the visit.

During the reassessment, the case worker must:

To comply with the National Voter Registration Act of 1993, the individual must be offered the opportunity to register to vote at the time of application and at each annual redetermination. Provide assistance to any individual who requests assistance in completing Form 0030, Review Form 0030 for completeness in the individual's presence. The individual may:

2661 Individual Unavailable for Reassessment

Revision 17-1; Effective March 15, 2017

In some situations, the case worker will use his judgment to determine how long a case should remain open when the individual is unavailable for a reassessment. As a general rule, if the individual continues to be unavailable for more than 30 days, it should be determined if the unavailability is temporary. If an individual is repeatedly unavailable after an appointment has been scheduled, refer to the procedures in Section 2830, Refusal to Comply with Service Delivery Provisions. If the individual is unavailable because of temporary nursing home admission, use the time limits and procedures in Section 2822, Service Suspension by Case Workers.

2661.1 Delay in Home Visits Due to Individual Illness

Revision 17-1; Effective March 15, 2017

While it is important that required home visits are performed on a timely basis, due to the increase in serious transmittable diseases in the general population, there may be circumstances that could place staff at risk for contracting contagious illnesses.

In order to ensure the health and welfare of staff members who could come in contact with individuals reporting a contagious illness, case workers may delay home visits under the following circumstances.

If a case worker contacts an applicant/individual to schedule a home visit (initial, reassessment or monitoring visit) and the individual states he has a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker should schedule a future date for the visit when the individual thinks he will be better. If unable to schedule the visit for a future date, the case worker must contact the individual at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

2662 Redetermination of Financial Eligibility

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must redetermine financial eligibility within 24 months of the previous determination of financial eligibility.

The financial reassessment must be completed by the last day of the 24th calendar month from the previous financial redetermination. To redetermine financial eligibility for income-eligible individuals, use the policies and procedures in Section 3000, Eligibility for Services. The case worker must:

Case workers must be diligent in ensuring that individuals receiving personal attendant services (PAS) are served by Title XIX PAS whenever possible. If the financial situation of an ongoing Family Care (FC) individual has changed in a way that might make him eligible for Community Attendant Services (CAS), a referral should be made to Medicaid for the Elderly and People with Disabilities (MEPD).

Example: An FC individual was denied CAS eligibility at the time of application because of resources that exceeded the $2,000 eligibility limit. However, the individual now reports a total of $1,200 in resources and all other CAS eligibility criteria (for example, a need for a personal care task) are met. A referral to MEPD must be made.

2662.1 Financial Reassessments for Community Attendant Services

Revision 17-1; Effective March 15, 2017

Texas Health and Human Services Commission (HHSC) Medicaid for the Elderly and People with Disabilities (MEPD) redetermines financial eligibility annually for individuals receiving Community Attendant Services (CAS).

In order for individuals to maintain financial eligibility, redetermination packets must be returned to HHSC in a timely manner. Individuals may not recognize the envelope as being an official HHSC document and therefore do not open the envelope. As a result, redetermination packets are not returned and financial eligibility is denied.

Due to changes in the wording on the envelopes, HHSC staff must provide individuals with an explanation of the changes. Previously, the envelopes contained the following wording, “ Important Insurance Information.” The envelopes now state the following:

Picture of Time Sensitive Stamp

HHSC staff must take examples of the envelopes to face-to-face contact visits so individuals can become familiar with the new appearance of the envelopes. HHSC staff can make copies of the envelope examples (see Appendix XXXIX, Examples of HHSC Envelopes) to provide to individuals at face-to-face contact visits. HHSC staff must discuss with individuals at face-to-face contact visits the importance of returning Form H1200-EZ, Application for Assistance – Aged and Disabled, to HHSC within the required time frame provided in the redetermination packet.

HHSC has also implemented Form H1200-SR, Streamlined Redetermination for MEPD. Form H1200-SR is generated from the Texas Integrated Eligibility Redesign System (TIERS). HHSC may determine an individual appropriate for a streamlined redetermination if the individual has had a minimum of one annual redetermination using Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-A, Medical Assistance Only (MAO) Recertification. The individual will receive Form H1200-SR instead of Form H1200, Form H1200-A or Form H1200-EZ. The cover sheet to Form H1200-SR provides specific directions for the individual to follow to determine if the form needs to be completed and returned to HHSC.

HHSC staff must discuss with the individual the importance of thoroughly reviewing Form H1200-SR to determine if changes need to be reported to HHSC. If the individual has any questions regarding the information on Form H1200-SR, he should contact HHSC by mail or fax using the address or fax number on the application or by calling 211.

In addition to receiving one of the forms mentioned above from HHSC, the individual may also receive Form H1010, Texas Works Application for Assistance – Your Texas Benefits. Individuals may only return Form H1010 thinking this form will suffice for all services the individual is receiving. HHSC staff must inform these individuals that Form H1200, Form H1200-A, Form H1200-EZ or Form H1200-SR (if changes need to be reported) and Form H1010 must both be completed and returned to HHSC. HHSC staff must make individuals aware they can track the status of their application using the “"HHSC Your Texas Benefit"s” website at www.yourtexasbenefits.com, or by calling 211.

For some ongoing CAS cases, the functional information was not retained in TIERS due to automation issues. When MEPD completes an annual review for an individual on CAS and there is no functional information available in TIERS, the MEPD specialist will send an MEPD to HHS Communication Tool to the CCAD case worker requesting functional information on the individual if the MEPD specialist is unable to verify the information in the Service Authorization System (SAS).

If requested by the MEPD specialist, the CCAD case worker must send a copy of the Service Authorization screenshot in SAS to MEPD showing the individual is currently active on CAS. Form H1746-A, MEPD Referral Cover Sheet, must be used as a cover sheet when faxing this information to the Document Processing Center (DPC). Any time an MEPD specialist requests Form H1746-A from the CCAD case worker to clarify information on an individual receiving CAS, the CCAD case worker must send Form H1746-A to MEPD with the requested information.

If an individual on CAS has not returned his recertification packet to MEPD, the MEPD specialist may contact the individual, or the authorized representative/responsible person listed in the Texas Integrated Eligibility Redesign System (TIERS), by phone approximately 30 days after the recertification packet was sent to the individual to remind him to return the packet to MEPD. The MEPD specialist may contact the HHSC case worker for assistance with contacting the individual or authorized representative/responsible person. Both the individual and the authorized representative/responsible person will receive the recertification packet to help reduce the number of CAS denials for failure to return recertification packets.

2663 Reassessment of Functional Need

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker reassesses the individual's need within 12 months of the previous assessment. The functional assessment must be completed by the last day of the 12th calendar month from the previous functional assessment.

To reassess functional need, use the policies and procedures in Section 2430, Functional Assessment, and in the instructions for Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

2663.1 Annual Home Visit Required for Individuals Receiving PAS

Revision 17-6; Effective June 28, 2017

Program Standard: A home visit must be conducted with all individuals receiving Community Attendant Services (CAS) for all annual reassessments and 90 day monitoring contacts. A home visit must be conducted with all individuals receiving Primary Home Care (PHC) and Family Care (FC) at least once every 24 months at the same time the financial redetermination is conducted.

During the home visit, the case worker provides oversight of the individual's health and safety. The case worker must evaluate the individual's ability to cope with the activities of everyday living in the home environment and identify when changes to the service plan or the addition of other services provided by the Texas Health and Human Services Commission (HHSC) may be of benefit.

For CAS, it is recommended the case worker complete the annual functional reassessment during the last 90-day monitor for the year prior to the annual being due. If the annual functional reassessment is not completed during the last 90-day monitoring visit prior to the annual being due, then an additional home visit is required to complete the reassessment. An exception to having to make a home visit is when Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, has been completed within the last 60 days due to an interim change, the case worker may conduct the annual reassessment by telephone.

For all CCAD services, if an individual requests a change at the annual reassessment, the change must be worked within five days or by the annual reassessment due date, whichever is earlier.

For CAS, Form 2101, Authorization for Community Care Services, will continue to be sent within five business days of the home visit due to the nurse approval requirements for the program.

All annual reassessments must be recorded on Form 2314, Satisfaction and Service Monitoring, and in the Service Authorization System Wizards (SASW). It must include the individual as the primary contact and the location as a home visit.

2663.2 Determining When a Home Visit is Necessary for Other Services

Revision 17-1; Effective March 15, 2017

For services other than Community Attendant Services, determine if the reassessment should be done in a face-to-face home visit or by telephone interview, based on the service received and the individual's circumstances. See Section 4000, Specific CCAD Services, for home visit requirements for each specific service.

Individual circumstances that may include the need for a face-to-face reassessment include but are not limited to:

Case worker circumstances may warrant that a home visit be made, such as case worker trainees assigned to a caseload.

2664 Redetermination of Unmet Need

Revision 17-1; Effective March 15, 2017

The unmet need policy applies to ongoing cases as well as to applications. At each reassessment, the case worker must evaluate whether the Community Care for Aged and Disabled (CCAD) services already being purchased are meeting needs that would go unmet if no services were purchased. During the annual functional assessment or for each request for a change in service plan or hours, review each task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

In the Service Arrangement column, determine if needs are being met through other sources or if the individual continues to have a need for the task to be purchased. If there are no tasks to be purchased, the individual no longer has an unmet need and is no longer eligible. If unmet need exists, continue with the development of an appropriate service plan.

In situations in which the individual's caregiver also serves as the paid attendant, carefully review the tasks marked "C" on the Service Arrangement Column on the previous Form 2060. These are the tasks that the caregiver agreed to perform voluntarily at the last assessment. These tasks may not be purchased. If the caregiver states that he/she is no longer able or no longer willing to provide the tasks, then advise the caregiver that the provider will be notified to hire a new paid attendant for those tasks. Document any changes in caregivers or caregiver tasks on Form 2060 and Form 2059-W, Summary of Individual's Need for Service Worksheet. The information on Form 2059-W is entered in the Service Authorization System Wizards (SASW) for Form 2059, Summary of Client's Need for Service.

In reassessment decisions, apply policy about duplicate services.

2670 Notifications at Reassessment

Revision 17-10; Effective October 6, 2017

40 Texas Administrative Code §48.3902 – To continue receiving services, the client must meet the CCAD eligibility requirements at the time of recertification of financial eligibility and reassessment of needs.

Program Standard: Notify the individual in writing, using Form 2065-A, Notification of Community Care Services, of changes in the individual's service plan, to include: addition of service(s), increase in hours, decrease in copayment, or loss of priority status based on the individual's request.

Form 2065-A must be sent within two workdays of the decision if the change involves:

For Community Attendant Services (CAS) case actions initiated by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, the Community Care for Aged and Disabled (CCAD) case worker is only required to check the notice forwarded by MEPD for accuracy and file it in the case record. The case worker's only liability for any MEPD-issued Form 2065-A is to report the error to the MEPD specialist via Form 2067, Case Information.

Program Standard: Notify the individual in writing of any reduction, termination in services, loss of priority status or increase in copayment at least 12 days before the effective date of the decision.

If an individual loses eligibility, Form 2065-A must be sent with 12 days advance notice. Exception: Advance notice is not required if the individual loses Medicaid eligibility such as Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF).

Program Standard: Notify the applicant/individual or his authorized representative of his rights and responsibilities and of HHSC service limitations.

The case worker gives Form 2307, Rights and Responsibilities, to the Adult Foster Care (AFC) individual/responsible person before AFC is authorized or reauthorized. The form is given to the CCAD individual/responsible person at the initial face-to-face visit. (For individuals receiving only Day Activity and Health Services (DAHS) or Home-Delivered Meals (HDM), the initial Form 2307 may be reviewed over the telephone.)

The case worker also gives Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, when the applicant/individual requests attendant care and when the individual moves into a new home. At least annually, the case worker discusses all parts of Form 2307 with the individual/responsible person to ensure that he understands the form's content.

2680 Recertification

Revision 17-1; Effective March 15, 2017

The following forms must be sent upon completion of the reassessment:

Additionally, for Adult Foster Care (AFC), send:

If a case is closed after Form 2101 has been updated by the system and Form 2065-A, notifying the individual of termination of services, has not been sent, send Form 2065-A as soon as it is determined the case must be closed. Allow 12 days prior notice before the effective date of termination. See Section 2811, Effective Dates for Service Reduction and Termination. Advise the individual that approved services have ended. Include the date and the reason in the comments section of Form 2065-A.

2700 Service Monitoring, Changes and Transfers

Revision 17-1; Effective March 15, 2017

2710 Monitoring Visits and Contacts

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must monitor the individual's situation, the service(s) the individual receives and the adequacy of the service plan, in accordance with the requirements of the specific service he receives. Monitoring of the service plan includes checking for the appropriate priority level, ensuring the individual has the appropriate Community Care for Aged and Disabled services and ensuring the hours/units authorized meet the individual's needs.

2710.1 Monitoring Initiation of Services

Revision 17-1; Effective March 15, 2017

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care for Aged and Disabled (CCAD) cases. Monitoring visits to ensure service initiation are required for two groups of individuals:

For these two groups, the case worker must:

Case workers should be aware of service initiation issues and complete optional three-day or 30-day contacts if it is deemed appropriate based on the:

Although not required, case workers should verify service initiation by:

2710.2 Monitoring Ongoing Services

Revision 17-6; Effective June 28, 2017

In addition to the initial three-day or 30-day monitoring contact, the minimum requirements for additional individual contacts are as follows:

The case worker must also contact the individual or make a home visit as individual circumstances warrant. Individuals with weak or informal support systems may need to be seen more frequently. Staff must make home visits as necessary to ensure the individual's safety and well-being are not compromised.

Some individuals may need additional monitoring or problems may arise that require additional contacts. The case worker must develop a monitoring plan that takes into account:

Inform the individual in advance if a visit is required by telephone or in writing, using Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is indication of abuse, neglect or fraud.

2710.3 Service Plan Changes at the Monitoring Contact

Revision 17-1; Effective March 15, 2017

Reduce hours or terminate services at annual reassessment or any other time the individual:

The case worker uses his judgment to determine if the individual's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. See Section 2721.6, Long-term Versus Short-term Changes in the Individual's Condition, for additional details in making that determination.

The individual and provider may agree to change the number of personal attendant service (PAS) hours to be provided based on the individual's needs without prior approval from the case worker. The amount of service provided should be sufficient to meet the individual's needs depending on the loss or gain in the individual's functional ability to perform activities of daily living.

Case worker approval or denial is required for all requests to increase PAS service hours previously authorized or to add or delete priority status.

2710.4 Monitoring Documentation Requirements

Revision 17-1; Effective March 15, 2017

The primary purpose of each monitoring contact, whether it is a home visit or a telephone call, is to determine the adequacy of the current service plan and actual service delivery.

Form 2314, Satisfaction and Service Monitoring, must be used for all required monitoring contacts, including three-day, 30-day, 60-day, 90-day, six month and annual contacts. Case workers are not required to use Form 2314 for other contacts.

Assess the quality of services the individual receives and whether the services continue to meet the needs of the individual by determining at the monitoring visits whether:

Ask enough questions at each contact so the individual's current responses, together with the written case record, form a reasonable basis upon which each applicable question can be answered. See Appendix XVI, Monitoring Questions, for examples of specific questions that may be appropriate.

At every contact, document each of the following:

Form 2314 may be used to document other contacts with the individual, including requests for changes in the service plan or complaints regarding service delivery. All contacts with the individual or regarding the individual must be documented in the case record. Form 2058, Case Activity Record, may be used, or other case narratives as determined by the region.

All requests for changes in services, whether received from the individual or the provider, must be documented and clearly show the date the request is received. Documentation may be on Form 2067, Case Information, or recorded in the case record narrative. If the individual requests a change during the monitoring contact, then the request, as well as the action to be taken, must be documented on Form 2314.

All monitoring contacts, whether by telephone or face-to-face, must be entered in the SAS Monitoring Wizard. The copy of the Service Authorization System (SAS) automated Form 2314 must be filed in the case record.

See Section 7300, Service Authorization System (SAS) Wizards and Use Requirements.

2710.5 Actions Required After Monitoring

Revision 17-9; Effective September 15, 2017

Case workers report and discuss with the provider any problems or deficiencies in service provision and strive to resolve the problems. See Section 2736.1, Reporting Service Delivery Issues, for detailed instructions for handling service delivery issues.

2711 Monitoring Community Attendant Services Individuals

Revision 17-1; Effective March 15, 2017

Individuals receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of §1929(b) of the Social Security Act. The act requires the case worker to monitor the home and community care provided under the State plan and specified in the “ICCP” (Individual Community Care Plan). This monitoring must involve visiting each individual’s home or community setting where care is being provided not less often than once every 90 days.

An HHSC case worker must meet this requirement by conducting a face-to-face  visit with the individual receiving CAS in the individual’s home or community setting where CAS services or State Plan services included in the individual’s Individual Service Plan (ISP) are being provided. This face-to-face visit must occur not less often than once every 90 days. The 90 day visit will be for the purpose of monitoring the individual’s satisfaction of services.  

The Texas Health and Human Services Commission (HHSC) is required to make every reasonable attempt to complete the CAS monitoring, as the Social Security Act requires. In order to meet the reasonable attempt requirement, case workers must adhere to the following guidelines:

Federal law specifically requires visits every 90 days, not every three months. This 90-day deadline will usually be one or two days short of three calendar months. Example: If a CAS case is monitored March 15, the next monitoring visit must be on or before June 13 (the 90th day after March 15). See Appendix XVIII, Time Calculation.

For CAS cases, the case worker sets the initial 90-day home visit schedule from the date within 90 days of the initial start of care (SOC), as determined by the regional nurse and documented on Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO). The case worker is not required to conduct a 90-day monitor home visit prior to the SOC date determined by the regional nurse. Once the initial SOC has been determined, the case worker sets subsequent 90-day monitors using the Deadline Calculation Chart within Appendix XVIII to calculate when the next 90-day monitoring visit is due. It is recommended that case workers conduct the annual reassessment simultaneously with the 90-day monitor due prior to the first annual reassessment to align future 90-day monitors due at the annual reassessment.

All 90-day monitors must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System (SAS) Monitoring Wizard. Use the coding for entry into the SAS Monitoring Wizard. See Section 7300, Service Authorization System (SAS) Wizards and Use Requirements, or the SAS Help File for assistance in completing the SAS monitoring visit.

Inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of any changes that may affect the eligibility of a CAS individual.

2712 Six-Month Monitoring Contacts

Revision 17-1; Effective March 15, 2017

When a six-month monitoring contact is required but a home visit is not required by the region, the contact may be completed by telephone. If the individual does not have a telephone or cannot communicate by telephone, and a caregiver or relative can tell the case worker about the individual's condition, service needs and the adequacy of service delivery, the contact may be with a caregiver or responsible relative. If contact cannot be made by telephone with the individual, caregiver or responsible relative, a face-to-face visit is required. The first attempted contact should be at least seven days before the contact due date. All attempts to contact the individual must be documented in the case record.

Before a face-to-face or telephone contact is made with someone other than the individual, make at least two attempted contacts with the individual. Document all attempts in the case record. For a priority status individual, two attempted contacts are defined as:

During each six-month monitoring contact, ask about the:

Determine if any changes are needed in the service plan. The case worker may have to make a face-to-face contact if the:

A face-to-face contact is not required if the individual requests a decrease in hours, unless eligibility could be affected.

2720 Interim Changes

Revision 17-1; Effective March 15, 2017

2721 Service Plan Changes

Revision 17-1; Effective March 15, 2017

Changes to the service plan may be necessitated by changes in the individual's functional abilities or personal circumstances, including:

2721.1 Individual Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Discuss with the individual the importance of reporting changes and explain the consequences of failing to do so. If the individual receives Primary Home Care (PHC), Community Attendant Services (CAS), Family Care (FC) or Home-Delivered Meals (HDM), explain the need to notify the provider if the individual will not:

2721.2 Provider Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Attendants are also responsible for reporting to supervisors any changes in the individual's status or environment that threaten the individual's health or safety or that may affect his service plan. The provider supervisor reports these changes to the case worker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, skin problems, bruises, mental instability that endangers the individual or others, onset of incontinence, unusual complaints of pain, unusual behaviors, or unusual changes in food intake.

The attendant also reports changes that may affect social resource systems, family relationships and assistance programs Examples include changes or problems in housing, household make-up, loss or change in caregiver arrangements or loss of benefits. If necessary, refer the individual to Adult Protective Services.

If a provider fails to report changes that affect an individual's service plan, the problem must be discussed with provider staff. If the problem continues, document the instances and discuss them with the Community Care for Aged and Disabled (CCAD) supervisor, who notifies the contract manager and program manager.

2721.3 Determining if a Home Visit is Necessary

Revision 17-1; Effective March 15, 2017

The case worker will use his judgment to decide if he has enough information to respond to the reported change without visiting the individual. If in doubt, a home visit should be made. Consider the following when making that determination:

Make a home visit and complete a functional reassessment if the individual needs or requests a new service and his current Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, score is below the minimum score for that service.

Reduce hours or terminate services at annual reassessment, or any time before the annual review, when the individual:

2721.4 Revising the Service Plan

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must revise the service plan, which is priority level, need for more/less hours or tasks, within 14 calendar days of learning of a change in the individual's status/condition, or must document why no changes to the service plan are needed. If the case worker becomes aware of the need for a service plan change as a result of conducting an annual reassessment, the change must be completed as part of that reassessment. If the individual is released for another CCAD service, the case worker will refer to Section 2611, Processing Time Frames.

Contact the individual and determine whether a new assessment, a revised service plan or a revised monitoring plan is needed, based on the individual's new condition or situation. Assess the needs of the individual and develop or revise the individual's service plan, including:

2721.5 Long-term Versus Short-term Changes in the Individual's Condition

Revision 17-1; Effective March 15, 2017

The case worker uses his judgment to determine if the change in the individual's condition is expected to last through the current authorization period or beyond before reducing or terminating services. Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition.

If it is determined the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week. Send the provider Form 2067, Case Information, to inform the provider that fewer service hours may be provided if the individual agrees to the reduction. In this situation, the case worker would not update the Service Authorization System (SAS) record or send Form 2065-A, Notification of Community Care Services, to the individual for a reduction of hours.

If a change in the individual's condition impedes his functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Case worker approval or denial is required for all requests to increase personal attendant services hours previously authorized or to add or delete priority status. The amount of service provided must be sufficient to meet the individual's needs.

2721.6 Authorizing and Documenting Changes

Revision 17-1; Effective March 15, 2017

All requests for changes in services, whether received from the individual or the provider, must be documented in the case record. Documentation may be on Form 2067, Case Information, or recorded in the case record narrative. Form 2058, Case Activity Record, may be used as well as other case narratives. Form 2314, Satisfaction and Service Monitoring, may also be used, but is not required for changes.

Make all necessary changes in the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. To authorize changes in priority level and/or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the individual if the:

Document the outcome of the request for the change in the case record. If it is determined that no revision is needed in the service plan, document the decision and the reasons in the case record. If the provider or regional nurse requested the change, use Form 2067.

2722 Individual Moves and Case Transfers

Revision 17-1; Effective March 15, 2017

At times, an individual's move requires transferring the individual's case to a new case worker within the same region or a different region.

When an individual moves to an area served by a different case worker within the same region or outside the region, the case remains open and the existing service plan stays in effect until a new plan is implemented. Every effort should be made to minimize gaps in coverage for the individual. Although the old plan remains in effect until amended, actual services may in some cases have to be temporarily suspended. For example, the new area/region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility. The case worker who is notified of the move should initiate the action for the transfer.

2722.1 Procedures If the Losing Case Worker Initiates Action

Revision 17-8; Effective September 1, 2017

If the current case worker (losing case worker) is contacted by the individual (or individual's representatives) and the individual has not already moved, it is that case worker's responsibility to:

2722.2 Procedures If the Gaining Case Worker Initiates Action

Revision 17-3; Effective May 15, 2017

It is the gaining case worker's responsibility to:

2722.3 Additional Procedures

Revision 17-1; Effective March 15, 2017

The regional nurse does not need to give prior approval unless a reassessment is being conducted at the same time the transfer is being done, and then a copy of Form 2101, Authorization for Community Care Services, needs to be forwarded to the regional nurse with the transfer agency information.

The provider does not have to obtain new physician's orders for prior approval from the regional nurse for a transferring case.

2723 Freedom of Choice

Revision 17-3; Effective May 15, 2017

In areas where there is more than one provider for a specific service, allow the individual the freedom to choose/change providers without restriction.

When an individual requests to change providers, the case worker must first determine the individual's reason for dissatisfaction and whether the individual's satisfaction can be met without the provider change. The case worker completes the following steps within fourteen days of the individual's request:

  1. Ask the individual or his representative to select a new provider, and document the choice.
  2. Contact the gaining provider before the transfer occurs to determine when services can begin.
  3. Update the information on Form 2059, Summary of Client's Need for Service.
  4. Update Form 2101, Authorization for Community Care Services, by entering:
    • the nine-digit vendor provider number; and
    • a statement in the comments section that this is an individual-requested change of providers and the effective date of the change.
  5. Send the new provider Form 2110, Form 2059 and Form 2101.
  6. For non-Community Attendant Services (CAS) cases, send the current (losing) provider a copy of Form 2101 that reflects the effective date of the transfer.
  7. On CAS cases where the change is being made in conjunction with an annual reassessment, the regional nurse will:
    • update Form 2101 upon receipt; and
    • send the updated form that shows the effective date of the transfer to the new provider.

The case worker will send the current (losing) provider a copy of the updated form that reflects the effective date of the transfer.

In situations in which the individual has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC case worker must determine how much information to share with the new provider regarding the previous actions. See Section 2840.1, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for Individuals Denied SSI

Revision 17-1; Effective March 15, 2017

In almost all instances, receipt of Supplemental Security Income (SSI) entitles an individual to Medicaid. In most instances, loss of SSI eligibility also means loss of Medicaid benefits. There are several exceptions to this, however, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCAD individual receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the individual to apply to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for an eligibility determination. Send a referral to the MEPD specialist if the individual is interested.

2725 Certificates of Insurance Coverage

Revision 17-1; Effective March 15, 2017

Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health insurers, including Medicaid, furnish certificates of creditable coverage whenever an individual ceases coverage under a plan or policy. The purpose of the certificate is to provide evidence that the individual had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the individual may obtain.

This legislation will affect community care individuals who are Medicaid recipients. Information regarding certificates of coverage is provided to CCAD applicants and individuals on Page 2 of Form 2065-A, Notification of Community Care Services.

Texas Medicaid & Healthcare Partnership (TMHP) is the contractor that produces these certificates for denied Medicaid individuals. If an individual has questions about the certificate or needs a replacement certificate, he should write or call TMHP.

2730 Special Procedures for Helping Individuals Enter or Leave a Nursing Facility, Institution, or Hospice

Revision 17-1; Effective March 15, 2017

2731 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

Some individuals living in their own homes may need counseling about the available options for receiving long-term care, including nursing facility placement. Caregivers of individuals who have heavy care needs may experience severe stress or be unable to continue the duty for weeks and months without reprieve. Individuals may be at risk if they remain in their current environments. Assess these situations from the standpoints of both the individual's safety and the caregiver's ability to withstand the stress of constant care. Offer them the opportunity to consider nursing facility care.

If an individual wants to enter a nursing facility, help him make his plans. If the individual is not a Medicaid recipient, refer him to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as quickly as possible.

If an individual lacks family or a responsible person to help him with all the final activities involved in moving into a nursing facility, help him by involving his friends and other volunteers.

Nursing Facility Care for Individuals Under Age 22

State Law (Chapter 242, Health and Safety Code) requires that the Community Resource Coordination Group (CRCG) be notified no later than the third day after the date a Community Care for the Aged and Disabled child under age 22 with a developmental disability is initially placed in an institution.

The name and telephone number of the CRCG contact person may be obtained by calling the CRCG State Office at 512-206-4564. A CRCG list is also available via the Internet at:

https://crcg.hhs.texas.gov/faq.html.

If notice is received of an initial placement of a child in an institution, contact the person making the placement to ensure that family members of the family are aware of:

2732 Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

2732.1 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

A batch process is in place that closes the service authorization records for Community Care individuals who have entered a nursing facility. When Form 3618, Resident Transaction Notice, is submitted by the nursing facility, all Service Authorization System (SAS) authorization records, except Service Code 20-Emergency Response Services, are closed by an automated batch process that occurs five times a week.

The batch process uses the date in Item 11 (Date of Above Transaction) on Form 3618 as the end date of the service authorization. A daily report is generated and posted to the Claims Management Project Documents website.

