Case Manager Medically Dependent Children Program Handbook

CM-MDCP, Section 1000, Overview and Eligibility

Revision 15-9; Effective December 15, 2015

 

 

1100 Program Goal and Handbook Purpose

Revision 14-2; Effective September 1, 2014

 

The Medically Dependent Children Program (MDCP) is a home and community-based service authorized under §1915(c) of the Social Security Act. MDCP provides Respite, Flexible Family Support Services, Minor Home Modifications, Adaptive Aids, Transition Assistance Services, Employment Assistance, Supported Employment and Financial Management Services.

MDCP Goal

To provide support services that help prevent unnecessary placement of an individual in a long-term care facility and to support de-institutionalization of individuals who reside in nursing facilities.

MDCP strives to:

Handbook Purpose

To provide general program information and procedures for MDCP case managers and nurses.

 

1200 Program Definitions

Revision 15-9; Effective December 15, 2015

 

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

1915(c) waiver program — A home or community-based service authorized by §1915(c) of the Social Security Act and approved by the Centers for Medicare and Medicaid Services.

Activities of daily living — Activities that are essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer and ambulation, positioning, range of motion and assistance with self-administered medications.

Adaptive aid —A device that is needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps an individual perform the activities of daily living or control the environment in which the individual lives.

Appeal —A request for a fair hearing to challenge a program or service suspension, service reduction, service denial or termination.

Applicant — A Texas resident seeking services in the Medically Dependent Children Program (MDCP).

Attendant — An employee of a program provider or of an individual who has selected the Consumer Directed Services (CDS) option who provides direct care to the individual and meets the requirements in §51.421 of Chapter 51 of the Texas Administrative Code (TAC), Requirements for Attendants Providing Respite and Flexible Family Support Services.

Backup plan — A documented plan to ensure that services are provided to an individual when a service provider is not available to deliver services as specified on the service schedule.

Basic child care — Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training or at school.

BON — Board of Nursing for the state of Texas.

Case closure — A Department of Aging and Disability Services (DADS) action that terminates an individual from the MDCP.

Case manager — A DADS employee who is responsible for case management activities for an individual, including eligibility determination, enrollment, assessment and reassessment of the individual's need, service plan development, and intercession on the individual's behalf.

Consumer Directed Services — A means of service delivery in which an individual or the individual's parent or guardian is the employer of record.

Contract — A written agreement between DADS and a program provider to provide MDCP services to an individual. A contract is a provisional contract that DADS enters into in accordance with §49.208 of Chapter 49 of the TAC, Provisional Contract Application Approval, that has a stated expiration date or a standard contract that DADS enters into in accordance with §49.209, Standard Contract, that does not have a stated expiration date.

Cost ceiling — The maximum dollar amount available to an individual for MDCP services per individual plan of care (IPC) year.

DADS — Department of Aging and Disability Services.

Day — Any reference to a day means a calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

Delegated task — A task that a practitioner or registered nurse (RN) delegates in accordance with state law.

DFPS — Department of Family and Protective Services.

Employment assistance — Assistance provided to an individual to help the individual locate paid employment in the community.

Facility-based respite — Respite services provided to an individual in a licensed hospital or nursing facility.

Family member — A person who is related by blood, affinity or law to an individual.

Financial Management Services (FMS) — Services delivered by the FMS agency to an employer, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the employer.

Financial Management Services Agency (FMSA) — An entity that contracts with DADS to provide FMS.

Flexible Family Support Services — Direct care services needed because of an individual's disability that:

Foster home — Means a foster home as defined in the Human Resources Code, §42.002.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

HHSC — Texas Health and Human Services Commission.

HCSSA — A home and community support services agency licensed by DADS in accordance with Texas Health and Safety Code, Chapter 142.

Host family — A provider with whom an individual lives when the individual's parents are unable to care for him.

Imminent danger — An immediate, real threat to a person's safety.

Individual — A person who has been determined eligible to receive MDCP services.

Interest list — A list of people who have contacted DADS and expressed an interest in MDCP services, but have not applied for nor been determined eligible for MDCP services.

IPC — Individual plan of care. A plan that documents:

IPC period — A period that is recorded on the IPC with a beginning and end date.

Legally Authorized Representative (LAR) — A person authorized or required by law to act on behalf of an individual, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult.

LVN — Licensed vocational nurse. A person licensed by the BON or who holds a license from another state recognized by the BON to practice vocational nursing in Texas.

MDCP — Medically Dependent Children Program. A §1915(c) waiver program that provides community-based services to help the primary caregiver care for an individual in the community.

Medical Necessity — The medical criteria an applicant and individual must meet for admission to a Texas nursing facility.

Military member — A member of the United States military serving in the Army, Navy, Air Force, Marine Corps or Coast Guard on active duty.

Military family member — An applicant who is the spouse or child (regardless of age) of:

Minor home modification — A physical change to an individual's residence that is needed to prevent institutionalization or to support the most integrated setting for an individual to remain in the community.

Parent — An individual's natural or adoptive parent or the spouse of the natural or adoptive parent.

Personal Cost — An individual’s contribution towards the cost of adaptive aids or minor home modifications for items or services that exceed the waiver service limit or that do not meet the waiver service criteria.

Practitioner — A physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or an RN approved by the BON to practice as an advanced practice nurse, or a licensed physician currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities, even when he does not have a Texas license.

Primary caregiver —A person, including a parent or guardian, who cares for an individual who receives:

Protective device — An item or device, such as a safety vest, lap belt, bed rail, safety padding, adaptation to furniture, or helmet, if used only to protect an individual from injury or for positioning the individual to ensure health and safety, and not used as a mechanical restraint to modify or control behavior.

Provider — An entity that has a contract with DADS to provide MDCP services.

Reckless behavior — Acting with conscious indifference to the consequences.

Residence — The place where an individual lives.

Respite services — Direct care services needed because of an individual's disability that provides a primary caregiver temporary relief from care giving activities when the primary caregiver would usually perform such activities.

Restrictive intervention — An action or procedure that limits an individual’s movement, access to other individuals, locations or activities, or that restricts an individual’s rights.

RN — Registered nurse. A person licensed by the BON or who holds a license from another state recognized by the BON to practice professional nursing in Texas.

Service authorization form — Document that shows DADS' approval for a provider to deliver MDCP services.

Service initiation date — The first day an individual begins receiving MDCP services.

Service planning team — A team comprised of persons convened and facilitated by a DADS case manager for the purpose of developing, reviewing and revising an individual’s IPC. In addition to a DADS case manager, the team includes the individual and primary caregiver, and may include the program provider and other persons whom the individual or primary caregiver invite to participate.

Service reduction — A temporary or permanent decrease in the number of service hours delivered to an individual.

Service schedule —A schedule for delivering respite or flexible family support services to an individual that is agreed upon and signed by the individual or the primary caregiver. A fixed service schedule specifies certain days, times of day or time periods for delivery of the services. A variable service schedule specifies the number of authorized hours of services to be delivered per day, per week or per month, but does not specify certain days, times of day or time periods for delivery of the services.

Service suspension — A temporary stoppage of MDCP services without loss of program or Medicaid eligibility.

Supported employment — Assistance provided in order to sustain paid employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.

Texas Accessibility Standards — Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

Third-party resources — Goods and services available to an individual from a source other than MDCP, such as Medicaid home health, Texas Health Steps Comprehensive Care Program, local community resources and private insurance.

Transition Assistance Services (TAS) — One-time service provided to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community to receive MDCP services.

Working day — Any day except Saturday, Sunday, a state holiday or a federal holiday.

 

1300 Eligibility

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203, Eligibility Requirements

If the applicant/individual does not meet eligibility requirements, the case manager must deny the application following procedures in Section 9000, Service Reductions, Suspensions, Denials, Case Closures, Appeals and Fair Hearings.

 

1310 Age

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203(b)(1), Eligibility Requirements

The case manager must confirm the applicant's age by reviewing any of the following documents:

The case manager must document applicant age by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file.

 

1320 Financial Eligibility

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203(b)(2), Eligibility Requirements

Applicants/individuals who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. The case manager must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from Medicaid for the Elderly and People with Disabilities (MEPD) staff or through the Texas Integrated Eligibility Redesign System (TIERS).

Case managers must determine if an applicant/individual is currently on Medicaid and check TIERS to confirm the current status of an applicant/individual. An MEPD determination may have already been completed for an applicant and must be used unless there have been changes in the applicant's financial situation.

Case managers must document financial eligibility of an applicant by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file. Case managers must document financial eligibility of an individual during the annual reassessment on Form 2405, Narrative Notes, and place it in the case file.

If the applicant does not have a Medicaid eligibility determination, it is the case manager's responsibility to assist the applicant with completing the application and obtaining the necessary verifications to establish eligibility. See Section 2300, Initial Home Visit, for details.

Applicants/individuals who have qualified income trusts may still be eligible for the Medically Dependent Children Program (MDCP) if they meet all other MDCP eligibility criteria. Income applied to the trust does not affect eligibility, but is included for the calculation of the copay for MDCP services.

 

1330 Disability

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203(a)(1), Eligibility Requirements

Case managers must confirm at initial enrollment only that the applicant receives disability benefits by reviewing:

If the applicant does not meet any of the above criteria, the case manager will assist the applicant with the disability determination process. See Section 3110.2, Coordination of Disability Determinations.

Case managers must document disability by completing Form 2438, Applicant Eligibility Checklist, attaching a copy of the verification documentation and placing it in the case file. Documentation of ME-Waiver approval in the case file is sufficient documentation that disability determination has also been approved.

 

1340 Medical Necessity

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code (TAC) §51.203(b)(2), Eligibility Requirements

TAC §51.207, Medical Necessity

Case managers must confirm that the applicant or individual meets medical necessity by:

TMHP assigns a Document Locator Number (DLN) to each electronic copy of a Medical Necessity and Level of Care (MN/LOC) Assessment that allows the case manager, regional nurse, case analyst or utilization review nurse access to the information from the MN/LOC Assessment. 

The case manager must file a copy of the TMHP web-based portal screen or SAS inquiry screen in the case file or document in the case file the DLN, the resource utilization group (RUG) value and whether the medical necessity determination was approved or denied.  The case manager must also complete Form 2438, Applicant Eligibility Checklist.

It is the MDCP nurse's responsibility to prepare and submit the MN/LOC Assessment to TMHP for determination.

 

1350 Individual Plan of Care (IPC)

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203(b)(4), Eligibility Requirements

The individual plan of care (IPC) is developed and signed by the applicant/individual, applicant's/individual's parents or guardian, case manager, Medically Dependent Children Program nurse and others who participate in the individual's care.

 

1360 Living Arrangement

Revision 15-4; Effective April 28, 2015

 

Texas Administrative Code §51.203(b)(5), Eligibility Requirements

Case managers must confirm that the applicant/individual, if under age 18, lives with a family member such as a parent, guardian, grandparent or sibling, as defined in Section 1200, Program Definitions. The case manager must review guardianship documentation or obtain a statement from the applicant/individual or family member regarding relation.

The applicant/individual may reside with a foster family that includes no more than four other children unrelated to the applicant.

Example:

Case managers must document living arrangement by completing Form 2438, Applicant Eligibility Checklist, and place it in the case file.

 

1370 Monthly Service Utilization

Revision 15-4; Effective April 28, 2015

 

MDCP Waiver - Appendix B-6a: MDCP Waiver: TX0181.90.R3 Appendix B-6a - Reasonable Indication of Need for Services: An Individual must require the provision of at least one waiver service and the provision of waiver services at least monthly.

The case manager must confirm that the applicant has a need for and will use MDCP services monthly to be eligible at initial enrollment. Case managers should review MDCP service criteria with applicants to determine the need for waiver services.

 

1400 Safeguarding Personally Identifiable Information

Revision 12-1; Effective May 1, 2012

 

All personally identifiable information (PII) obtained from the Social Security Administration (SSA) must be safeguarded. Wire Third Party Query (WTPY) System, State On Line Query (SOLQ) or other SSA documentation is considered SSA-protected and cannot be printed or kept in the case record.

Staff must not print or file PII (WTPY/SOLQ) printouts in applicant/individual case records. Staff must document the date they verified and viewed the online/printed verification, the amount of income and source (WTPY, SOLQ, other) used to verify the information.

If a WTPY or SOLQ report must be printed for a specific purpose, such as a legal request or legislative inquiry, the document must not be filed in the case record or sent for imaging. The SSA documents must be stored in a central locked filing cabinet only accessible by Health and Human Services Commission or Department of Aging and Disability Services authorized staff.

 

1410 Requests for Information About a Deceased Individual

Revision 12-1; Effective May 1, 2012

 

Case managers may apply the following list of acceptable documentation for recording a request and release of information to the requestor:

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

Case managers should first ask the requestor for any available document. If a document is not available, the case manager must determine and document if the requestor has authority under Texas law to act for the deceased individual. The case manager may release information to the requestor if one of the documentation requirements identified in this section is met and filed/recorded in the case record.

CM-MDCP, Section 2000, Intake and Interest List Procedures

Revision 15-9; Effective December 15, 2015

 

 

2100 Initial Requests

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code (TAC) §51.201, MDCP Interest List

Individuals requesting Medically Dependent Children Program (MDCP) services must be placed on the MDCP interest list, regardless of the program's enrollment status, according to the date and time of their request. Individuals are released in order of the request date.

An individual is placed on the MDCP interest list at any time by:

When the regional office receives a request for MDCP services, DADS staff inform the individual about DADS services and the MDCP interest list. DADS staff refer the individual directly to the CSIL Unit at 877-438-5658 for placement on the MDCP interest list.

The applicant’s name is added to the interest list if the applicant is less than 21 years of age and resides in Texas. The interest list request date is determined by following TAC §51.201.

DADS local staff must assist individuals with placement on the MDCP interest list if they are unable to do so or do not wish to call themselves.

DADS removes the applicant’s name from the MDCP interest list, according to TAC §51.201.

 

2100.1 Caregiver Support Assessment Initiative

Revision 12-1; Effective May 1, 2012

 

This policy applies to all intakes processed by regional staff for community service programs.

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Department of Aging and Disability Services (DADS) staff to:

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

Form 1027, Caregiver Status Questionnaire (CSQ), is designed to meet the requirements of SB 271. The information collected will be analyzed and included in DADS' report to the governor and the Legislative Budget Board. DADS is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

When possible, the CSQ will be completed at the time of the intake contact. 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.

The purpose of the CSQ is to collect the information described above. This information is not being used to determine unmet need criteria, and is not forwarded to the case manager.

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. Staff 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, read aloud the response category headings. For example, "Has caregiving affected your employment schedule, pay, leave, performance or work relationships?" If further clarification is necessary, staff 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 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 he is:

Accessing the CSQ

A copy of Form 1027 should be used when the automated system is unavailable; however, all information must be entered in the automated system as soon as possible. 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 AAA, make a referral following regional procedures.

It is possible that staff could conduct multiple assessments in situations where DADS staff receive more than one request for services for an individual. 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.

 

2110 Interest List Release and Notification

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.211, Enrollment

The DADS Community Services Interest List (CSIL) Unit:

Within five calendar days of receipt of designated names from the CSIL Unit, the regional MDCP supervisor assigns case managers and returns the list of names and assigned case managers to the CSIL Unit.

Within three business days of receipt of the assigned case managers, the CSIL Unit:

The enrollment packet sent to the individual contains:

The individual has 60 days from the date of the MDCP interest list release notification letter to complete and return enrollment materials to the case manager. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services, the individual may request to remain on the MDCP interest list, but will be placed at the bottom of the list.

 

2110.1 Rural Addresses

Revision 12-1; Effective May 1, 2012

 

The U.S. Postal Service (USPS) is phasing out rural route addresses as a result of local 9-1-1 systems converting business and residential rural routes to street-style addresses. Mail carriers will continue to deliver mail showing either address to allow time for changing to the Coding Accuracy Support System (CASS) standardized address. Since this address change is not the result of a residential move, a change of address form is not required.

In July 2008, official USPS notices were sent to affected rural route addresses notifying residents of the address change. In August 2008, the new addresses were introduced in the USPS address database. At some time in the future, mail addressed to rural routes not showing the new CASS address will be returned to the sender with the notice "Undeliverable as Addressed."

 

2110.2 Referrals from Midland Document Processing Center

Revision 13-1; Effective February 1, 2013

 

When the Document Processing Center (DPC) receives an application in which a request is made for a Department of Aging and Disability Services (DADS) program or service, the DPC will fax only the first three pages of the application and a cover sheet to the DADS local office. DADS staff will review each of the referrals and contact the applicant to determine if he is interested in a DADS program or service.

If it is determined the applicant is interested in a DADS program or service without an interest list, DADS staff will complete an intake for the program or service requested and access the Health and Human Services Commission (HHSC) Benefits Portal to print a complete copy of the application.

To print the application, DADS staff must access the HHSC Benefits Portal and select the PT Inquiry tab. Once the PT Inquiry is open, select Inbound Correspondence Image Repository Search and search for the applicant. Select the appropriate document and click view. When the document opens, click on the printing icon to print the application.

If the applicant is interested in a program or service with an interest list, the applicant will be placed on the interest list and DADS staff will not need to print a copy of the application.

If the applicant is not interested in a DADS program or service or one with an interest list, DADS staff must file the fax from DPC following local office procedures.

 

2120 Transfer of Individuals Between Waiver Interest Lists

Revision 12-1; Effective May 1, 2012

 

If an individual is denied MDCP based on medical necessity, the case manager will inform the individual that he may be placed on an interest list for an alternate program with the original MDCP request date. Regional staff will provide Form 2121, Long Term Services and Supports, and explain alternate service options to the individual.

If the individual requests placement on another program's interest list, the case manager must contact the state office Community Services Interest List (CSIL) Unit staff, the designated regional interest list staff, or the Local Authority serving the individual's county of residence for placement on the requested program's interest list, as applicable.

 

2130 Conflict of Interest

Revision12-1; Effective May 1, 2012

 

DADS staff have an obligation to report any relationship in which a conflict of interest may exist that could result in an unethical or biased business relationship. This applies to all staff involved in awarding benefits and determining eligibility for MDCP benefits.

DADS staff must not work on or review an ongoing MDCP case, nor assist an applicant/individual/responsible party to receive MDCP benefits, if the applicant or individual is a relative (by blood or marriage), roommate, dating companion, supervisor or someone being supervised. DADS staff may not determine eligibility, the need for MDCP services or the amount of services authorized to an applicant/individual in which the relationship may result in a conflict of interest.

DADS staff may provide anyone with an application for MDCP services and information on how and where to apply. DADS staff may help anyone gather any documents the applicant/individual needs to verify eligibility and need for services, but must not take any other role in determining eligibility for MDCP services for an applicant/individual with whom a relationship may result in a conflict of interest.

DADS staff must consult with a supervisor if the applicant or individual is a friend or acquaintance. Generally, case managers should not work on cases or applications involving these applicants/individuals, but the degree and nature of the relationship must be reviewed by the supervisor to determine if a conflict of interest exists.

If DADS staff have relatives (by blood or marriage), roommates, dating companions or close friends who are contracted with DADS to provide MDCP services or who own or are employed by a provider that contracts with DADS to provide MDCP services, staff must not demonstrate any special consideration toward that provider. Referrals to a provider must be based strictly on applicant/individual preference and the applicant's/individual's need for the service the provider offers. In addition, instructions (or lack of instructions) to the provider concerning the delivery of service must be based solely on the applicant's/individual's needs and DADS policy.

DADS staff must complete Form 2115, Conflict of Interest Notification, to inform the supervisor of the relationship. The first-level supervisor must complete the supervisory response section of the form outlining what action, if any, may be necessary and return the signed/dated form to the DADS staff person who initiated the form.

Form 2115 must be completed even if no conflict of interest exists when:

Staff must complete Form 2115 anytime a potential conflict of interest exists.

 

2140 Creating the Case File

Revision 12-1; Effective May 1, 2012

 

The case manager will create a case file for each referral and information packet provided by the Community Services Interest List (CSIL) Unit.

The case file will include:

If the individual applies and is certified for MDCP services, the active case file will include:

All documents must be kept in chronological order with the most recent information on top, progress notes on the left and all other documentation on the right.

Case files are confidential and all health information pertaining to the applicant/individual is subject to the Health Insurance Portability and Accountability Act (HIPAA). Case files for applicants denied MDCP services are retained until the end of the fiscal year, plus five years. Case files for an active MDCP individual are retained for seven years after case closure.

 

2200 Initial Contact

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.211(f), Enrollment

The individual has 60 days from the date of the notification of release from state office to complete and return the required enrollment materials to the case manager.

Staff must contact the individual by telephone within 14 days of the date of the notification from state office or the Community Services Interest List (CSIL) database to determine if the individual received the enrollment packet and confirm interest in applying for MDCP services. The first attempt to contact the individual must be made during the first seven-day period and the second attempt, if needed, must be made during the second seven-day period. All contacts and attempted contacts must be documented in the case file using Form 2405, Narrative Notes.

If staff are unable to contact the individual within 14 days of the date the notification from state office, they must complete Form 2442, Notification of Interest List Release Closure. Form 2442 must include the release date and release closure date, and must indicate that staff have not been able to contact the individual to begin the eligibility determination process. Staff must mail Form 2442 30 days after the date of the notification from state office or the CSIL database.

Staff continue to attempt contact with the individual weekly through the duration of the 60-day period.

Staff should not attempt to contact an individual if DADS receives information about the individual's death. The effective date of the release closure is the date staff received information of the individual's death. Staff must follow procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2210 Scheduling a Home Visit

Revision 15-9; Effective December 15, 2015

 

During the initial telephone contact, staff should schedule a home visit that must be completed by the case manager and regional nurse within seven days of the initial telephone contact with the applicant. If the individual has not received the enrollment packet, the case manager must provide an enrollment packet for completion during the home visit. If the individual has not yet decided to apply for MDCP services, the case manager must review MDCP services with the individual during the home visit.

When scheduling the home visit, staff must request:

An individual's delay in obtaining the requested documentation must not delay scheduling the home visit.

If the individual cannot meet within seven days, staff must inform the individual that the home visit must occur within the 60-day period listed on Form 2440, Release from the MDCP Interest List, or the release will be closed. If the individual can meet within the 60-day period, staff must schedule the home visit.

If the individual cannot meet within the 60-day period, but is interested in applying for MDCP services, staff must ask the individual the reason for the delay. Staff must inform the individual that the individual must mail Form 2439, Selection Acknowledgement, indicating interest in MDCP services within the 60-day period and that the individual's request for the delay will be forwarded to the MDCP supervisor.

If the individual cannot meet within the 60-day period and has not made a decision to apply for MDCP services, staff must ask the individual what concerns are preventing the individual from applying for MDCP services. Staff may address the concerns or schedule a telephone interview that will include DADS staff to address the individual's concerns. Staff must inform the individual to contact staff or mail Form 2439 with a decision to either apply or decline MDCP services within the 60-day period or the release will be closed.

If the individual indicates that the enrollment packet has not been received and the individual is unable to meet within the 60-day period, staff must request the current address.

If the address is the same as recorded on the notification from state office or the Community Services Interest List (CSIL) database, complete and mail:

If the address does not match DADS records, case managers complete Form 2440 using the date of contact as the mail date on Form 2440. Case managers document a new 60-day time frame on the "Remember to sign and date all of the forms and return them by" section on Form 2440, using 60 days from the date of contact as the date entered in this field. Case managers must mail the enrollment packet with Form 2440 to the individual on the date of contact and continue application procedures using the new date identified on Form 2440.

The case manager and nurse should complete the home visit together whenever possible. The home visit must be conducted on the earliest possible date. If the case manager and nurse cannot visit the applicant's home on the same day, they may conduct separate home visits to prevent delays in determining eligibility for MDCP, but both must complete the home visit within seven days of the initial telephone contact with the applicant.

An individual's request to delay a home visit or inability to keep scheduled home visits is subject to the MDCP supervisor's review, as indicated in Section 2210.1, Scheduling a Home Visit after the Release Closure Date.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2210.1 Scheduling a Home Visit after the Release Closure Date

Revision 15-9; Effective December 15, 2015

 

The initial home visit must be scheduled no later than the release closure date, which is the 61st day after the date of the email notification from state office or the date in the Community Services Interest List (CSIL) database. If the case manager receives the enrollment packet or is contacted by the individual after DADS last attempted telephone contact, but before the release closure date, staff must schedule a home visit within seven days of receiving the notice or contact.

If staff cannot schedule a home visit within seven days due to the individual's schedule, staff must inform the individual that a notice will be mailed and that the home visit must be completed within the time frame on the notice or the release will be closed. Regional staff must complete and mail Form 2442, Notification of Interest List Release Closure, notifying the individual to contact the case manager and be available for a home visit within 10 days of the date on Form 2442 or the release will be closed. If the individual is available for a home visit after the seven-day time frame, but before the 10-day time frame, staff must schedule the home visit and complete and mail Form 2442.

Any requests to exceed the 10-day home visit time frame must be reviewed by the MDCP supervisor. The MDCP supervisor will consider the individual's reason for delaying the application process. The date of the home visit cannot exceed 45 days past the 60 days from the date of the email notification from state office or the date in the CSIL database. Staff must close the release the day it is determined that the home visit cannot be completed during the extended time frame. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed due to inability to conduct a home visit within the required time frame.

Staff must document all attempts to contact the individual in the case file, including certified mail return receipts, using Form 2405, Narrative Notes.

 

2210.2 Outbreak of Transmittable Disease in the General Population

Revision 12-1; Effective May 1, 2012

 

During the time when Texas experiences an increase in serious transmittable diseases in the general population, certain precautions are necessary to ensure the health and welfare of the case manager who may come in contact with an individual reporting he has a contagious illness. While it is important that the required home visit is performed on a timely basis, there may be circumstances that could place the case manager at risk for contracting contagious illnesses.

If a case manager contacts an individual to schedule a home visit and the individual states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case manager 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 manager must contact the individual at least weekly until the home visit can be made. The home visit must be conducted in time for the case manager to redetermine MDCP eligibility and develop a new Individual Plan of Care (IPC) prior to the end date of the current IPC.

Each contact must be documented in the case file on Form 2405, Narrative Notes. This documentation will be considered as an acceptable reason for delaying a required home visit.

 

2220 Declining MDCP Services

Revision 15-3; Effective March 11, 2015

 

Staff must attempt to contact the individual following the contact time frames before the release closure date, which is the 31st day after the date of the email notification from state office or the date in the Community Services Interest List (CSIL) database. If the individual does not confirm interest in MDCP services before the release closure date, regional staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442, Notification of Interest List Release Closure, informing the individual that the release was closed due to not submitting the enrollment materials within the 30 day time frame.

If the individual chooses not to apply for MDCP services during the home visit, the case manager must obtain a signed Form 2439, Selection Acknowledgement, indicating that the individual does not wish to apply for MDCP services. The case manager informs the individual that the release will be closed on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed because the individual does not wish to apply for MDCP services.

If the individual completes and mails Form 2439 indicating no interest in applying for MDCP services, staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed due to being informed that the individual no longer wishes to apply for MDCP services.

If the individual at any time declines MDCP services before the release closure date, staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed because the individual does not wish to apply for MDCP services.

If the individual changes his mind after declining MDCP services and contacts the case manager or returns the enrollment materials to apply for services before the release closure date, staff must schedule a home visit within seven days of contact to continue the application process. Staff must follow the home visit time frames as indicated in Section 2210.1, Scheduling a Home Visit after the Release Closure Date, if the home visit cannot be scheduled before the release closure date.