Regional Claims Management System (CMS) coordinators must access the reports and notify case workers when they have individuals whose service authorization records are closed by the batch process. Case workers must monitor these cases for 30 days until it is determined whether the individual's nursing facility stay will be long term. If the individual will be remaining in the facility, the case worker closes the remaining Service Code 20 record, if applicable.

2732.2 Individuals Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

For individuals being discharged from a nursing facility who are to begin receiving Community Care services, Provider Claims Services has established a hotline number to call to close the nursing facility authorization. The hotline number is 512-438-2200. Select Option 1.

The case worker should call the hotline directly to request the nursing facility record in the Service Authorization System (SAS) be closed so Community Care services can be authorized. The case worker will no longer contact the regional Claims Management Services (CMS) coordinator for this action. The case worker must confirm the individual has been discharged from the facility and Community Care services are negotiated to begin on or after the date of discharge.

When calling the hotline, the case worker must identify himself as a Texas Health and Human Services Commission (HHSC) employee and report that the individual has discharged from the nursing facility and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SAS, including the Service Code 60. The case worker documents the contact in the case record.

2732.3 Individuals Denied a Determination of Medical Necessity

Revision 17-1; Effective March 15, 2017

When a Medicaid nursing facility resident is denied a determination of medical necessity, Texas Medicaid & Healthcare Partnership (TMHP) sends a denial letter to the individual and the individual's physician. The facility and the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are notified via TMHP's weekly status report.

If the individual requests CCAD services, respond to this request by following the usual intake procedures, including interviewing and assessing needs. If the individual is determined eligible to receive CCAD services but prefers to receive services outside the intake unit's geographical area, the intake unit staff refers the case to the appropriate case worker or region. When CCAD staff receive an out-of-town referral or inquiry, they help with alternate placement activities.

2732.4 Promoting Independence Initiative

Revision 17-1; Effective March 15, 2017

Promoting Independence (PI) Initiative, enacted by House Bill 1867 of the 79th Session of the Texas Legislature, is intended to ensure a system of services and supports that fosters independence and productivity, and provides meaningful opportunities for the elderly and people with disabilities to live in their home communities.

Money Follows the Person (MFP) is available for persons requiring waiver services. It allows Medicaid funds that are being used to pay for the individual's care in a nursing facility to be transferred to pay for Medicaid waiver services in the community. Individuals identified as using MFP-funded services do not use regional interest list allocations.

MFP does not apply to non-waiver community care services.

For additional information, see the appropriate program handbook for the desired community care or waiver service.

2733 Individuals Receiving Services through Local Authorities

Revision 17-1; Effective March 15, 2017

Local Authorities (LAs) specialize in working with persons who have intellectual developmental disabilities (IDDs), intellectual disabilities (IDs) or persons with mental illness, especially those who are in crisis situations. Close coordination with LA is vital to ensure the safety and well-being of the individual and others. Contact the local LA agency to determine what procedures to follow to obtain permission from the individual to discuss his case with LA staff.

The liaison case workers at the LA community center are responsible for helping individuals with IDD/ID with the process of admission to or discharge from state supported living centers or intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID). Refer to the appropriate liaison worker any persons requesting or requiring entry into these facilities. Liaison case workers also have primary case management responsibility for individuals with IDD/ID who return to the community from state supported living centers. Contact liaison workers for specific information about their responsibilities and about the availability of LA resources for individuals with IDD/ID.

Persons discharged from state hospitals are referred to the appropriate LA community center or outreach program for follow-up. LA case management services are available to them if they meet eligibility and priority criteria. Contact the liaison worker for specific eligibility information. These individuals may also apply personally for CCAD services.

If there is no LA case worker assigned to the individual's case, contact the local LA agency to discuss the individual's condition. Refer the individual to them for services, assistance and/or case management, if appropriate. Include the LA case worker in the development of the individual's CCAD service plan and clearly define the case worker's roles and responsibilities in managing the case. Encourage the LA case worker to offer support counseling and training to the:

Keep the LA case worker informed of changes in:

Document in the case record contacts with LA staff, including any agreements reached.

Refer to Appendix XV, Services Available from Other State Agencies, for a list of the services that may be available through the LA agency.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2734 TDC Individuals Leaving TDC

Revision 17-1; Effective March 15, 2017

Texas Department of Corrections (TDC) staff are responsible for discharge planning for elderly or disabled persons being released from TDC. TDC tries to make a referral at least 30 days before the inmate is to be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the individual in the community and provides or arranges for other services he may need. Follow the usual case management procedures to certify the individual eligible for services, to refer his case for service, and to monitor or evaluate any services authorized.

2735 Individuals Who Need Hospice Services

Revision 17-1; Effective March 15, 2017

Medicare and Medicaid hospice services are available to terminally ill Medicare/Medicaid eligibles who file an election statement with a particular hospice. Hospice applicants must be certified as terminally ill (six months or less to live) by a physician. For dually eligible individuals who elect hospice care, coverage is concurrent for the Medicare and Medicaid programs. Hospice care is also available on a private-pay basis.

Hospice staff contact the case worker by telephone concerning the start and cancel dates for hospice care. Hospice staff will no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. Individuals may elect or cancel hospice care at any time.

Individuals electing hospice may be eligible for services through HHSC as long as there is no duplication in the services delivered. A Medicaid recipient, age 21 and older, who elects Medicaid hospice, waives his rights to other programs with Medicaid services related to the treatment of the terminal illness. The Medicaid recipient does not waive his rights to services offered by HHSC that are unrelated to the treatment of the terminal illness. Individuals under 21 years of age who elect hospice do not waive rights to Medicaid services related or unrelated to the terminal illness.

HHSC case workers must follow up with the individual receiving services to determine what hospice will provide and adjust the individual’s service plan to assure no duplication of services. Case workers must respond to a notification of hospice election within the time frames of a change request.

The unmet need policy in Section 2433, Determining Unmet Need in the Service Arrangement Column, does apply to hospice individuals. Coordinate any CCAD service plan with the hospice provider to prevent duplication and to assure adequate services to the individual. If an individual's need for help with a particular task is adequately met by the hospice provider, do not authorize purchased services for that task.

If the need for help will not be met by the hospice provider, or if the need will be only partly met, authorize services on the same basis used for any other individual.

Case workers may receive a request to initiate a CCAD service for an individual who is already receiving that service from a hospice. In this case, it must be determined whether the hospice will continue to provide the needed care. Authorize the CCAD service if the hospice service will end on a particular date, or if the hospice provider will provide the service only until the CCAD service can begin. Coordinate service initiation and ending dates with the hospice provider in order to prevent a break in services. When a CCAD individual enters a nursing home under hospice, terminate CCAD services effective the date the individual entered the facility. If the individual receives hospice care at home, making reduction or termination of CCAD services necessary, give the individual the usual 12-day advance notice before the effective date of the reduction or termination.

If an HHSC individual with Medicaid for the Elderly and People with Disabilities (MEPD) eligibility determination (Community Attendant Medicaid Hospice Program Services) enters a nursing facility under Medicaid hospice, the HHSC case worker notifies the MEPD staff of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In relevant situations, consider hospice services as a resource available to CCAD applicants and individuals. Monitor CCAD individuals on an ongoing basis to determine whether they need or are receiving hospice services.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2736 Complaints, Grievances or Suggestions

Revision 17-1; Effective March 15, 2017

The applicant or individual has the right to lodge a complaint, voice a grievance or recommend changes in policy or service without restraint, interference, coercion, discrimination or reprisal. Staff must:

2736.1 Reporting Service Delivery Issues

Revision 17-9; Effective September 15, 2017

Program provider service delivery issues may be reported to the Health and Human Services (HHS) Office of the Ombudsman. These reports may be generated by:

Service delivery issues include any dissatisfaction expressed by the individual regarding a service delivery provider. The individual may express dissatisfaction about:

This list is not all inclusive.

Complaints of a regulatory nature about nursing facilities, home and community support service agencies, intermediate care facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, and Home and Community-based Services and Texas Home Living providers should be reported to Consumer Rights and Services at 1-800-458-9858 or crscomplaints@hhsc.state.tx.us to generate an investigation by Regulatory Services.

Within five working days of receiving a report or becoming aware of service delivery issues, the case worker must respond to the individual and the provider either by phone or face-to-face contact to discuss the issues. The case worker must inform the provider of the service delivery issues and discuss resolutions. The case worker convenes an interdisciplinary team (IDT) meeting, if appropriate. The case worker coordinates with the individual and provider to implement actions required to resolve the issues. The case worker must document the receipt of the report and contacts with the individual and the provider in the case record. The case worker must document any barriers or hindrance by either party that interferes with resolution of the issues. The resolution of the issues and/or attempts to resolve the issue must be documented.

If service delivery issues cannot be resolved within 10 working days of the initial receipt of a report or becoming aware of service delivery issues, the case worker must:

The case worker must make the report to the HHS Office of the Ombudsman within three working days after the 10-working-day resolution period ends.

In situations where service delivery issues may compromise the individual's health and safety, the case worker must report as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case worker must also contact Adult Protective Services (APS) or Child Protective Services (CPS) within 24 hours if there is an immediate or imminent threat to the health and safety of the individual. The case worker must continue to work with the individual and provider to resolve the issues within the 10-working-day time frame.

The case worker must identify the specific service the provider is delivering when calling to report a complaint. For example, the case worker identifies the provider as a "Primary Home Care provider" when making a referral that involves Primary Home Care service delivery issues. The case worker must provide specific information related to the service delivery issue, including actions taken to resolve the issues and why the actions did not resolve the issues.

2740 Fraud Detection and Documentation

Revision 17-1; Effective March 15, 2017

2741 Provider Fraud

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

Examples of provider fraud include (list is not all-inclusive):

2742 Responding to Allegations of Provider Fraud

Revision 17-1; Effective March 15, 2017

When an allegation of provider fraud is received, staff should follow these procedures:

2743 Individual Fraud

Revision 17-1; Effective March 15, 2017

Individuals receiving Long Term Care Services are perceived honest and entitled to the same protection under the law as all other individuals. However, when there is indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

Examples of individual fraud include (list is not all-inclusive):

2744 Responding to Allegations of Individual Fraud

Revision 17-1; Effective March 15, 2017

When potential individual fraud is discovered, staff should follow these procedures:

  1. Record all pertinent facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct,
    • what the suspected violation was,
    • when the conduct occurred (dates or time periods),
    • where the conduct occurred,
    • how the fraudulent action was performed, and
    • the names of individuals with knowledge of the situation and how they can be contacted.
  2. If fraud is alleged by a third party, staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
  3. Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

Restitution must not be requested in cases where fraud is being pursued. Restitution is securing payment from an individual when fraud is not indicated. Once restitution is requested, you cannot refer the case for fraud.

2745 Reporting Suspected Fraud in the Consumer Directed Services Option

Revision 17-1; Effective March 15, 2017

Following are established procedures for reporting suspected fraud in the Consumer Directed Services (CDS) option to the Office of Inspector General (OIG). This applies when there is suspected fraud committed by the individual receiving services, the CDS employer or the CDS employee. This does not apply to provider fraud.

When the HHSC case worker suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, or is made aware of suspected fraud from an entity other than the Financial Management Services Agency (FMSA), the case worker must report the suspected fraud to the OIG. The case worker can submit the referral using the OIG website, https://oig.hhsc.state.tx.us/wafrep/, or by calling 1-800-436-6184. The case worker must inform the OIG the individual is using the CDS option.

If the case worker does not receive a referral number after submitting the information on the OIG website, it means the referral may not have transmitted successfully. The case worker must call 1-800-436-6184 to confirm the OIG received the referral and ask for the referral tracking number. The case worker must document the suspected fraud and referral information on Form 2058, Case Activity Record.

Once the case worker submits the fraud referral to the OIG, the case worker must inform the FMSA about the suspected fraud and that a referral was made to the OIG using Form 2067, Case Information. The case worker must also send a secure email to CDS Operations staff, cds@hhsc.state.tx.us, at state office containing the following information for tracking purposes:

When an FMSA suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, the FMSA will make a referral to the OIG. The FMSA will inform HHSC CDS Operations staff at state office that the FMSA submitted a fraud referral to the OIG for tracking purposes.

The FMSA will also inform the HHSC case worker that a fraud referral was submitted to the OIG using Form 2067. The case worker must file Form 2067 received from the FMSA in the individual’s case file. No further action is needed by the case worker regarding the fraud referral once the FMSA notifies HHSC the referral was made to the OIG.

2750 Fraud Referral

Revision 17-1; Effective March 15, 2017

2751 Development of the Fraud Referral Packet

Revision 17-1; Effective March 15, 2017

Consult the unit supervisor for guidance in determining the appropriateness of the referral and the information being provided. If it is decided that a referral is to be submitted, complete the online reporting document, Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, available at https://oig.hhsc.state.tx.us/Fraud_Report_Home.aspx. The online reporting system will prompt the user to enter:

Once all of the information has been entered, the system will allow users to print the information to be included in the referral packet.

2752 Expedited Referrals

Revision 17-1; Effective March 15, 2017

If staff have reason to believe that the conduct of the suspected provider, individual or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the unit supervisor must first be consulted. An expedited referral should be made when a delay would:

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit at 512-436-6184 before the referral packet is produced. The HHSC representative will instruct staff as to what portions of the required information should be completed and sent.

2753 Referral of Potential Fraud

Revision 17-1; Effective March 15, 2017

If the unit supervisor determines that the criteria for fraud exists, a fraud referral to the Texas Health and Human Services Commission (HHSC) Medicaid Program Integrity Unit is initiated (even if the potential fraud does not affect Title XIX funds). Mail the referral packet to:

Office of Inspector General
Mail Code 1361
P.O. Box 13247
Austin, TX 78708-5200

HHSC is responsible for ensuring that all pertinent information is obtained and may subsequently request additional information. Providing requested material to the HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. Continue to maintain the case as usual. HHSC staff should preserve a professional working relationship with the provider, individual or authorized representative while the fraud referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.

2800 Notifications, Suspensions, Denials and Terminations

Revision 17-1; Effective March 15, 2017

2810 Individual Notification Procedures

Revision 17-1; Effective March 15, 2017

Program Standard: Notify the individual in writing using Form 2065-A, Notification of Community Care Services, of all eligibility/ineligibility decisions or any changes in the individual's service plan, to include: addition of service(s), increase or decrease in hours, increase or decrease in copayment, or loss of priority status based on the individual's request within two business days of the decision.

When notifying the applicant of eligibility, specify on Form 2065-A:

An applicant/individual certified for one CCAD service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the hours per week or meals per week he is eligible to receive. If certified for DAHS, the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

For ongoing individuals, on Form 2065-A, record the:

If the notification is an adverse action, the notice must also state the:

See the Form 2065-A Attachment for handbook and rule references.

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

2811 Effective Dates

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker notifies the applicant or individual in writing of any action that denies, suspends, reduces or terminates services. The HHSC case worker sends the notice of adverse action to the individual 12 calendar days before the effective date of the action, except in situations in which services have been suspended due to threats to health and safety. In those situations, the HHSC case worker sends the written notice of adverse action without advance notice if the crisis cannot be resolved.

An applicant or individual has the right to appeal any decision that denies, reduces or terminates his services and request a fair hearing in accordance with Title I, Texas Administrative Code (TAC) §357.

For information about calculating effective dates of reduction or termination of services, see Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation.

In general, the effective date of the reduction in services is 12 calendar days after the Form 2065-A, Notification of Community Care Services, date. The effective date of an increase in hours is seven calendar days after the Form 2101, Authorization for Community Care Services, date. For an adverse action, if the day after the effective date is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. (See Appendix XVIII.)

The date at the top of Form 2065-A is the date the HHSC case worker completes the form. Since offices have different mail pickup times, staff are not required to consider the mail date when completing the form. Staff must ensure applicants and individuals are notified within the required time frames.

Services will be reduced or terminated at annual reassessment, or any other time the case worker becomes aware before the annual review, when the individual:

An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits. The effective date of the action depends on the situation, as shown in the following table:

If . . . Then . . .
Termination or reduction is because client lost his eligibility as an income eligible, failed to qualify as an income-eligible after a verbal referral, failed to meet the client needs assessment score or medical criteria for the service, repeatedly (more than three times), directly or knowingly and passively condoned the behavior of someone in his home and thus, refused to follow the service delivery provisions, experienced a change in his need for the specific service, or failed to pay fees for services, The action is effective 12 days from the date of the notice unless the action is appealed. In the event of appeal, services continue until the hearings officer gives a decision. The cost of providing services during this period is subject to recovery by the department from the client. Services to clients in Residential Care facilities are terminated five days after the hearings officer gives his decision.
Termination is because client lacks TANF, SSI, Medicaid, or Supplemental Nutrition Assistance Program eligibility, Services continue only to the end of the month that the client is determined ineligible, even if the action is appealed.
Termination is because client lacks physician's orders for the service, Services continue only through the date the previous orders end, even if the action is appealed.
Termination or reduction is because of budgetary constraints or changes in federal law or state regulations, and services are reduced or terminated for an entire categorical client group, Services continue only through the date of termination of a categorical client group, even if appealed.
Termination is because the client or someone in his home threatens the health or safety of others, or because the client threatens his own health or safety. Services may be terminated immediately under the following conditions:
  • a client receiving Residential Care, Adult Foster Care, DAHS, or special services to persons with disabilities threatens his own health or safety or that of others, or
  • someone in the client's home or an individual receiving Emergency Response Services, Home-Delivered Meals, waiver services, Family Care, Primary Home Care, or special services to persons with disabilities threatens the Texas Health and Human Services Commission (HHSC)  staff or provider's health or safety.

2812 Changes in the Individual's Need for Services

Revision 17-1; Effective March 15, 2017

Case workers determine if the individual's long-term improvement is expected to last through the current authorization period or beyond, before reducing or terminating services.

If it is determined that the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week.

Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition. If the individual feels he temporarily needs fewer hours, send the provider Form 2067, Case Information, informing the provider that fewer service hours may be provided if the individual agrees to the reduction. If the individual is experiencing temporary functional improvement, the case worker would not change the task/hour guide or authorization, or send Form 2065-A, Notification of Community Care Services, to the individual for reduction of hours.

The individual and provider may agree to change the delivery schedule for personal attendant services (PAS) hours based on the individual's needs without prior approval from the case worker.

Case worker approval or denial is required for all requests to increase PAS hours previously authorized or to add or delete priority status. In these situations, terminate or reduce services 12 calendar days after the Form 2065-A completion date.

2813 Situations in Which the 12-Day Adverse Action Period May Be Reduced

Revision 17-1; Effective March 15, 2017

There may be situations when an individual wants to waive or shorten the 12-day notice period before services are reduced or terminated. Some examples of applicable situations include the following:

If the individual indicates a desire to waive or reduce the 12-day advance notice, be very cautious and remember that an individual may change his mind. In most instances, the provider can be verbally notified to stop service and still maintain the formal effective date 12 calendar days in the future.

If the individual still wants to waive or shorten the 12-day advance notice, complete Form 2065-A, Notification of Community Care Services, with the effective date being the date the individual wants services to end or be reduced. Explain in the comments section that the individual is voluntarily waiving or reducing his right to the 12-day advance notice. The individual must:

2814 Transfers Between Primary Home Care, Community Attendant Services and Family Care

Revision 17-1; Effective March 15, 2017

Send Form 2065-A, Notification of Community Care Services, when an individual is transferred from Primary Home Care (PHC) or Community Attendant Services (CAS) to Family Care (FC) or FC to PHC or CAS. Do not send another form to terminate the previous service. Specify on the form the:

Indicate in the comments section that the individual should not notice any difference in the amount or type of services received because of this transfer.

Example:
The service you were receiving, Primary Home Care, 16 hours a week, will change to Family Care, 16 hours a week, effective June 1, 2010.

Comments: Primary Home Care will terminate because you lost financial eligibility for that program. You should not notice any difference in the amount or type of services you will receive because of this transfer.

Although Form 2065-A must be sent when an individual transfers between PHC, CAS and FC, the effective date is either the negotiated date or the date following the Medicaid end date.

See Section 4600, Primary Home Care and Community Attendant Services, for additional transfer procedures.

Refer to Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation, for other exceptions to the 12-day notice requirement. The effective date of the transfer does have to be at least 12 days following the date of notification if the number of hours is decreased.

 

2820 Service Suspensions

Revision 17-1; Effective March 15, 2017

Services may be suspended by the provider or by the case worker.

2821 Service Suspension by Providers

Revision 17-1; Effective March 15, 2017

Providers may suspend services to individuals before the service approval period ends. See Section 4000, Specific CCAD Services, for information about suspension of each specific service.

On the day of suspension or by the first Texas Health and Human Services Commission workday following suspension, the provider must contact the case worker to explain the reason for suspending services. The Emergency Response Services provider must submit written notification (Form 2067, Case Information, optional) within five workdays of the oral notification or suspension of services.

If an individual meets the criteria for Adult Protective Services, refer him accordingly. Refer other individuals to other appropriate service resources as needed.

The case worker documents in the case record the incident that caused the suspension and the date of the incident. The results of any related interdisciplinary team meetings must be included in the documentation. After evaluating suspensions to determine whether services should be terminated and the case closed, the case worker takes the appropriate action. In some situations, the problems that caused the suspension can be resolved. If they are resolved:

2822 Service Suspension by Case Workers

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

(c) A client is not eligible for CCAD services when:

(1) he dies;
(2) he is admitted to an institution;
(3) his physician requests service termination (Medicaid services only); or
(4) he requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case, or he refuses to comply with his service plan.

2822.1 Hospital and Nursing Facility Stays

Revision 17-1; Effective March 15, 2017

Unless the case worker has definite information that a nursing home or hospital stay will be longer than 30 days, suspend Community Care for Aged and Disabled services. Send Form 2067, Case Information, to the provider to suspend services effective the date of nursing home or hospital entry. It is not necessary to send updates to the provider.

The case worker must closely monitor the situation. If the individual has not returned home by the 30th day, the case worker must check with the individual to see if a discharge date has been planned. If the individual has a discharge date planned within the next 30 days, leave the case open and monitor on the planned discharge date.

If information is received that the nursing facility or hospital stay will be longer than 30 days, terminate services, using the date of admission as the effective date of termination. Exception: The effective date of termination for Residential Care or Special Services to Persons with Disabilities (SSPD) 24-hour shared attendant program should be the 30th day after admission to the nursing facility or 60 days after admission to a hospital.

In many instances, determining the length of stay will be a judgment call. Consult with the individual, family and others associated with the individual. Be cautious about terminating Title XX services, especially if the region has an interest list for those services.

Emergency Response Services (ERS) may remain open until the decision is made to terminate all services because the nursing facility stay has become permanent. See Section 4300, Emergency Response Services, for suspension of ERS by the ERS provider.

The following situations should always be considered short-term and services should be suspended for up to 30 days, rather than terminated:

Services may be suspended indefinitely if the individual is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

2830 Refusal to Comply with Service Delivery Provisions

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

Examples of refusal to comply with the service delivery provisions include, but are not limited to, the following:

If the provider notifies the Texas Health and Human Services Commission about a service delivery compliance problem, contact the individual or the responsible party. Attempt to resolve the problem in a way that is satisfactory to the individual and the parties involved. A joint staffing may be conducted at the individual's home to try to resolve the situation.

2830.1 Individuals Who Refuse to Comply with Electronic Visit Verification Requirements

Revision 17-1; Effective March 15, 2017

Individuals requesting or receiving attendant services from a Home and Community Support Services Agency (HCSSA) are required to participate in Electronic Visit Verification (EVV) by allowing the attendant to use their home landline to report the start of work and the end of work. If an individual does not have a home landline, or if the individual will not allow the attendant to use the home landline, the individual must agree to an alternate device installation in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services.

It is the case worker’s responsibility to review the information on the rights and responsibilities form and adequately explain the EVV requirements to the applicant or individual receiving services. It is important to communicate that an individual’s failure to cooperate with EVV requirements can result in the suspension or termination of services. The case worker must explain the following points:

For individuals using the CDS option, the case worker must explain that the individual receiving services, or a designated representative (DR), is the employer of record and can choose to use the EVV system or use paper time sheets. The three choices are:

The FMSA will require the employer of record to complete Form 1722, Employer’s Selection for Electronic Visit Verification (EVV), to indicate his choice.

If an individual is refusing to cooperate with EVV requirements, it is considered as a refusal to comply with service delivery provisions and policies in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, are applicable. Some individuals whose provider is required to participate in EVV are not allowing the attendant to use their home phone and are also refusing to allow a Fixed Visit Verification (FVV) device to be placed in their home.

Providers are required to participate in EVV for services delivered by an attendant. Individuals who refuse to allow the attendant to record hours worked through EVV, either through the use of their home phone or a FVV device, are non-compliant with their service delivery plan. These individuals are essentially not allowing the provider to carry out services in accordance with provider requirements.

2831 Suspensions Due to Refusal to Comply with Service Delivery Provisions

Revision 17-10; Effective October 6, 2017

The provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. After the IDT meeting, the case worker must send the individual a letter within five working days stating services can be terminated if he does not comply with service delivery provisions and stating specifically what the individual must do to continue services.

If the situation is not resolved and the individual continues to refuse to comply, the case worker convenes a second IDT and sends the individual a second notice stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues not to be resolved and a third situation arises, the case worker convenes a third IDT and must send a third and final letter to the individual stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues, the case worker may terminate services by sending Form 2065-A, Notification of Community Care Services. See Section 2810, Individual Notification Procedures. Denials based on refusal to comply with service delivery provisions must be approved by the supervisor. Document the conference and approval in the case narrative.

There is no time period during which the instances of refusing to comply must occur.

2832 Documentation of Compliance Issues

Revision 17-1; Effective March 15, 2017

Documentation in the case narrative is required in all situations involving the individual's refusal to comply with service delivery provisions. Opinions or evaluative conclusions are not appropriate documentation to substantiate a denial of services. Documentation should stress a factual statement of actions constituting noncompliance.

Determine and document whether the individual is aware of and able to understand the consequences of his or other's actions. If the individual is not aware of his behavior or the behavior of someone in his home, discuss the issues with him.

Determine if the person seems to be abusing, neglecting or exploiting the individual, and refer the individual to Adult Protective Services (APS), if necessary. Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian, to resolve the problem if the individual is abused, neglected or exploited.

Document the date and content of each discussion with the:

2833 Reauthorization of Services After Termination for Refusal to Comply

Revision 17-1; Effective March 15, 2017

If an individual's services have been terminated because of his refusal to comply with service delivery provisions that involve a provider, confer with the unit supervisor prior to referral to another. It may be necessary to discuss the individual's particular compliance issues before reauthorizing services. The unit supervisor must approve the referral. Note the approval in the comments section of Form 2101, Authorization for Community Care Services.

Follow these steps when an applicant who had been authorized services in the past, but whose services were terminated due to his failure to comply with service delivery provisions, reapplies:

  1. Before contacting the applicant, review with the supervisor circumstances of the previous denial and the steps to be taken with the applicant. Document the review in the case record.
  2. Review with the individual/responsible party:
    • the reason for the previous termination,
    • the responsibility of the individual/responsible representative to notify the provider and Texas Health and Human Services Commission (HHSC) about problems related to the service delivery provisions and the importance of good communication, and
    • each task to be authorized, emphasizing the only tasks to be performed by the attendant are those authorized by HHSC.
  3. Authorize services if the individual agrees to follow the service delivery provisions.
  4. Record the conversation with the individual in the case record narrative.
  5. Contact the individual or provider weekly for one month to assess the individual's compliance with service delivery provisions. If the individual continues to have problems complying with service delivery provisions, contact the individual and emphasize the need for him to comply.
  6. If the provider complains about the individual refusing to follow his service delivery provisions, contact the individual monthly after the first month of service. Discontinue monthly contacts when complaints cease.
  7. Terminate services if the individual refuses more than three times to comply with service delivery provisions.

2840 Threats to Health or Safety

Revision 17-1; Effective March 15, 2017

Occasionally, an individual or someone in his home might exhibit behavior that constitutes a threat to the health or safety of another person. Examples include, but are not limited to:

If, during the initial contact or any other contact by the case worker or provider staff, an individual or someone in his home exhibits threatening behavior or makes comments that are threatening, hostile or of a nature that would cause concern for the individual, provider or Texas Health and Human Services Commission (HHSC) employee, the case worker must immediately notify management. Regional management must review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's safety may be at risk, the case worker must follow current policy regarding notification to the Department of Family and Protective Services Adult Protective Services (APS). If the case worker believes there is a potential threat to others, regional management should determine the best method for notifying the provider and addressing the individual's needs without placing staff members at risk.