Staff must follow procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2230 Failure to Contact the Individual

Revision 15-9; Effective December 15, 2015

 

Staff must close the release by the release closure date, if staff have not:

Within three days after closing the release, staff must notify the CSIL Unit of the release closure following procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

Staff must not send Form 2442 to the responsible party if the release was closed due to death of the individual.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2300 Initial Home Visit

Revision 13-3; Effective August 1, 2013

 

§51.215 — After DADS mails the enrollment materials as described in §51.211 of this chapter (relating to Enrollment), the case manager and a DADS RN conduct a home visit to:

(1) complete the medical assessment;

(2) complete the social assessment;

(3) develop the IPC as described in §51.217 of this chapter (relating to Individual Plan of Care); and

(4) assist the family in completing the application for Medicaid, if necessary.

The case manager and nurse should complete the home visit together whenever possible following the time frames in Section 2210, Scheduling a Home Visit. If the case manager and nurse cannot visit the applicant's home on the same day, they may conduct separate home visits to prevent delays in determining MDCP eligibility.

Note: DADS staff must not discard the original Form 2410, Medical-Social Assessment and Individual Plan of Care, or any other form or document completed during the face-to-face visit. The case manager must file the original handwritten document in the case file even if the form is typed after returning to the office.

 

2310 Reviewing the Enrollment Materials

Revision 15-3; Effective March 11, 2015

 

Staff must review the enrollment materials with the applicant and provide assistance in completing the required forms.

Form 2439, Selection Acknowledgement — Staff must verify the applicant's choice to apply for MDCP services. Staff must review MDCP services and eligibility requirements, and answer questions if the applicant remains unsure about applying for MDCP.

Form H1200, Application for Assistance – Your Texas Benefits — Staff must follow procedures listed in Section 2360, Applicant Without Medicaid, if the applicant does not currently receive Medicaid. If the applicant is a Medicaid recipient, staff must review the Texas Integrated Eligibility Redesign System (TIERS) to verify the applicant's current Medicaid status.

Form 0003, Authorization to Furnish Information — Staff must obtain written authorization to request and receive applicant information. On Form 0003, the applicant authorizes staff to request and receive information from non-DADS entities to determine program eligibility. Form 0003 must include the applicant's name and signature, if the applicant is 18 or older. A parent, guardian or responsible party must sign for a minor child or adult applicant who is not able to sign the form. The applicant's signature on Form 0003 does not authorize staff to release information.

 

2310.1 Individual is Still Unsure about Applying for MDCP Services

Revision 15-9; Effective December 15, 2015

 

If the individual has not yet decided to apply for MDCP services, the case manager must continue with the home visit and provide and obtain as much information as possible to develop the Individual Plan of Care (IPC). The case manager must inform the individual that a response is needed within 60 days of the date on Form 2440, Release from the MDCP Interest List.

Within three DADS workdays of the home visit, staff must complete and mail Form 2442, Notification of Interest List Release Closure, to the applicant. Staff must attempt weekly contact with the individual up to the release closure date or until a decision is made regarding the application for MDCP.

If the individual decides to apply for MDCP, continue with the application process.

If the individual does not respond or decides not to apply for MDCP services within 60 days of the date on the email notification from state office or the date in the CSIL database, see Section 2220, Declining MDCP Services.

 

2310.2 Explaining Long Term Services and Supports

Revision 15-9; Effective December 15, 2015

 

When conducting the initial assessment, case managers must present Form 2121, Long Term Services and Supports. Document in the case record and on Form H1746-A, MEPD Referral Cover Sheet, that Form 2121 was presented. Send Form H1746-A to Medicaid for the Elderly and People with Disabilities (MEPD) at the same time the financial application is sent for processing.

 

2320 Initiating the Individual Plan of Care

Revision 13-2; Effective May 1, 2013

 

§51.217

(a) The IPC is developed by:

(1) the individual;

(2) the individual's parent or guardian;

(3) the case manager;

(4) a DADS RN; and

(5) any other person who participates in the individual's care, such as the provider, a representative of the school system, or other third-party resource.

§51.219

(a) To maintain enrollment in MDCP, the individual or the individual's parent or guardian must:

(2) Ensure that there is not a 60-day break in services delivery, unless the 60-day break in service is due to extenuating circumstances and the case manager has approved the 60-day break in service.

The case manager determines the services the applicant needs and whether those needs are currently being met by family or other community resources. The case manager must identify the applicant's need for services and discuss service delivery options through MDCP and non-waiver resources.

Before planning the extent of services to be provided through MDCP, the case manager must identify any other sources of services that the applicant may be receiving, including the family's contribution to care giving. Other sources may include:

The case manager must ask the applicant what current sources of services are available or are currently being used. The case manager must also inform the applicant of the requirement to use all possible non-waiver resource options that are either currently available to the applicant or that may become available once the applicant's eligibility is determined.

Case managers must not refer individuals to Local Authorities (LAs) for case management or service coordination. Per Title 40 Texas Administrative Code, Chapter 2, Subchapter L, service coordination funded by Medicaid targeted case management may not be provided to an individual who is receiving waiver services through any waiver program except the Texas Home Living (TxHmL) Program.

With the exception noted above, case managers may continue referring individuals for services not already covered by MDCP following the LA referral process. DADS allows each LA to determine whether an individual may receive general revenue services. For this reason, general revenue services available to the individual may vary throughout the state.

The case manager reviews definitions, criteria and limitations of MDCP services. The case manager must inform the applicant that he must have a need for either Respite or Flexible Family Support services and, if determined eligible, must use either service without a 60-day break in the service.

During the initial home visit, the case manager completes Form 2410, Medical-Social Assessment and Individual Plan of Care, Page 2, Part IIA, Social Assessment, and Page 3, Part IIB, MDCP Schedule Planning Grid.

The MDCP nurse completes Form 2410, Page 1, Part I, Medical Assessment.

 

2330 Assessment for Medical Necessity

Revision 13-4; Effective November 1, 2013

 

§ 51.207

(a) An entity contracted by HHSC determines medical necessity.

(b) A determination that an individual meets medical necessity is valid for one year. An individual must receive a determination of medical necessity annually to remain eligible for MDCP.

If the applicant does not have a current medical necessity (MN) determination, the MDCP nurse must complete the Medical Necessity and Level of Care (MN/LOC) Assessment. The MDCP nurse must inform the applicant that the MN/LOC Assessment requires a physician's signature. The applicant's assistance may be needed to obtain the physician's signature.

The MDCP nurse must also complete and sign Part I – Medical Assessment, of Form 2410, Medical-Social Assessment and Individual Plan of Care. The MDCP nurse may attach additional health information pages, as needed. The MDCP nurse should also complete Form 3653, Cover Letter for the Physician Signature Page, and submit it with the MN/LOC Assessment to the applicant's physician. Included on Form 3653 is a list of MDCP services, the items on the MN/LOC Assessment that require the physician's review and the MDCP nurse's contact information.

Within three DADS workdays of the home visit, the MDCP nurse must submit the MN/LOC Assessment to the applicant's physician for review and signature. At a minimum, staff must attempt weekly contacts with the physician until the MN/LOC Assessment has been returned to DADS. These contacts should be documented in the case file.

Licensed physicians currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities can sign orders for community services even when they do not have a Texas license. This includes signatures on the MN/LOC Assessment.

Within three DADS workdays of receipt of the MN/LOC Assessment, the MDCP nurse must submit the form electronically to Texas Medicaid & Healthcare Partnership (TMHP) for MN determination and Resource Utilization Group (RUG) calculation using TMHP's web-based online portal. TMHP is the entity contracted by the Health and Human Services Commission to determine MN. It is important for the MDCP nurse to review all entries for accuracy before transmitting the MN/LOC Assessment. An MN determination will not appear in the Service Authorization System (SAS) when information on the MN/LOC Assessment does not meet all the required SAS data entry criteria.

An approved initial MN determination is valid for 120 days from submission of an MN/LOC Assessment by the regional nurse to TMHP. If enrollment occurs within 120 days of an MN determination, the case manager does not take further action.

Enrollments After 120 Days of the Initial MN Determination

When enrollment occurs after 120 days and before 181 days of the initial MN determination, the case manager must ask the regional nurse to contact the applicant to determine if there are any significant changes in the applicant’s condition. The regional nurse may conduct a telephone contact, face-to-face contact, or both, to make this determination. A significant change is a decline or improvement in an applicant’s condition that could potentially impact the current MN determination or resource utilization group (RUG) value. The regional nurse will use professional judgment to determine if the applicant has a significant change in condition and inform the case manager of the result. If the regional nurse determines there is no significant change in the applicant’s condition, the regional nurse must inactivate the previously submitted MN/LOC Assessment, create a new initial MN/LOC Assessment using the “Use as template” feature and submit it to the TMHP portal.

If the regional nurse determines there is a change in condition, the regional nurse must make a face-to-face contact to complete a new MN/LOC Assessment. The nurse will inactivate the previously submitted MN/LOC Assessment, create a new initial MN/LOC Assessment using the “Use as template” feature and submit it to the TMHP portal. The nurse must inform the case manager that the new initial MN/LOC Assessment was submitted. The case manager must also adjust the Individual Plan of Care (IPC) if a change to the IPC is warranted.

Enrollments After 180 Days of the Initial MN Determination

When enrollment occurs after 180 days of the initial MN determination, the case manager must ask the regional nurse to make a face-to-face contact to complete a new MN/LOC Assessment. The nurse will inactivate the previously submitted MN/LOC Assessment, and create a new initial MN/LOC Assessment using the “Use as template” feature and submit to the TMHP portal. The nurse must inform the case manager that the new initial MN/LOC Assessment was submitted. The case manager must also adjust the IPC if a change to the IPC is warranted.

Applicants Residing in Nursing Facilities

Some applicants who currently reside in nursing facilities (NF) and receive Medicaid reimbursed NF services will not need an MN/LOC Assessment for MN determination. MDCP recognizes the applicant's current MN and RUG if the applicant begins receiving MDCP services within 60 days of discharge from the NF.

 

2330.1 Authorization to Release Medical Records

Revision 14-1; Effective February 3, 2014

 

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of medical information and gives applicants and individuals privacy rights. HIPAA 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 applicant or individual and that relates to the:

Under HIPAA, agency staff should use standardized forms. The following forms, available in Spanish and English, can be accessed at:

https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms

The privacy notice explains individual privacy rights, DADS responsibility to protect an individual’s health information and how DADS may use or disclose health information. HIPAA requires that DADS distribute the notice to MDCP applicants. The privacy notice is available in both English and Spanish at https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms.

The MDCP nurse must review and provide the applicant with copies of HIPAA-related forms.

An applicant authorizes DADS to obtain or release medical records by completing and signing Form 2076, Authorization to Release Medical Information. The applicant's authorization is necessary for completing and transmitting the Medical Necessity and Level of Care (MN/LOC) Assessment. The MDCP nurse must assist the applicant with completing Form 2076.

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 applicant and individual medical information from DADS records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or individual authorizes release of income verification, including disability income, do not release related case medical information, unless specifically authorized by the applicant or individual.

 

2340 Freedom of Choice

Revision 12-1; Effective May 1, 2012

 

Case managers must review Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, with the applicant. The applicant is given the opportunity to make a free choice between institutional care and the services of the waiver. The applicant signs Form 2417 acknowledging his rights and choice of MDCP services.

If the applicant chooses institutional services, the case manager assists by providing the information on medical necessity and Medicaid to the applicant to take to the nursing facility of his choice.

 

2350 Choosing a Provider

Revision 13-2; Effective May 1, 2013

 

§51.233

(a) The individual or the individual's parent or guardian must choose the provider. The case manager gives a list of providers to the individual or the individual's parent or guardian.

(b) If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

Case managers must provide a list of MDCP providers to the applicant at the home visit. Applicants/individuals may access the Consumer Directed Services (CDS) option, a Home and Community Support Services Agency (HCSSA), or both for Respite and Flexible Family Support Services. An applicant/individual may only have one HCSSA and one financial management services (FMS) provider.

The applicant must choose a provider within 14 days of the initial home visit. If the applicant is unable to choose a provider during the home visit, a selection must be made within 14 days of the home visit; the case manager must contact the applicant seven days after the home visit to determine if the applicant selected a provider. If the applicant is unable to make a selection on the 15th day, the case manager must offer a provider to begin services from the list of providers on a rotating basis.

For areas in which there is more than one MDCP provider for a specific service, the applicant or individual may choose and/or change providers without restriction.

If the applicant wishes to receive services from an entity that is not on the list, the applicant may encourage the entity to apply for an MDCP provider contract with DADS. The applicant or individual may change providers when the entity becomes an MDCP provider.

 

2360 Applicant Without Medicaid

Revision 12-1; Effective May 1, 2012

 

If the applicant is not eligible for Medicaid, the case manager may assist the applicant in completing the forms required to determine financial eligibility.

Form H1200, Application for Assistance – Your Texas Benefits — The case manager should remind the applicant that questions regarding income and resources are specific for any income or resources under the applicant's name.

Form H3034, Disability Determination Socio-Economic Report — The case manager should remind the applicant that questions regarding socio-economic information are specific for the applicant. Staff must assist applicants in completing Form H3034; however, this form should not contain any DADS staff information.

Form H3035, Medical Information Release/Disability Determination — The case manager should inform the applicant that Page 2 of Form H3035 will authorize release of medical information necessary to determine if the applicant's condition meets Medicaid requirements. Staff must assist applicants in completing Form H3035. The applicant may provide any or all information on Page 2 of Form H3035.

Case managers must refer all questions to the Texas Health and Human Services Commission's Medicaid for the Elderly and People with Disabilities (MEPD) staff.

Case managers must send the completed forms to MEPD staff, as outlined in Section 3110, Medicaid Eligibility for the Initial Application.

 

2370 Explaining Electronic Visit Verification Requirements

Revision 14-1; Effective February 3, 2014

 

Individuals requesting attendant services from a Home and Community Support Services Agency (HCSSA) in mandatory Electronic Visit Verification (EVV) areas are required to participate in EVV by allowing the attendant to use his home telephone to report the start of work and the end of work. If an individual does not have a telephone, the individual must agree to a fixed visit verification device placed in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services. Mandatory areas for EVV may be found at https:hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/electronic-visit-verification.

The case manager must review the EVV information on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and adequately explain the EVV requirements to the applicant. In areas where EVV is not yet implemented, the case manager explains that this section of Form 2417 is not applicable at this time. The case manager must explain the following points:

If the applicant is interested in the CDS option, the case manager explains that the individual receiving services or a designated representative (DR) is the employer of record and can choose if he wants to use the EVV system or use paper time sheets. The three choices are:

The FMSA will have the employer of record complete Form 1722, Employer's Selection for Electronic Visit Verification (EVV), to indicate his choice.

 

2400 Initial Presentation of the Consumer Directed Services Option

Revision 14-1; Effective February 3, 2014

 

§51.235 — An individual may choose to participate in a payment option that allows the individual or the individual's parent or guardian to direct the recruiting, hiring, management, and termination of the individual's attendant or nurse as described in Chapter 41 of this title (relating to Consumer Directed Services Option). The consumer directed services option is available only for respite or adjunct support services.

Case managers must review the Consumer Directed Services (CDS) option with all applicants during the initial home visit. MDCP services available through the CDS option are Flexible Family Support Services and Respite.

Case managers must review Form 1581, Consumer Directed Services Option Overview, with the applicant. The applicant must sign Form 1581, Page 2, acknowledging review and receipt of the form.

If the applicant is interested in the CDS option, the case manager must review Form 1582, Consumer Directed Services Responsibilities, with the applicant. After completing the self-assessment portion of Form 1582 with the applicant, the case manager must assist to determine if the applicant is able to meet requirements for CDS. If the applicant chooses to pursue the CDS option, the case manager reviews Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice.

Refer to Section 2370, Explaining Electronic Visit Verification Requirements, for talking points on explaining Electronic Visit Verification requirements to the applicant requesting the CDS option.

If the applicant is not interested in the CDS option, the case manager informs the applicant that a request to change to the CDS option can be made at any time and will be reviewed annually during the Individual Plan of Care reassessment. The case manager leaves a copy of Form 1581 with the applicant and files the form with the applicant's signature in the case file. The case manager must also review Form 1584 with the applicant and select the "Program Provider – Agency Option" as the choice for MDCP service delivery.

 

2500 Contacting the CSIL Unit for Interest List Release Activities

Revision 12-1; Effective May 1, 2012

 

Staff must notify the Community Services Interest List (CSIL) Unit to change the status of an interest list release.

 

2510 Contacting the CSIL Unit to Report the Status of Interest List Releases

Revision 12-3; Effective November 1, 2012

 

Staff request closure of Community Services Interest List (CSIL) records when an individual cannot complete the application process or when the individual receives an MDCP determination.

CSIL closures are documented on Form 2419, Community Services Interest List (CSIL) Closure Communication, and must be mailed, faxed or emailed to the designated CSIL staff in the state office CSIL Unit. Case managers must use the CSIL closure codes found in the CSIL Closure User Guide. The guide can be found at http://dadsview.dads.state.tx.us/handbooks/csil.

Staff must notify the CSIL Unit of the closure within three calendar days of staff's determination of a need to change the status of the interest list release.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2520 Closing the Interest Release for an Applicant Choosing CLASS

Revision 12-1; Effective May 1, 2012

 

When an individual is offered both MDCP and Community Living Assistance and Support Services (CLASS) and the individual chooses CLASS, Form 2419, Community Services Interest List (CSIL) Closure Communication, is completed to close the MDCP release effective the date DADS is notified of the decision to apply for CLASS. Within three calendar days of this notification, Form 2442, Notification of Interest List Release Closure, must be mailed to the CLASS applicant with a copy of Form 2419 that was mailed, faxed or emailed to the state office CSIL Unit. A copy of Form 2442 must be filed in the MDCP case file. Once Form 2442 is sent to the CLASS applicant, no follow-up contacts with the individual/family are necessary.

If the CLASS application is denied, Form 2442 instructs the individual to contact DADS if he/she wishes to apply for MDCP. When the individual contacts DADS, he/she will be reinstated on the MDCP interest list using the procedures in Section 2530, Contacting the CSIL Unit to Reopen an Interest List Closure.

 

2530 Contacting the CSIL Unit to Reopen an Interest List Closure

Revision 12-1; Effective May 1, 2012

 

Staff must submit a request to the Community Services Interest List (CSIL) Unit to reopen an individual's closed CSIL record for the following reasons.

Within three days of receiving the request to apply for MDCP services, staff must fax a completed Form 2067, Case Information, to 512-438-3549 and must include:

The CSIL Unit will notify regional staff the outcome of the request. If an exception is granted, staff must contact the individual and schedule a home visit within seven days of the exception to begin the application process.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2540 Adding Names Back to CSIL

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.201(e)(f)(g), MDCP Interest List

An individual's name may be added back to the Community Services Interest List (CSIL) when the name has been removed because staff are unable to locate or the individual's failure to respond to attempted contacts. A name is added back if the individual:

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

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

 

2540.1 Earliest Date for Adding an Individual Back to CSIL After Denial

Revision 12-1; Effective May 1, 2012

 

The earliest date an applicant may be added back to the Community Services Interest List (CSIL) for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program.

Example: The applicant is released from the MDCP interest list on Aug. 2, 2011. The case manager determines the applicant is not eligible for MDCP on Aug. 28, 2011, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the MDCP interest list is Aug. 28, 2011.

The earliest date an individual may be added back to the CSIL for the same program the individual is denied is the first date the individual is no longer eligible for the program denied. If the individual's name is added back to the interest list prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System will cause the name to be removed from the interest list for that program.

Example: An individual's MDCP services are denied due to denial of medical necessity and end on July 31, 2011. The first date the individual can be added back to the MDCP interest list is Aug. 1, 2011.

CM-MDCP, Section 3000, Intake and Case Management

Revision 16-1; Effective May 3, 2016

 

Rules:

40 Texas Administrative Code (TAC) §51.217, Individual Plan of Care
40 TAC §51.413, Response to Service Authorization
40 TAC §51.415, Notification to the Individual

 

3100 Interests Lists

Revision 16-1; Effective May 3, 2016

 

40 TAC Chapter 51, Division 2, Enrollment, §51.221, Other Responsibilities

Individuals requesting Medically Dependent Children Program (MDCP) services must be placed on the MDCP interest list, regardless of the program's enrollment status, according to the date and time of their request. Individuals are released in order of that date. An individual is placed on the MDCP interest list at any time by:

When the regional office receives a request for MDCP services, Department of Aging and Disability Services (DADS) staff inform the individual about DADS services and the MDCP interest list. DADS staff refer the individual directly to the CSIL Unit at 877-438-5658 for placement on the MDCP interest list.

DADS staff must assist individuals with placement on the MDCP interest list if they are unable to do so or do not wish to call themselves.

The applicant’s name is added to the interest list if the applicant is less than 21 years of age and resides in Texas. The interest list request date is determined by following TAC §51.201, MDCP Interest List.

The DADS CSIL Unit:

Within five calendar days of receipt of designated names from the CSIL Unit, the regional MDCP supervisor assigns case managers and returns the list of names and assigned case managers to the CSIL Unit.

Within three business days of receipt of the assigned case managers, the CSIL Unit:

The enrollment packet sent to the individual contains:

The information packet sent to the case manager contains:

The individual has 60 days from the date of the MDCP interest list release notification letter to complete and return enrollment materials to the case manager. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services, the individual may request to remain on the MDCP interest list, but will be placed at the bottom of the list.

DADS staff collect data on the state of the individual’s caregiver, and make a home visit as part of the eligibility determination process to complete medical and social assessments, develop the Individual Plan of Care and assist the individual’s family with completing an application for Medicaid, if necessary.

DADS send a letter with attached enrollment materials to the individual’s parent or guardian which must be completed and promptly returned to DADS. If the application packet is not returned to DADS by 60 days from the date of the MDCP interest list release notification letter, DADS removes the applicant’s name from the MDCP interest list, according to TAC §51.201.

 

3110 Medicaid Eligibility for the Initial Application

Revision 15-5; Effective May 8, 2015

 

Medicaid Eligibility for the Initial Application

An applicant meets the Medicaid eligibility requirement for the Medically Dependent Children Program (MDCP) if the applicant is a Texas resident and receives Supplemental Security Income (SSI) or when the requirements in the following items are met:

The case manager must verify the applicant's current eligibility for an appropriate Medicaid program type from Medicaid for the Elderly and People with Disabilities (MEPD) staff. If the applicant is not a current Medicaid recipient, the case manager must initiate the Medicaid financial eligibility determination process.

As needed, case managers assist with the completion of Form H1200, Application for Assistance – Your Texas Benefits, during the home visit and help obtain necessary documentation for MEPD staff to establish financial eligibility. The case manager should explain the financial determination process and inform the applicant that MEPD staff may call for additional information.

No later than close of business on the second working day following the date of receipt of Form H1200, the case manager must fax or mail Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center (DPC). See Appendix XXI, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, for form completion procedures.

If the case manager faxes Form H1200 to MEPD, he must not send the original to MEPD. DADS staff must retain the original Form H1200 with the applicant's valid signature in the case file. The original form must be kept for three years after the case is denied or closed. Case managers must also retain a copy of the successful fax transmittal confirmation in the case file.

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 file. Scanning Form H1200 and sending it by electronic mail is prohibited. The day DADS receives the Medicaid application form is day zero and starts the two working day time frame.

The case manager requests financial eligibility determination for MDCP on Form H1746-A. All available verifications provided by the applicant or individual must be attached. The case manager keeps a copy of all documents and records the date the application was faxed or mailed in the case file.

Example: Form H1200 is received on Sept. 18, which is a Friday. Friday is considered day zero. The case manager has until close of business on Tuesday, Sept. 22 to fax or mail the Medicaid application to DPC.

For Money Follows the Person (MFP) Medicaid applications, the case manager must fax or mail Form H1200 and Form H1746-A to MEPD no later than close of business on the second working day following the date of receipt of Form H1200 or by the date of the nursing facility admission, whichever occurs first. This will prevent delays in certification of financial eligibility.

If the applicant is admitted to the nursing facility on a weekend or holiday, the case manager sends the Medicaid application on the next working day and documents the delay in the case file on Form 2405, Narrative Notes.

For an applicant who is medically fragile applying for MDCP using the MFP option, the case manager must notify the designated MEPD program manager when sending a Medicaid application. The MEPD program manager must be made aware of these applications in order to ensure they are processed quickly.

Case managers assisting with the completion of Form H1200 for applicants requiring a Medical Assistance Only (MAO) determination must understand the importance of providing the most complete packet possible to MEPD. Ensuring the following items are included will facilitate the financial eligibility process:

It is recommended that case managers explain to applicants that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

The case manager notifies MEPD staff of approved medical necessity (MN) and the individual plan of care (IPC) via the Eligibility Data Exchange and Notification (EDEN) system, as outlined in Section 3133, Notifying MEPD of Approved IPC and MN.

The case manager should obtain information from MEPD staff about the status of the financial determination. If the financial decision cannot be readily made, the case manager requests MEPD staff to provide notification when the decision can be made. The case manager should inform the applicant or the applicant's representative and potential providers of the delay in MDCP enrollment.

If the applicant does not have a Medicaid determination within 30 days of the initial home visit, the case manager has 14 days to determine MDCP eligibility from the date MEPD staff indicate that Medicaid eligibility requirements can be met.

Staff must follow procedures in Section 3500, Money Follows the Person Option, regarding Medicaid eligibility for applicants transitioning from a nursing facility to the community.

 

Establishing the Medical Effective Date

Once MEPD has processed the financial application and is ready to establish the medical effective date (MED), MEPD will send an MEPD to DADS Communication Tool to the Outlook resource mailbox requesting a start date for waiver services from the case manager. The case manager will email the MEPD specialist indicating the date MDCP services will begin. The MED cannot be negotiated before the MN effective date or the date the case manager determined all other MDCP eligibility criteria were met. The MEPD specialist will set the MED to be the first day of the month in which waiver services begin if the individual is not currently receiving Community Attendant Services (CAS).

If the individual is receiving CAS, the case manager submits information to MEPD on Form 1746-A to request a program transfer from CAS to MDCP and explains in the additional comments section of Form 1746-A the individual currently receives CAS and is transferring to MDCP. The case manager must also request in the additional comments section of Form 1746-A to end CAS financial eligibility the day before waiver services are to begin. The MED will be the same as the IPC begin date.

For MDCP applicants already on SSI, the MED was established when their SSI was granted.

 

Unsigned Applications

If MEPD receives an unsigned application from DADS even with Form H1746-A, MEPD Referral Cover Sheet, attached, MEPD will return the application to DADS with an annotation on Form H1746-A that the application is unsigned and must be signed before the Health and Human Services Commission (HHSC) can establish a file date. Once DADS staff receive an unsigned application from MEPD, it is DAD's responsibility to coordinate with individuals in getting the application signed and returned to MEPD for processing. Sending unsigned applications delays the MEPD and DADS eligibility processes and could adversely affect service delivery to individuals.

Refer to MEPD Policy Bulletin Number 11-07, Unsigned Applications, released Dec. 30, 2010, for complete information. The bulletin can be found at: hhs.texas.gov/laws-regulations/handbooks/medicaid-elderly-and-people-disabilities-handbook.

If the individual submits a Medicaid application to DADS when a Medicaid application is not required, DADS staff must forward the application to MEPD within the two working day time frame. DADS staff must document on Form H1746-A that a Medicaid application was sent to DADS in error.

 

Requesting Form H1027-A

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 DADS Forms website for completion of the form. Designated DADS staff may continue to assist individuals in the following situations.

Ongoing Medicaid Recipients – DADS staff may assist with a manual Form H1027-A upon request because the recipient either lost the Your Texas Benefits Medicaid card or did not receive it. DADS staff issuing Form H1027-A should inform the recipient of the following:

New Medicaid Recipients - Eligibility information is not immediately available for providers/pharmacies to verify after Medicaid is approved. DADS staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time the eligibility is determined and the time the eligibility is available in the on-line system.

Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time he requests services. 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.

 

3110.1 Medicaid Buy-In and Medicaid Buy-In for Children

Revision 12-1; Effective May 1,2012

 

The Medicaid Buy-In for Children (MBIC) program is an acceptable categorically eligible type of Medicaid for eligibility purposes for individuals applying for MDCP. The case manager can determine if an individual is an MBIC recipient by looking in the Texas Integrated Eligibility Redesign System (TIERS) database. The MBIC program is coded TA-88, and will display as ME-MBIC.

The MBIC program was implemented by the Health and Human Services Commission (HHSC) effective Jan. 1, 2011, to provide Medicaid to children with disabilities up to the age of 19 with family income up to 300 percent of the Federal Poverty Level (FPL).

The Medicaid Buy-In (MBI) program is also an acceptable categorically eligible type of Medicaid for eligibility purposes for 19 and 20-year-old individuals applying for MDCP. The case manager can determine if an individual is an MBI recipient by looking in the TIERS database. The MBI program is coded TP-87, and will display as ME-Medicaid Buy-In.

The MBI program was implemented by HHSC effective Sept. 1, 2006, to provide Medicaid to disabled working individuals who, because of earnings, would otherwise be ineligible for Medicaid. Additional information about the MBI program can be found on Medicaid Buy-In Program - Frequently Asked Questions website.

 

3110.2 Coordination of Disability Determinations

Revision 16-1; Effective May 3, 2016

 

In order for the Disability Determination Unit (DDU) to complete a disability determination, the case manager must obtain medical evidence from the applicant, or the applicant's parent or guardian. The medical evidence required is the most recent 12 months of medical records signed by the treating physician, listing the diagnosis and any impact the condition(s) has on the applicant's activities of daily living. The case manager must inform the applicant, or the applicant's parent or guardian, when scheduling the initial face-to-face contact that the medical evidence must be provided to the case manager at the initial face-to-face contact. If the case manager schedules the initial face-to-face contact at least seven calendar days in advance, the case manager must send Form 2423, Request for Medical Evidence, to the applicant on the same day of the telephone contact to advise the applicant of the evidence requirement. If the case manager schedules the initial face-to-face contact less than seven calendar days in advance, the case manager must present Form 2423 at the initial face-to-face contact.

The case manager must assist an applicant, or an applicant's parent or guardian, in completing Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact.

The case manager must transmit a complete packet to Medicaid for the Elderly and People with Disabilities (MEPD), or in the case of a Category 02 applicant, to the DDU within 14 calendar days of the home visit. The packet must contain Form H1746-A, MEPD Referral Cover Sheet. The packet must also contain Form H3034, Form H3035, Pages 1 and 2 of Form 2410, Medical-Social Assessment and Individual Plan of Care, and the medical evidence. The DDU may request additional information if needed.

If medical evidence is not available at the initial face-to-face contact, the case manager must allow the applicant 14 calendar days after the initial face-to-face contact to provide the medical evidence. If the medical evidence is not provided by the 14th day after the initial face-to-face contact, the case manager must transmit Form H3034 and Form H3035 to either MEPD or in the case of a Category 02 applicant, to the DDU within 20 calendar days of the face-to-face contact, indicating in the notes section of Form H3034 all requests for medical evidence and that none was provided.

Case managers transmit the DDU packet directly to the:

MDCP applicants who receive Medicaid through the Medicaid Buy-In (MBI) program or Medicaid Buy-In for Children (MBIC) program do not require a disability determination. MBI and MBIC require individuals to meet the same rules for disability used to establish SSI. Verification an individual receives MBI or MBIC is sufficient documentation that disability has also been approved.

The case manager will identify an applicant's Medicaid type in the Texas Integrated Eligibility Redesign System (TIERS), whose required evidence will be sent directly to DDU by using the chart below.

The case manager must wait for a determination from DDU or ME-Waiver approval before determining MDCP eligibility. Once DDU determines the applicant has a disability or the case manager receives confirmation of ME-Waiver approval, the case manager proceeds with the enrollment process. If the applicant is denied a disability determination, then the applicant has not met eligibility requirements and the case manager denies MDCP eligibility.

Medicaid Type Programs (TP) Category 02

SAVERR TIERS TP/TOA Coverage
40 TP 40 Pregnant women (can include children)
36 TP 36 Pregnant women – Emergency
42 TP 42 Pregnant women – Presumptive
45 TP 45 Newborn children up to age one, born to Medicaid-eligible mothers
43 TP 43 Children under age 1
35 TP 35 Children under age 1 – Emergency
48 TP 48 Children ages 1 through 5
33 TP 33 Children ages 1 through 5 – Emergency
44 TP 44 Children ages 6 through 18
34 TP 34 Children ages 6 through 18 – Emergency
01 TP 08 Parents and caretaker relatives
  TA 31 Parents and caretaker relatives – Emergency
56 TP 56 Medically Needy with Spend Down
32 TP 32 Medically Needy with Spend Down – Emergency
07 TP 07 Earnings Transitional
  TA 66 Medicaid for Breast and Cervical Cancer – Presumptive
55-Address has MBCC Category 02 TA 67 Medicaid for Breast and Cervical Cancer (MBCC) (for women 18 – 65) – full Medicaid
  TP 70 Medical coverage for foster care youths age 18-21 who have aged out of foster care
  TA 82 Former Foster Care Children
  TA 74 Children under age 1 – Presumptive
  TA 75 Children ages 1 through 5 – Presumptive
  TA 76 Children ages 6 through 18 – Presumptive
  TA 83 Former Foster Care Children – Presumptive
  TA 86 Parents and caretaker relatives – Presumptive

 

Protective and Regulatory Services Category 02

SAVERR TIERS TP/TOA Coverage
N/A 91 Adoption Assistance – Federal Match – No Cash
N/A 92 Adoption Assistance – Federal Match – With Cash
N/A 93 Foster Care – Federal Match – No Cash
N/A 94 Foster Care – Federal Match – With Cash
N/A 95 Adoption Assistance – Federal Match – No Cash
N/A 96 Adoption Assistance – Federal Match – With Cash
  TA 78 Permanency Care Assistance (PCA) Medicaid – Federal Match – No Cash
  TA 80 PCA Medicaid – Federal Match – With Cash

 

3111 Qualified Income Trust (QIT)

Revision 12-1; Effective May 1,2012

 

Applicants with a qualified income trust (QIT) may be determined eligible for the Medically Dependent Children Program (MDCP) even though their incomes are greater than the Medicaid income limit for waiver programs if they also meet all other MDCP eligibility criteria. Income diverted to the trust does not count for the purpose of financial eligibility determination, but is calculated for the determination of the co-payment for MDCP services.

Individuals with a QIT are responsible for contributing toward the cost of their MDCP services.

Medicaid for the Elderly and People with Disabilities (MEPD) staff provide information to the applicant about maintaining the QIT to remain eligible for Medicaid. A trustee is designated to manage the QIT and disburse payment to service providers on behalf of the individual. The case manager must emphasize that funds deposited into the trust must be used toward the co-payment for the cost of MDCP services.

For applicants who are financially eligible based on a QIT, the eligibility based on the level of care cost limit is determined before considering the co-pay to purchase services. The applicant must meet the initial individual plan of care (IPC) cost limit requirement before deducting the co-payment.

First, the case manager develops the IPC without consideration of the co-payment. If the applicant is eligible for MDCP within the cost limit, the co-payment is allocated to purchase MDCP services identified on Form 2410, Medical-Social Assessment and Individual Plan of Care. The IPC total and the amount of the provider's service authorizations are reduced by the amount of the co-payment. The individual will have to pay the provider(s) directly for services. The case manager must document the QIT in Item 36, Special Needs/Considerations, on Page 2 of Form 2410. The individual's continuing Medicaid eligibility through MDCP is contingent on payment to the provider(s).

 

3111.1 Determination of Co-payment

Revision 13-2; Effective May 1, 2013

 

After determining financial eligibility, Medicaid for the Elderly and People with Disabilities (MEPD) staff determine the amount of money available for co-payment. Case managers must verify the co-payment amount in the Texas Integrated Eligibility Redesign System (TIERS).

MEPD staff determine the applicant's co-pay by calculating the applicant's total monthly income in excess of the institutional income limit and subtract any allowable deductions.

Co-payments must first be applied to purchase Respite services. If there are funds remaining, the balance must be applied to Flexible Family Support Services, Adaptive Aids, Minor Home Modifications, Financial Management Services or Transition Assistance Services.

If the applicant has a qualified income trust (QIT), the case manager must complete and mail Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement, notifying the individual that co-payment must be paid to the provider for services. The case manager also documents the co-payment as a requirement of the applicant's eligibility on Form 2065-B, Notification of Waiver Services.

For applicants and individuals with a QIT, the case manager must:

Example: The co-payment amount reduces the MDCP payment amount for Respite provided by an attendant on the Adjusted QIT IPC. For a co-payment adjustment for 1400 units of Respite included in the Adjusted QIT IPC, calculate the following on Form 2401:

The case manager sends a copy of the updated Form 2410, Page 5, and a copy of Form 2401 to the provider(s) reimbursed by the co-payment. The updated Form 2410, Page 5, with the new IPC total is used for Service Authorization System (SAS) data entry.

If the individual is responsible for co-payment, the amount that the Department of Aging and Disability Services (DADS) pays to the provider will be reduced by the co-payment amount. The combined reimbursement from DADS and the individual co-payment cannot exceed the rate authorized for the MDCP service.

 

3111.2 Refusal to Participate

Revision 12-1; Effective May 1,2012

 

If an individual refuses to sign Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement, the case manager must deny Medically Dependent Children Program services for failure to agree to pay co-payment.

 

3111.3 Refund of Copayment

Revision 13-1; Effective February 1, 2013

 

If services are not utilized by the individual or the provider is unable to complete service delivery, the provider must refund any unused co-payment funds to the trustee and notify the individual and case manager.

Example:

The case manager must notify the Medicaid for the Elderly and People with Disabilities (MEPD) staff of this refund on Form H1746-A, MEPD Referral Cover Sheet.

 

3111.4 Refusal to Pay the Copayment

Revision 13-1; Effective February 1, 2013

 

The trustee must pay the copayment directly to the provider by the 10th of the month, or no later than 10 days after MDCP services have started in situations when services did not start on the first of the month.

If the trustee did not pay the copayment to the provider, the provider is required to notify the case manager by the next working day following the 10-day time frame. When the case manager is made aware the copayment was not made, the case manager must notify MEPD staff of the trustee's failure to pay the copayment using Form H1746-A, MEPD Referral Cover Sheet.

The case manager must investigate the refusal to pay and contact the trustee to learn the reason for not paying within two working days of the provider's notification. The case manager must inform the trustee failure to pay the copayment may result in the loss of Medicaid. If the trustee is not the primary caregiver, the case manager must contact the individual/primary caregiver to inform them the refusal to pay the copayment may result in the loss of Medicaid.

MEPD staff will determine if the nonpayment results in a loss of Medicaid. If MEPD staff determines Medicaid must be denied, the case manager must follow procedures in Section 5500, Loss of Medicaid.

The case manager must document all contacts, dates of contact and outcome with the trustee, individual/primary caregiver and provider in the case file using Form 2405, Narrative Notes.

 

3120 Medical Necessity

Revision 12-1; Effective May 1,2012

 

A Medically Dependent Children Program (MDCP) applicant must have a valid medical necessity (MN) determination before admission into MDCP. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The Resource Utilization Group (RUG) is calculated based on the MN/LOC Assessment.

The case manager may verify MN by viewing either the Medical record in the Service Authorization System (SAS) or the Texas Medicaid & Healthcare Partnership's (TMHP) web-based portal.

For applicants applying for Medicaid, staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) staff within three working days of the applicant's MN determination. Staff must notify MEPD staff via the Eligibility Data Exchange and Notification (EDEN) system as outlined in Section 3133, Notifying MEPD of Approved IPC and MN.

If the MN decision is not available to the case manager by 30 calendar days after the initial home visit, the case manager must complete the MDCP eligibility determination within 14 calendar days from the date of MN determination, provided all other eligibility criteria have been met. Staff must follow procedures in Section 3500, Money Follows the Person Option, regarding Medicaid eligibility for applicants transitioning from a nursing facility to the community.

 

3121 Medical Necessity Determination for Applicants Residing in Nursing Facilities

Revision 12-1; Effective May 1,2012

 

During the initial contact with the applicant in the nursing facility (NF), the case manager must determine whether the applicant is a current Medicaid recipient, is applying for Medicaid or is on Medicare.

 

Current Medicaid Recipient

The applicant who is a Medicaid recipient has already received a medical necessity (MN) determination to satisfy Medicaid eligibility. Staff may view the Service Authorization System (SAS) to verify a valid MN determination, which is identified by a purpose code 2, 3, 4, R or E in the Level of Service record and a Yes in the MN record. In this situation, the MDCP nurse should not complete a new Medical Necessity and Level of Care (MN/LOC) Assessment. The MN determination on record for the NF is valid for an MN determination for MDCP. The NF completes the Minimum Data Set (MDS) to assess an NF resident's MN. Staff may ask the NF for a courtesy copy of the applicant's MDS for the case file. The case manager proceeds with the MDCP eligibility determination.

 

Applying for Medicaid

If an applicant is applying for Medicaid as a resident in the NF and is also applying for MDCP, the NF should complete the MDS. If the NF has not completed the MDS, the MDCP nurse must complete the MN/LOC Assessment for the applicant.

 

Current Medicare Recipient

If the applicant is currently on Medicare, the case manager needs to know the length of the Medicare stay. A different situation exists when an MDCP applicant enters the NF on Medicare. Although the NF completed an MDS, SAS will not register the NF resident's MN determination until the NF resident is on Medicaid. In this situation, the MDCP nurse may complete the MN/LOC Assessment to expedite an MN determination and avoid a delay for the NF resident returning to the community.