If an individual threatens his own health or safety by threatening or attempting suicide or self-injury and is at immediate risk, place a 911 call to report the emergency. A referral to APS must also be made. If the applicant or individual seems to be abused, neglected or exploited by the person who threatens the health or safety of others, refer the individual to APS.

In most cases where there is a potential for danger, services should be suspended immediately.

The case worker must send Form 2065-A, Notification of Community Care Services, by the next working day after receiving notice from the provider that services have been suspended for failure to comply or threats to health and safety. The notice must reference 40 Texas Administrative Code §48.3903, state the last day services are delivered, and include a clear statement in the comments explaining why services have been suspended.

Within three working days after the case worker becomes aware of the suspension, the case worker must arrange an interdisciplinary team (IDT) meeting to try to resolve the issue with the provider and the individual. Depending on the severity of the reason for the suspension, some IDT meetings may be conducted by telephone or some may require a face-to-face contact.

The case worker may conduct the IDT meeting by telephone or a face-to-face contact for all suspension reasons listed in this section. Case workers are required to discuss the specific case with their supervisors to determine the best approach for conducting the IDT. Case workers must document the rationale for conducting the IDT by telephone.

During the IDT meeting, the case worker, provider staff, the individual and the individual’s representative, if any, must evaluate the issue and discuss the program requirements for continued services. The IDT should identify any solutions to resolve the issue, including the individual’s understanding of the issue and what must be done to resolve the issue. The case worker must document the requirements for continued services. See Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, and Section 2832, Documentation of Compliance Issues, for additional guidelines.

If the issue leading to suspension is resolved during the IDT, the provider must, within two business days after the IDT meeting, either implement the recommendations of the IDT or discharge the individual and refer the individual to the case worker for referral to another provider. The case worker must notify the individual orally or in writing of the reinstatement of services. If services continue, assess if the individual meets the guidelines for an individual at risk and if so, follow procedures outlined in Section 2550, Identifying Individuals at Risk. If the issue is not resolved and services cannot be continued, the case worker begins the termination process.

2840.1 Monitoring or Annual Home Visit Delay Due to Unsafe Environmental Circumstances

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker is required to make every reasonable attempt to complete the Community Attendant Services (CAS), Primary Home Care (PHC) and Family Care (FC) service monitoring or annual reassessment visit. All attempts to contact the individual must be documented in the case record to support the efforts to meet the requirements. In some situations, the case worker is unable to make the face-to-face home visit due to a dangerous environmental situation beyond the case worker or individual’s control. These situations may include but are not limited to:

When such situations occur and the case worker feels threatened, he or she can make the home visit at another time. The case worker must immediately notify regional management of his inability to conduct the home visit. The case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain ongoing documentation of attempts to complete the visit and the reason for the delay until the monitoring visit has been completed.

If, during the home visit an individual or someone in his home exhibits threatening behavior or makes comments that are threatening or hostile, the case worker can end the service monitor or annual reassessment and reschedule for a later time. The case worker must immediately notify regional management of his or her inability to conduct the home visit. The case worker will refer to Section 2840, Threats to Health or Safety, to suspend or terminate services. If the threatening behavior is resolved, the case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain documentation of all attempts to complete the visit, along with any reasons for delays until the monitoring visit has been completed.

2840.2 Chronic Contagion/Infestation Conditions

Revision 17-1; Effective March 15, 2017

While the chronic contagious medical condition or infestation of the individual’s home may not pose an immediate danger to the health and safety of the individual, provider agency staff or case worker, either situation may adversely affect the health of all such persons involved in supporting the individual’s services and may pose a risk of exposing other individuals to the contagious medical condition or environmental infestation. Examples of unresolved chronic adverse medical or environmental related condition(s) may include the presence of bed bugs, fleas, ticks, lice or scabies.
 
The case worker must assess the individual’s ability to comply with the request to eradicate contagions or infestations and should exhaust all efforts in arranging for assistance to eradicate contagions or infestations, based upon the assessment of the individual’s capabilities. The case worker should identify available local resources which may provide the needed assistance in meeting the individual’s specific needs in relation to resolving the risks associated with the spread of the contagion or environmental infestation to others.

As stated in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, the provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. Efforts to identify local resources and natural supports to assist the individual if any such resources and supports exist, should be well documented as part of the IDT meeting. Any specific actions and responsibilities required of the individual and other persons and an agreed-upon time frame for completion of the eradication should be documented. Information from a pest control professional must be the basis in the establishment of a timeline expectation for eradication, as each situation will be unique. The specific actions and responsibilities required of the individual or other persons, such as family members or friends, who have agreed to provide support as part of the eradication plan should be documented as service provision requirements.

If the eradiation plan is not followed and the situation is unresolved, the case worker refers to Section 2830, Refusal to Comply with Service Delivery Provisions, and Section 2831 for guidance in instances in which the individual is non-compliant with service delivery provisions.

The case worker follows policy in 40 Texas Administrative Code §48.3903, (f) Denial, Reduction or Terminations of Benefits, to provide adequate notice of possible termination of services if the individual fails to cooperate with service delivery provisions.

2840.3 Active Tuberculosis (TB) Diagnosis

Revision 17-1; Effective March 15, 2017

An applicant or individual with a TB diagnosis cannot have services denied or terminated as a consequence of his disease.

Under state law, physicians must report all cases of TB to the Texas Department of State Health Services (DSHS). Upon receiving the physician's report, DSHS assigns a representative to monitor the case through "directly observed therapy." This process involves observation of the individual taking his medication; it may also involve health-related training and the provision of additional care of the individual.

For cases with active TB, a team meeting should be set up to include the regional nurse, case worker, provider and the local DSHS representative handling the case. These individuals will ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct the Texas Health and Human Services Commission to suspend the case while the TB remains active; if so, it will provide care for the individual during this period. Most individuals become negative for TB within a few weeks of drug therapy.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2840.4 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 17-1; Effective March 15, 2017

When services have been suspended due to health and safety reasons, HHSC staff are required to convene an interdisciplinary team (IDT) meeting to resolve the issues. If the issues cannot be resolved, the provider may report it will no longer serve the individual due to health and safety concerns.

In some situations, HHSC may terminate the individual’s services due to health and safety issues. In other situations, HHSC may initiate services with a new provider. If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions.

The HHSC case worker must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.

2841 Reinstatement of Services Terminated for Threats to Health or Safety

Revision 17-6; Effective June 28, 2017

An applicant whose services were terminated in the past due to his or someone in his home being a threat to the health or safety of the client, department staff, or provider agency staff may be authorized services if the applicant signs Form H0003, Agreement to Release Your Facts, authorizing release of information, and:

(1) The applicant/person in home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that he is no longer a threat to himself or others; or
(2)The applicant/person in home allows a collateral contact with his physician, psychiatrist, or psychologist and the contact indicates that the applicant is no longer a threat to himself or others; or
(3)The person in the home who posed the threat no longer poses the threat.

Complete the eligibility determination in the Service Authorization System Wizards within 30 calendar days after the date the signed application is received by the department. (See Section 2344, Individual Rights and Responsibilities.)

2841.1 Sharing Information on Previous Actions for Reinstatement

Revision 17-1; Effective March 15, 2017

If an individual who has been previously terminated from services due to health and safety reasons reapplies for services and meets the requirements in Section 2841, Reinstatement of Services Terminated for Threats to Health and Safety, information may need to be shared with a newly selected provider.

If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions that resulted in termination of services. The case worker must share sufficient information with the new provider to avoid putting the provider at risk and allow the provider to adequately plan for safely delivering services to the individual. This includes selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.

2900 Appeals and Fair Hearings

Revision 17-1; Effective March 15, 2017

2910 Individual’s Right to Appeal and Request a Fair Hearing

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903

(a) An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits.
(b) A client is entitled to be notified 10 days before any reduction or termination of his services, or to have the notification mailed 12 days before the date of reduction or termination. If a client threatens his own health or safety or that of others, purchased services may be terminated without advance notice.

Inform the applicant/individual in writing by sending Form 2065-A, Notification of Community Care Services, about his right to request a fair hearing if services are denied, reduced or terminated. An individual may appeal his dissatisfaction concerning

An individual also may appeal when the individual requests a new service, or requests an increase in the number of tasks or units of service, and the request is not acted on within required time limits.

To request a hearing, an individual may return Form 2065-A with a check mark in the appropriate box, or the individual may make an oral or written request for a fair hearing.

An individual must request a fair hearing within 90 days from the date of the action he wants to appeal. To continue receiving benefits until the hearings officer gives a decision, the individual must request the fair hearing before the effective date shown on Page 1 of Form 2065-A. In situations where services were terminated because of threats to the health or safety of another person, the individual is not entitled to continued services even if appealed before the effective date shown on Page 1 of Form 2065-A. (See Section 2811, Effective Dates, and Appendix IX, Notification/Effective Date of Decision, for guidance on effective date of termination in which the individual is not entitled to continued benefits.)

When a fair hearing is requested after the 90 day time period, HHSC staff may not prevent an applicant or individual from filing an appeal because they believe the appeal was not requested within the required number of days. If a fair hearing request is received after 90 days from the date of the notice, the case worker must follow current procedures to file the appeal. The hearings office will make the decision regarding the individual’s right to appeal.

The hearings officer is the final authority regarding the timeliness of appeal requests and accepts appeals filed after the time limit in order to determine whether there was good cause for the delay in filing.

2911 Notice to the Provider for Continuing Services

Revision 17-1; Effective March 15, 2017

If the individual appeals before the effective date on Page 1 of Form 2065-A, Notification of Community Care Services, the case worker must continue services at the current level pending the hearings officer’s decision, unless denial is based on threats to health and safety. (See Section 2840, Threats to Health and Safety). Within three business days after receipt of the request for a fair hearing, the case worker must complete a new Form 2101, Authorization for Community Care Services, in the Service Authorization System (SAS) reinstating services at the current level. The case worker sends Form 2101 to the provider notifying them to provide services at the current level until the hearings officer’s decision is rendered. The “Begin Date” of services is the day after the termination date or reduction date on the previous Form 2101. The case worker also sends Form 2067, Case Information, informing the provider to reinstate services pending the hearings officer’s decision.

Example 1: At the annual reassessment, the case worker determines the Primary Home Care personal attendant services (PAS) hours must be reduced from 20 hours per week to 15 hours per week. The case worker sends Form 2065-A to the individual and Form 2101 to the Home and Community Support Services Agency (HCSSA) as notification of the reduction in hours. The individual appeals before the effective date of the case action. The case worker authorizes PAS at 20 hours per week until the hearings officer’s decision is rendered.

When all services are terminated, such as at the annual reassessment when the individual does not meet eligibility criteria, case workers must continue services at the current level when the individual files an appeal before the effective date.

Example 2: At the annual reassessment, a Family Care individual is terminated due to scoring 21 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The case worker sends Form 2065-A to the individual and Form 2101 to the provider as notification of the termination of services. The individual appeals before the effective date of the case action. The case worker authorizes services at the same level as the previous Form 2101 authorization.

When the individual submits a clear, written statement requesting services stop during the appeal process, the case worker sends Form 2067 to the provider with an effective date to stop service delivery. The case worker does not send the individual another Form 2065-A.

HHSC does not continue services during the appeal process if Medicaid eligibility has been terminated, unless Medicaid eligibility is reinstated during the appeal period. Refer to Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 2932, Coordination of Fair Hearings with MEPD Utilizing OES CRU, for procedures related to Medicaid terminations and continuation of services.

2912 Special Procedures for Denials of Community Attendant Services (CAS) Individuals

Revision 17-1; Effective March 15, 2017

Denials of CAS individuals must be coordinated with both the HHSC regional nurse and with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. If the HHSC case worker denies the individual based on functional need, Form H1746-A, MEPD Referral Cover Sheet, must be sent to advise MEPD of the denial.

If the individual appeals the denial, another Form H1746-A must be sent to MEPD advising that services will be reinstated pending the fair hearings officer’s decision. MEPD must also be notified on Form H1746-A when a decision is rendered.

If the change that prompted the request for an appeal on a Community Attendant Services decision occurred in the course of an annual reassessment, use Form 2067, Case Information, to notify the provider and the HHSC regional nurse. The HHSC regional nurse submits Form 2101, Authorization for Community Care Services, to reinstate services.

2913 Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings

Revision 17-1; Effective March 15, 2017

HHSC case workers must notify the utilization review (UR) nurse and UR regional manager when an applicant or individual has requested a fair hearing as a result of UR findings for concurrent reviews.

Case workers must follow normal time frames and procedures for implementing UR findings following receipt of a UR tool indicating a case action is required. When the action is completed for an addition/increase in services or termination/decrease in services, the case worker must send a notice to the applicant or individual notifying him of the case action. The applicant or individual has the option to appeal the case action indicated on the notice. Case workers must follow current policies and procedures regarding continuation of services pending an appeal.

If the applicant or individual requests a fair hearing, the case worker must inform the UR nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR findings. The case worker will complete Form H4800, HHSC Fair Hearing Request Summary, and send the form to the Hearing Division and supervisor within three days of the request for a hearing.

On Form H4800, the case worker will list the UR nurse, Agency Representative, UR regional manager, and Agency Representative Supervisor. The case worker may be listed. The case worker must confirm the correct UR nurse and UR regional manager to list on the form. The case worker includes the UR nurse whose name is located in Section A of the UR tool. The case worker identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The designated data entry representative (DER) will be responsible for uploading the case worker’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The evidence packet submitted by the case worker will include the applicable notification form. If available, the case worker includes the signed notification form returned by the applicant or individual. The case worker does not include any other documentation in the evidence packet.

The UR nurse and UR regional manager will develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or individual. The evidence packet will include a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for each fair hearing evidence packet. The DER and UR representative must upload the fair hearing evidence packets in TIERS no later than 10 calendar days prior to the fair hearing date. The case worker and UR nurse must forward a copy of the fair hearing evidence packets to the applicant or individual no later than 10 calendar days prior to the fair hearing date.

The UR nurse, UR regional manager (optional) and case worker will participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony regarding the case action.

2913.1 Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered

Revision 17-1; Effective March 15, 2017

When a case record is selected for concurrent review and a fair hearing is pending, the case worker must inform the Utilization Review (UR) nurse that a fair hearing is pending. The case worker does not submit the case record for concurrent review. UR will then replace the case with another randomly selected case record for concurrent review.

When a case record is selected for concurrent review and a fair hearing decision has been rendered during the current plan year, the case worker must inform the UR nurse of the fair hearing decision details by providing the UR nurse with a copy of the final order submitted by the hearings officer. The case worker must provide specific information to the UR nurse about the service(s) appealed and the actions the case worker took to implement the hearings officer’s decision. The case worker submits the case record for concurrent review following current procedures. The case worker will follow current policy and procedures for implementing UR findings.

2914 Withdrawal of an Appeal

Revision 17-1; Effective March 15, 2017

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. HHSC staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts HHSC staff regarding the withdrawal, HHSC staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to HHSC staff, HHSC staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on an HHSC decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify HHSC by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and a written notice will be sent to participants informing them of the fair hearing cancellation.

2920 Request for Increase in Services During an Appeal

Revision 17-1; Effective March 15, 2017

When services are reduced or terminated, such as at the annual reassessment, and the individual files an appeal before the effective date of the reduction or termination, the case worker must continue services at the current level until the hearings officer’s decision is rendered. If the individual requests increased services pending the hearings officer’s decision, the case worker cannot process the request. Within 14 calendar days of the request, the case worker must send the individual Form 2065-A, Notification of Community Care Services, explaining the request for increased services is denied pending the hearings officer’s decision and may be reviewed for authorization once the hearings officer’s decision is rendered, if the individual is determined eligible.

2930 Fair Hearing Procedures

Revision 17-1; Effective March 15, 2017

All fair hearings are processed through the Fair and Fraud Hearings section of the Appeals Division of the Texas Health and Human Services Commission (HHSC). The appeals division receives appeal requests from applicants and individuals contesting actions taken regarding benefits and services of various programs. These include the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program), Temporary Assistance for Needy Families, all Medicaid-funded services, and other agency programs that are required by state or federal law, or rules, to provide the right to a fair hearing. Hearings officers conduct hearings, consider evidence and issue decisions in accordance with rules, regulations and state and federal law.

See the HHSC Fair and Fraud Hearings Handbook for specific information regarding the HHSC rules and requirements governing the fair hearings process.

2931 Processing Fair Hearing Requests Using TIERS

Revision 17-1; Effective March 15, 2017

When a request for a fair hearing is received from an applicant or individual orally or in writing, the Texas Health and Human Services Commission (HHSC) must refer the request to the hearings officer within five calendar days from the date of the request. Information is not mailed to the hearings officer, but is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by the designated data entry representative.

Upon receipt of the fair hearing request, the case worker completes Form H4800,  Fair Hearing Request Summary.

The case worker sends Form H4800 to the Hearing Division and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the TIERS system. See the Form H4800 Instructions for specific directions for completion and transmittal.

Designated Data Entry Representative Procedures

Within two calendar days of receipt of Form H4800, the data entry representative enters the information into the Fair Hearings and Appeals system in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry representative will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the case worker and supervisor.

HHSC Fair Hearings and Appeals Procedures

The TIERS system will generate a hearing packet which includes Form H4803, Notice of Hearing, and Form H4800. The case worker and supervisor will receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the hearing. It is the supervisor's responsibility to ensure that the case worker or a designated representative participates in the hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

If Form H4800 has already been submitted into TIERS and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for a fair hearing, the case worker completes Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submits it to the data entry representative.

The data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending information, the data entry representative completes the following activities according to the situation:

2932 Coordination of Fair Hearings with MEPD Utilizing OES CRU

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) Centralized Representation Unit (CRU) handles all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works staff. CRU replaces the MEPD specialist in specific steps related to denial of MEPD applications and ongoing cases. CRU:

The case worker must coordinate all appeals with CRU in which MEPD staff determine financial eligibility. The case worker must remember CRU replaces the local MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and CRU administrative assistant.

Applicants/individuals may appeal a decision orally, in person or in writing. The case worker is responsible for completing Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/individual requests a fair hearing. The method in which the form is completed depends on the action being appealed. HHSC staff must determine if the appealed action is:

If the appealed action is related to Community Care for Aged and Disabled (CCAD) criteria other than an MEPD financial denial action, the case worker completes Form H4800 and enters his name as the "Agency Representative." In the "Additional Witnesses” field, HHSC staff enter "CRU Supervisor" (enter the actual name), and "CRU Administrative Assistant" (enter the actual name). The CRU supervisor and administrative assistant names must be entered by using the "MOR Search" function. This will ensure that all the correct information is populated in TIERS and both the CRU supervisor and the administrative assistant receive the notice of the appeal.

If the appealed action is an MEPD financial denial, the case worker completes Form H4800 and enters "CRU Supervisor" (enter the actual name) as the "Agency Representative." This information must be entered through the "MOR Search" function for CRU to receive the hearing information. List the HHSC case worker, supervisor and titles in the "Additional Witnesses” section. The name of the local MEPD specialist is not entered by staff on Form H4800 for MEPD financial appeals. HHSC staff must include the title, such as HHSC case worker or HHSC supervisor. Enter the HHSC staff email address. Enter the CRU administrative assistant (enter the actual name) in "Additional Witnesses” using the "MOR Search" function.

When Form H4800 is sent to the Hearing Division, the case worker sends an email notification regarding the request for an appeal to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, oesfairhear@hhsc.state.tx.us. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, HHSC staff must also include a copy of the HHSC notification form sent to the applicant or individual. The email must include the:

For example, the financial case or application may need to remain open pending an appeal decision regarding medical or functional eligibility. The case worker must notify CRU to keep the MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU requests the MEPD evidence packet from the local MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent MEPD at the hearing, if required, and takes steps to ensure the appropriate MEPD financial case action is taken once a hearings officer's decision is rendered.

When a hearing decision based on program criteria is rendered by the hearings officer, the case worker (staff name entered as "Agency Representative") will be notified via email of the decision by the hearings officer. Based on the hearing decision, the case worker determines the appropriate action according to program specific time frames. The case worker may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor and administrative assistant for the coordination. The case worker reports the implementation of the hearing decision through TIERS on Form H4807, Action Taken on Hearing Decision, according to current procedures.

The local MEPD specialist will continue to notify the case worker if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU will notify HHSC staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, the case worker determines the appropriate action for the service. The email sent by CRU will include:

The case worker must not put an applicant/individual back on a specific interest list while an MEPD denial is in the appeal process. The case worker must take appropriate action to certify or deny the case, or resume services once the MEPD hearing decision is rendered. The individual may choose to be added back to the interest list once the case worker denies the service.

2933 Submitting the Appeals Evidence Packet

Revision 17-1; Effective March 15, 2017

When an applicant or individual requests a fair hearing, the burden of proof to uphold the Texas Health and Human Services Commission (HHSC) decision rests with HHSC. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency decision.

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case worker and his/her supervisor receive a copy of Form H4800 and the letter identifying the hearings officer assigned, and the time and location of the hearing. Staff or the designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

Each entity involved in the fair hearing is responsible for preparing its packet and forwarding the packet to both the:

All documentation must be neatly and logically organized, and all pages numbered. Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

Provide the names, titles, addresses and telephone numbers of all persons or designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send additional staff (e.g., the regional nurse, regional attorney, etc.); however, it is mandatory that the following staff attend:

All related documentation necessary to support the agency's decision must be sent by the data entry representative (DER) to the fair hearings officer as soon as possible, but no later than 10 calendar days before the hearing. Examples of additional information and who is responsible for submitting that information to the state fair hearings officer and appellant include, but are not exclusively limited to:

Uploading the Appeals Evidence Packet into TIERS

All evidence packets must be scanned into the TIERS Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation (also referred to as the "appeals packet") to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A. The DER must upload the fair hearing evidence packet in TIERS no later than 10 calendar days prior to the fair hearing date.

The case worker must provide the information to the DER no later than 12 calendar days prior to the fair hearing date, to allow enough time for the evidence packet to be submitted timely. The case worker must:

No later than 10 calendar days prior to the fair hearing date, the case worker must forward a copy of the fair hearing evidence packet to the applicant or individual requesting the fair hearing.

Within two business days after receipt, the DER must:

Users who make mistakes that cannot be reversed may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

2934 Presentation of Evidence at the Fair Hearing

Revision 17-1; Effective March 15, 2017

Staff listed on Form H4800, Fair Hearing Request Summary, will receive Form H4803, Notice of Hearing, notifying participants when the hearing will be held. HHSC staff must adequately prepare both the fair hearing packet and presentation of evidence at the fair hearing. The burden of proof to uphold the agency's decision rests with the agency. The hearings officer is a neutral party and is restricted by law from presenting the agency's case.

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Joe Smith. Pages 1-10 contain information relating to the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Community Care for Aged and Disabled Handbook, which relate directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form 2065-A, Notification of Community Care Services, which was mailed to the applicant on March 2, 2010."

The hearings officer usually can only consider the specific information offered in evidence when making the hearing decision. For example, the case worker may clearly explain how the applicant must score 24 points on Form 2060 to be eligible for Primary Home Care. However, if documentation backing up that explanation (Handbook policy, Form 2060 Instructions and appropriate appendices) is not contained in the packet, the explanation will not be considered.

Oral testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if he received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record in order to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

2935 Action Taken after the Hearing Decision

Revision 17-1; Effective March 15, 2017

2935.1 Action Taken on the Hearing Decision for Reductions

Revision 17-1; Effective March 15, 2017

After the hearing is held, the Texas Health and Human Services Commission (HHSC) hearings officer will send a decision letter, Form H4807, Action Taken on Hearing Decision, to the appellant and send copies to the case worker and the supervisor. If the HHSC decision is sustained, then the case worker takes the appropriate action. If services continued during the appeal period, then the case worker completes a new Form 2101, Authorization for Community Care Services, and sends it to the provider with the reduced service amounts. The action must be completed within 10 calendar days after the hearings officer’s decision. It is not necessary to send the individual another Form 2065-A, Notification of Community Care Services, since the individual has already been notified of the change.

If the hearings officer reverses the decision, the hearings officer also sends HHSC Form H4807 and specifies the corrective action to be taken and a 10-day time frame for the completion of the action. The case worker continues authorization at the higher level of services. The case worker sends the individual Form 2065-A showing the new level of services. A new Form 2101 is not required, since the provider is already delivering services at the higher level. The case worker actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Form H4807 is no longer completed and mailed back to the hearings officer. All communication will be through TIERS.

2935.2 Action Taken after the Hearing Decision of Terminations

Revision 17-1; Effective March 15, 2017

Once the hearings officer’s decision is rendered and if the individual is determined eligible to continue receiving services, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual to notify him that the hearings officer’s decision overturned the termination and his eligibility is continued. The case worker includes the following statement in the comments: “The hearings officer has overturned the termination decision and you have been determined eligible for continued services effective (the begin date).” The case worker sends the provider an updated Form 2101, Authorization of Community Care Services, reinstating services.

If the hearings officer sustains the termination decision and services were not continued, then no further case worker action is required on the case. If the hearings officer sustains the termination decision and services were continued, the case worker must terminate services in Service Authorization System and send the provider Form 2101 ending services within 10 calendar days after the hearings officer decision, or in accordance with instructions provided by the hearings officer. The case worker does not send another Form 2065-A to the individual to provide notification that the individual is not eligible based on the hearings officer’s decision. The case worker orally notifies the individual of the termination of services and the effective date and documents the contact in the case record.

2935.3 Fair Hearings Officer Orders a New Assessment

Revision 17-1; Effective March 15, 2017

If the hearings officer’s final decision orders completion of a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the hearing is closed as a result of this ruling. The case worker must notify the individual of the results of the new assessment on Form 2065-A, Notification of Community Care Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, the case worker must indicate in Section 8, Summary of Agency Action of Form H4800, HHSC Action Taken on Hearing Decision, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision. If the individual requests an appeal of the new assessment, HHSC continues services until the second fair hearing decision is implemented.

2935.4 Reporting the Action Through TIERS

Revision 17-1; Effective March 15, 2017

The case worker completes Form H4807, Action Taken on Hearing Decision, recording case actions taken and sends it to the supervisor and the designated data entry representative. The case worker must send Form H4807 within the time frames to allow at least two days for the data entry representative to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, the case worker must complete Section B on Form H4807 and send to the supervisor and data entry representative providing the reason for the delay. Acceptable reasons are listed on the form and the begin delay date and end delay date must be included. See the form instructions for detailed information on completing Form H4807.

2936 Fair Hearing Exception Process

Revision 17-1; Effective March 15, 2017

When a fair hearing decision is rendered, staff must implement the decision of the fair hearings officer within the applicable time frames, including the restoration of any benefits or services.

Staff who disagree with the result of a fair hearing must follow regional procedures in referring the issue to the regional director. Staff use Form 1590, Request for a Fair Hearing Exception, to initiate a fair hearing exception request. The form documents the region's request for a review of a fair hearing decision.

If he agrees with the region's request, the regional director forwards Form 1590 to the Community Services Policy (CSP) unit manager. The CSP unit manager must receive the form by the fifth calendar day following the date on the hearing decision. A copy of the form is kept in regional files, not in the case record.

Upon reviewing the region's exception request, the CSP unit manager will decide whether to forward the exception request for consideration by HHSC. If the CSP unit manager (or designee):

If the CSP unit manager forwards the exception request for consideration by HHSC, then the HHSC case worker or designee must mail Form 1015 or Form 1015-S, Fair Hearing Exception Letter, and a copy of the exception request to the applicant or individual. The case worker or designee must place the letter and exception request in the outgoing mail by the close of the next business day following receipt of the notification from the CSP unit manager. A copy of the letter and exception request must be placed in the case record.

The region will be notified of the decision whether the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames.

CW-CCAD, Section 3000, Eligibility for Services

Revision 17-8; Effective September 1, 2017

 

 

3100 Eligibility Determination Procedures

Revision 17-1; Effective March 15, 2017

 

 

3110 Eligibility for CCAD Services

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2901(a). To receive Community Care for Aged and Disabled (CCAD), a client must meet income, resource, age, and need criteria.

40 TAC §48.2910(b). Clients who live in nursing homes are not eligible to receive CCAD services.

An applicant or individual who lives in Texas may qualify to receive most CCAD services regardless of citizenship or the duration of residency. However, individuals may not receive Community Attendant Services or waiver services without verification of citizenship and identity.

Provider agencies must accept HHSC' decision about which individuals are eligible. For eligibility requirements for specific CCAD services, see Section 4000, Specific CCAD Services.

Note: Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the applicant/individual.

 

3111 Age Limits

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2906, Age Limits

(a) A person must be 18 years of age or older, or an emancipated minor, to receive Community Care for the Aged and Disabled (CCAD) services, except:

(1) a person of any age may receive CCAD Medicaid-funded day activity and health services;
(2) a person of any age who is not eligible for the Texas Health Steps program may receive CCAD Medicaid-funded community attendant services.

Although age limits do not apply to Title XIX Day Activity and Health Services (DAHS), licensure prohibits service providers to deliver DAHS services in facilities that are not licensed to serve individuals under age 18. There are currently no facilities licensed in Texas that can serve non-adults.

 

3120 Loss of Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3903(c). The client is not eligible for CCAD services when

(1) he dies;
(2) he is admitted to an institution;
(3) his physician requests service termination (Medicaid services only); or
(4) he requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case, or he refuses to comply with his service plan.

The case worker must notify the provider as soon as an individual has died or is entering a nursing home. Terminate services effective the date of death or entry into the nursing home. The provider cannot bill for attempting to deliver services after the effective date of the termination.

 

3200 Resource Eligibility Criteria

Revision 17-1; Effective March 15, 2017

 

 

 

3210 Resource Limits

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2922. An individual applicant or client is not eligible for CCAD services if the value of nonexempt resources owned by him exceeds $5,000. A couple is not eligible for CCAD services if the value of nonexempt resources they own exceeds $6,000.

The individual limit applies to individuals who are single, even if they live with relatives. The individual limit also applies to individuals whose spouses live in different households. The couple limit applies to married individuals who live in the same household, even if the spouses are ineligible.

Include in the individual's resources those resources the individual owns even if the resources are managed and controlled by someone else acting on the individual's behalf. Also include funds that are not in the individual's name if those funds clearly belong to the individual and are available for use. Determine ownership based on the individual's statement unless contradictory evidence from another source exists.

 

3220 Types of Resources

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2923. In determining eligibility for CCAD services, the department considers the following to be resources:

(1) Liquid resources including cash on hand, CDs, checking or savings accounts, money market funds, revocable trust funds, saving certificates, stocks, or bonds. Liquid resources also include the individual's or couple's portion of money in a checking or savings account or a money market fund held jointly with another person.

(A) Jointly held liquid resources are the resources of the applicant/client if he has unrestricted access to the funds, regardless of the source. The applicant/client may move his portion of jointly held funds in a joint account to a new account. Although the new account may be jointly owned, all funds in the new account are considered to be his.
(B) Money received as a nonrecurring lump sum payment is not considered a resource until 30 days from the date of receipt. Lump sum payments include, but are not limited to, income tax refunds; earned income tax credits or rebates; one-time bonuses from mineral rights; retroactive lump sum Social Security, SSI, or railroad retirement benefits; lump sum insurance settlements; one time gifts, awards, or prizes; and refunds from rental or utility deposits. The applicant/client is responsible for reporting the receipt of a lump sum payment.

(2) Nonliquid resources including nonexempt licensed or unlicensed vehicles; buildings and land not designated as homestead that are not producing income, or are producing income less than 6% of the equity value; and any other property not specifically excluded.

 

Evaluate nonliquid resources according to the equity value. Equity value is the market value of the resource minus any recorded encumbrances.

Money received from the sale of a countable or excluded resource, other than a homestead, is not counted as a resource until the first day of the month following a full month after it was sold. Example: The resource is sold on June 15; proceeds are not counted until Aug. 1.

 

Annuities

A revocable annuity is a countable resource. If an individual has an annuity, the case worker must review the contract or agreement terms to determine if the principal is an available resource. Refer the annuity document to the regional attorney if there is a question as to whether or not the annuity is revocable.

Irrevocable annuities are not countable resources for Community Care for Aged and Disabled individuals. However, the purchase of an annuity may affect the individual's eligibility for institutional care or waiver services. If the individual is concerned about the effect the annuity may have on future eligibility for services, refer the individual to consult with a Medicaid for the Elderly and People with Disabilities specialist.

 

Guardianships and Power of Attorney

If the individual is a guardian for a person other than his spouse, do not include in his resources any separately identifiable funds belonging to the other person but accessible to the individual as that person's guardian.

A person who has a financial power of attorney for another is acting solely as a fiduciary agent. The fiduciary agent acts in a financial capacity, whether formal or informal, regardless of title (for example, representative payee, guardian or conservator); therefore, assets belonging to the other individual should not be considered as part of the individual's available assets.

Assets held by a fiduciary agent for an individual are considered available to the individual, unless otherwise excludable.

 

3230 Resource Exclusions

Revision 17-8; Effective September 1, 2017

 

In determining eligibility for CCAD services, the department does not consider the following to be resources. They are considered to be excluded for eligibility purposes. Any item not listed as an exclusion is considered a resource.

(1) Homestead — Any structure used by the client as a residence, including other buildings and contiguous land. Mobile homes, houseboats, and motor homes are considered structures. Vacant property is not a homestead. Contiguous land means land adjacent to the home, including any land separated only by roads, rivers, and streams. Land is contiguous as long as it is not separated by property owned by another person. The homestead is excluded as a resource regardless of its location, even if the client no longer lives there (unless he has purchased another residence). If he owns two houses, his homestead is the property that he uses as a residence. Only one homestead may be excluded for each client or couple.
If the individual lives in a house, but also has a mobile home, houseboat or motor home on the property, these are all excluded as part of the homestead.

(2) Personal property — Household goods and personal effects.
(3) Property essential to employment — Tools and equipment required for employment or self-employment.
(4) Prepaid burials — Prepaid burial arrangements, burial insurance, and burial plots.
(5) The cash surrender value of all life insurance.
(6) Vehicles — One passenger car or other vehicle, such as a van or truck, used for transportation; or one unlicensed vehicle.

(A) A second vehicle may be excluded if it is:

(I) specially equipped to enable a person with a disability to drive, or
(II) essential to the employment or self-employment of the family.

(B) Any additional vehicles, licensed or unlicensed, are considered resources.

 

An inoperable junk vehicle can be assigned a value of $100, if the individual's resources are less than:

The case worker must verify the value of an inoperable vehicle when the individual's resources are within $100 of the CCAD resource limit ($5,000 for a single person or $6,000 for a couple).

(7) Income-producing property — Property that annually produces net income equal to or greater than 6% of the property's equity value. The equity value is the current market value of the property less any recorded encumbrances. (See Section 3231, Rate of Return on Income-Producing Property.)
(8) Installment contracts from mortgages, notes, or loans — The value of installment contracts for the sale of land, other property, or repayment of loans, if the contract or agreement is producing income according to the fair market value at the time of the agreement. An installment is a mortgage or similar contract in which the buyer promises to pay a fixed amount over a period of time until the principal of the note is paid. Even though the seller retains legal title, the property is not considered a countable resource as long as the buyer is fulfilling the contractual obligation. The payment is considered income.
(9) Disaster assistance — Government payments granted for the rebuilding of homes destroyed or damaged in a disaster.

Reverse mortgages are treated as loans. The money received is not considered to be income. However, it is a resource the month after receipt.

(10) Energy assistance — Payments or allowances for energy assistance made under any federal, state, or local law.
(11) Supplemental Nutrition Assistance Program (SNAP) allotments — The value of SNAP allotments and USDA-donated foods.
(12) Inaccessible resources — The cash value of resources that are inaccessible to the client. Examples are irrevocable trust funds, property in probate, and pension funds. Real property that the client or family is making a good faith effort to sell is exempt. The client or family must ask a fair price for the property, according to its current market value. Property is also exempt if it is jointly owned and the other co-owners refuse to sell.

(13) Mineral rights — The value of mineral rights.
(14) Life estates and remainder interests — A life estate is the right an individual has to property during the individual's lifetime. A remainder interest is the right of ownership to the property when the life estate holder dies.
(15) Replacement value of excluded resources — The replacement value of an excluded resource if it is lost, damaged, or stolen. The cash received from an insurance company for replacing the resource is not considered for three months if the resource is personal property or six months if it is real property. Any cash not spent within the specified period is considered a resource.
(16) Monthly gross income — All income received monthly. Monthly gross income is counted as income in the month received and excluded as a resource in that month.

(17) Sale of a homestead — Proceeds from the sale of a homestead up to six months after they become available to the seller. The six months gives the client time to acquire another homestead. If he does so, any balance from the original sale must be considered as an available resource. If, before the end of the six-month period, the client declares that he has no intention of acquiring another homestead, the proceeds from the sale must be counted as an available resource.
(18) Agent Orange Settlement Payments — Payments from the Agent Orange Settlement Fund or any other fund established in settlement of the Agent Orange product liability litigation.
(19) Radiation exposure compensation — Payments received under the Radiation Exposure Compensation Act (P.L. 101-246).
(20) Funds from the Transition to Life in the Community Program.
(21) Livestock.
(22) Earned income tax credit (EITC) refunds from the Internal Revenue Service.

 

3231 Rate of Return on Income-Producing Property

Revision 17-1; Effective March 15, 2017

 

To determine whether the property is producing enough income to be excluded as a resource:

Step Procedure
1 Determine the current market value, or the amount the property would bring on the open market. The current market value may be based on an estimate by a knowledgeable source such as a realtor or bank official.
2 Determine the total amount owed on the property (encumbrances) by viewing a copy of the loan agreement, purchase contract, or contract with the creditor.
3 Calculate the equity value by subtracting the encumbrances from the current market value.
4 Multiply the equity value by 6% to determine the required gross yearly revenue that must be produced to exempt the property.
5 Calculate the net yearly income the property produces from rents, leases, etc. by subtracting from the gross yearly income any expenses such as taxes, insurance, costs of repairs and maintenance, and interest on the property's mortgage. (Expenses for capital improvement and depreciation are not deductible.)
6 Compare the required gross yearly revenue calculated in step 4 (yearly income that must be produced) with the net yearly income from step 5 (actual yearly income produced) to determine whether the net income equals or exceeds 6% of the equity value. If the property is not producing income equal to or greater than 6% of the equity value, consider the equity value of the property a resource.

 

3300 Income Eligibility

Revision 17-1; Effective March 15, 2017

 

 

 

3310 Income and Income Eligibles

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2902 . To be eligible for CCAD services, the applicant/client must:

  1. be categorically eligible by receiving Supplemental Security Income, Aid to Families with Dependent Children, Supplemental Nutrition Assistance Program, Medicaid, Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Medicare Beneficiary (QMB) benefits; or
  2. be income eligible. The applicant/client's and spouse's countable income must be equal to or less than the income limit set by the department. For an individual, this amount is the same as the special income limit set for institutional care (medical assistance only) by the Texas Legislature. For a couple, the income limit is twice the special income limit.

 

Categorical Eligibility for Title XIX Services

Recipients with full Medicaid eligibility have already been determined financially eligible for Title XIX services. These individuals are referred to as being categorically eligible.

See Section 7110, TIERS Inquiries, to determine which programs give an individual financial eligibility for Community Care for Aged and Disabled (CCAD) Title XIX programs.

If a CCAD individual receiving Supplemental Security Income (SSI) has excess income or resources, the case worker must share this information with the Social Security Administration (SSA). The individual will continue to be eligible for CCAD based on SSI status until SSI is denied.

 

Categorical Eligibility for Title XX Services

Recipients of some non-Medicaid programs are financially eligible for Title XX benefits based on existing program eligibility. These individuals are referred to as having categorical eligibility for Title XX services. See Section 7110.

Financial Eligibility Determination for Title XX Services

CCAD case workers determine financial eligibility for applicants for Title XX programs unless financial eligibility has already been determined based on existing program eligibility. These individuals are referred to as income eligibles.

For details on the income eligible determination process, see:

 

Financial Eligibility for Community Attendant Services (CAS) and Non-SSI Waiver Recipients

Financial eligibility for CAS and non-SSI waiver services is determined exclusively by Medicaid for the Elderly and People with Disabilities (MEPD) specialists CCAD case workers must never deny CAS or 1915(c) Medicaid waiver cases based on income. This applies even if the applicant's assets appear to substantially exceed the eligibility limits.

The Health and Human Services Commission (HHSC) is designated as the single state Medicaid agency in the Code of Federal Regulations (CFR). Chapter 42 CFR 431.10(c) maintains that the state plan must specify the agency that determines eligibility and that there are only three choices:

In Texas State Plan, Section 2.2, HHSC is designated as the state agency that determines eligibility.

Effect of Living Arrangement on Financial Eligibility

If both a husband and wife apply for services and only the wife receives SSI, TANF, Medical Assistance Only or other programs shown in Section 7110 as granting categorical eligibility for CCAD services, compare the total income of both spouses with the couple’s income limit to determine the husband's eligibility.

If a married individual does not live with his spouse, use the individual income limit. Do not consider the income of the spouse unless that income (or part of it) is given to the individual. Income diverted from a spouse in a nursing home to the individual at home is included in the individual's income calculation. If an individual must be denied because of income diverted from a spouse in a nursing home, tell the individual that the amount of income diverted may be reduced or discontinued. Ask the individual to speak to his MEPD specialist, and tell the individual he may reapply for CCAD if the situation changes.

Use the CCAD monthly income limits as reflected in Appendix XI, Monthly Income/Resource Limits.

If a CAS, Primary Home Care or Title XIX Day Activity and Health Services individual wants to receive another CCAD service in addition to the original Title XIX program, the case worker may certify the individual as categorically eligible for Title XX services based on the current Medicaid eligibility certification.

 

3320 Determination of Countable Income

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2903, Determination of Countable Income. Countable income is determined by totaling gross income from all the following sources, less all applicable exclusions and exemptions. Applicable exclusions/exemptions are specified in 40 TAC §48.2904 and 40 TAC §48.2905 of this title (relating to Income from Excludable Sources and Income from Exempt Sources.)

(1) Total gross earnings — This includes money, wages, commissions, tips, piece-rate payments, cash bonuses, or salary received for work performed as an employee. This also encompasses pay for members of the armed forces (including allotments from any armed forces pay received by a member of the family group from a person not living in the household).
(2) Self-employment income (including farm income) — For earned income to be considered self-employment, either the individual or spouse must be actively involved or materially participating in producing the income.
(3) Social security and railroad retirement benefits.
(4) Dividends — This consists of dividends from stocks or membership in associations, and periodic receipts from estates of trust funds. These payments are averaged over a 12-month period.
(5) Rental income — This includes payments to the individual from the rent of housing, store, or other property, as well as from boarders or lodgers.
(6) Net income derived from oil, gas, or mineral rights — This can include both lease and royalty payments. These payments are averaged over a 12-month period.

(Reminder: Refer to Section 3330, Budgeting Countable Income, to determine if this income can be excluded as infrequent and irregular or as a lump sum payment.)

(7) Income from mortgages or contracts.
(8) Public assistance or welfare payments — Temporary Assistance to Needy Families, Supplemental Security Income, and general assistance (cash payments from a county or city) are included.
(9) Veterans' pensions and compensation checks — This may include money paid periodically by the Veterans Administration to disabled members of the armed forces or to survivors of deceased veterans, subsistence allowances paid to veterans for education and on-the-job training, and refunds paid to ex-servicemen as GI insurance premiums.
(10) Educational loans, grants, fellowships, and scholarships.
(11) Unemployment compensation — Unemployment compensation may be received from government employment insurance agencies or private companies during periods of unemployment, and includes any strike benefits received from union funds.
(12) Workers compensation and disability payments — This includes compensation received periodically from private or public insurance companies for injuries incurred at work.
(13) Alimony.
(14) Regular monthly cash support payments from friends or relatives.
(15) Pensions, annuities, and irrevocable trust funds — Payments may be paid to a retired person or his survivors by a former employer or by a union, either directly or through an insurance company. Periodic payments from annuities, insurance, irrevocable trust fund payments, and civil service pensions are included.
(16) Income from the client's share of a life estate.

 

3330 Budgeting Countable Income

Revision 17-1; Effective March 15, 2017

 

The sources of income that may be included in the income eligibility budget fall into one of three categories: countable, excludable and exempt. Countable income is addressed in Section 3320, Determination of Countable Income. Treatment of the excludable and exempt income varies, as illustrated below.

 

3330.1 Excludable Income

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2904, Income from Excludable Sources. Income may be fully or partially countable, or may be excluded from the current eligibility budget. Excludable income will continue to be monitored by the caseworker at each financial review to determine how eligibility is affected. Excludable sources of income include:

(1) deductions from earned income, including social security payments, Medicare premium payments, bonds, pensions, and union dues;
(2) the first $65 of a client's (or couple's) net earned income, plus 1/2 of the remainder;
(3) loans, grants, scholarships, and fellowship funds obtained and used under conditions that preclude their use for current living costs. Any portion used to pay any other expense (room, board, books, etc.) cannot be excluded;
(4) Veterans Administration aid-and-attendance benefits, homebound elderly benefits, and payments to certain eligible veterans for purchase of medications;
(5) infrequent or irregular income (income received less frequently than once a month) that averages $20 per month or less;
(6) 1/3 of the total amount of child support payments for an eligible child; and
(7) allowable exclusions from self-employment income, as indicated on the following chart.

Expense Excludability
Money paid to or for employees not living in the home Excludable
Money paid to or for employees living in the home Excludable
Federal, state, or local income taxes Excludable
Sales tax Excludable
Property tax Excludable
Rental of business property Excludable
Utilities for business property Excludable
Stock/inventory, raw materials Excludable
Supplies Excludable
Fuel expenses for the business Excludable
Insurance premiums Excludable
Linen service Excludable
Interest for business loans or property Excludable
Lodging when traveling (when not counted as shelter) Excludable
Own meals when traveling for business Excludable
Net loss for same determination period Excludable
Additional expenses related to self-employment (advertising, co-op, license fees, journals, etc.) Excludable
Additional farming-related expenses (feed, seed, plants, seedlings, farm supplies, breeding fees, fertilizer and lime, crop insurance, crop storage, fees for livestock testing, etc.)

Excludable for self-employment farming

Excludable for unearned income farming only if part of the lease agreement

Depreciation related to self-employment Excludable
Cost of doing business in the home (separately identifiable from home expenses), including utilities. For rooms designated for business purposes in a single residence, expenses are compared to the total number of rooms in the house. Bathrooms are not counted as rooms; basements and attics are counted only if they have been converted into living spaces. Excludable
Purchase and cleaning of uniforms Not excludable
Capital asset purchases Not excludable
Capital asset improvements Not excludable
Payment on principal of loan for income producing property Not excludable
Travel to/from place of business Not excludable
Net loss from previous determination period Not excludable
Depreciation related to unearned income (e.g., rental income) Not excludable

 

Mandatory deductions from unearned income may also be excluded from the eligibility budget. Documentation in the case record must clearly state that the deduction is mandatory and whether/when the mandatory deductions will end.

For earned income to be considered self-employment, either the individual or spouse must be actively involved or materially participating in producing the income. A business owner is determined to be materially participating if he meets any one of the following criteria:

A blind or disabled student under 22 years of age who regularly attends school, college, a university or a course of vocational or technical training can have limited earnings that are not counted toward the income eligibility budget. (This exclusion does not apply to unearned income.)

The maximum amount of the income exclusion varies from year to year and is determined annually by the Social Security Administration (SSA). Exclusion amounts can be determined online at www.ssa.gov/OACT/COLA/studentEIE.html.

Section 2002 of the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes additional unemployment compensation benefits of $25 per week for individuals receiving unemployment benefits. The additional $25 unemployment compensation benefits received as a result of ARRA are not countable income for either eligibility or co-payment purposes. As the additional unemployment compensation may be included either with the regular payment or as an additional payment, a contact with the Texas Workforce Commission may be needed to determine if any of the payments are part of the ARRA additional compensation.

 

3330.2 Exempt Income

Revision 17-8; Effective September 1, 2017

 

There are numerous exemptions on countable income. These exemptions can be found in Appendix XXX, Income and Resource Exemptions for Determining Financial Eligibility.

Exempt income is not included in the income eligibility calculation. Once identified and documented, caseworkers will not be required to monitor exempt income at subsequent financial redetermination. Sources of exempt income include:

(1) interest income.
(2) cash received from the sale of a resource. This cash is a resource, not income.
(3) income of minor children who are supported by or dependent upon the client.
(4) refunds from the Internal Revenue Service for earned income tax credit.
(5) reimbursement from an insurance company for health insurance claims.
(6) any cash from a non-governmental medical or social services organization if the cash is:

(7) proceeds of either a commercial loan or an informal loan, for which repayment is required with or without interest. The proceeds (amount borrowed) are not counted as income in the month in which they are received, but are considered to be a resource in the following month(s). To claim exemption of the proceeds of a loan, a client must prove that he acknowledges an obligation to repay and that some plan for repayment exists. If these conditions can be verified, no written contract is required.
(8) the amount of the cost-of-living increase in any pension or benefit, received on or after January 1, 1985, that would cause the client to be ineligible for continued services. This exclusion applies only to community care clients who are already receiving services or case management and would become ineligible because of the increase. It does not apply to applicants.
(9) in-kind income, such as food, clothing, shelter, rent subsidies.
(10) one-time or lump-sum payments from any source.
(11) funds from the Transition to Life in the Community Program.

For a complete list of income exemptions, see Appendix XXX.

The term "lump sum," as listed in (10) above, can be defined as income that is not expected to recur with a predictable pattern of frequency.

Income received less than three times per year that does not meet the $20 monthly average requirement, as listed in (5) above, should be treated as a lump sum payment. If the lump sum could affect eligibility, the case should be monitored 30 days following receipt to ensure that resource eligibility is not affected.

 

3340 Computation of Gross Income

Revision 17-1; Effective March 15, 2017

 

If an individual receives gross income more often than monthly, compute the income as follows.

 

3341 Income Averaging

Revision 17-1; Effective March 15, 2017

 

Calculate the income average of all income that may be received monthly, but is usually received less often. The case worker also may need to calculate the 12-month average income for monies received for seasonal employment, such as agricultural or construction work.

If an individual ends regular employment to accept seasonal employment but later returns to the regular job, calculate the income average from the combined sources over the 12-month period.

 

3400 Verification Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

3410 Verification of Public Assistance Status

Revision 17-1; Effective March 15, 2017

 

Within 24 months of the last financial review, verify the correct categorical financial status of current Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individuals (QI), Supplemental Nutrition Assistance Program, Medicaid Buy-In or Medicaid individuals and certify eligibility on this basis. Documentation on Form 2064, Eligibility Worksheet, or a printed copy of an HHSC computer inquiry placed in the individual's case folder will satisfy verification requirements for an individual receiving service(s) based on categorical financial status.

Refer to Section 7110, TIERS Inquiries, for a full listing of programs that provide categorical eligibility for Community Care for Aged and Disabled programs.

 

3420 Verification of Income and Resources

Revision 17-1; Effective March 15, 2017

 

Program Standard: The case worker must accurately establish the countable amount of income and resources to determine the income-eligible applicant's financial eligibility.

Determine the amount of countable assets for persons applying as income eligibles. Within 24 months of the last financial review, financial eligibility must also be redetermined for these individuals. An individual's declaration of income/resources for all programs is acceptable (excluding waiver services) unless:

If an individual meets the criteria in Section 3430, Eligibility Before Verification, refer the individual for services before verifying income and resources, and complete the verification within 30 days of the application.

Applicants are responsible for providing all information needed to establish eligibility. Ask the applicant or responsible party to provide the needed information to verify income and resources.

When information is requested from the applicant or responsible party, give a specific due date and explain the result of not providing the requested information. During a review, make the due date two weeks before the day the current certification period ends. This will allow a few more days to give the individual a second chance before terminating services effective the last day of certification. Follow up at least one time before denying the applicant for failure to cooperate.

During a financial review, if an individual reports closing a bank account or no longer having an account that was included in the last review, and adding the last known balance would bring the individual to within $100 of the resource eligibility limit, verify with the bank that the account has been closed.

If the information can be obtained by making a telephone call or mailing a verification form, attempt to obtain the information before denying the application. If the case worker cannot obtain the information and the applicant does not provide the information, deny the application. If the case worker cannot obtain information needed for a financial recertification and the individual does not provide the information, send Form 2065-A, Notification of Community Care Services, at least 12 days before termination becomes effective.

The case worker may, without verifying the income or resources, deny an application because the individual reports excess income or resources. Explain the reason for the denial to the individual or responsible party. Explain in the comments section of Form 2064, Eligibility Worksheet, that the denial was due to the individual's declaration of excess income or resources.

See Appendix XII, Examples of Methods to Verify Income and Resources, for examples of methods to verify income and resources. The case worker may use a verification source not listed in Appendix XII if it is determined the source is both knowledgeable and objective. A person is considered knowledgeable if that person routinely assesses values on that type of resource in the area where the resource is located. A person may not be considered objective if that person has a vested interest in the individual's eligibility.

Documentation on Form 2064 should contain enough information to determine what, when, where and how the applicant's/individual's income/resources were verified, so that they can be traced to the original source. For categorically eligible applicants and individuals (Temporary Assistance for Needy Families (TANF), Medical Assistance Only (MAO), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI) and the Supplemental Nutrition Assistance Program), the case record must:

Form 2064 must show that verifications were received before the date eligibility rules were processed.

 

3421 Financial Documentation Requirements

Revision 17-1; Effective March 15, 2017

 

This chart is designed to assist in determining what is required for financial eligibility documentation.

If the individual's: and then:
income is not within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker matches information on the application form, no verification is required. Enter the monthly dollar amount in SASW and select the client statement option. No other documentation is required.
income is not within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker does not match information on the application form, no verification is required. Enter the monthly dollar amount in SASW and select the client statement option. No other documentation is required.
income is within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker matches information on the application form, view verification containing all information listed in Column 3 of Appendix XII. Enter the monthly dollar amount and select the appropriate documentation source in SASW/TIERS. No further documentation is required.

If the case worker is not able to view adequate documentation, verification of income and resources is required.

income is within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker does not match information on the application form, view verification containing all information listed in Column 3 of Appendix II. Enter the monthly dollar amount and select the appropriate documentation source in SASW/TIERS. Explain the discrepancy in documentation.
income is within $10 of the eligibility limit
and/or
resources are within $100 of the eligibility limit
N/A verification of income and resources is required.

 

3422 Exceptions to Verification Requirements

Revision 17-1; Effective March 15, 2017

 

Within 24 months of the initial financial determination, income-eligible individuals must complete a new Form H1200, Application for Assistance – Your Texas Benefits,/Form H1200-EZ, Application for Assistance — Aged and Disabled. Subsequent financial redeterminations will not require completion of Form H1200/Form H1200-EZ, unless the case worker has reason to believe the individual's financial eligibility may be in question.

Even though a new Form H1200/Form H1200-EZ is not needed, the case worker still must contact the individual and confirm that significant changes in income and resources have not occurred.

If there is a new source of income at a financial review or a new resource, then re-verify all of the individual's resources. If adding the individual's new assets to existing income/resources brings the total income within proximity of financial eligibility limits, re-verify all of the individual's resources.

Following these guidelines, at a review the case worker may need to verify both income and resources, income but not resources, resources but not income, or neither income nor resources.

If an individual loses categorical eligibility (for example, stops receiving Temporary Assistance for Needy Families or the Supplemental Nutrition Assistance Program) between reviews, that individual may be able to continue receiving services without a financial review until the next financial review is due (see Section 3441, Loss of Categorical Status). In such a case, the case worker must verify both income and resources at the next financial review.

 

3430 Eligibility Before Verification

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3901(g). A Medicaid-certified applicant for CCAD-purchased services who requires a verbal referral is eligible to receive CCAD-purchased services when his eligibility for Medicaid is verified. A non-Medicaid certified applicant who meets the requirements for a verbal referral is eligible to receive CCAD purchased services while income and resources are verified. [See Section 1130, Definitions, and Section 2631, Negotiated Referrals.]

(1) To be eligible, this applicant must:

(A) be a new applicant for CCAD services;
(B) appear to be eligible based on the declaration of income and resources on his application for services or to have possession of a current medical care identification card; and
(C) meet the age and need criteria for the CCAD service he requires.

(2) The eligibility period for non-Medicaid applicants begins on the date of application.
(3)To continue receiving services, a non-Medicaid applicant must provide within 30 days of the application date the information needed to verify the applicant's income and resource amounts.