 

SAS Medical Necessity Record

For an applicant who satisfies the MDCP MN requirement based on the MN determination made while in an NF, a copy of the SAS record showing the applicant has MN approval must be filed in the case file. The case manager will use the initial individual plan of care (IPC) effective date as the MN effective date for MDCP and enter that date into the SAS MN record for MDCP. The case manager will use the initial IPC end date as the MN end date in the SAS MDCP MN record.

 

NF Residents Released from the Interest List

Policy in this section applies to applicants referred from the interest list. However, if an applicant remains in the NF and enrolls directly into MDCP, the case manager must determine eligibility following procedures in Section 3500, Money Follows the Person Option. If the applicant chooses to leave the NF before the case manager determines eligibility, the case manager will continue the application process for applicants released from the interest list.

 

3122 Medical Necessity Determination for Applicants Recently Discharged from Nursing Facilities

Revision 12-1; Effective May 1,2012

 

The case manager may use the nursing facility (NF) medical necessity (MN) determination if the applicant has a valid MN at the time of NF discharge and has a negotiated service plan initiation date within 60 days of the discharge. The Medically Dependent Children Program (MDCP) nurse does not need to complete and transmit a Medical Necessity and Level of Care (MN/LOC) Assessment. If the applicant does not have a valid MN or if services will not begin within 60 days, a new MN determination is required.

To verify a valid MN determination for applicants recently discharged from an NF, the case manager follows the procedures identified in Section 3121, Medical Necessity Determination for Applicants Residing in Nursing Facilities.

Policy in this section is applicable to applicants referred from the interest list and to applicants who were former nursing facility residents, and may not be applied to applicants using the Money Follows the Person option. Staff must follow procedures in Section 3500, Money Follows the Person Option, for applicants utilizing that option.

 

3123 Medical Necessity Inquiry through the Online Portal

Revision 12-1; Effective May 1,2012

 

The Texas Medicaid & Healthcare Partnership (TMHP) reviews the Medical Necessity and Level of Care (MN/LOC) Assessment, verifies medical necessity (MN) and calculates the Resource Utilization Group (RUG). The case manager must review the TMHP web-based portal for the status of the MN/LOC Assessment. TMHP will report the status of the MN/LOC Assessment as pending review, approved, MN denied.

If the TMHP web-based portal indicates that the status is pending review, it means TMHP received the MN/LOC Assessment and has not made a determination for MN. No information is processed in the Service Authorization System (SAS). Staff must check the TMHP web-based portal weekly for a change in this status.

If the TMHP web-based portal indicates that the status is approved, it means MN has been verified. The case manager may check the SAS Medical records for TMHP's results. If TMHP's results do not appear in SAS, the case manager must use the information available from the TMHP web-based portal and the MN/LOC Assessment to create Level of Service, Diagnosis and MN records in SAS. TMHP's results will not appear in SAS when information on the MN/LOC Assessment does not meet all the required SAS data entry criteria.

If the TMHP portal indicates MN Denied status, the MDCP applicant's physician has 14 business days to submit additional information. Once the TMHP portal indicates the MN Denied status, several actions may occur:

The case manager must not mail Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to deny the MDCP case until after 14 business days from the date the MN Denied status appears in the Long Term Care Portal. The case manager must meet initial certification and annual reassessment time frames unless the time frames cannot be met due to the pending MN status. All delays must be documented on Form 2405, Narrative Notes, and filed in the case file.

Once the MN/LOC Assessment has been approved, the applicant has met the criteria for MN. The case manager may continue with MDCP eligibility determination.

 

3130 Individual Plan of Care Development

Revision 14-2; Effective September 1, 2014

 

§51.217

(a) The IPC is developed by:

(1) the individual;

(2) the individual's parent or guardian;

(3) the case manager;

(4) a DADS RN; and

(5) any other person who participates in the individual's care, such as the provider, a representative of the school system, or other third-party resource.

§51.221

(b) The individual or the individual's parent or guardian must sign and return the completed IPC to the case manager within 10 days of receipt.

Within 30 days of the initial home visit, the case manager will complete the authorization of Medically Dependent Children Program (MDCP) services. The case manager is responsible for the development of the individual plan of care (IPC) and must ensure that all applicable policies and procedures associated with IPC development are carried out. The IPC is developed before MDCP services are authorized. The applicant and the applicant's primary caregiver must be involved in the development of the IPC.

The case manager must inform the applicant of:

To develop the IPC, the case manager must:

Service planning requires the synthesis of assessment results and the identification of goals and preferences of the applicant and caregiver into a comprehensive IPC that uses third-party resources and MDCP services to adequately serve the applicant in the community. Key purposes of the IPC are to summarize the services that will meet the needs identified during the assessment process and to document that MDCP services are feasible and cost-effective. There must be a reasonable expectation that the third-party resources and MDCP services on the IPC are adequate to meet the needs of the applicant in the community.

The IPC must reflect consideration of:

The case manager must document on Form 2410 if the applicant is using Aid and Attendance (A&A) or Housebound Benefits (HB) from Veterans Affairs to purchase respite care or flexible family support services. The use of these funds and services purchased must be considered in the development of the IPC.

By signing Form 2410, the applicant, the case manager and other people participating in the applicant's care certify that the MDCP services proposed on the IPC are necessary to avoid nursing facility (NF) care and are adequate and appropriate to meet the needs of the applicant in the community.

The case manager must meet with the applicant during the development of the IPC to allow the applicant the opportunity to review the assessment and make choices regarding the IPC. The case manager must inform the applicant of the feasibility and consequences of choices, including IPC cost limit implications. Example: If the applicant chooses only Respite provided by a registered nurse (RN), the cost of Respite services may cause the applicant to either be ineligible for MDCP because IPC costs exceed the cost limit or limit the amount of other MDCP services that can be purchased. The applicant's goal may be to obtain a much-needed bathroom modification. By using other supports to provide Respite under the supervision of an RN, the applicant may be able to obtain this goal.

The case manager determines how many units of respite or flexible family support services to authorize based on the need of the primary caregiver. The case manager must round units per week up to the next quarter-hour on the IPC because providers are only able to bill in quarter-hour increments. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour. Example: An individual's primary caregiver requested 15 hours and 20 minutes of respite per week. The case manager would authorize 15.50 hours of respite per week.

In cases in which the cost of all the services cause the applicant to be ineligible for MDCP because the IPC exceeds the cost limit, the applicant may choose to reduce or delay some services that are not critical for health or welfare. Example: The applicant may choose to delay a vehicle modification for the following IPC period in order to access Minor Home Modifications in the initial IPC.

The initial IPC identifies services to be provided after approval and enrollment of the individual and includes the schedule of authorized units for Respite, Flexible Family Support Services or both. Other eligibility factors, such as the financial eligibility, may be outstanding, so it is important that the case manager communicate to providers that services delivered before an eligibility determination are not reimbursable.

Once all eligibility factors are met, the case manager will notify Medicaid for the Elderly and People with Disabilities (MEPD) staff verbally or by Form H1746-A, MEPD Referral Cover Sheet, and a medical effective date (MED) will be negotiated. The case manager establishes the IPC effective date and enters it on Form 2410 and Form 2065-B, Notification of Waiver Services. The IPC effective date cannot be before the effective date for medical necessity or MED.

Coordinating Multiple Services

When the case manager is evaluating the need for MDCP services for an individual receiving nursing or attendant services through programs other than MDCP, he must first evaluate if there is a need for MDCP services based on the criteria found in Section 4100, Medically Dependent Children Program (MDCP) Services. He must also determine if MDCP services are needed at least monthly, as required by the MDCP waiver and that there is no duplication in services.

The primary caregiver identified on the IPC is ultimately responsible for providing care to the individual, regardless of whether there is a service provider in the home. Therefore, a caregiver could feasibly need respite during the time another service provider is in the home, provided there is no duplication of services.

Example: A Comprehensive Care Program (CCP) private duty nurse is in the home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing personal care services to the individual to relieve the caregiver of tasks he or she would normally be responsible for performing.

The only exception to the no duplication of services policy would be instances requiring two-person transfers. In that scenario, the CCP private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

The combined waiver and third-party resources may not be reduced below a level that is adequate to meet the applicant's needs. If there are disagreements between the applicant, the primary caregiver, the providers, the case manager or the MDCP nurse regarding the type or amount of necessary MDCP services, the case manager must convene a meeting to resolve the conflict. The meeting should include the applicant, the primary caregiver, the provider or entity that participates in the applicant's care, the case manager and the MDCP nurse. If necessary, staff should also involve the applicant's physician. The decision reached by DADS staff involved in this consultation is final.

 

3130.1 Setting Funds Aside in the IPC

Revision 12-1; Effective May 1,2012

 

During the development of the Individual Plan of Care (IPC), an individual may wish to set funds aside for future service requests, such as adaptive aids or minor home modifications.

The case manager may document future service requests under Comments in Fields 47a through 47f of Part II C – Individual Plan of Care Summary on Form 2410, Medical-Social Assessment and Individual Plan of Care. As indicated in the form instructions, these fields are completed when the applicant/individual/family is selecting to use the service during the IPC period. The case manager must not document funds that are set aside for future service requests in Part III – MDCP Applicant/Consumer Plan of Care/Budget Worksheet. Information in Part III must reflect authorized services for the IPC period.

 

3130.2 Coordinating IPC Development with the Provider

Revision 14-2; Effective September 1, 2014

 

Case managers are required by 40 Texas Administrative Code (TAC), Chapter 51, §51.217, Individual Plan of Care (IPC), to include the provider in the development of an IPC. Case managers must contact the provider of choice by phone to discuss the draft IPC developed after the initial home visit. The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion with the provider must occur in time to meet the 30 day time frame for authorizing services from the initial home visit. Once all parties agree with the draft IPC, the service initiation date must be negotiated with the provider. Case managers should also include the MDCP nurse in the discussion, as appropriate, for any proposed changes to the IPC.

Case managers must also contact the provider of choice by phone to discuss draft IPCs developed at the annual reassessment. The provider may request time to review the draft IPC; therefore, the discussion with the provider must occur in time to authorize services before the end of the current IPC. See Section 7130, Individual Plan of Care Development.

Case managers must document all dates of contact with the provider on Form 2405, Narrative Notes. The documentation must include details of the case manager's efforts to coordinate the IPC development and any concerns the provider may have regarding the draft IPC.

 

Service Authorizations

The requirement in 40 TAC, Chapter 51, §51.411, General Service Delivery Requirements, states:

(a) A provider must provide services as indicated on the service authorization form.

The Department of Aging and Disability Services (DADS) MDCP case manager authorizes services on Form 2414, Flexible Family Support Services Authorization, and/or Form 2415, Respite Service Authorization, showing the services to be provided, the amount of services and the type of provider (RN, LVN, attendant with delegation or attendant) authorized to provide the service. The MDCP provider must sign Form 2414 and/or Form 2415, check a box in Section D of the form showing if skilled tasks will or will not be delivered, and then return the form to the DADS MDCP case manager. The provider type sent to provide the designated service must be at or above the skill level designated by the case manager.

The table below shows the type of providers and claims allowable in relation to the case manager's authorization.

Provider Authorized by Case Manager Provider Allowed to Provide Services Allowable Billing Rate
Specialized RN Specialized RN Specialized RN
Specialized LVN Specialized LVN
Specialized RN
Specialized LVN
RN RN RN
LVN RN, LVN LVN
Attendant with delegation RN, LVN, Attendant with delegation Attendant with delegation
Attendant RN, LVN, Attendant with delegation, Attendant Attendant
Employment Assistance Service Provider Employment Assistance Service Provider Employment Assistance Service Provider
Supported Employment Service Provider Supported Employment Service Provider Supported Employment Service Provider

If at any time after the development of an IPC the provider has concerns about the provider type authorized, the provider may contact the case manager who will discuss the change or issue with the individual or the individual's parent or guardian. If the concern is not resolved, the case manager will arrange a meeting, which will include the provider and the individual, or individual's parent or guardian, to discuss the provider's concern. If the provider type changes, the case manager must complete Form 2412, Budget

Revision, for IPC changes. The case manager must also update Form 2414 and/or Form 2415 to reflect the changes in service authorizations.

 

3131 Determining Cost Effectiveness

Revision 12-2; Effective August 1,2012

 

All applicants, at initial enrollment, must have a service plan within the individual plan of care (IPC) cost limit. The cost limit is the maximum dollar amount available to an applicant for Medically Dependent Children Program (MDCP) services per IPC effective period. A list of the MDCP IPC cost limits is located in Appendix I, Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits, Provider Types and Service Rates.

The applicant's IPC cost limit is based on the assigned RUG calculated from the Medical Necessity and Level of Care (MN/LOC) Assessment. The costs of MDCP services necessary for the IPC effective period are based on the estimated service needs included in Form 2410, Medical-Social Assessment and Individual Plan of Care.

If the case manager determines that the cost of MDCP services is within the IPC cost limit, MDCP is a feasible alternative to nursing facility care. The case manager may continue with MDCP eligibility determination.

The case manager must deny MDCP services if the applicant's initial IPC is not under the cost limit.

 

3132 The Individual Plan of Care Service Initiation Date and Effective Period

Revision 15-3; Effective March 11, 2015

 

Once the case manager determines that all Medically Dependent Children Program (MDCP) eligibility requirements are met, the case manager must negotiate the individual plan of care (IPC) effective date with the applicant, the applicant's parent or guardian, the provider (Home and Community Support Services provider or the Financial Management Services Agency) and the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable.

The case manager must document communication with the MEPD specialist, if applicable, regarding the Medicaid eligibility date using Form H1746-A, MEPD Referral Cover Sheet, email correspondence, or Form 2405, Narrative Notes, in the case file. The case manager must also document the individual's/parent's/guardian's and provider's participation in determining the IPC effective date in the case file.

The IPC effective date must occur within 30 days of MDCP eligibility determination, as documented on Form 2065-B, Notification of Waiver Services.

For applicants determined eligible who cannot be without services, such as an applicant returning to the community from a hospital or nursing facility, the case manager must negotiate a service initiation date for the applicant's discharge date.