If, pending financial eligibility verification, the non-Medicaid applicant appears eligible for immediate service initiation, use the following procedures, as appropriate.

  1. Refer the applicant to the provider according to Section 2631.
  2. On Form 2101, Authorization for Community Care Services, enter the earliest date negotiated with the provider as the date services begin.
  3. If the applicant is determined ineligible within the 30-day verification period, or if the applicant does not provide the information needed to verify income and resource amounts by the 30th day, send Form 2065-A, Notification of Community Care Services, to the individual to terminate services 12 days after the Form 2065-A date. (Refer to Appendix IX, Notification/Effective Date of Decision.)

 

3440 Changes in Financial Circumstances

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3901(f). The client must report promptly any changes in income, resources, or family size; loss of assistance grant or Medicaid benefits; or other changes in functional ability or circumstances that affect eligibility. The client is subject to fraud prosecution if he willfully fails to report changes and continues to receive services for which he is not eligible.

Individuals must report promptly any changes in income or resources. Note in the case record, but do not verify, reports of changes in income or resources that do not affect eligibility. Newly acquired resources that may affect eligibility, such as an inheritance involving property, are disregarded for 30 days from the date received. After 30 days, determine the amount of resources and terminate the individual's eligibility if the amount exceeds the resource limit.

 

3441 Loss of Categorical Status or Financial Eligibility

Revision 17-1; Effective March 15, 2017

 

In situations in which a Community Care for Aged and Disabled (CCAD) individual temporarily loses categorical or financial eligibility, the case worker must contact the individual and/or the appropriate agency to determine the reason for the denial and determine if reinstatement is likely.

If the individual loses Medicaid eligibility because his Supplemental Security Income (SSI) is being denied, the case worker must contact the individual and/or the Social Security Administration (SSA) to determine the reason for the denial and if the individual may be reinstated without a break in coverage.

Case workers may receive a copy of a denial notice or the monthly Loss of Eligibility Report for eligibility for the following programs:

Upon learning of the denial, the case worker must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The case worker must contact the individual to discuss the situation and, if feasible, assist the individual with completing the actions necessary for reinstatement of eligibility. If the individual has been denied on failure to furnish information, the case worker must contact the individual as soon as possible to advise him of the loss of service and the necessity of providing the information required by Medicaid for the Elderly and People with Disabilities (MEPD) or TANF. The case worker may also contact the MEPD or TANF specialist involved, ask about the individual's current income and resource amounts, and whether reinstatement will be occurring.

 

3441.1 Procedures Pending Reinstatement

Revision 17-1; Effective March 15, 2017

 

If the case worker is advised by the Social Security Administration (SSA), Medicaid for the Elderly or People with Disabilities (MEPD) or Temporary Assistance for Needy Families (TANF) that the individual will be reinstated within a month or is working on reinstatement, the case worker explores transferring the individual to Family Care (FC), if enrollment is possible in the region.

If the individual has not responded to requests for information and continues to fail to furnish information to the appropriate agency by the agency's deadline, he is not eligible to transfer to FC and the case is denied.

During times of extreme budget limitations on a regional or statewide basis, no individual may bypass the FC interest list. In absence of these budget limitations, the following procedures may be used.

If the individual or case worker reports income and resources within eligibility limits (and no other information exists to contradict this report), the individual may continue to receive Title XX (block grant) services or be transferred from Primary Home Care (PHC) to FC without being placed on an interest list. Note the individual's changed status and record the self-declared income and resources in the case record. Update the Service Authorization System (SAS) to show the individual as income eligible. It is not necessary to obtain Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, from the individual or to verify income and resource amounts until the next financial review is due.

The case worker must process a change within 14 days resulting from the individual’s loss of Medicaid resulting in a need to transfer from PHC to FC. When applicable, submit Form 2101, Authorization for Community Care Services, to transfer an individual from PHC to FC. Use the comments section on Form 2101 to document the individual’s services being transferred from PHC to FC due to a loss of Medicaid. Enter the day after the last date of Medicaid coverage as the "from" date on Form 2101. (If the Medicaid denial is unknown until after the last day of Medicaid coverage, use the earliest date FC can begin as the "from" date.) In the event that the individual has been receiving a block grant service and will continue to receive the same service, the same authorization may be continued.

If transferring to FC is not an option due to regional constraints, the case worker may suspend services for 60 calendar days to allow a determination on the individual's Medicaid status to be made regarding the reinstatement of services. Within four business days of determining suspension is appropriate, the case worker sends the individual Form 2065-A, Notification of Community Care Services, checking the Notification of Ineligibility or Termination of Benefits, the date services end, and noting services are suspended pending reinstatement of Medicaid or financial eligibility (as applicable). The case worker also sends the provider Form 2067, Case Information, suspending services effective the date of Medicaid denial.

During the period in which services are temporarily suspended by Medicaid, all case actions, such as monitoring and annual visits, changes, and transfers will be suspended. However, the case worker must set a special review for the 60th day following the suspension to check  if eligibility has been re-established.

At any time during the initial 60-day period the case worker learns that eligibility has been re-established, the case worker has 14 days to resume services. Case workers must call the provider to negotiate the earliest date for services to resume. Case workers follow up the telephone call with Form 2067 to the provider, noting reinstatement of services with the negotiated date. Case workers must make any 90-day monitoring or annual reassessment visits which would have occurred during the suspension. The case worker documents the reinstatement of eligibility and the reason in delay for monitoring or annual reassessment visits due to the suspension of services in the case record and sends the individual Form 2065-A with a statement that services have been reinstated.

If, on the 60th day eligibility has not been re-established, the case worker may extend the temporary suspension for an additional 30 days for a total of 90 calendar days if the case worker determines the individual may still have eligibility reinstated. This determination will be established based on research of MEPD case-specific information. At any time during the additional 30 days the case worker learns that eligibility has been reinstated, the case worker has 14 days to resume services. Case workers must send Form 2067 to the provider to have services resumed, and must make any 90-day monitoring or annual reassessment visits which would have occurred during the suspension. The case worker documents the reinstatement of eligibility and the reason in delay for monitoring or annual reassessment visits due to the suspension of services in the case record and sends the individual Form 2065-A with a statement that services have been reinstated.

If reinstatement of eligibility will not be granted, the case worker sends the individual Form 2065-A denying services. The date of denial will be based on the:

Form 2101 must be sent to the provider on the same date, noting services are denied effective the date of the financial denial.

 

3441.2 Reinstatement Procedures After Denial

Revision 17-1; Effective March 15, 2017

 

If financial or categorical eligibility is re-established within 60 days of the denial date and the individual reapplies for services, the case worker may use the information currently on file to determine eligibility. Completing new forms will not be required, except for a new Form 2110, Community Care Intake, and Form 2101, Authorization for Community Care Services. The case worker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date and may use the following forms currently on file:

The case worker must contact the individual and review the functional assessment, including Form 2060 and Form 2059, to determine if there have been any changes in the individual's physical condition or needs. If Form 2060 is over one year old, if there have been changes in the individual's condition or needs or if the individual has difficulty communicating by telephone, the case worker must make a home visit to review/revise the assessment. Initial eligibility time frames will apply.

The case worker must send an initial referral packet and initial Form 2101 referral to the selected provider. For Primary Home Care and Community Attendant Services, the provider must complete all pre-initiation activities, including obtaining a new Form 3052, Practitioner's Statement of Medical Need.

 

CW-CCAD, Section 4000, Specific CCAD Services

Revision 17-9; Effective September 15, 2017

 

4100 Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

 

4110 Description

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) provides a 24-hour living arrangement in a Texas Health and Human Services Commission (HHSC) contracted foster home for persons who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes. Services may include meal preparation, housekeeping, minimal help with personal care, help with activities of daily living and provision of or arrangement for transportation. The unit of service is one day.

Providers of AFC must live in the household and share a common living area with the individual. Detached living quarters do not constitute a common living area. The individual enrolled to provide AFC must be the primary caregiver. Providers may serve up to three adult individuals in an HHSC-enrolled AFC home without licensure as a personal care home.

 

4111 Four Bed Adult Foster Care Homes

Revision 17-1; Effective March 15, 2017

 

A Type C Assisted Living license is obtained if the provider wants to serve four individuals. The home cannot be approved for the fourth individual until the provider has applied for and received the Type C license. After the enrollment is complete, the provider may apply for a Type C license from the Texas Health and Human Services Commission Regulatory Services Division. The license must be renewed yearly and requires an annual fee.

 

4112 Small Group Homes

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) may also be provided in a small group home licensed by the Texas Health and Human Services Commission (HHSC) as Assisted Living Type A, Small, under the Minimum Licensing Standards for Assisted Living. The provider must submit a copy of the Assisted Living license to contract management staff before enrollment and upon renewal thereafter. The provider must report to contract management staff any problem(s) identified by Regulatory Services. HHSC regional contract managers enroll small group homes and providers must meet all applicable requirements in the Minimum Standards for AFC. Providers must serve no more than eight adult individuals in an enrolled small group home.

AFC provided in small group homes is subject to two sets of regulations: HHSC minimum standards for AFC and Licensing Standards for Assisted Living Facilities. The stricter requirements apply when requirements conflict; therefore, an enrolled AFC provider whose home is 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 individuals currently residing in the facility.

 

4113 Contract Manager and Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

 

 

4113.1 Contract Manager Responsibilities

Revision 17-1; Effective March 15, 2017

 

Texas Health and Human Services Commission regional contract managers are responsible for all requirements for adult foster care (AFC) providers and homes. The contract manager's responsibilities include:

 

4113.2 Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

Texas Health and Human Services Commission (HHSC) case workers are responsible for all requirements for adult foster care (AFC) applicants and individuals. The case worker's responsibilities include:

 

4120 Eligibility

Revision 17-1; Effective March 15, 2017

 

 

 

4121 Basic Eligibility

Revision 17-1; Effective March 15, 2017

 

To be eligible for adult foster care (AFC), applicants and individuals must meet basic eligibility requirements for Community Care for Aged and Disabled services as well as specific requirements related to AFC. These requirements can be found in Section 3000, Eligibility for Services.

 

4122 Appropriate Characteristics for Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

Applicants and ongoing individuals in adult foster care (AFC) must display appropriate characteristics for AFC placement.

AFC placement is not appropriate for all individuals. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed for all applicants. If any inappropriate characteristics are identified, the applicant/individual is not appropriate for AFC and cannot be authorized for services.

A new Form 2330 must be completed at each annual review to ensure the individual's needs can be met within the foster care setting.

 

4123 Supervisory Approval

Revision 17-1; Effective March 15, 2017

 

It is the supervisor's responsibility to ensure that the applicant/individual meets the appropriate characteristics and their needs can be adequately met in adult foster care (AFC). The supervisor indicates on Form 2330, Assessment and Service Plan Approval for Adult Foster Care, whether AFC is approved or disapproved. Supervisory approval is required before AFC is authorized and also required to reauthorize.

See Section 3000, Eligibility for Services, for additional eligibility requirements.

 

4130 Adult Foster Care Intake and Assessment

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) is appropriate for individuals who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes and who need and desire the support and security of family living. AFC is also appropriate for individuals who do not need institutional care, but are unable to resume independent living or have no relatives who are able to provide a home.

 

4131 Response to Request for Services

Revision 17-1; Effective March 15, 2017

 

Upon receipt of an intake for adult foster care (AFC), the case worker arranges a home visit to conduct the assessment based on the intake priority. Refer to Section 2340, The Initial Interview and Application Process, for complete procedures. During the home visit, the case worker assesses the applicant for financial eligibility and functional eligibility, using Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and also completes Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to determine whether the applicant is appropriate for AFC. Form 2330 lists the appropriate and inappropriate mental and physical characteristics for AFC individuals.

AFC is not appropriate and should not be authorized for a person who:

 

4132 Individual Rights and Responsibilities

Revision 17-1; Effective March 15, 2017

 

The case worker must explain the room and board requirements in adult foster care (AFC) and ensure that the applicant understands that he must pay a portion of his monthly income for room and board. Review Form 2307, Rights and Responsibilities, and Form 2307-F, AFC Rights and Responsibilities, with the applicant. Make sure the individual understands his responsibilities as a resident in an AFC home.

 

4133 Assessing Potential Adult Foster Care Homes

Revision 17-1; Effective March 15, 2017

 

If the applicant displays the appropriate characteristics and appears to meet eligibility criteria, the case worker provides information about potential adult foster care (AFC) homes. The case worker can arrange visits to appropriate AFC homes or if the applicant is capable or has family/supports available, he may make the arrangements to visit potential AFC homes. In some situations, the case worker may need to assist the applicant in making the visit(s).

The purpose of the visits to potential AFC homes is to let the applicant assess the home and let the AFC provider assess if the applicant will be appropriate in the foster home. The case worker may contact the provider and share information about the applicant, including the applicant's particular needs and problems, to ensure that the potential provider is fully aware of the responsibilities involved in caring for the particular applicant and to prevent a potential mismatch of the applicant and provider.

 

4134 Placement on the Interest List

Revision 17-1; Effective March 15, 2017

 

If an intake is received for adult foster care (AFC) but no foster homes are available to provide care, place the individual's name on the interest list and determine if other services may be appropriate to meet the individual's needs while waiting for placement in AFC. Refer to Section 2930, Community Services Interest List (CSIL), for interest list procedures. The application process for AFC begins when the individual's name is released from the interest list.

 

4135 Adult Protective Services Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

 

 

4135.1 Placement of Adult Protective Services Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

In some areas, Adult Protective Services (APS) may use adult foster care (AFC) as a resource for placement of APS individuals. Approval by the contract manager is required before an APS individual moves into a Texas Health and Human Services Commission enrolled AFC household. The purpose of the approval is to determine the:

If it is determined by the contract manager that placement in foster care is inappropriate, the APS worker and the provider will help the individual make other living arrangements.

 

4135.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 17-1; Effective March 15, 2017

 

Any time Texas Health and Human Services Commission (HHSC) staff suspect abuse, neglect or exploitation of an adult foster care (AFC) individual in a foster home, a report must be made immediately to Adult Protective Services (APS).

If reports are made to APS from outside sources, HHSC staff may not be notified of individual allegations against a service provider until after those allegations have been validated. However, APS staff may ask Community Care for Aged and Disabled (CCAD) staff to assist with the delivery of services during the course of their investigation if the alleged mistreatment poses an immediate threat to the safety of AFC residents.

The contract manager assigned to the facility handles disenrollment and corrective actions against the foster home, as appropriate. If the case worker is unable to find a suitable residence for the individual, the individual is referred to APS for assistance in moving from the foster home.

An individual who has the capacity to consent may decide not to move from the foster home, even though the allegation has been validated and the situation is likely to recur. In such an instance, the individual's AFC services will be denied and payments to the home will terminate. However, the individual may continue to reside in the home by making private pay arrangements with the provider.

If an individual who does not appear to have the capacity to consent refuses to move from a home operated by an individual identified as the perpetrator in a case of validated abuse, neglect or exploitation, make a referral to APS.

 

4136 Private Pay Individuals and Retroactive Payment Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4136.1 Private Pay Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

Some adult foster care (AFC) providers may wish to take private pay individuals. Approval by the contract manager is required before the private pay individual is accepted in the home. The AFC provider must contact the contract manager when considering admitting a private pay individual. The contract manager will furnish Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to the AFC provider. The AFC provider must complete Form 2330 and return it to the contract manager to approve or disapprove the private pay individual. The purpose of the approval is to determine the:

If it is determined by the contract manager that placement in foster care is inappropriate, the AFC provider cannot accept the individual.

Refer any issues regarding placements to the contract manager to resolve.

 

4136.2 Retroactive Payment Procedures

Revision 17-1; Effective March 15, 2017

 

If a private pay applicant already in the foster home applies for adult foster care (AFC) and meets all eligibility requirements, AFC can be approved retroactive to the date of intake.

AFC may be authorized retroactively with supervisory approval to the latter of the date of:

Supervisory approval is required in all situations. If an applicant does not meet eligibility requirements including appropriate characteristics, then AFC is not authorized and it is the individual's responsibility to arrange for payment to the foster home or relocate.

 

4140 Adult Foster Care Case Worker Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4141 Eligibility Determination

Revision 17-1; Effective March 15, 2017

 

To determine eligibility for adult foster care (AFC), the case worker must:

After eligibility is determined, the case worker submits the individual's case record to his supervisor for review and approval. Documentation in the case record must be complete to enable the supervisor to certify the individual's need for care and the appropriateness or inappropriateness of the placement arrangement.

 

4142 Supervisory Approval

Revision 17-1; Effective March 15, 2017

 

Upon receipt of the case record, the supervisor reviews:

The supervisor may consult with the contract manager to evaluate the capacity of the foster care provider to meet the unique needs of the individual in the foster home setting.

The supervisor decides whether the foster home can meet the needs of the individual and if the individual is appropriate for adult foster care (AFC). If so, the supervisor approves AFC and the service plan by signing and dating Form 2330 or by giving verbal approval, which is documented by the case worker. If the service is not approved, the supervisor confers with the case worker about problems with the plan, as perceived through the record reviews. The case worker must find a more suitable arrangement or resolve the potential problems with the individual and the foster care provider to his supervisor's satisfaction. Refer the individual to Adult Protective Services (APS) if there is reason to suspect abuse, neglect or exploitation.

 

4143 Service Planning

Revision 17-1; Effective March 15, 2017

 

Upon approval for adult foster care (AFC), the supervisor and case worker discuss if the individual has any special needs that require additional monitoring in the foster home setting beyond the scheduled monitoring. If needed, a monitoring schedule is developed and documented in the case record.

The final care and monitoring plan for the individual should address his functional, medical, social and emotional needs and how they might be met in the selected foster care home. Assess whether other resources in the community should be used to meet specialized needs of the individual. Use of those resources should be documented in the care plan.

If there are health concerns regarding the individual, the regional nurse may be consulted and a recommendation may be made for the individual to have a physical/medical exam prior to moving into the AFC home.

Once the supervisor has approved the individual and potential placement in AFC, the case worker contacts the individual and the AFC provider to arrange for the initial visit and a negotiated move-in date for the individual.

 

4150 Finalizing the Care Plan – Required Initial Home Visit

Revision 17-1; Effective March 15, 2017

 

Program Standard: On or before the date the individual moves into the adult foster care (AFC) home, a meeting with the individual and the AFC provider is required to discuss the individual's care plan and to complete Form 2327, Individual/Member and Provider Agreement.

The individual's family members or responsible person may be included in the meeting and the meeting should preferably take place in the AFC home.

During the initial home visit, discuss the individual's needs and care plan as indicated on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care. Reach an agreement about how the individual's needs should be met through daily care and activities.

Discuss the individual's care plan with the individual and family members/responsible party and reach understanding with them about how the foster care provider will meet his needs. This discussion should ensure that the individual, his family/responsible party and the foster care provider are adequately prepared for a new individual in the home and that adjustments occur smoothly. Document the care plan and any special needs of the individual or special agreements between the individual and provider on Form 2327.

 

4151 Individual and Provider Agreement

Revision 17-1; Effective March 15, 2017

 

During the initial home visit, the case worker documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The case worker reviews all of the information on the agreement with the individual, family and/or responsible person and the provider. All conditions of the agreement and the following topics must be covered in the discussion:

Fully discuss with the foster care provider the likelihood of problems arising after the individual moves into the home, notification procedures and suitable actions that should be taken to resolve problems. Also, discuss with the provider the impact of a new individual on members of the foster care family and other individuals in the home. Anticipate problems that might arise and how they should be handled. Outline the schedule of monitoring visits that have been planned for the individual.

The individual and the provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement.

 

4152 Personal Needs and Medical Expenses Allowance

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3906, Adult Foster Care Personal Needs and Medical Expenses Allowance. Adult foster care clients must be allowed to keep funds for personal needs and medical expenses as specified in paragraphs (1)-(3) of this section.

(a) Clients with Medicaid coverage must be allowed to keep at least $50 a month for personal needs.
(b) Clients without Medicaid coverage must be allowed to keep at least $85 a month for personal needs and medical expenses.
(c) All clients must be allowed to keep at least one-half of any cost-of-living adjustment received on or after January 1, 1993.

Ensure that the individual keeps sufficient funds each month for personal needs and medical expenses. The $50 and $85 amounts are minimum amounts. The individual may need to keep more depending on his particular circumstances. Help the individual determine how much he spends on prescription drugs and medical bills each month. When the room and board agreement is negotiated, also consider personal expenses such as replacement of clothing and toiletries.

 

4153 Room and Board Agreement

Revision 17-1; Effective March 15, 2017

 

Ensure that the individual and provider understand that the room and board arrangement with the provider is separate from the Texas Health and Human Services Commission (HHSC) payment for services. The individual pays the provider for room and board. Help the provider and the individual negotiate the room and board agreement. The amount paid may be influenced by prevailing rates in the community. The room and board agreement and any other monetary arrangements are entered on Form 2327, Individual/Member and Provider Agreement.

If the individual is moving into the adult foster care home mid-month, prorate the amount of room and board for the month and advise the individual and provider of the prorated amount. The ongoing amount of room and board is negotiated with the individual and provider and both amounts are recorded on Form 2327.

 

4153.1 Changes in the Room and Board Agreement

Revision 17-1; Effective March 15, 2017

 

If the individual has a change in income or expenses, he or the provider may request a change in the amount of room and board payment. Changes in the room and board payment are negotiated between the individual and the provider and are documented on Form 2327-A, Room and Board Amendment to the Individual/Member and Provider Agreement.

 

4154 Leave Away from the Foster Home and Bedhold Charges

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.3904(f). The Texas Department of Human Services pays the daily rate for up to 14 days of leave for each 12-consecutive-month period when an authorized client is away from the foster home. Payment for leave in excess of 14 days per year is the responsibility of the client. Any bedhold charges are between the client and provider because they have negotiated a monthly room and board agreement. Bedhold charges, however, may not exceed the daily room and board rate.

§48.3904(g). The adult foster care provider is responsible for notifying the case worker by the next workday when a client is away from the foster home for personal leave or hospitalization.

During the initial home visit, the case worker reviews the information regarding the individual's responsibility to pay a bedhold charge when away from the home. Ensure that the individual understands that if he uses more than 14 days of leave during a 12-month period, he is responsible for paying the provider the full daily rate.

 

4155 Authorization of Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

After all procedures are completed, the case worker sends the individual Form 2065-A, Notification of Community Care Services. The case worker authorizes adult foster care on Form 2101, Authorization for Community Care Services, in the Service Authorization System wizards and sends the provider a copy of Form 2101.

 

4156 Adult Foster Care and Day Activity and Health Services

Revision 17-1; Effective March 15, 2017

 

Some services cannot be authorized at the same time as Adult Foster Care (AFC). Refer to the chart in Appendix XX, Mutually Exclusive Services. Day Activity and Health Services (DAHS) may be authorized for AFC individuals under the following conditions. The AFC individual:

Documentation in the case record must clearly specify that at least one of the above conditions is met. See Section 4221, Medical Criteria, for the DAHS eligibility requirements for a medical need.

DAHS may be authorized for the maximum of 10 units per week; however, the authorization must be related to the individual's need and not authorized for the convenience of the AFC provider.

40 Texas Administrative Code §48.8907(a), Resident care and services. The adult foster care provider must:

(1) provide services to residents according to the individual service plan and the client/provider agreement;
(2) meet all requirements and conditions stated on the client/provider agreement, approval of foster care, and client service plan;
(3) ensure that an approved substitute provider is present in the home if at least one resident remains in the home when the provider plans to be absent from the home for more than three hours in a 24-hour period. Residents whose care plans specify the need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period of time.

If an individual is authorized to attend DAHS but is ill or prefers not to attend on a particular day, it is the AFC provider's responsibility to provide supervision in the AFC home for the individual.

 

4160 Monitoring

Revision 17-1; Effective March 15, 2017

 

Program Standard: Monitoring contacts are required monthly for the first three months the individual is in the foster home. Two of the monitoring contacts may be made by telephone if appropriate for the individual. At least one of the contacts must be a home visit to the individual in the foster home and the individual must be interviewed privately.

 

4161 60-Day and 90-Day Monitoring Contacts

Revision 17-1; Effective March 15, 2017

 

Monitoring contacts must be completed during the first three months after the individual is certified for adult foster care. Two of the monitoring contacts may be made by telephone. At least one of the three monitoring contacts must be made in person with the individual in the foster home. The individual must be seen alone so that he can freely discuss any problems with the provider or the home. It is the case worker's responsibility to assist in resolving any problems noted. Contact the contract manager if there are problems with the home or the provider.

 

4162 Six-Month Monitoring Contact

Revision 17-1; Effective March 15, 2017

 

After the first three months, the individual must be monitored at regularly scheduled six-month intervals, unless the case worker and supervisor have determined that the individual requires more frequent monitoring. The first six-month monitoring contact occurs three months after the 90-day monitoring contact.

Regular monitoring visits should assess the individual's needs and whether the provider is addressing and meeting those needs. Report to the contract manager if the adult foster care provider is not addressing or meeting those needs. The individual's physical and medical condition should be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness. Regional nurses should be used in this assessment/monitoring process as needed.

All monitoring contacts must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System monitoring wizard.

 

4170 Significant Changes

Revision 17-1; Effective March 15, 2017

 

It is the responsibility of the case worker and the adult foster care (AFC) provider to ensure that the AFC individual is in an appropriate setting to meet his needs. When the AFC individual has a change in functional need, health problems or changes in behavior, it is the responsibility of the AFC provider to notify the case worker.

Within 14 days or sooner, as appropriate, the case worker must follow-up with the individual and provider to determine if changes to the care arrangement are needed. The case worker may consult with the supervisor to determine how quickly a response is needed to the situation.

Give particular attention to individuals who reflect dramatic changes in functional need, medical problems or behaviors that are inappropriate for foster care. Alert family members and/or the responsible party or guardian to the situation. Discuss with them and the individual the potential for the individual to remain in the foster home. If an individual has a guardian appointed by the courts, the guardian acts on the individual's behalf. If the individual has had a decline in his medical condition or functional ability, consult the regional nurse and request that the nurse make a visit to the individual for a medical assessment.

 

4171 Changes in the Service Plan

Revision 17-1; Effective March 15, 2017

 

Document the changes in an individual's condition on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, noting changes in the individual's functional ability and appropriateness for adult foster care (AFC) placement. Discuss the changes with the supervisor, regional nurse (if needed), AFC provider and family members. Refer to Section 2550, Identifying Individuals at Risk, if the individual's health and safety are at risk and additional service planning is needed. If AFC continues to be appropriate for the individual, document the needed changes in the service plan on Form 2327, Individual/Member and Provider Agreement.

 

4172 Adult Foster Care No Longer Appropriate

Revision 17-1; Effective March 15, 2017

 

If after a review of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, the individual's needs can no longer be met or the individual is no longer appropriate for adult foster care, discuss alternative living arrangements with the individual and family/responsible party. Long-range care plans should be discussed frankly with the individual, family members and the foster care provider to ensure that all are aware of the capabilities and limitations of adult foster care services for individuals with deteriorating medical or functional conditions. Individuals who become inappropriate for foster care must be advised of other available options. Help individuals and their family members in this decision process and with transfer activities when necessary. If the provider decides that the individual is not appropriate for care in his home, the provider contacts the case worker to request that the individual be transferred to another placement. The case worker is responsible for preparing the individual for the move and transition.

 

4173 Termination of Adult Foster Care Services

Revision 17-1; Effective March 15, 2017

 

Once an individual is identified as inappropriate for foster care, the case worker must negotiate a time frame with the individual, family/responsible party and the adult foster care (AFC) provider for the individual to move. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the individual has been a threat to the health and safety of other individuals or has exhibited inappropriate behaviors so that the provider is asking the individual to move immediately, then the case worker must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the individual, refer to Adult Protective Services (APS) to assist in locating appropriate placement for the individual.

If the individual will not be transferring to another AFC setting, send the individual Form 2065-A, Notification of Community Care Services, with the negotiated move date as the end date of services. Unless the individual's service is being terminated due to threat to health and safety (see Section 2811, Effective Dates for Service Reduction and Termination), give the individual at least 12 days notice. Terminate AFC services on Form 2101, Authorization for Community Care Services.

If there is resistance to the move from the individual, family or the provider, an additional staffing with the individual, family/responsible party and provider may be required to resolve the problem. Request that the supervisor and contract manager attend the staffing, if necessary. Advise the individual and provider that AFC services will terminate on the date specified on Form 2065-A. The provider has the right to begin eviction proceedings as specified in the provider's resident rights and responsibilities. Ensure that the individual and responsible party understand the consequences of eviction. If the provider must use eviction procedures and the individual has refused to make other living arrangements, refer the individual to APS.

If the individual and provider decide that the individual will remain in the home as a private pay individual, then the contract manager must give approval. Make sure the individual and provider understand that there are no case management services or payment arrangements from the Texas Health and Human Services Commission for a private pay individual.

 

4180 Annual Reassessment

Revision 17-1; Effective March 15, 2017

 

Reassess the adult foster care (AFC) individual every 12 months as outlined in Section 2660, Reassessments and Recertification Procedures. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed annually and signed by the supervisor. Carefully review the appropriate and inappropriate characteristics on Form 2330 and be alert for changes that indicate that the individual is no longer appropriate for AFC or that his medical/functional needs can no longer be met. If the individual's condition is deteriorating, but not to the point that AFC is currently inappropriate, discuss with the individual that a move may be necessary in the future.

Reevaluate the service plan at each reassessment and update according to the individual's new/changed needs. Discuss changes in the individual's need level and in the service plan with the foster care provider and obtain supervisory approval.

Reauthorize AFC on Form 2101, Authorization for Community Care Services.

 

4200 Day Activity and Health Services

Revision 17-1; Effective March 15, 2017

 

 

 

4210 Description

Revision 17-1; Effective March 15, 2017

 

Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed and certified by the Texas Health and Human Services Commission. Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.

40 Texas Administrative Code §98.211(a) ─ The method of payment is a unit of authorized service and is defined as half a day. One unit of service constitutes three hours but less than six hours of covered services provided by the DAHS facility. Six hours or more of service constitutes two units of service. Time spent in approved transportation provided by the DAHS facility shall be counted in the unit of service.

Services must be provided according to the individual's service plan and according to the standards for participation in the Day Activity and Health Services Provider Manual.

Discuss with the individual (or, if necessary, his family or other involved individuals) the individual's condition, program plan and staff administering the plan.

Individuals must be given the opportunity to receive medical attention and help in getting health services not available from the provider.

The facility must be used only for authorized purposes.

 

4211 Nursing and Personal Care

Revision 17-1; Effective March 15, 2017

 

Services include:

 

4212 Physical Rehabilitation

Revision 17-1; Effective March 15, 2017

 

Services include:

 

4213 Nutrition

Revision 17-1; Effective March 15, 2017

 

Services include:

 

4214 Transportation

Revision 17-1; Effective March 15, 2017

 

If needed, the Day Activity and Health Services (DAHS) facility ensures transportation to and from the facility.

 

4215 Other Supportive Services

Revision 17-1; Effective March 15, 2017

 

Services include:

 

4220 Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §98.201, Eligibility Requirements for Participation

Community Care for Aged and Disabled (CCAD) policy prohibits the provision of CCAD services to individuals who live in an institution. An institution is defined as a skilled nursing facility or an intermediate care facility, including an intermediate care facility for persons who have an intellectual disability.

An individual who needs less than one unit (three hours of service) per week is not eligible for DAHS. One unit of DAHS service equals at least three hours but less than six hours per week. Authorization for DAHS cannot exceed more than 10 units per week.

 

4221 Financial Eligibility Criteria

Revision 17-1; Effective March 15, 2017

 

Medicaid recipients are financially eligible for Title XIX Day Activity and Health Services (DAHS). Applicants who are not Medicaid recipients but who are categorically eligible or within the Community Care for Aged and Disabled (CCAD) income and resource limits are financially eligible for Title XX DAHS. Applicants are not eligible if they are receiving another CCAD service that duplicates DAHS. See Section 3000, Eligibility for Services, for the policies concerning income and resources.

 

4222 Medical Eligibility Criteria

Revision 17-1; Effective March 15, 2017

 

For an individual to be eligible for Day Activity and Health Services (DAHS):

If a physician has accepted Medicaid payments for the diagnosis and treatment of the individual's illness that makes him eligible for DAHS, that physician cannot bill the individual for completing Form 3055.

 

4223 Unmet Need Criteria

Revision 17-1; Effective March 15, 2017

 

Applicants must have an unmet need for services and are not eligible for Day Activity and Health Services (DAHS) if they are receiving another CCAD service that duplicates DAHS. DAHS may be received with some other services as long as there is not a duplication of services.

 

4223.1 DAHS in Conjunction with Other Services

Revision 17-6; Effective June 28, 2017

 

Day Activity and Health Services (DAHS) may be received in conjunction with some other services, including the following:

See Appendix XX, Mutually Exclusive Services, for complete information regarding which Long-term Services and Supports may be received in conjunction with others. Staff must also ensure that individuals with active Medicaid coverage are not certified for Title XX DAHS.

 

4224 DAHS Licensure Age Requirements

Revision 17-1; Effective March 15, 2017

 

Day Activity and Health Services (DAHS) facilities licensed as adult day care centers are unable to serve individuals under age 18. An individual under age 18 requesting DAHS must be advised that even if eligibility criteria for DAHS are met, he may not be able to access the service unless a facility is licensed to serve children and has a separate facility not accessible to adults. The case worker should refer the applicant to alternative services, such as:

 

4230 DAHS Approval

Revision 17-1; Effective March 15, 2017

 

Determination and redetermination of eligibility for Day Activity and Health Services (DAHS) involves the cooperative efforts of the regional nurse, the case worker, the facility nurse and the individual's physician.

 

4231 Intake

Revision 17-1; Effective March 15, 2017

 

Intake into Day Activity and Health Services (DAHS) begins when the case worker receives a request for services. Requests for DAHS services may be made by:

A DAHS facility may also request services for an individual who is already attending the DAHS facility if the applicant is:

 

4231.1 Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

The Texas Administrative Code stipulates that facility-initiated referrals for Day Activity and Health Services (DAHS) apply only to Title XIX services:

40 Texas Administrative Code §98.204(a)(1)(2), DAHS Facility-Initiated Referrals

Only Medicaid recipients are eligible for facility-initiated referrals. The facility may admit and serve the Medicaid recipient before approval by the Texas Health and Human Services Commission (HHSC) is obtained if it is willing to risk the loss of revenue if the applicant is determined ineligible. The individual cannot be someone who is currently receiving DAHS at any facility that has a DAHS contract. Individuals have freedom of choice in the selection of qualified providers. It is critical that the case worker and/or regional nurse coordinate transfers from one DAHS facility to another to prevent duplication of services or gaps in coverage.

For the facility-initiated referral, the facility must:

The date of the verbal notification is the date of request for Community Care for Aged and Disabled Services.

 

4231.2 Intake Response

Revision 17-1; Effective March 15, 2017

 

Within 14 calendar days of receipt of the intake, the case worker must contact the applicant either by telephone or face-to-face contact to complete the application for Day Activity and Health Services (DAHS). Time frames for responding to other requests for services (intakes) are based on the priority of the intake. See Section 2320, Case Worker Response, for priorities and time frames. A home visit is required only at the applicant's request.

Prior to the contact, the case worker checks the Texas Integrated Eligibility Redesign System (TIERS) to determine if the applicant is Medicaid eligible or categorically eligible. The case worker also checks the Service Authorization System (SAS) to determine the applicant is not a current DAHS individual.

If the applicant is not Medicaid eligible, determine if the applicant will meet the criteria for Title XX Services and if Title XX Services are available. See Section 2230, Interest List Procedures.

If the applicant is not Medicaid eligible and the intake is a facility-initiated referral, notify the facility by telephone and follow up with Form 2067, Case Information, letting the facility know the applicant is not Medicaid eligible and is not eligible for the facility-initiated referral.

If the applicant is already a DAHS individual at another facility, notify the facility by telephone and follow up with Form 2067, letting the facility know the applicant is already an individual, is not eligible for the facility-initiated referral and must follow the transfer procedures as outlined in Section 4262, DAHS Transfers.

 

4231.3 Initial Interview

Revision 17-1; Effective March 15, 2017

 

The case worker contacts the applicant either by telephone or face-to-face to complete the assessment interview. During the interview, the case worker discusses services available through Day Activity and Health Services (DAHS) and determines if the applicant appears to have a medical diagnosis and a functional disability related to the medical diagnosis, an unmet need for services or is receiving other services that duplicate DAHS.

During the assessment, the case worker:

The date of assessment begins the 30-day time frame for the case worker to complete the application process.

 

4231.4 Response to Individuals Who Are No Longer Attending DAHS

Revision 17-1; Effective March 15, 2017

 

If the applicant has stopped attending Day Activity and Health Services (DAHS) before the application process is complete, the applicant does not have to complete an application or Form 2307, Rights and Responsibilities, if he was Medicaid-eligible when DAHS was received. Attempt to contact the individual by telephone, mail or home visit to:

If unable to locate the individual or if the individual refuses to provide any information, verify through automation records the individual's effective date of Medicaid coverage and whether the individual is receiving other CCAD services that may duplicate DAHS. See Section 2433, Determining Unmet Need in the Service Arrangement Column, to determine CCAD services that duplicate each other. Complete and send to the facility:

Send Form 2065-A to the applicant.

See Section 4233, Initial Eligibility Determination and Referral.

Note: Coordinate with the local Area Agency on Aging to ensure there is no service duplication.

 

4232 Facility Choice

Revision 17-1; Effective March 15, 2017

 

If the individual is to be referred to a Day Activity and Health Services (DAHS) facility, describe the facility to the individual and the type of service available. When possible, the individual should visit the facility before services begin. Based on federal requirements for services that are funded under Medicaid, the individual maintains freedom of choice among the DAHS facilities that serve the individual's area. If the individual meets all DAHS eligibility requirements, he has freedom of choice to choose a DAHS facility, regardless of any relationship to the provider.

40 Texas Administrative Code §98.202(a)(3). A Day Activity and Health Services (DAHS) facility must serve eligible clients, unless a facility is at licensed capacity.

Individuals must be referred to DAHS facilities based on the following priorities:

Contact the facility selected by the individual to determine if the facility has openings. If the facility is operating at capacity, contact the individual and arrange another placement that is satisfactory to him.

The facility staff maintain an interest list for Title XIX and private-pay individuals since Medicaid regulations prohibit the Texas Health and Human Services Commission (HHSC) from maintaining an interest list for any Title XIX service. HHSC regional staff maintain the Title XX interest list. See procedures in Section 2930, Community Services Interest List (CSIL).

 

4233 Initial Eligibility Determination and Referral

Revision 17-3; Effective May 15, 2017

 

If the case worker determines the applicant meets the initial eligibility criteria of being financially eligible and having an unmet need for Day Activity and Health Services (DAHS) (no duplication of Community Care for Aged and Disabled (CCAD) services), the case worker, within five business days of the assessment, completes a referral Form 2101, Authorization for Community Care Services, and sends the referral packet to the facility.

The referral packet includes:

See Appendix XIII, Content of Referral Packets.

If the referral is facility-initiated, the case worker indicates in the comments section of Form 2101 that the applicant is being referred for facility-initiated DAHS. If the applicant no longer attends the DAHS facility, enter the date the applicant stopped as the "end" date on Form 2101 and note in the comments section the applicant is no longer attending DAHS.

If the case worker determines the applicant is not eligible for DAHS, the case worker sends the applicant Form 2065-A, Notification of Community Care Services. If the referral was facility-initiated, the case worker sends a copy of Form 2065-A to the DAHS facility and notifies the facility by telephone of:

 

4234 Facility Response for Facility-Initiated Referrals

Revision 17-3; Effective May 15, 2017

 

40 Texas Administrative Code §98.204(c)-(d), DAHS Facility-Initiated Referrals

For facility-initiated referrals, the Day Activity and Health Services (DAHS) facility must submit a full prior approval packet to the Texas Health and Human Services Commission (HHSC) regional nurse within 30 calendar days after the date of the initial physician's orders (verbal or written) by submitting:

 

4234.1 Regional Nurse Responsibilities for Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

The Day Activity and Health Services (DAHS) facility must request written prior approval for the applicant from the regional nurse within 30 days after the date of the physician orders. If the DAHS facility submits the prior approval packet to the Texas Health and Human Services Commission (HHSC) regional nurse within 30 calendar days of the initial physician's orders and the applicant meets all eligibility requirements, the HHSC regional nurse authorizes services. Within five business days of receipt of the prior approval packet, the HHSC regional nurse sends the Authorization Form 2101, Authorization for Community Care Services, to the facility and the case worker. The effective date is the date of the physician's orders on Form 3055, Physician's Orders (DAHS).

Example: The facility receives Form 3055 on April 5 with a physician's signature date of April 1. The facility receives Form 2101 and the referral packet from the case worker on April 20. The facility submits the prior approval packet to the regional nurse on April 22 and the nurse receives the packet on April 24. This is within 30 calendar days of the physician's orders and the applicant meets all eligibility requirements, so the regional nurse authorizes services effective for April 1.

If the DAHS facility fails to submit the prior approval packet or additional documentation within the required time frames, or if the additional documentation is not adequate, or if the applicant is determined ineligible by the HHSC case worker, the regional nurse cancels the DAHS facility-initiated prior approval and the DAHS facility is not reimbursed for services. If the applicant meets all eligibility requirements, the HHSC regional nurse authorizes services by sending Form 2101 to the facility and the case worker. The nurse may send Form 2101 to the case worker by secure electronic mail (email) as determined by regional procedures. If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into the Service Authorization System (SAS) and print a copy of the Authorization Form 2101 from SAS and a copy of the email for the case record.

The effective date is the earliest of the following dates on the prior approval packet:

The facility is not reimbursed for any services delivered prior to the authorization date.

Example: The facility obtains verbal physician's orders and requests services through HHSC on April 1. The facility sends Form 3055 to the physician for his completion and signature. The HHSC case worker completes the assessment on April 13 and sends the facility Form 2101 and the referral packet. The facility has not received Form 3055 back from the physician. On May 2, the facility receives Form 3055 and mails the prior approval packet to the HHSC regional nurse. The regional nurse receives the packet on May 4, which is more than 30 days from the physician's verbal orders. The regional nurse establishes eligibility and authorizes services effective May 2, which is the U.S. Postal Service date on the envelope mailed from the facility.

 

Critical Omissions for Facility-Initiated Referrals

If there are critical omissions, the HHSC regional nurse sends Form 3070, Day Activity and Health Services Notification of Critical Omissions, within five business days of receipt of the prior approval packet to the facility with a copy to the case worker. The corrections from the facility must be submitted to the regional nurse within 14 days. If the corrections are received within the time frame and the applicant meets eligibility requirements, the regional nurse authorizes services effective the date of the physician's orders on Form 3055. If the facility fails to meet this time frame, the date of prior approval can be no earlier than the postmark or HHSC-stamped date on the corrected documentation. See Section 4236, Critical Omissions, for additional information.

 

4234.2 Case Worker Responsibilities for Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

It is the case worker's responsibility to determine the applicant's eligibility within 30 calendar days from the assessment date and to track if Form 2101, Authorization for Community Care Services, has been completed by the Texas Health and Human Services Commission (HHSC) regional nurse. If, on the 30th day the case worker has not received Form 2101 or received notice of critical omissions, the case worker contacts the regional nurse to inquire if the required information has been received. The case worker must document the contact and the regional nurse's response. The case worker will take one of the following actions:

The applicant may reapply for services, but new physician's orders and a new assessment must be completed.

 

4235 Facility Response to Case Worker Referrals

Revision 17-3; Effective May 15, 2017

 

For Texas Health and Human Services Commission (HHSC) case worker initiated referrals, the Day Activity and Health Services (DAHS) facility must respond within 14 days of receipt of the referral Form 2101, Authorization for Community Care Services, from the case worker.

40 Texas Administrative Code §98.203(d)-(f), Written Referrals for Services

Within 14 days of the receipt of the referral Form 2101, the DAHS facility sends the prior approval packet to the HHSC regional nurse. The prior approval packet consists of:

If the DAHS nurse notifies the case worker that the health assessment or the physician's orders will be delayed beyond 14 days, evaluate the cause of the delay. Consult the individual to determine whether he should be referred to another provider of his choice. If the case worker decides to make a new referral, verbally notify the original provider and HHSC regional nurse of the new referral. Send Form 2067, Case Information, to the original provider to confirm the withdrawal.

 

4235.1 Regional Nurse Responsibilities for Case Worker Referrals

Revision 17-3; Effective May 15, 2017

 

When the regional nurse receives the required forms from the facility, the regional nurse reviews Form 2101, Authorization for Community Care Services, Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 3055, Physician's Orders  (DAHS), to determine if the individual meets the Day Activity and Health Services (DAHS) medical eligibility criteria found in Section 4222, Medical Eligibility Criteria. If there are critical omissions/errors in the required documentation, the regional nurse follows procedures in Section 4236, Critical Omissions.

The regional nurse must keep the envelope in which the prior approval material is mailed. If more than one prior approval packet is included in the envelope, the regional nurse or his designee must indicate on the outside of the envelope the names of the prior approval packets that are included in the envelope.

Within five business days of the receipt of the prior approval request, the regional nurse generates and sends the authorization, Form 2101, to the facility and the case worker for notification of approval or denial of the applicant. The regional nurse grants approval if the:

The region has the option of allowing the regional nurse to send notification of the authorization to the case worker by secure electronic mail (email), rather than sending the paper copy. Each region may determine which method best suits its needs. The regional nurse will continue to send a paper copy to the provider.

If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into the Service Authorization System (SAS) and print a copy of the Authorization Form 2101 from SAS, and a copy of the email for the case record.

 

4235.2 Effective Dates for Initial Cases

Revision 17-1; Effective March 15, 2017

 

The regional nurse establishes the beginning date of Day Activity and Health Services (DAHS) coverage based on whether the individual is referred by the case worker or by the facility as a facility-initiated referral, and if there are critical omissions/errors in the required documentation.

For case worker referrals, the regional nurse establishes the Begin Date of coverage on Form 2101, Authorization for Community Care Services, as the date it is expected to be mailed to the facility. If this date is not feasible, the regional nurse negotiates the Begin Date of coverage on Form 2101 with the case worker and the facility, according to the individual's needs and the individual's unique circumstances.

The regional nurse establishes the beginning date of coverage on Form 2101 for a facility-initiated referral using the date of the physician orders. If there are corrections for critical omissions/errors in the required documentation, the regional nurse follows procedures in Section 4236, Critical Omissions, and establishes the effective date as the:

 

4235.3 Case Worker Responsibilities for Case Worker Referrals

Revision 17-1; Effective March 15, 2017

 

Within two business days of receipt of Form 2101, Authorization for Community Care Services, from the regional nurse, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual notifying the individual of eligibility or ineligibility.

If the individual was a facility-initiated referral, a copy of Form 2065-A is also sent to the facility. The effective date on Form 2065-A must match the effective date on Form 2101 from the regional nurse.

 

4236 Critical Omissions

Revision 17-1; Effective March 15, 2017

 

For a list of critical omissions, please refer to 40 Texas Administrative Code (TAC) §98.204(e), DAHS Facility-Initiated Referrals.

If the required documentation contains errors and/or omissions, the HHSC regional nurse:

Corrections of critical omissions or errors in DAHS facility documentation must be postmarked or date stamped as received by HHSC within 14 days after the regional nurse mails HHSC Notification of Critical Omissions/Errors in Required Documentation form to the facility. If the facility fails to meet this time frame, the case worker will contact the individual within three workdays after being notified by the regional nurse and refer the individual to another DAHS facility, if the individual or the individual’s family/representative prefers this option.

The regional nurse uses the earliest of the following dates to establish the date that prior approval material and corrections of critical omissions or errors are received from the facility:

The facility has 14 days to correct critical omissions/errors. If the facility returns the packet before the 14th day but all identified omissions/errors have not been corrected, the facility has the remainder of the 14 days to resubmit additional corrections. The regional nurse verbally notifies the facility that:

The regional nurse documents this verbal notification (date, name of contact, etc.) in the case record.

 

4240 Facility Initiation of Services

Revision 17-1; Effective March 15, 2017

 

The facility must complete and return HHSC’s authorization for community services form to the case worker within 14 days from the begin date on HHSC’s authorization for community care services form. The Day Activity and Health Services (DAHS) facility must indicate the date services were initiated, the schedule for delivering services, and the total units authorized for the individual.

The 14-day period (for the facility to return Form 2101, Authorization for Community Care Services) encourages the facility to start services promptly. The 14-day period does not apply if an individual is already attending a DAHS facility when the facility refers him to the case worker (for example, a facility-initiated referral). For facility-initiated referrals, the facility returns Form 2101 as soon as possible after receiving it from the case worker.

 

4250 Monitoring

Revision 17-1; Effective March 15, 2017

 

Monitor the services based on the priority assigned to the individual's case. For priority levels, see:

Timelines for Day Activity and Health Services (DAHS)-only cases are measured differently than other situations because there is no Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, date from which to count. Measure DAHS-only timelines from the:

The regional nurse also monitors DAHS through utilization review.

 

4260 Changes

Revision 17-1; Effective March 15, 2017

 

The Day Activity and Health Services (DAHS) facility must inform the case worker of changes in the individual's status, condition and when the individual is suspended from attending DAHS.

 

4261 Service Plan Changes Reported by the Facility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.208(b), Notifications

Approve changes in the plan of care which may affect eligibility or units of service. Within 14 calendar days of receipt of Form 2067, Case Information:

If the case worker and individual agree with the facility's request, complete and send Form 2101, Authorization for Community Care Services. If the case worker and individual agree to terminate or reduce services, follow adverse action procedures in:

If the case worker or individual disagree with the request, send Form 2067 to the facility to explain the reason for not making the change.

 

4261.1 Individual Absences

Revision 17-1; Effective March 15, 2017

 

If a Day Activity and Health Services (DAHS) participant is absent from the facility for 15 consecutive days, the DAHS facility must verbally notify the Texas Health and Human Services Commission (HHSC) of the suspension no later than the first workday after services are suspended and then send Form 2067, Case Information, within seven workdays after the incident was reported verbally.

If an individual is absent from a regularly scheduled program, the DAHS facility must contact the individual or someone knowledgeable about his condition the same day that the absence occurs. If the DAHS facility is unable to contact the individual or someone knowledgeable about his condition, the DAHS staff must document this in the individual's record. DAHS facilities are not required to notify the case worker of daily absences from the facility.

 

4262 DAHS Transfers

Revision 17-1; Effective March 15, 2017

 

Only the individual may initiate a Day Activity and Health Services (DAHS) facility transfer; the change cannot be requested by facility staff.

When an individual decides to transfer to a new DAHS facility (including a facility in a different region), the individual must contact the HHSC case worker before making the move. The individual may make the request to the case worker orally or in writing. If a request for a DAHS transfer is received from anyone other than the individual, the case worker must contact the individual to ensure he desires the change. Services at the new facility may begin no earlier than one day after the individual receives services from the previous facility.

Within 14 days of the request from a current individual to transfer to another facility, follow these procedures:

It is critical for the case worker to coordinate individual transfers from one facility to another to ensure that no duplication of service or gaps in dates of coverage exist. Facility-initiated referrals are for applicants only and may not be used for individuals currently receiving DAHS services.

 

4263 Suspensions

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.207, Suspension of Day Activity and Health Services

For procedures on how to respond to suspension of services, see Section 2820, Service Suspension.

 

4264 Ensuring Health and Safety at DAHS Facilities

Revision 17-1; Effective March 15, 2017

 

If an individual attending a Day Activity and Health Services (DAHS) facility exhibits reckless behavior that may result in imminent danger to the health and safety of other DAHS individuals and/or DAHS staff, the DAHS facility must take immediate action to protect the individuals and staff in the facility. This may require removing the individual from the facility or away from other individuals and/or contacting the local authorities (police, sheriff's department or mental health authorities) to ensure safety. The facility may make a referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) Adult Protective Services (APS). The facility must immediately suspend services to the individual.

The DAHS facility must verbally inform the HHSC case worker by the following HHSC workday of the reason for the immediate suspension and follow up with written notification to HHSC within seven HHSC workdays of verbal notification, in accordance with 40 Texas Administrative Code (TAC) §98.207(b). Upon notification, the case worker must follow the procedures outlined in Section 2731, Threats to Health or Safety, including notifying management of the incident and conferring to ensure all appropriate actions are taken to maintain a safe environment in the facility.

An interdisciplinary team meeting must be arranged at the earliest opportunity to determine if the issue can be resolved and services continued. If the threat to health and safety was serious enough, services may be terminated immediately. See additional guidelines in Section 2811, Effective Dates.

If the individual reapplies for services at a later date, the policy outlined in 40 TAC §48.3902 applies and the individual must provide information or authorize collateral contacts to verify he is no longer a threat. See additional policy in Section 2732, Reinstatement of Services Terminated for Threats to Health or Safety.

 

4270 Reassessment

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.201, Eligibility Requirements for Participation

After the regional nurse gives initial prior approval for Day Activity and Health Services (DAHS), the authorization is transferred to the case worker. Review ongoing DAHS for these individuals according to Section 4271, Renewal of Prior Approval. The DAHS facility does not obtain new physician's orders for individuals receiving ongoing DAHS.

Review the DAHS individual's eligibility at least every 12 months. Timelines for DAHS-only cases are measured differently than other case situations because there is no Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, date from which to count. Measure DAHS-only reassessment timelines from the:

When reassessing a DAHS individual's eligibility, examine the individual's past history of attendance and reauthorize only the number of units which the individual is likely to use. Explore the reasons for underutilization by discussing the situation with the individual, facility staff and the individual's family.

If underutilization has been sporadic due to temporary factors such as acute illness or hospitalization, no change in service authorization may be needed. However, if underutilization has occurred consistently during the previous six months, discuss changing the service plan with the individual and family. The case worker may need to decrease the number of units authorized per week.

A review of the service plan may be appropriate during the 12-month period if a change in units of service is required.

If the case worker determines that the individual continues to be eligible for DAHS, and if the number of units changes, submit Form 2101, Authorization for Community Care Services, to the facility. If the facility does not agree with the service plan change, the facility representative must contact the case worker before the effective date of the change, if possible, to resolve the disagreement.

Follow procedures in Section 4271 and Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services, to complete Form 2101.

If the case worker determines that the individual no longer qualifies for DAHS, send the individual Form 2065-A, Notification of Community Care Services, to terminate services. Update Form 2101 to terminate services. Follow procedures in:

Send Form 2101 to the facility.

 

4271 Renewal of Prior Approval

Revision 17-1; Effective March 15, 2017

 

Although the coverage period is open-ended in the Service Authorization System, the case worker must conduct a reassessment/redetermination of the individual and send the facility Form 2101, Authorization for Community Care Services, confirming eligibility status if the number of units changes or if services are terminated. Use the following procedures for renewal of prior approval, including late renewals.

If the case worker . . . Then . . .
reassesses/redetermines the individual eligible for services and there are no changes to the service plan,

verbally notify the individual that services will continue at the same level.

Do not send any forms to the Day Activity and Health Services facility if there are no changes.

reassesses/redetermines the individual eligible for services and there are changes to the service plan (units),
  • send the individual Form 2065-A, Notification of Community Care Services, to notify him of the change in the service plan; and
  • send the facility an updated and signed Form 2101 to notify it of the change.

The effective date for a decrease is 12 days following the Form 2065-A date. The effective date for an increase is seven days following the Form 2101 date.

reassesses/redetermines the individual ineligible for services,
  • send the individual Form 2065-A to notify him of the termination; and
  • send the facility an updated and signed Form 2101 as notification of the termination.

See Appendix IX, Notification/Effective Date of Decision, to determine the effective date.

 

4300 Emergency Response Services

Revision 17-1; Effective March 15, 2017

 

 

 

4310 Introduction

Revision 17-1; Effective March 15, 2017

 

Emergency response services (ERS) are provided through an electronic monitoring system. This system is for use by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps ensure that the appropriate person or service agency responds to an alarm call from an individual.

ERS can be delivered to individuals with a landline telephone or in some areas may be available to individuals with cellular phone service or Voice Over Internet Protocol (VOIP). The provider agency choice list designates which ERS providers in the contracted service area are able to accommodate applicants who elect to receive ERS without a landline telephone. The rates for the service are the same regardless of the ERS delivery mechanism (e.g., cellular, landline, VOIP).

 

4311 Program Definitions

Revision 17-1; Effective March 15, 2017

 

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

Alarm call — A signal transmitted from the equipment to the provider's response center indicating that the individual needs immediate assistance.

Call button — An electronic device that, when pressed, triggers an alarm to the response center to alert the provider that an individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment or kept within the individual's reach.