If the case manager has negotiated a service initiation date with the provider, the case manager must also fax Form 2067, Case Information, to the provider documenting the negotiated service initiation date.

The case manager must not delay the IPC effective date if a provider is not able to provide services as negotiated. A delay in initiating the IPC may delay services provided by Medicaid or other authorized MDCP services.

For an initial IPC, the case manager must negotiate the earliest possible date. If the case manager negotiates the service initiation date for the first of the month, the "to" date of the IPC must be the last day of the 12th month. For example, if the negotiated date for an initial IPC falls on Oct. 1 of the current year, the "to" date for the IPC will be Sept. 30 of the following year. If the case manager negotiates the service initiation date for any other date besides the first of the month, the "to" date for the IPC must be the last day of the 13th month. For example, if the negotiated date for an initial IPC falls on Dec. 12 of the current year, the "to" date for the IPC will be Dec. 31 of the following year. The effective period for the next IPC will be from Jan. 1 to Dec. 31. If the applicant's 21st birthday falls within the effective period, then the IPC is effective until 12 a.m. the day of the applicant's birthday.

 

3132.1 Determining the Number of Weeks in the Initial IPC Period

Revision 13-3; Effective August 1, 2013

 

When determining the length of the Individual Plan of Care (IPC) period, case managers round up for the total number of weeks. If the length of the IPC period is exactly 12 months, case managers must use 53 weeks to calculate the cost of services.

To calculate the number of weeks in an IPC period, case managers must:

Example: An initial IPC period is from July 15, 2010, through July 31, 2011.
Step 1: July 15, 2010, through July 31, 2011 (including the first and last day), is 382 days.
Step 2: 382 days divided by seven days equals 54.57 weeks.
Step 3: 54.57 weeks is rounded up to 55 weeks.
The total number of weeks for this IPC period is 55.

Case managers apply the same methodology to determine the number of weeks in the IPC period for an applicant who will age out during the initial IPC period.

Case managers must not reduce the amount of weeks for other services when including camp in the IPC. The time spent at camp does not affect the number of weeks authorized for other services. Case managers must authorize services based on the amount of weeks in the IPC year. During the time the individual is attending camp, the parent can make minor changes in the service schedule and may utilize those unused hours later in the week or later in the month.

Example: Joe Smith has an IPC year of Feb. 1, 2013 to Jan. 31, 2014. He will attend one summer camp session during the IPC year. His primary caregiver requests 15 hours per week of respite at the face-to-face visit. On Form 2410, Medical-Social Assessment and Individual Plan of Care, Section 56, the case manager documents 53 weeks for respite on one line and one week of camp on the second line.

 

3133 Notifying MEPD of Approved IPC and MN

Revision 12-3; Effective November 1,2012

 

The Eligibility Data Exchange and Notification (EDEN) system is a web-based program that allows DADS and the Health and Human Services Commission to exchange information on waiver cases. The system is accessed through the Health and Human Services (HHS) Enterprise Portal and DADS Work Center. Refer to EDEN Permissions below.

Once an approved individual plan of care (IPC) and approved medical necessity (MN) are ready, the information must be transmitted to Medicaid for the Elderly and People with Disabilities (MEPD) using the following steps:

  1. Once in EDEN, right click on Client Number.
  2. Select Initial Functional Assessment.
  3. Enter the Client Number and click on Load Client.
  4. View the Initial Functional Assessment Screen.

The Initial Functional Assessment Screen is used to provide data to MEPD on initial applications for new individuals. The following information will be provided to MEPD:

  1. Approved IPC.
  2. Approved Medical Necessity/Level of Care (MN/LOC).

On the Initial Functional Assessment Screen, the Client Name will be populated. Continue with the following steps:

  1. Enter the begin date (which is the date the case manager has an accepted IPC and valid MN/LOC).
  2. Select the Service Group from the drop down menu. The Service Code and the functional boxes are not applicable and are reserved for future use.
  3. On the IPC screen, select Approved or Denied from the drop down menu.
  4. On the MN/LOC screen, select Approved or Denied from the drop down menu.
  5. Check the Information Complete box and click on Send to TIERS.
  6. Print a copy of this screen for the case record.

 

Receiving Notifications from MEPD

The MEPD to DADS Communication Tool is an automated system that sends notification from MEPD staff when financial eligibility or ineligibility is determined or when they need DADS assistance in obtaining pending information. The notifications that are submitted through the MEPD to DADS Communication Tool arrive in a DADS regional-specific resource mailbox.

 

EDEN Permissions

EDEN is accessed through the HHS Enterprise Portal and DADS Work Center at https://hhsportal.hhs.state.tx.us/wps/portal. New users must sign up for an account.

 

3134 Other Resources and Services

Revision 14-2; Effective September 1, 2014

 

The case manager is responsible for identifying, determining and assessing all possible third-party resources (TPR) that can benefit the applicant. Available resources must first be used to meet the applicant's needs rather than services purchased through the Medically Dependent Children Program (MDCP).

Case managers are responsible for assisting the applicant to apply for and use all available TPRs. Case managers must first consider TPRs in the development of the individual plan of care (IPC). Authorized MDCP services must supplement TPRs and must not replace available TPRs.

The use of Medicare, Medicaid, private insurance, home health services provided by a community agency, supported employment or employment provided by the Department of Assistive and Rehabilitative Services, personal care provided by friends or relatives and other community services must be explored to determine if any of the individual's needs can be met through these resources. Staff must ensure that requests for services must first be sought through these resources. Example: If the applicant needs an adaptive aid, the Comprehensive Care Program (CCP) available through Medicaid must be used before requesting the adaptive aid through MDCP. Any available benefits should be documented in the case file and used before MDCP services are used.

The provision of MDCP and TPRs must be a cooperative and collaborative effort between the various providers and is coordinated by the case manager. For applicants receiving funds from other sources, the case manager must consider whether the intended use of these funds is to pay for a service or item that is available in MDCP.

To determine the services available through TPRs, the case manager must attempt to obtain copies of documents from the applicant, the applicant's family or other agencies providing funds and services. If a service plan or other documentation is not available, a summary of services or the applicant's statement is sufficient to determine need and develop the IPC.

Information on the applicant's TPRs, such as private insurance, Medicare or Medicaid, and informal supports, such as family members, friends and other involved organizations providing services to the applicant, is recorded on Form 2410, Medical-Social Assessment and Individual Plan of Care (Part IIB, Page 3, MDCP Schedule Planning Grid), and included in the case file.

The IPC identifies services for the applicant to remain in or return to the community. The IPC must include those services funded by MDCP and TPRs provided by, or funded by, the applicant/family/guardian, a TPR or another private or government program.

 

3135 Coordinating with IDD Services During the Development of the Initial IPC

Revision 12-2; Effective August 1,2012

 

Home and Community-based Services (HCS), Texas Home Living (TxHmL) and Local Authority (LA) general revenue services are intellectual developmental disability (IDD) services that must not be accessed in coordination with Medically Dependent Children Program (MDCP) services. In order to prevent dual enrollment with these programs, the MDCP case manager or intake screener must check the Client Assignment and Registration (CARE) System to see if an individual is receiving LA services, which could be mutually exclusive with other DADS services. The DADS case manager checks the mutually exclusive chart for programs that are not mutually exclusive. The chart is in Appendix V, Mutually Exclusive Services.

 

3135.1 Access to the CARE System

Revision 12-2; Effective August 1,2012

 

The Client Assignment and Registration (CARE) System is used for enrollment for the following programs: Home and Community-based Services (HCS), Texas Home Living (TxHmL) and Local Authority (LA) general revenue services. The Instructions for Access to the CARE System and CARE Logon and Inquiry attachments are located in Appendix IX, Instructions and Access to CARE.

 

3136 Individual Residing in Dual Households

Revision 15-3; Effective March 11, 2015

 

There are cases where the individual’s living arrangement may include two different households; this also means there are two primary caregivers. If only one primary caregiver is requesting services, the case would be worked as if it were a single household case; however, services would only be provided during the time the individual was with the primary caregiver that requested services.

In cases where both primary caregivers are requesting services, the case manager makes an initial visit to each home. Although there are two different households and two different primary caregivers, the case manager only completes one set of forms for the case. Both primary caregivers are listed on Page 1 of Form 2410, Medical-Social Assessment and Individual Plan of Care, and both household schedules are documented on Page 3. If there is contradicting information given by the primary caregivers the case manager would note which primary caregiver provided the information.

The individual must receive services from only one Home and Community Support Services Agency (HCSSA) and only one Financial Management Services Agency (FMSA) in instances in which flexible family support services and /or respite services are provided in dual households.

The case manager works with each primary caregiver to determine the amount of hours authorized for each service within each household. If the total requested amount of hours fall below the individual plan of care (IPC) cost limit, the case manager authorizes the requested hours. If the total requested hours cause the individual to be ineligible for MDCP because the IPC exceeds the cost limit, the case manager must explain the problem to both primary caregivers and facilitate a mutual agreement between them for services authorization which will meet the individual’s needs, meet the caregiver needs as much as possible, and bring the IPC under the annual cost limit. If the primary caregivers do not agree on the division of the authorized hours between the two households, the case manager prorates the hours based on the percentage of time each parent has custody of the child. In instances where an agreement can’t be reached, the case manager may need to consult with his/her regional legal representative.

Example: Primary caregiver 1 has the child 75% of the time and primary caregiver 2 has the child 25% of the time. There are 20 authorized hours each month. Primary caregiver 1 would be allotted 15 hours and primary caregiver 2 allotted 5 hours.

The case manager follows procedures in Section 4210, Applicant/Individual Eligibility Notification, to complete the case and notify the primary caregivers. The case manager must send a copy of the applicable forms to each primary caregiver.

 

3200 Personal Care Services (PCS)

Revision 12-1; Effective May 1,2012

 

The PCS program is available to Medicaid recipients under the age of 21 who are eligible for Texas Health Steps (THSteps).

PCS provides assistance with activities of daily living (ADL), instrumental ADL and health-related functions due to a physical, cognitive or behavioral limitation related to a disability or chronic health condition. The PCS program is administered by the Texas Health and Human Services Commission (HHSC); however, the Department of State Health Services (DSHS) determines eligibility for services.

MDCP applicants may receive services from PCS, in addition to receiving services from MDCP. Since PCS addresses different needs than those met by MDCP services, the applicant's/individual's decision to access PCS should not affect the MDCP services authorized by DADS case managers. The DADS case manager must document the applicant was referred to PCS on the Individual Plan of Care (IPC) or on Form 2405, Narrative Notes, in the case file.

For applicants receiving services from both PCS and MDCP, close coordination between DADS and PCS case managers is necessary to ensure the IPC accurately reflects all services being received.

 

3200.1 PCS Data Reports

Revision 12-1; Effective May 1,2012

 

Department of Aging and Disability Services (DADS) case managers are required to coordinate services with Personal Care Services (PCS) case managers for individuals who are receiving both PCS and DADS waiver services. PCS data reports are available online at: ftp://dads4svtuvok/PCS. DADS case managers will access the PCS data reports before completing initial assessments to determine if coordination of services with PCS case managers is needed.

 

3200.2 Using the PCS Data Reports

Revision 12-1; Effective May 1,2012

 

After clicking the link ftp://dads4svtuvok/PCS, Department of Aging and Disability Services (DADS) case managers will find a zipped folder named PCS Files SFY10 Q3.zip. Double click that folder to access three excel spreadsheets: PCS Match File 1 FY10 Q3, PCS Match File 2 FY10 Q3 and PCS Match File 3 FY10 Q3. Note: The fiscal year and quarter will change as warranted.

DADS case managers must review PCS Match File 1 FY10 Q3 prior to conducting an initial assessment to search for individuals receiving PCS. DADS case managers open the PCS Match File by double clicking the file, and may search in column A by Medicaid number or column B by name for individuals being assessed. If the applicant is found in PCS Match File 1 FY10 Q3, DADS case managers must coordinate with PCS case managers to evaluate the level of PCS being delivered and the need for DADS waiver services.

 

3210 Procedures for the MDCP Applicant Who Receives PCS

Revision 15-3; Effective March 11, 2015

 

If the applicant receives services from Personal Care Services (PCS) and wants MDCP services, the DADS case manager must inform the applicant of the coordination of services that must occur between the DADS case manager and the PCS case manager. The DADS case manager must request a copy of the PCS Personal Care Assessment Form (PCAF) from the PCS case manager. The DADS case manager is not required to complete Form 0003, Authorization to Release Information, since DADS and the Department of State Health Services are state agencies within the HHSC Enterprise. The PCS case manager may provide DADS with a copy of the PCAF, which provides details on delivered PCS services. The PCAF is an assessment tool and an overview of services and may not necessarily follow the PCS delivery schedule.

The DADS case manager may accept the applicant's statement regarding the amount of PCS hours authorized and delivery schedule, and documents the applicant's use of PCS when developing Form 2410, Medical-Social Assessment and Individual Plan of Care (IPC). When developing the IPC, the DADS case manager must document that services through the PCS program assist the applicant with activities of daily living (ADL), instrumental ADL or health-related functions, and MDCP services address other needs.

The DADS case manager must inform the PCS case manager of the applicant's MDCP eligibility within two working days of eligibility determination. If the applicant is eligible for MDCP, the DADS case manager sends a copy of Form 2410 and Form 2067, Case Information, to the PCS case manager. On Form 2067, the DADS case manager informs the PCS case manager of the name of the MDCP provider(s) or Financial Management Services Agency (FMSA) and the contact information for the individual.

If the applicant is denied eligibility, the DADS case manager sends Form 2067 within two working days of eligibility determination to the PCS case manager indicating the MDCP applicant was denied MDCP eligibility.

If the applicant decides that PCS meets all of his needs and voluntarily withdraws from the MDCP application process, the DADS case manager closes the interest list referral and follows procedures in Section 2220, Declining MDCP Services, and Section 2510, Contacting the CSIL Unit to Report the Status of Interest List Releases. The DADS case manager sends Form 2067 within two working days of the individual's decision to the PCS case manager, indicating the MDCP individual withdrew his application from MDCP.