Installer — A volunteer, a subcontractor or an employee of a provider who connects, maintains or repairs the equipment.

Monitor — A volunteer, subcontractor or an employee of a provider who monitors Emergency Response Services (ERS) and ensures that an alarm call is responded to immediately.

Responder — A person designated by an individual to respond to an emergency call activated by the individual. A responder may be a relative, neighbor or a volunteer.

Response center — The site where a provider's ERS monitoring system is located.

Subcontractor — An organization or individual who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.

 

4312 Eligibility and Referral Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4312.1 Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2928. To be eligible for emergency response services, a client must:

(1) meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility; and

(2) meet the requirements:

(A) live alone, be alone routinely for eight or more hours each day, or live with an incapacitated individual who could not call for help or otherwise assist the client in an emergency;
(B) be mentally alert enough to operate the equipment properly, in the judgment of the DHS case worker;
(C) have a telephone with a private line, if the system requires a private line to function properly;
(D) be willing to sign a release statement that allows the responder to make a forced entry into the client's home if he is asked to respond to an activated alarm call and has no other means of entering the home to respond; and
(E) live in a place other than a skilled institution, assisted living facility, foster care setting, or any other setting where 24-hour supervision is available.

The eight hours mentioned in requirement (1) of the rule does not have to be continuous, provided the individual is alone at least eight hours in each 24-hour period. Even if the individual has an attendant, consider the individual alone.

If the provider is unable to complete installation, inform the individual that installation of ERS equipment is pending for the reasons stated by the provider. If the individual is unable or unwilling to make the needed modifications, explore other community resources to determine if these could be used to complete the needed modifications. If none are available, services may then be denied using termination code "other." Document the reason in the case record.

See Section 3000, Eligibility for Services, for additional eligibility requirements.

40 TAC §48.3903(d). The client is not eligible for emergency response services if:

(1) he abuses the service by activating:

(A) four false alarms which result in a response by fire department, police/sheriff, or ambulance personnel within a six-month period; or

(B) twenty false alarms of any kind within a six-month period;

(2) he is admitted to a skilled institution, personal care home, foster care setting, or any other setting where 24 hour supervision is available;

(3) in the case worker's judgment, he is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to:

(A) he damages the equipment,

(B) he disconnects the equipment and has received two warnings that are documented in the case record,

(C) he refuses to participate in the monthly systems checks; or

(4) he is away from the home or is unable to participate in the service delivery for a period of three consecutive months or more.

 

4312.2 Referral Process

Revision 17-1; Effective March 15, 2017

 

A provider must accept all HHSC referrals.  A case worker makes a routine referral on Form 2101, Authorization for Community Care Services, or makes a negotiated referral by phone and Form 2101.  

The case worker gives eligible applicants an explanation of the service. He explains that applicants/individuals are required to:

The case worker follows procedures as outlined in Section 3000, Eligibility for Services.

 

4313 Case Management Duties Related to Emergency Response Services (ERS)

Revision 17-1; Effective March 15, 2017

 

If the applicant/individual appears to be in need of ERS and wants to receive ERS, the case worker determines if the applicant/individual meets the general criteria for participating in ERS.

If eligible for ERS, the case worker shares the regional list of all ERS providers and encourages the applicant to choose the most economical alternative for service provision. The applicant/individual selects a provider from the list of providers. If the applicant/individual has no preference, the case worker refers the applicant to the provider with the lowest rate. If more than one provider has the same lowest rate, the case worker makes the referral by rotation of providers. If the individual is currently receiving services from a provider that does not have the lowest rate, but is not satisfied with that provider, the case worker should encourage the individual to choose another provider. The individual should not be encouraged to choose another provider just because it has a lower rate.

The case worker may assist the individual or the provider in identifying potential responders, and in periodically updating the information the provider maintains in its files on responders and other emergency numbers. The case worker must not be an emergency responder for the individual.

HHSC rules require the ERS provider to notify the case worker no later than the next HHSC workday of alarms, other individual emergencies or changes in the individual's behavior or condition that preclude ERS.

At least annually, the case worker must review the list of responders provided to the provider to ensure the list is current. During the course of the services, the case worker and the provider have the joint responsibility of keeping each other informed of changes or problems.

Report to the contract manager any provider tendency or pattern of designation of emergency personnel as respondents. Advise the individual that he is responsible for any charges assessed by emergency personnel if they are summoned to the individual's home for a non-medical emergency.

 

4320 Service Delivery Requirements

Revision 17-1; Effective March 15, 2017

 

 

 

4321 Service Initiation

Revision 17-1; Effective March 15, 2017

 

The service initiation process is located in 40 Texas Administrative Code (TAC) §52.403, Service Initiation.

When the provider receives a copy of Form 2101, Authorization for Community Care Services, and Form 2065-A, Notification of Community Care Services, he:

If there is a negotiated service initiation date, the provider will receive confirmation from the case worker of the negotiated service initiation date by which services must begin.

The case worker evaluates whether an alternative service or other resources are available to meet the individual's needs. The case worker instructs the provider to retain the authorization and initiate services as soon as possible, or requests the return of the written referral packet.

 

4322 Securing Responders

Revision 17-1; Effective March 15, 2017

 

Responders must follow the rules as specified in 40 Texas Administrative Code §52.303, Responders.

 

4323 Equipment Installation

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §52.405, Equipment Installation.

(a) During an initial home visit, an installer must:

(1) install and make an initial test of the equipment;

(2) ensure that the equipment has an alternate power source in the event of a power failure;

(3) install within limits set forth in manufacturers' installation instructions; and

(4) if necessary:

(A) purchase a telephone extension cord;

(B) connect and run a telephone extension cord not to exceed 50 feet between the wall jack and the equipment; and

(C) safely tack the telephone extension cord against the wall or floorboard to prevent a hazard to an individual.

(b) An installer is not required to:

(1) adapt the physical environment in an individual's home to make it compatible with the equipment;

(2) arrange or pay for relocation of the telephone; or

(3) purchase or install electrical extension cords. An installer must not use an electrical extension cord when installing equipment.

(c) A provider must document a failure to install the equipment, including:

(1) the reason for the delay;

(2) the date the provider anticipates it will install the equipment or the specific reason the provider cannot anticipate a date; and

(3) a description of the provider's ongoing efforts to install the equipment, if applicable.

During the visit to the applicant's home, the installer connects the equipment and obtains the information needed to complete the applicable provider forms.

If the installer is unable to complete installation, the provider will document the reason for the delay, the date he anticipates he will install the equipment and a description of ongoing efforts to install the equipment, if applicable.

After installing the equipment, the installer demonstrates the equipment and allows the individual to activate an alarm call to become familiarized with the equipment. The installer explains the following service delivery requirements for which the individual is responsible:

The installer provides the individual with a written copy and an explanation of the complaint procedures.

 

4324 Provider Follow-Up Procedures

Revision 17-1; Effective March 15, 2017

 

The provider notifies the case worker of service initiation as outlined in Section 4321, Service Initiation.

The provider maintains ongoing communication with the case workers and the regional contract manager. He discusses individual-specific issues with the case worker, and contract management issues (overall service delivery, policies and procedures) with the regional contract manager.

 

4325 Selection of Providers and Provider Changes

Revision 17-5; Effective June 13, 2017

 

HHSC will encourage the individual to choose the most economical alternative for service provision.

The individual must contact his case worker to request a provider change. The case worker determines:

The case worker attempts to resolve any problems the individual may have with the current provider before processing a transfer. If the case worker determines the individual's dissatisfaction is based on the individual's failure to comply with the service plan, the case worker may convene an interdisciplinary team (IDT) meeting to discuss the issues. If it is not necessary to terminate services due to the failure to comply with the service plan, the case worker may authorize a transfer if it is necessary to meet the individual's satisfaction or if the individual insists on changing providers.

The case worker asks the individual to select another provider and processes the transfer coordinating the date the current provider will end services and the date the new provider will begin services. As stated in Section 4340, Suspension and Termination of Services, and Texas Administrative Code §52.421, an Emergency Response Services (ERS) provider may receive payment for the month of service regardless of the number of days services were provided in the month services were terminated.  During a transfer of ERS services, the case worker must make every effort to coordinate the last day of service of the first provider to end on the last day of the month, and the begin date of transfer service of the second provider to start on the first day of the following month. Coordination by the case worker of transfer ERS end and begin dates reduces the need for administrative payment of services to a second ERS provider for the same calendar month.

 

4330 Service Delivery

Revision 17-1; Effective March 15, 2017

 

 

 

4331 Alarm Calls

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §52.409, Alarm Calls.

Activated alarms received at the response center are responded to immediately. The monitor keeps track of an incident from the time the alarm is activated to the time the participant receives assistance. Each activated alarm call must be considered an emergency, not an accident.

The monitor immediately contacts the responder(s) and/or proper authorities if the individual activates an alarm. If the monitor contacts the individual before a responder, he must talk to the individual to verify that an emergency exists.

Monitors contact a responder whenever an alarm call is activated and the monitor is unable to reach the individual.

 

4332 Systems Checks

Revision 17-1; Effective March 15, 2017

 

 40 Texas Administrative Code §52.407, System Checks.

(a) Purpose. The purpose of a system check is to ensure:

(1) that an individual can successfully make an alarm call; and

(2)that the equipment is working properly.

(b) Conducting a system check.

(1) A provider must conduct a system check at least once during each calendar month.

(2) The system check must be conducted during normal working hours or as negotiated with the individual.

(3) A provider must document a completed system check. The documentation must include the date and time of the completed system check and confirm that the individual was contacted.

The test involves contacting the individual and instructing him to press the call button to activate the alarm call. If two individuals live in the same residence, the monitor conducts a monthly systems check for each individual.

The following procedures apply when the monitor is unable to reach the individual to conduct a monthly systems check.

Calendar Procedures
For three consecutive months
  1. Try to reach the individual at least three times on three different days during the month.
  2. After three attempts, contact a responder and try to find out why the individual is unable to participate in the test.
  3. If a provider is unable to complete a system check during a calendar month, the provider must notify the case worker in writing as outlined in Chapter 52, Contracting to Provide Emergency Response Services.

Note: If within three consecutive months a monthly systems check is not successful, the provider may continue to receive payments if the provider continues to attempt to conduct system checks and convene an IDT meeting.

Note: In each of the three months, the provider is eligible for payment if all the requirements are met. The provider is not eligible for partial payment for partial completion of procedures.

The provider documents the reasons why the individual is unable to participate in the monthly systems check. The provider will contact the responder if he does not have a documented reason why the system checks have not been completed. The provider must ask the responder to find out why the individual is unable to complete the system check. The information may be documented in the individual's case folder or the monthly log of systems checks. Written notification is provided to the case worker as outlined in Chapter 52, Contracting to Provide Emergency Response Services.

An IDT is convened and the case worker evaluates the situation and determines if the individual continues to be appropriate for the service. The case worker completes and returns Form 2067, Case Information, if continuing services for the individual; if terminating services, he completes Form 2101, Authorization for Community Care Services.

The case worker may allow the authorization for ERS to remain effective if the individual continues to be eligible for the services, but is unable to participate in the monthly systems check.

The case worker ensures that the individual's authorization does not exceed three consecutive billing months during which the individual is unable to participate in the monthly systems check.

 

4333 Equipment Malfunction

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §52.411, Equipment Maintenance.

(a) Equipment failure. A provider must:

(1) contact an individual by the end of the next working day after learning of an equipment failure; and

(2) replace the equipment:

(A) by the end of the next working day after learning of an equipment failure if the individual is available; or

(B) by the end of the third working day after learning of an equipment failure if the individual is not available within one working day.

(b) Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.

(c) Documentation. A provider must document and maintain a record of each equipment failure and low battery signal. The documentation must include:

(1) the date the provider became aware of the equipment failure or low battery signal;

(2) the equipment or subscriber number;

(3) a description of the problem; and

(4) the date the equipment is repaired or replaced.

The provider must ensure the equipment is functioning properly and that each participant receives services during the entire authorization period.

The following persons may report equipment malfunctions to the provider:

As equipment malfunctions are reported, the provider sends the installer to the individual's home to repair or replace the equipment.

The provider keeps a record of each equipment malfunction in the provider's files.

§52.411(b), Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.

The provider must respond to "low battery" signals received from individual's equipment. Provider staff should contact the individual by telephone after receiving a "low battery" signal to determine if the "low battery" could be caused by an accident, such as the unit having been unplugged. If the "low battery" signals continue, the provider must send a staff member to check, and repair or replace, the individual's ERS equipment within five days after the receipt of the fifth "low battery" signal.

 

4340 Suspension and Termination of Services

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code (TAC) §52.417, Required Notification,  §52.419, Suspension, and §52.421, Termination.

An interdisciplinary team (IDT) meeting may need to be called if monthly system checks are unsuccessful or an individual or someone in their home engages in illegal discrimination against a provider staff or HHSC employee. The case worker uses Form 2067, Case Information, to notify the provider that services should continue and Form 2101, Authorization for Community Care Services, to terminate services.

The case worker reports to the provider any changes involving the individual (Example: hospitalization, change of residence or visits with relatives.)

A provider may leave ERS equipment in a participant's home and continue service delivery when the individual has temporarily entered an institution. The provider must suspend services once the individual has been in the institution for more than 120 consecutive days. The provider is eligible for payment if the system checks are conducted during the 120-day period.

The provider requests termination of services when the individual is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to, when the individual:

The provider documents staff's inability to test the home unit in the individual's case file.
The provider requests the installer to remove the equipment from the individual's home after the case worker authorizes that services be terminated.
A provider may leave ERS equipment in an individual's home and continue services until the end of the month the service authorization expires. The provider receives payment for the month the service authorization ends, as long as:

If HHSC terminates ERS, a provider may be paid for the last month of service regardless of how many days of service were provided in that month, if the provider has complied with ERS requirements.

The individual is not liable for payment for lost or damaged equipment.

 

4341 Interdisciplinary Team (IDT) Meeting

Revision 17-1; Effective March 15, 2017

 

Interdisciplinary teams must follow the rules as specified in 40 Texas Administrative Code §52.413, Interdisciplinary Team.

The provider will convene an IDT meeting when the need arises. A meeting should be called for situations in which the provider is unable to resolve issues with the individual. The case worker must participate in the IDT to assist in resolving issues. The IDT could result in continuation or discontinuation of services. If applicable, policy relating to failure to comply with the service plan must be considered.

 

4350 Rates and Contracts

Revision 17-1; Effective March 15, 2017

 

The Health and Human Services Commission (HHSC) determines a unit rate ceiling for ERS. Rates can be accessed at: http://legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs/ers/index.shtml. The provider must maintain financial records and documentation of claims as outlined in 40 Texas Administrative Code §52.501, Record Keeping, in addition to the records required to be maintained for the participants.

 

4351 Advertising and Solicitation

Revision 17-1; Effective March 15, 2017

 

HHSC may investigate complaints of solicitation or coercion of individuals. Validated complaints may lead to adverse actions or termination of contracts. The ERS provider is in violation of the ERS contract if the provider employs a person:

The ERS provider may have an employee who is responsible for recruitment in addition to other assignments, as long as he is paid a regular salary and does not receive bonuses or anything that could be construed as a bonus for recruitment of Medicaid recipients.

 

4352 Disclosure of Previous Employment and Certification

Revision 17-1; Effective March 15, 2017

 

If a former or current HHSC employee or former or current council member or their relatives are an officer, director, owner or employee, the commissioner of HHSC or designee must approve the contract or contract renewal.

 

4353 Participant Records

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §52.501, Record Keeping.

 

4360 Reassessment

Revision 17-1; Effective March 15, 2017

 

Reassess for eligibility within 12 months of the last functional assessment for services. Call or make a home visit to re-determine the individual's eligibility for ERS. During the home visit, ask the individual to explain how to initiate an alarm call. Evaluate whether the individual continues to be sufficiently mentally alert to operate the equipment. (See Section 4312.1, Eligibility.)

If the individual continues to be eligible and there are no changes, do not send anything to the provider. If services are terminated, coordinate the effective date of termination to match on Form 2065-A, Notification of Community Care Services, and Form 2101, Authorization for Community Care Services, to allow the individual 12 days prior notice.

 

4400 Family Care Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4410 Primary Home Care Program

Revision 17-1; Effective March 15, 2017

 

The Primary Home Care Program (PHCP) is the personal attendant services (PAS) umbrella program under Chapter 47 of the Texas Administrative Code (TAC), which includes the following services:

FC provides in-home PAS to individuals eligible under Title XX of the Federal Social Security Act (relating to block grants to states for social services). Providers delivering PAS must meet all the requirements in Texas Administrative Code §47.11, Contracting Requirements.

With the exception of this section and Section 4610, Primary Home Care Program, all non-Chapter 47 rule references within the Community Care for Aged and Disabled Handbook to "Primary Home Care" or "PHC" refer to the service, not the umbrella program.

For information on the Title XIX PHCP programs, see Section 4600, Primary Home Care and Community Attendant Services.

 

4411 Family Care Services Description

Revision 17-1; Effective March 15, 2017

 

Family Care (FC) provides assistance with activities of daily living to eligible individuals who have functional limitations caused by age, disabilities or medical problems. Services are limited to 50 hours per week (42 hours per week for a priority individual). Services include help with personal care, household tasks, meal preparation and escort.

FC is a non-skilled, non-technical service delivered by an attendant employed by the provider. The attendant must be age 18 or older. Providers must comply with the requirements in the contract with the Texas Health and Human Services Commission and in the Contracting to Provide Primary Home Care Services Handbook.

 

4412 Allowable Tasks

Revision 17-1; Effective March 15, 2017

 

Personal attendant services (PAS) that may be delivered under Family Care (FC) include the tasks defined in 40 Texas Administrative Code §47.41, Allowable Tasks.

For information on Escort Services, refer to 40 TAC §48.2919(a) and (b), Time Allocation for Escort Services.

Escort may include accompanying the individual on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist/barber or social events. The time used to provide the escort task must not exceed the total time purchased for attendant care. No additional time for escort is allocated to the individual's service plan. The individual may elect to receive escort in place of assistance with household or personal care on a day that best meets his/her needs. This service does not include the direct transportation of the individual by the attendant.

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

To facilitate safe individual ambulation or movement, arranging furniture may be provided (Example: Individuals who use wheelchairs, walkers or crutches or for blind individuals). The provider supervisor addresses this activity during orientation for an attendant who provides services to this type of individual.

Refer to Page 3 & 4 of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for further definition of activities that may be provided within each task.

 

4413 Excluded Services

Revision 17-1; Effective March 15, 2017

 

Family Care (FC) does not include services that must be provided by a person with professional or technical training. Examples include but are not limited to the following:

Services that maintain an entire family or household are also excluded unless the entire household receives FC services. Examples:

An attendant may shop for items the individual needs and that the rest of the household also uses.

 

4420 Eligibility

Revision 17-8; Effective September 1, 2017

 

To be eligible for family care, the applicant/individual must:

The applicant/individual must require at least six hours of family care per week to be eligible, unless the applicant/individual:

For eligibility policy not contained in this section, see:

 

4421 Residence

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(b). To receive services, the applicant/client must reside in a place other than:

(1) a hospital;
(2) a skilled nursing facility;
(3) an intermediate care facility;
(4) an assisted living facility;
(5) a foster care setting;
(6) a jail or prison;
(7) a state school;
(8) a state hospital; or
(9) any other setting where sources outside the primary home care program are available to provide personal care.

Family Care (FC) cannot be authorized if the individual lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

FC can be provided to a private pay applicant/individual living in a residential care facility (whether or not contracted with HHSC) under the following conditions. The case worker:

If the individual begins receiving Residential Care (RC) through HHSC, FC is terminated effective no later than the date RC services are started.

 

4430 Case Worker Procedures for Determining Eligibility

Revision 17-1; Effective March 15, 2017

 

See Section 2200, Intake Procedures, for intake, screening criteria and interest list procedures.

Upon receipt of a Family Care intake or release from the interest list, the case worker makes a home visit within the required time frames to begin the application process.

Conduct a home visit to determine whether the individual meets eligibility criteria as outlined in Section 4420, Eligibility. The applicant must provide information to determine financial eligibility as outlined in Section 3000, Eligibility for Services, and must be screened for eligibility for Community Attendant Services (CAS).

Give Form 2307, Rights and Responsibilities, and Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, to all applicants. Explain that the case worker must approve increases in the number of hours of services he receives. Also inform the individual that he may select another provider if he is dissatisfied with the services or with the attendant providing the services.

 

4431 Family Care Financial Eligibility

Revision 17-1; Effective March 15, 2017

 

To be eligible for family care, the applicant/individual must:

The case worker must determine that an applicant for Family Care is not eligible for services through Primary Home Care (PHC) or Community Attendant Services (CAS). See Section 2340, The Initial Interview and Application Process, for information on the determination of financial eligibility and screening for eligibility for CAS.

See Section 3000, Eligibility for Services, and Appendix XII, Examples of Methods to Verify Income and Resources, for specific information on determining financial eligibility.

 

4432 Family Care Functional Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2911, Family Care

(a) To be eligible for family care, the applicant/client must:
(2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

40 TAC §48.2907, Need

(a)The client needs assessment questionnaire is used to determine an individual's functional need for CCAD services.
(b) Regardless of a client's functional eligibility as determined by his score on the client needs assessment questionnaire, he receives CCAD services only if he has an unmet need for those services.

Applicants and individuals must score at least 24 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to be eligible for Family Care.

See Section 2400, Assessment Process, Section 2500, Service Planning, and Section 2600, Authorizing and Reassessing Services, for case worker procedures for full determination of functional eligibility and unmet need determination.

 

4433 Time Frames

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3901(d). Eligibility for CCAD services for income-eligible applicants is determined within 30 calendar days after a signed application is received.

The case worker must complete all eligibility determination within 30 calendar days from the assessment date and send the applicant Form 2065-A, Notification of Community Care Services, within two business days of the eligibility decision.

 

4440 Referral Process

Revision 17-3; Effective May 15, 2017

 

Send the selected provider a referral packet consisting of:

Follow the procedures in Section 2630, Referrals to the Provider.

All referrals to the provider, both initial and ongoing, must include the tasks being authorized, the total number of authorized hours and the number of days the applicant/individual requests services to be delivered. If the individual has special needs that require a specific schedule, document the requested schedule and the reason on Form 2101. Example: An individual may need a specific eating schedule due to a diabetic condition or a person with sleep problems may require that service delivery not begin until the afternoon.

Case workers must document in the comments section of Form 2101 the number of days the individual is to receive services based on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Example: "The individual requests a 5-day plan," or "The individual requests a 7-day plan."

Case workers must also document if there are any persons designated not to hire as outlined in Section 2514, Who Cannot Be Hired as the Paid Attendant.

 

4440.1 Types of Referrals

Revision 17-1; Effective March 15, 2017

 

 There are two methods of referral:

Routine Referrals

Within five business days of the eligibility decision, the case worker mails the referral packet to the provider to authorize service delivery.

Expedited Referrals

In some instances, the individual's need for services, based on the case worker's judgment, is such that delivery of services must be facilitated. When weighing whether an expedited referral is warranted, consider:

The expedited referral process includes:

 

4441 Provider Responsibilities after Receipt of Referral

Revision 17-1; Effective March 15, 2017

 

Upon receipt of the referral packet, the provider must conduct pre-initiation activities, develop a service plan and assign an attendant to perform services for the individual in accordance with 40 Texas Administrative Code §47.45. These activities must be completed within 14 days after one of the following dates, whichever is later:

For expedited referrals, the provider must document the date, time and the name of the case worker who gives the verbal authorization. Provider staff contact the case worker if the packet is not in their office by the seventh day after the verbal referral.

The provider can request a corrected authorization if the information (for example, hours or dates of coverage) conflicts with what was given over the telephone. In these situations, correct and initial Form 2101 and mail a copy of it to the provider.

Within 14 days after initiating services, the provider must send notice of service initiation to the case worker. The provider may, but is not required, to use Form 2101 to notify the case worker of service initiation.

 

4441.1 Delay of Service Initiation

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §47.61, Service Initiation.

(c) Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond its control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider's control;

(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and

(3) a description of the provider's ongoing efforts to initiate services.

(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

 

4441.2 Initial Service Delivery Plan Variances

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §47.45(b), Service delivery plan variances.

 

 

4442 Resolution of Service Plan Disagreement

Revision 17-1; Effective March 15, 2017

 

If a disagreement exists about the appropriateness of a referral or about service delivery issues involving the individual, the case worker and the provider staff attempt to resolve the disagreement. If the disagreement is not resolved at this level, supervisory staff of the two agencies attempt to resolve it. If supervisory staff of both agencies are unable to resolve a disagreement, the regional director or designee resolves it. Do not delay service initiation because of a disagreement. The regional nurse may always be consulted regarding health and safety issues or the appropriateness of the service plan.

 

4443 Change of Providers

Revision 17-3; Effective May 15, 2017

 

Monitor the individual after services are initiated and periodically thereafter to check on the adequacy of the service plan, the quality of service delivery and the individual's condition. Report to the unit supervisor any apparent deficiencies in the provider's delivery of Family Care (FC) services.

When an FC individual plans to change providers, the individual must first contact his case worker, who will:

Within 14 calendar days of notification that an ongoing FC individual is requesting a transfer to another provider, the case worker contacts the individual and the provider to determine:

The case worker considers the following to identify the individual's reason for dissatisfaction:

If the case worker determines that the individual's dissatisfaction is based on the individual's failure to comply with the service plan, the case worker contacts the individual or the party involved and attempts to resolve the problem in a way that is satisfactory to all parties involved. The case worker discusses the problem with the supervisor. An interdisciplinary team meeting may be conducted at the individual's home to try to resolve the situation. The case worker may terminate the individual's services if the individual refuses more than three times to comply with service delivery provisions by repeatedly and directly, or knowingly and passively, condoning the behavior of someone in his home.

By the 14th day, authorize the transfer if:

Within 14 calendar days of receiving a request from the individual or the individual's representative to change providers, the case worker:

 

4443.1 Service Interruptions

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §47.63(a), Service interruptions.

A service interruption occurs anytime service delivery is discontinued for 14 days or more for a reason that is not covered in Section 4446, Suspension of Services and Interdisciplinary Team (IDT) Procedures. The provider should make every effort to ensure that interruptions in service last less than 14 days, particularly if a break in service would jeopardize the individual's health or safety. When an interruption of services is unavoidable, the provider must document all service interruptions by the:

30th day that exceeds 14 days after the service interruption for non-priority individuals.

 

4444 Reporting Significant Changes

Revision 17-1; Effective March 15, 2017

 

The provider notifies the case worker or the case worker's office (by telephone or in person) about a change in the individual's condition or circumstances that may require a service plan change or service termination.

The provider must notify the case worker by the first Texas Health and Human Services Commission workday after provider staff notice the change and must follow up in writing, using Form 2067, Case Information, within seven days after verbal notification.

Any of the following changes in the individual's condition or circumstances may require a change in his service plan. (These are examples only; this list is not intended to be all inclusive.)

If the case worker receives a request for a change, respond to it within 14 days from the date the request is received. Review the individual's service plan to decide whether the change is necessary. If the case worker decides the change is not necessary, document the decision on Form 2067 and send it to the provider, keeping a copy in the case record.

Depending on the individual's new condition or situation, a new assessment or

Revision of the service plan (such as a change in priority status or a need for more hours) may be necessary. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, according to Section 2720, Changes Reported in the Individual's Condition or Status during the Certification Period. Consult with the supervisor about the requested change, if necessary. If the report meets the criteria for Adult Protective Services (APS), refer the individual to that service. See Section 2220, Response to Requests for Service.

 

4445 Service Plan Changes

Revision 17-1; Effective March 15, 2017

 

If a service plan change is authorized, mail two copies of Form 2101, Authorization for Community Care Services, and one copy of Form 2059, Summary of Client's Need for Service, to the provider. If a service plan change increases hours or adds priority status, the beginning date of coverage is seven days from the Form 2101 date.

For a service reduction/termination, the provider must abide by the case worker's 12-day prior notice provided to the individual before implementing the change. The case worker must advise the provider using the comments section on Form 2101, if applicable, not to implement an adverse action until after the 12-day notice. The individual may appeal the decision and choose to continue to receive services pending the outcome of the appeal. These time frames apply only to those cases in which the provider has a current authorization for the individual.

When the individual requires an immediate change to the service plan, approve the change by telephone or in person. Respond by the next Texas Health and Human Services Commission (HHSC) workday when any of the following situations occur:

If necessary, verbally authorize a service plan change, initial the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and send two copies of Form 2101 to the provider within two workdays of the verbal request.

See Appendix XVIII, Time Calculation, for assistance in determining the change effective date.

 

4446 Suspension of Services and Interdisciplinary Team (IDT) Procedures

Revision 17-1; Effective March 15, 2017

 

 The provider agency must suspend services if:

Note: When notified of an active SSI/Medicaid individual's death, complete and send Form SSA-1610-U2, Public Assistance Agency Information Request, to report the death of the individual to the Social Security Administration. Keep a copy of Form SSA-1610-U2 and file in the case record.

Services may be suspended indefinitely if the individual is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

The provider agency may also suspend services if:

The provider agency must notify the case worker by fax of any suspension by the next working day. The faxed notice of a suspension must include:

The provider agency must convene an interdisciplinary team (IDT) meeting to resume services.

The provider agency must resume services after suspension:

The provider agency must notify the case worker in writing of the date services resume and must send the notice within seven days of that date.

 

4447 Reassessment

Revision 17-7; Effective July 1, 2017

 

At each annual functional reassessment of Family Care individuals, the case worker must review the screening exception criteria to see if the individual’s circumstances have changed. For example, if an individual was placed on Family Care due to no personal care tasks, but at the annual reassessment he now requires a personal care task, then the case worker must refer the individual to Primary Home Care (PHC) or Community Attendant Services (CAS).

Financial eligibility must be redetermined for Family Care within 24 months of the last eligibility determination. If Medicaid for the Elderly and People with Disabilities (MEPD) previously determined the individual was ineligible for CAS due to resources, the case worker must review the individual’s financial status in accordance with Section 3422, Exceptions to Verification Requirements. If it appears the individual would now meet CAS requirements, the case worker must assist the individual in completing a new Form H1200-EZ, Application for Assistance – Aged and Disabled, and obtain verifications of income and resources to send to MEPD.

If the individual or provider reports interim changes between annual reassessments, the case worker will apply the screening exception criteria at the next annual review.

For Family Care services, if an individual requests a change at the annual reassessment, the change must be worked within five days or by the annual reassessment due date, whichever is earlier.

 

4448 Complaints

Revision 17-9; Effective September 15, 2017

 

An individual has the right to voice grievances or complaints concerning the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation. The individual has a right to report service delivery issues to the Health and Human Services Office of Ombudsman at 1-877-787-8999. If the case worker is aware of the issue, the case worker must work to resolve the individual's issues. See policy outlined in Section 2736.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

 

4500 Meals Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4510 Description

Revision 17-1; Effective March 15, 2017

 

Home-Delivered Meals (HDM) provides hot, nutritious meals that are typically served in the individual's home. Meals may be delivered to alternate locations, provided the location is within the provider's normal service delivery area.

Example: An individual receives dialysis treatments on Mondays, Wednesdays and Fridays. Because the treatment center is within the provider's normal service delivery area, HDMs can be delivered to that location on the days the individual receives treatments.

When it is necessary for the individual to receive meals in an alternate location out of the service area on a regular basis, shelf-stable or frozen meals may be delivered to the individual's home for use in the other location. The case worker must check with the contract manager to ensure that the provider's contract allows delivery of shelf-stable/frozen meals.

Meals delivered by contracted providers 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.

40 Texas Administrative Code (TAC) §55.15, Menus.

(a) A dietary consultant must approve each menu with a list of allowable substitutions as meeting one-third of the recommended daily dietary allowance. The approval must be dated before the date the meal is served. A provider agency may not deviate from the approved menu and its allowable substitutions, unless the provider agency is providing a therapeutic medical diet.
(b) Planned menus must provide foods with a variety of flavor, consistency, texture and temperature.
(c) A provider agency must maintain approved menus that meet the terms of the contract.

40 TAC §55.19, Modified Diets.

(a) A provider agency must keep documentation from the client's physician of the client's need for a therapeutic medical diet, according to the terms of the contract.
(b) A provider agency must determine the extent to which the provider agency can provide therapeutic medical meals.

In addition to healthy meals, monthly nutrition education is provided to HDM individuals.

40 TAC §55.11, Nutrition Education. A provider agency must provide nutrition education on a monthly basis, either verbally or in writing, to clients. An annual written plan for nutrition education must be developed, identifying subject matter, method of presentation, materials used, and source of the information presented. This plan must be maintained according to the terms of the contract.

 

4520 Eligibility

Revision 17-1; Effective March 15, 2017

 

Individuals who apply for or receive Title XX meals are not subject to an income and resource eligibility determination.

40 Texas Administrative Code §48.2912. To be eligible for home-delivered meals, applicants and clients must meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

An individual must score at least 20 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to be functionally eligible for Home-Delivered Meals.

 

4521 Home-Delivered Meals Interest List Procedures

Revision 17-1; Effective March 15, 2017

 

If all service authorization slots are filled at the time an individual requests home-delivered meals, consult the individual to decide whether his needs can be met through other services. If no other service is available or suitable, add the individual's name to the Home-Delivered Meals Interest List(s) by entering the information in the Community Services Interest List (CSIL) system. Individuals who request placement on an interest list must be Texas residents. Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for service become available. See Section 2230, Interest List Procedures, for additional information.

If the individual is receiving meals through some other service, the case worker must explore if the meals are through a temporary service. There are several organizations within communities that offer temporary delivery of meals until another source is available. Meals received through the Area Agency on Aging (AAA) through Title III are limited and only meant to provide temporary assistance to individuals. Meals provided through other local organizations may also be temporary.

If an individual calls to request home-delivered meals through Title XX and is currently receiving meals, the intake person records the source of the current meals. The individual must not be screened out due to receiving meals from another source. The intake person completes the intake and either refers to a case worker for assessment, if the region has open enrollment, or places the individual's name on the interest list. If an ongoing individual requests Title XX meals, the same policy applies. The applicant/individual may continue to receive temporary meals while on the interest list for Title XX home-delivered meals.

When the case worker receives the request for services or an individual's name is released from the interest list, the case worker must determine if the source of current meals is ongoing or temporary. If the applicant/individual states the meals are ongoing, the case worker must verify with the source and document that the meals are ongoing. The applicant/individual has a right to choose between Title XX home-delivered meals and the other source. The case worker must document the applicant's/individual's decision and follow procedures for approving or denying the request for services.

If the source is a temporary service, the applicant must be authorized for Title XX meals if all other eligibility requirements are met. Service initiation through Title XX meals must be coordinated with the termination of the temporary service and documented in the case record.

 

4530 Casework Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

 

4531 Service Initiation

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §55.25, Service Initiation.

To refer individuals to providers for Home-Delivered Meals (HDM), complete Form 2101, Authorization for Community Care Services, and send the referral packet to the selected provider (see Appendix XIII, Content of Referral Packets). The provider must initiate services within 10 days from the date of referral and return Form 2101 to the case worker within 21 calendar days.

Inform the provider of any special circumstances that would be relevant to the individual's service provision. Whenever necessary for the individual's health, specify on Form 2101 that the provider must deliver meals that have been prepared without added salt as seasoning or flavoring. Ensure that the individual understands when the home-delivered meals will be delivered, his responsibility for receiving the meals and that he is not responsible for contributing or paying for them.

Reassess the individual's eligibility for services annually, within 12 months of the previous functional assessment.

Note: To ensure there is no service duplication of home-delivered meals, coordinate services with the local Area Agency on Aging.

 

4532 Individual Health and Safety

Revision 17-1; Effective March 15, 2017

 

 A provider agency must have written procedures in place to ensure it investigates and reports to the appropriate persons or entities any significant changes in the individual’s physical or mental condition or environment. These procedures must require the following:

A provider agency must inform the individual about safety, health, or fire hazards identified in the individual’s home when the provider agency discovers these hazards. The provider agency must retain documentation of such communications in its files, according to the terms of the contract.

A provider agency must notify the Texas Health and Human Services Commission (HHSC) personnel, orally or by fax, within one working day after an incident that may prevent the provider agency from delivering meals to one or more individuals.

A reportable incident includes:

The provider agency must report an incident to:

If the provider agency notifies the case worker orally, the provider agency must send written notification to the contract manager or case worker, or both, within five working days of the initial notification.

If the individual delivering the meal reports to the provider any individual illnesses, potential threats to safety or observable changes in the individual's condition, the provider must notify the case worker about the report within 24 hours. The provider must also notify the case worker within 24 hours whenever the meal is found uneaten or untouched.

 

4532.1 Waivers for Alternate Meal Delivery Methods

Revision 17-1; Effective March 15, 2017

 

Home Delivered Meals (HDM) providers are generally expected to deliver five hot meals a week to each individual. Occasional exceptions to allow the use of "…frozen, chilled or shelf-stable meals for emergency or inclement weather situations, emergency situations and for situations approved by the contract manager on a case-by-case basis…", may be granted under Texas Administrative Code, Title 40, §55.21, concerning Frozen, Chilled or Shelf-Stable Meals.

HDM providers must submit a waiver request to the Texas Health and Human Services Commission (HHSC) contract manager 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 waivers granted will be effective for a period not to exceed one fiscal year. The provider must not implement the waiver of the requirement for delivery of a hot meal five days a week prior to HHSC approval of the waiver request.

In order to be able to adequately inform individuals of the service delivery plan, case workers are expected to work closely enough with the contract manager to be aware of the delivery provisions of each HDM provider. Any inquiries by providers regarding the waiver must be referred to the contract manager.

 

4533 Suspension of Services

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §55.33, Suspension of Services.


The provider must notify the case worker on the day Home-Delivered Meals is suspended without the case worker's authorization. The provider must suspend services in any of the following situations when the:

Unless the interruption is the result of one of the above situations, the provider must obtain the case worker's approval for service interruptions of more than two consecutive days.

When the individual requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the case worker.

 

4534 Termination of Services

Revision 17-1; Effective March 15, 2017

 

The case worker must send the provider authorization for community care services for Title XX services, indicating the date services are to be terminated.

Send a copy of Form 2065-A, Notification of Community Care Services, to the provider as notification of the termination and of the date the service will end. For detailed information regarding service termination, see Section 2800, Procedures for Denying or Reducing Services.

 

4600 Primary Home Care and Community Attendant Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4610 Primary Home Care (PHC) and Community Attendant Services (CAS) Contracting

Revision 17-1; Effective March 15, 2017

 

PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under §1929(b)(2)(B) of the Social Security Act, respectively. Both programs require that recipients have a need for assistance with personal care tasks. Providers delivering PAS must meet all of the requirements in 40 Texas Administrative Code §47.11, Contracting Requirements.

For information on the Title XX PHCP program, see Section 4400, Family Care Services.

 

4620 Personal Attendant Services Description

Revision 17-1; Effective March 15, 2017

 

Primary Home Care and Community Attendant Services provide non-technical attendant services to eligible individuals who have a medical condition resulting in a functional limitation in performing personal care. Attendants help individuals with activities of daily living, such as bathing, grooming, meal preparation and housekeeping. Attendants are trained and supervised by non-medical personnel.

 

4621 Allowable Tasks

Revision 17-1; Effective March 15, 2017

 

Primary Home Care (PHC) and Community Attendant Services (CAS) provide in-home assistance to eligible Medicaid individuals who have medically-related health problems that cause them to be functionally impaired in performing personal care. Personal attendant services (PAS), which may be delivered under CAS and PHC, include the tasks defined in 40 Texas Administrative Code §47.41. PHC and CAS include the following tasks:

(1) personal care tasks related to the care of the individual's physical well being, including:
(A) bathing, which is:
(i) drawing water in sink, basin, or tub;
(ii) hauling or heating water;
(iii) laying out supplies;
(iv) assisting in or out of tub or shower;
(v) sponge bathing and drying;
(vi) bed bathing and drying;
(vii) tub bathing and drying; and
(viii) providing standby assistance for safety;
(B) dressing, which is:
(i) dressing the individual;
(ii) undressing the individual; and
(iii) laying out clothes;
(C) meal preparation, which is:
(i) cooking a full meal;
(ii) warming up prepared food;
(iii) planning meals;
(iv) helping prepare meals; and
(v) cutting individual's food for eating;
(D) feeding/eating, which is:
(i) spoon-feeding;
(ii) bottle-feeding;
(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and
(iv) providing standby assistance or encouragement;
(E) exercise, which is walking with the individual;
(F) grooming, shaving, or oral care, which is:
(i) shaving;
(ii) brushing teeth;
(iii)shaving underarms and legs, when requested;
(iv)caring for nails; and
(v)laying out supplies;
(G) routine hair or skin care, which is:
(i) washing hair;
(ii) drying hair;
(iii) assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair;
(iv) combing or brushing hair;
(v) applying nonprescription lotion to skin;
(vi) washing hands and face;
(vii) applying makeup; and
(viii) laying out supplies;
(H) assistance with self-administered medications, which is assistance with medication as defined in §97.2(11) (relating to Definitions);
(I) toileting, which is:
(i) changing diapers;
(ii) changing colostomy bag or emptying catheter bag;
(iii) assisting on or off bedpan;
(iv) assisting with the use of a urinal;
(v) assisting with feminine hygiene needs;
(vi) assisting with clothing during toileting;
(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;
(viii) changing external catheter;
(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and
(x) providing standby assistance; and
(J) transfer, which is:
(i) non-ambulatory movement from one stationary position to another, not including carrying;
(ii) adjusting or changing the individual's position in a bed or chair (positioning);
(iii) assisting in rising from a sitting to a standing position;
(K) ambulation, which is:
(i) assisting in positioning for use of a walking apparatus;
(ii) assisting with putting on and removing leg braces and prostheses for ambulation;
(iii) assisting with ambulation or using steps;
(iv) assisting with wheelchair ambulation; and
(v) providing standby assistance;
(2) home management tasks that support the individual 's health and safety, including:
(A) cleaning, which is:
(i) cleaning up after the individual's personal care tasks;
(ii) emptying and cleaning the individual's bedside commode;
(iii) cleaning the individual's bathroom;
(iv) changing the individual's bed linens and making the individual's bed;
(v) cleaning floor of living areas used by individual;
(vi) dusting areas used by individual;
(vii) carrying out the trash and setting out garbage for pick up;
(viii) cleaning stovetop and counters;
(ix) washing the individual 's dishes; and
(x) cleaning refrigerator and stove;
(B) laundry, which is:
(i) doing hand wash;
(ii) gathering and sorting;
(iii) loading and unloading machines in residence;
(iv) using Laundromat machines;
(v) hanging clothes to dry; and
(vi) folding and putting away clothes;
(C) shopping, which is:
(i) preparing a shopping list;
(ii) going to the store and purchasing or picking up items;
(iii) picking up medication; and
(iv) storing the individual's purchased items.
(3) escorting, which includes:
(A) accompanying the individual outside the home to support the individual in living in the community;
(B) arranging for transportation, not including direct individual transportation;
(C) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and
(D) waiting in the doctor's office or clinic with an individual if necessary due to individual's condition or distance from home.

The case worker must document a specific need for escort. If escort for medical trips occurs at least once a month, time may be allocated. To determine the weekly time allocation, divide the time by 4.33 to arrive at a weekly figure. If escort occurs more than once a week, the case worker must include additional documentation explaining why the individual needs escort this frequently. See Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for additional information.

Escort may also include accompanying the individual on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist, barber or social events. No additional time for escort for non-medical trips is allocated to the individual's service plan on Form 2060. The individual may elect to receive escort in place of assistance with household or personal care on a day that best meets his needs. The time used to provide the escort task must not exceed the total time purchased for attendant care.

This service does not include the direct transportation of the individual by the attendant. Transportation is available through the Medical Transportation Program (MTP). Contact the MTP manager in the case worker's region about referral of an individual to this program.

A provider contracted to deliver PHC or CAS must do so according to the requirements in the contract with the department and in the Contracting to Provide Primary Home Care Services Handbook.

 

4622 Excluded Tasks

Revision 17-1; Effective March 15, 2017

 

Services that must be provided by a person with professional or technical training may not be purchased through Title XIX personal attendant services. These excluded services include, but are not limited to:

Services that maintain an entire family or household, unless the entire household receives the service, are also excluded. Examples include:

 

4623 Personal Attendants

Revision 17-1; Effective March 15, 2017

 

The individual's or provider's choice of attendants is not limited unless the:

Per 40 Texas Administrative Code §97.404, personal attendant services tasks may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency to perform the tasks assigned by the supervisor. Additionally, tasks may be performed by an unlicensed person who is:

The attendant cannot be a legal or foster parent of a minor child who receives the service, or the individual's spouse. For additional information regarding personal attendants, see Section 2514.

 

4624 Priority Status Determination

Revision 17-1; Effective March 15, 2017

 

Priority status is determined by evaluating the effect that going without certain critical purchased tasks would have on an individual.

An individual with priority status may receive no more than 42 hours of service per week. An individual without priority status may receive no more than 50 hours of service per week.

The community care case worker establishes a priority status for each individual based on the functional assessment. An individual is considered to have priority status if the following criteria are met:

Each eligible individual may receive up to 50 hours of personal attendant services per week (42 hours per week for an individual with priority status). For additional information regarding the determination of priority status, see Section 2540, Priority Status Individuals.

 

4630 Eligibility

Revision 17-1; Effective March 15, 2017

 

For eligibility policy not contained in this section, see:

 

4631 Residence

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(b). To receive services, the applicant/client must reside in a place other than:

(1) a hospital;
(2) a skilled nursing facility;
(3) an intermediate care facility;
(4) an assisted living facility;
(5) a foster care setting;
(6) a jail or prison;
(7) a state school;
(8) a state hospital; or
(9) any other setting where sources outside the primary home care program are available to provide personal care.

Title XIX personal attendant services (PAS) cannot be authorized if the individual lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

Title XIX PAS services can be provided to a private pay applicant/individual living in a residential care facility (whether or not contracted with HHSC) under the following conditions. The case worker:

If the individual begins receiving Residential Care (RC) through HHSC, the Title XIX PAS service is terminated effective no later than the date RC services begin.

 

4632 Financial Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(1) be eligible for Medicaid in a community setting or be eligible under the provisions of the Social Security Act, §1929(b)(2)(B)

Before referring the individual to Primary Home Care (PHC), verify Medicaid eligibility for the month that financial/functional eligibility is determined.

To receive PHC services, applicants/individuals must be receiving benefits that include full Medicaid eligibility. Case workers must consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if an applicant or individual is receiving full Medicaid benefits. Note: Residence outside an institution is also an eligibility criterion so institutional type programs will not be eligible for PHC. See Section 7110, TIERS Inquiries, and Appendix XIV, SAVERR/TIERS Type Program Chart, for a description of all TIERS type programs.

Individuals obtain financial eligibility for Community Attendant Services (CAS) by applying to Medicaid for the Elderly and People with Disabilities. CAS eligibility can be confirmed by checking TIERS.

See Section 2347, Texas Medicaid Estate Recovery Program (MERP), when processing CAS applications.

 

4633 Functional Eligibility

Revision 17-8; Effective September 1, 2017

 

40 Texas Administrative Code (TAC) §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

Title XIX personal attendant services (PAS) eligibility only requires that an individual have a need for assistance with personal care. However, the provider is not allowed to provide services unless at least one personal task is authorized, scheduled and delivered by the provider.

Example: An applicant requests Primary Home Care (PHC) and scores 30 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. However, the only personal care task the individual needs is meals service, which is being provided via congregate meals. Therefore, PHC services cannot be approved.

Applicants and individuals must score at least 24 on Form 2060, and require at least six hours of service per week. An individual requiring fewer than six hours of service per week may be eligible if the individual:

See Section 4651, Assessing the Individual's Needs, for casework procedures involved in establishing functional need.

 

4634 Practitioner's Statement of Medical Need

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/individual must:

(3) have a medical need for assistance with personal care.
(A) The individual's medical condition must be the cause of the individual's functional impairment in performing personal care tasks.
(B) Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnosis. The diagnoses do not disqualify an individual for eligibility as long as the individual's functional impairment is related to a coexisting medical condition;
(4) have a signed and dated practitioner's statement that includes a statement that the individual has a current medical need for assistance with personal care tasks and other activities of daily living.

The need for Primary Home Care (PHC) and Community Attendant Services (CAS) must be documented by a practitioner's statement of medical need. As part of the determination of eligibility for Title XIX personal attendant services (PAS), case workers must verify that applicants have a medically related health problem that causes a functional limitation in performing personal care.

See Section 4661, Receipt of the Practitioner's Statement of Medical Need, for procedures to determine medical need.

 

4640 Retroactive Payments

Revision 17-1; Effective March 15, 2017

 

State law requires that home and community support services agencies that provide personal attendant services (PAS) be licensed by the Texas Health and Human Services Commission (HHSC). It is possible for a Medicaid-eligible person to begin receiving services before HHSC receives a referral for Primary Home Care (PHC). The information below states the procedures case workers, HHSC nurses and providers must use when processing an application for retroactive payment.

 

4641 Provider's Role

Revision 17-1; Effective March 15, 2017

 

A provider who delivers attendant care services to a non-Medicaid individual on a private pay basis risks losing revenue unless an agreement exists for the individual to pay the provider if he is not determined eligible. A provider may bill non-Medicaid individuals for services delivered before the time the individual is eligible for retroactive payment by the Texas Health and Human Services Commission (HHSC). However, federal requirements do not allow providers to bill Medicaid recipients for Medicaid reimbursable services.

 

40 Texas Administrative Code (TAC) §47.85(c)(1) ─ The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS' Application for Assistance –Aged and Disabled form is received: (A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and (B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

 

The three month prior period applies to non-Medicaid individuals who apply for Primary Home Care (PHC) services using retroactive payment procedures. The three month prior period does not apply to Medicaid recipients who request PHC services using retroactive payment procedures. For Medicaid recipients, HHSC can reimburse a provider for a retroactive payment period beyond three months as long as the services are Medicaid reimbursable and the individual was Medicaid eligible when the services were received. Medicaid recipients do not complete a written application (Form H1200, Application for Assistance – Your Texas Benefits) for retroactive or ongoing PHC services.

A request for retroactive payment can be made by the individual, provider or interested party by contacting Community Care for Aged and Disabled (CCAD) intake staff. CCAD staff who receive requests for retroactive payment use current intake procedures for a routine request for in-home care services. The beginning date of services cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.

40 TAC §47.85(e)  Pre-initiation activities. The provider agency must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).

(f) Intake referral. On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local DHS office by telephone and make an intake referral by providing DHS information on the person to start the eligibility process.
(g) Service initiation. The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

Within seven days after the date the provider processes the intake referral, the provider must submit the written request for retroactive payment to the case worker. The written request must include the:

If the provider billed the individual for tasks that are not Medicaid reimbursable, the provider must inform the case worker so he will know how many hours to deduct from the payment made by HHSC to the provider.

 

4642 Case Worker's Role

Revision 17-1; Effective March 15, 2017

 

The case worker must respond to the request for services according to the time frames in Section 2320, Case Worker Response, and make the home visit to assess the applicant for ongoing services.

The case worker is not responsible for determining functional need during the retroactive period. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed to determine ongoing functional eligibility but does not affect eligibility for retroactive payments. Also, the case worker does not apply the unmet need policy to the retroactive period. See Section 2433, Determining Unmet Need in the Service Arrangement Column.

 

4643 Applicant Approved for Retroactive Payment and Continued Services

Revision 17-1; Effective March 15, 2017

 

If the applicant is Medicaid eligible or was Medicaid eligible at service initiation, the Texas Health and Human Services Commission (HHSC) will only reimburse the provider for tasks/hours/costs within the scope of the Primary Home Care (PHC) program. If the applicant is eligible for the retroactive payment period and for continued PHC services, the case worker must verify that the service plan developed by the provider contains the following information:

Determine the amount of reimbursement the applicant is eligible to receive from the provider by multiplying the cost per hour of service found in the service plan developed by the provider times the total amount of hours of approved service provided to the applicant. Include this amount on Form 2065-A, Notification of Community Care Services, to advise the applicant and the provider of the dollar amount of retroactive payment the applicant should receive from the provider.

Note: Because the individual is receiving services up to the time of the service initiation date for continued PHC services, the case worker may not know the last day services were provided during the retroactive period. The reimbursement amount may vary from the actual amount due to the applicant depending on whether the applicant paid in full, or has not paid the provider for the most recent service provided during the retroactive period.

The provider will not be reimbursed for a retroactive payment period if:

The provider will not be reimbursed for amounts higher than the HHSC limits when the:

The case worker must deduct time for any task(s) that cannot be purchased as part of PHC service from the total hours of services provided by the provider in order to determine how many hours (at the non-priority status rate) HHSC will reimburse the provider. If more than 50 hours per week were provided, the time for the non-allowable tasks should be deducted first and then the additional hours deducted to be within the 50 hour per week limit.

Send the provider a copy of the same Form 2065-A sent to the applicant to advise the provider of the amount to reimburse the applicant. Multiply the total service hours the applicant received by the cost per hour of services reported in the provider's service plan. Note: The dollar amounts used in the examples are fictitious. The current PHC rates may be verified at http://legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs/index.shtml.

 

Example 1:

A provider documents in the service plan that an applicant received 52 hours of service at $12.00 an hour for one week of the retroactive period. Of the total 52 service hours reported to date, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

52 hours minus 3 hours— — (deduct 3 hours since transportation is not an allowable task in PHC) = 49 hours

49 hours x $9.61 — — (the non-priority participating rate in PHC) = $470.89

$470.89 is the amount HHSC will pay the provider.

Document 49 hours in Item 18, Units, on Form 2101, Authorization for Community Care Services, and send it to the provider.

49 hours x $12.00 an hour (estimated private-pay rate) = $588.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $588.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for three hours of services determined by the case worker not to be Medicaid-reimbursable tasks.

 

Example 2:

A provider documents in the service plan that an applicant received 55 hours of service at $10.00 an hour for one week of the retroactive period. All of the 55 service hours were performed on Medicaid-reimbursable tasks. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 5 hours — — (deduct five hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours x $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send to the provider.

50 hours x $10.00 an hour = $500.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $500.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the applicant.

 

Example 3:

A provider documents in the service plan that an applicant received 55 hours of service at $12.00 an hour for one week of the retroactive period. Of the total of 55 service hours provided, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 3 hours for transportation — (a non-Medicaid reimbursable task) = 52 hours

52 hours minus 2 hours — (deduct two hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours × $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send it to the provider. Send the usual initial PHC packet to the provider for the continued service period.

50 hours x $12.00 an hour = $600.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the applicant.

Document $600.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for the three hours for transportation since this is not a Medicaid-reimbursable task.

If a provider provides service to an individual during a retroactive period where all tasks/hours/costs are all within the scope of the PHC program, then the dollar amount due the individual and the provider will be the same.

Example: A provider documents in the service plan that the individual received 30 hours of allowable household and at least one personal care task per week and charged the individual $9.61 an hour non-priority participating PHC rate to provide the attendant care. Calculate 30 hours x $9.61 = $288.30. This is the amount HHSC pays the provider and is the same amount refunded by the provider to the applicant. In this example, advise both the provider and the applicant the same amount, using Form 2065-A.

Send the provider Form 2101 for the retroactive payment period with an end date the day before the beginning of the continued PHC services. Send a second Form 2101 authorizing ongoing services with the complete initial PHC packet.

 

4644 Applicant Approved for Retroactive Payment and Denied Continued Services by the Case Worker

Revision 17-1; Effective March 15, 2017

 

If the applicant is eligible for the retroactive period but is not financially or functionally eligible for continued Primary Home Care (PHC) services, the case worker must call the provider and notify the provider of the last day of the retroactive period and the ineligibility for ongoing services. Document the telephone call in the comments section of Form 2101, Authorization for Community Care Services, for the retroactive period.

The case worker must verify the following conditions are present in the service plan developed by the provider:

The provider will not be reimbursed if no personal care task(s) were provided. The amount of reimbursement will be reduced if the:

Within two business days of the decision of ongoing ineligibility, the case worker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, which includes the:

The case worker must complete and send Form 2101 to the provider for the retroactive payment period. Use the Form 2101 instructions to complete the items for the retroactive period with the following exceptions:

 

4645 Special Procedures for Community Attendant Services (CAS)

Revision 17-1; Effective March 15, 2017

 

Providers must be aware of the risk of losing revenue if attendant care services are delivered to a non-Medicaid individual. If the applicant is determined ineligible, retroactive payment will not be made by the Texas Health and Human Services Commission (HHSC).

The case worker proceeds with the referral to Medicaid for the Elderly and People with Disabilities (MEPD) upon receipt of