 

3220 Procedures for the MDCP Applicant Who Does Not Receive PCS

Revision 12-1; Effective May 1,2012

 

The DADS case manager must explain Personal Care Services (PCS) and give the MDCP applicant the Texas Medicaid & Healthcare Partnership (TMHP) toll-free PCS Line (1-888-276-0702). TMHP will forward referral information to the appropriate Department of State Health Services staff. The DADS case manager must review the status of PCS eligibility at the following six-month monitor.

The DADS case manager must not delay the applicant's MDCP enrollment by waiting for a PCS eligibility determination. The DADS case manager continues with MDCP eligibility determination and documents the PCS program referral in the case file. The DADS case manager processes an MDCP application following policy in Section 2000, Intake and Interest List Procedures, and Section 3000, Eligibility Determination and Individual Plan of Care Development.

If the MDCP applicant contacts the PCS case manager and requests PCS, the PCS case manager will provide PCS information describing the benefits of the program available to the MDCP applicant/individual. The PCS case manager will inform the MDCP applicant that both the PCS case manager and the DADS case manager must work together to coordinate the delivery of PCS and MDCP services. The PCS case manager will contact the DADS case manager to request the Individual Plan of Care (IPC). The DADS case manager must fax the applicant's/individual's IPC and provider names, including the Financial Management Services Agency (FMSA), and contact information using Form 2067, Case Information, to the PCS case manager within five working days of the request.

Once the MDCP applicant is determined PCS eligible, the PCS case manager will provide a copy of the final Personal Care Assessment Form to the DADS case manager with the PCS case manager's name and contact information.

 

3230 FMS for the MDCP Applicant Accessing CDS

Revision 12-1; Effective May 1,2012

 

If the applicant is using the Consumer Directed Services (CDS) option and wants to continue to use the option for both Personal Care Services (PCS) and MDCP, he must use only one CDS agency for both programs. If the applicant has a CDS agency serving both programs, he may continue to use the current CDS agency. If the applicant has a CDS agency that does not contract to deliver Financial Management Services (FMS) for both programs, the applicant must select a CDS agency that serves both PCS and MDCP.

 

3240 Coordination of Services in the MDCP IPC and Personal Care Assessment Form

Revision 13-2; Effective May 1, 2013

 

Although Respite and Flexible Family Support Services have different service criteria and are authorized to address different needs than Personal Care Services (PCS), coordination of service delivery is required of both the DADS case manager and the PCS case manager. Duplication of services will not be permitted. Duplication is defined as two different services providing an individual the same assistance at the same time without the presence of an unmet need. Both case managers must review the needs of the applicant/primary caregiver and reach an agreement on the Individual Plans of Care (IPCs) for service delivery for MDCP and PCS.

The DADS case manager must document all coordination efforts and decisions with the PCS case manager in the case file, using Form 2405, Narrative Notes.

The DADS case manager may contact the Department of State Health Services (DSHS) for information for current PCS individuals at the following telephone numbers:

DSHS Region 1
806-655-7151

DSHS Region 2/3
817-264-4627

DSHS Region 4/5 N
903-533-5231

DSHS Region 6/5 S
713-767-3111

DSHS Region 7
254-778-6744

DSHS Region 8
210-949-2155

DSHS Region 9/10
915-834-7682

DSHS Region 11
956-423-0130

DSHS regions differ slightly from DADS. To determine which DSHS office to call, the DADS case manager may access a list of DSHS regional offices and a DSHS County/Region map located at www.dshs.state.tx.us/regions/default.shtm.

 

3300 Targeted Case Management (TCM)

Revision 12-2; Effective August 1,2012

 

Local Authorities (LAs) provide service coordination to individuals with intellectual developmental disability (IDD) in the DADS LA priority population. This service is called Targeted Case Management (TCM).

 

3300.1 Coordination of TCM and MDCP Services

Revision 12-2; Effective August 1,2012

 

DADS waiver services, including the Medically D

ependent Children Program (MDCP), are mutually exclusive with Targeted Case Management (TCM). An individual receiving MDCP services cannot receive TCM at the same time.

The MDCP case manager can identify if TCM services are being used in the Service Authorization System (SAS). TCM services are identified in SAS as Service Group 14, Service Code 12A or 12C.

Since waiver programs provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The DADS case manager must contact the Local Authority to coordinate closing TCM for the waiver service to begin.

The MDCP case manager must refer to Appendix V, Mutually Exclusive Services, to determine if the individual can receive other DADS services, as some services are mutually exclusive and others are not. If the individual is receiving another DADS service and the requested MDCP service is mutually exclusive, then the case manager will contact the individual, or individual’s parent or guardian, to allow a choice of services.

 

3400 Reserved for Future Use

Revision 12-1; Effective May 1,2012

 

 

3500 Money Follows the Person Option

Revision 12-1; Effective May 1,2012

 

Money Follows the Person (MFP) allows individuals residing in a nursing facility to request services through the Medically Dependent Children Program (MDCP) waiver and bypass the MDCP interest list.

 

3500.1 Individuals Without Medicaid

Revision 12-3; Effective November 1,2012

 

Individuals without Medicaid who request Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option must remain in the nursing facility (NF) for no less than 30 days to meet the Health and Human Services Commission (HHSC) eligibility criteria to qualify for Medicaid. Individuals cannot leave the NF until MDCP eligibility is determined and waiver services have been authorized to allow for continuity of services. The MDCP eligibility process could potentially take longer than the 30 day HHSC eligibility criteria requirement for Medicaid. Case managers must follow current time frames for processing an application for MDCP.

For individuals who cannot reside in an NF for 30 days because they meet the medically fragile criteria, Medicaid for the Elderly and People with Disabilities (MEPD) can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP waiver to meet the 30-day requirement. See Section 3520, Limited Nursing Facility Stay for Medically Fragile Individuals.

 

3500.2 Individuals With Medicaid

Revision 12-1; Effective May 1,2012

 

Individuals with Medicaid who request MDCP services through the Money Follows the Person (MFP) option cannot leave the nursing facility until MDCP eligibility is determined and waiver services have been authorized to allow for continuity of services. Case managers must follow current time frames for processing an application for MDCP.

 

3510 Individuals Currently Residing in a Nursing Facility

Revision 12-1; Effective May 1,2012

 

For individuals residing in a nursing facility (NF) who are interested in utilizing the Money Follows the Person (MFP) option to transition from an NF must request to utilize the MFP option to transition from an NF once they have been admitted to the NF. The initial visit to begin the eligibility determination process must occur in the NF. The individual must be determined eligible for MDCP prior to discharge from the NF as described in Section 3500.1, Individuals Without Medicaid, and Section 3500.2, Individuals With Medicaid.

The state office Community Services Interest List (CSIL) unit will forward the name of the individual, or the individual's parent or guardian, interested in the MFP option to the appropriate regional MDCP supervisor or other regionally designated representative. This will not be a release from the interest list, but a referral of an individual interested in by-passing the interest list through the MFP option.

If the referral from the CSIL unit indicates the individual is currently residing in an NF, the regional MDCP supervisor must assign a case manager and notify the CSIL unit by email of the assignment within five working days of receipt of the referral. The case manager must conduct the initial visit with the individual, or the individual's parent or guardian, within 14 calendar days from the CSIL assignment date to begin the enrollment process. The MDCP supervisor must notify the CSIL unit by email within three working days once the individual is enrolled in MDCP.

 

3520 Limited Nursing Facility Stay for Medically Fragile Individuals

Revision 13-1; Effective February 1, 2013

 

Individuals who request MDCP services through the Money Follows the Person (MFP) option, but are too medically fragile to reside in a nursing facility (NF) for an extended period of time, may request to complete a limited NF stay. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care.

The Department of Aging and Disability Services (DADS) regional nurse will review the medical fragility of an individual requesting a limited NF stay. Medical judgment of the DADS physician will be applied on a case-by-case basis when the below criteria do not capture the severity/fragility of the individual's medical condition. An individual must meet two or more of the following criteria to be considered medically fragile:

Individuals determined medically fragile by the DADS physician and approved for a limited NF stay must stay at least part of two days in the NF. Admission and discharge from the facility must be on different days. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services (and establish Medicaid in an NF).

 

3520.1 MFP Procedures for Requesting a Limited Nursing Facility Stay

Revision 15-8; Effective July 31, 2015

 

Individuals who request MDCP services through the Money Follows the Person (MFP) option may contact the state office Community Services Interest List (CSIL) Unit at 877-438-5658 or a local DADS office. If an individual contacts a local DADS office, the local DADS office will refer the individual to the CSIL Unit only if the individual is not on the interest list for MDCP. The CSIL Unit will add the individual to the MDCP interest list and then forward the required contact information to the appropriate regional MDCP case management supervisor or other regionally designated representative. This will not constitute a release from the interest list, but will be a referral of an individual interested in by-passing the interest list through the MFP option.

Within five working days of receipt of the individual's name from the CSIL Unit or request from the individual, the regional MDCP supervisor assigns a case manager. The case manager must contact the individual requesting to by-pass the interest list, or the individual's parent or guardian, by phone within five working days from assignment to explain the following:

If the individual's physician recommends a limited stay, a DADS regional nurse will review the documentation and approve the limited stay request if the physician documentation clearly supports the individual meets two or more of the criteria on Form 2406. If, based on the documentation submitted, the applicant does not meet two or more criteria, the form and all medical documents submitted are scanned and emailed to the designated state office representatives for state office physician review.

Form 2406 will be used as the physician's verification that the individual meets the medically fragile criteria. Case managers must follow the procedures outlined in this policy before initiating the MDCP eligibility process.

The case manager informs the individual, or the individual's parent or guardian, that Form 2406 must be completed by the individual's physician and returned to the case manager within 30 calendar days of the initial contact with the individual, or the individual's parent or guardian. The individual cannot access MDCP services through the limited nursing facility stay until the physician completes and signs Form 2406 and DADS approves the limited nursing facility stay. The case manager mails Form 2406 to the individual within three working days of the contact with the individual, or the individual's parent or guardian.

 

3520.2 Case Manager Receipt of Form 2406

Revision 15-8; Effective July 31, 2015

 

Upon receipt of Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, the case manager reviews the documentation to determine the physician's recommendation. If the physician does not recommend a limited nursing facility stay, within three working days of receipt of Form 2406, the case manager contacts the individual by phone to inform him of the physician's recommendation, and of the option to transition from a nursing facility as described in Section 3510, Individuals Currently Residing in a Nursing Facility, to access MDCP through the Money Follows the Person (MFP) option. If the individual does not choose to transition from a nursing facility as described in Section 3510, his name will remain on the interest list. The case manager will inform the MDCP supervisor within three working days of being informed of the decision.

If the physician recommends a limited nursing facility stay, the case manager reviews Form 2406, in consultation with the regional nurse, to ensure it contains the required information. If the limited nursing facility stay is approved or the individual chooses to transition from a nursing facility, as described in Section 3510, the case manager will inform the MDCP supervisor within three working days of being informed of the decision. The MDCP supervisor must notify the Community Services Interest List (CSIL) Unit by email within three working days of being notified by the case manager that the individual meets the medically fragile criteria for the limited stay process and who the MDCP case will be assigned to for processing. After being notified by the MDCP supervisor of the decision, the CSIL Unit will place the individual in an MFP assigned status in the CSIL database, and the case manager will proceed with the application process.

If Form 2406 does not contain the required information, the case manager contacts the individual, or the individual's parent or guardian, within three working days of receipt, to discuss the elements of the form that are incomplete. The case manager informs the individual, or the individual's parent or guardian, that the form is being returned for completion by the individual's physician, and must be returned to the case manager within 30 calendar days of contact. The case manager returns Form 2406 to the individual, or the individual's parent or guardian, within three working days of contact with the individual, or the individual's parent or guardian. If Form 2406 has not been returned by the 30th day, the case manager notifies the individual that his request to access MDCP services through the MFP option is closed.

Attachments to Form 2406

Form 2406 must be completed by an individual's physician to be considered for a determination. The physician must attach documentation (such as a visit note, patient summary or hospital discharge summary) of permanent conditions to Form 2406. The medical documentation provided must document the current health status of the individual and substantiate the boxes checked on the form; this means the medical documentation must be within 12 months of the date the documentation is being submitted. If all medical documentation submitted is over 12 months old, the submission of Form 2406 is incomplete. The case manager must contact the individual, parent or guardian to inform them of the requirement that medical documentation be within 12 months of the date the documentation is being submitted. All incomplete forms will be returned to the region to be completed before a determination can be made by the DADS regional nurse or the DADS state office physician.

The case manager documents delays in obtaining a completed Form 2406, and conversations with the individual regarding the MFP option on Form 2405, Narrative Notes.

 

3520.3 Regional Nurse Approval

Revision 15-8; Effective July 31, 2015

 

Case managers must ensure the form is completed in its entirety. This includes ensuring the individual's name is printed on the form and is legible, the physician's name and address are complete in the Physician's Name and Address field on the first page of the form, and the physician's license number is entered on the second page of the form. If these items are not complete and legible when submitted to the regional nurse, they will be returned to the case manager as incomplete submissions.

A DADS nurse in each region will review each Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, received by the region. The case manager must submit Form 2406 to the DADS regional nurse within three working days of receipt to determine if the individual meets the medically fragile criteria.

The DADS nurse will approve the limited stay request if the physician’s documentation clearly supports the individual meets two or more of the criteria on Form 2406.

 

3520.4 Submission of Form 2406 to the DADS Physician

Revision 13-1; Effective February 1, 2013

 

If, based on the documentation submitted, the individual does not meet two or more criteria, Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and all medical documents submitted are scanned and emailed to the designated state office representatives for state office physician review. The case manager who received the Form 2406 must be included in the email. Before sending Form 2406 to state office, the regional nurse must ensure the form is complete. Complete is defined as the entire document being legible, all blanks filled in, physician’s signature and license number present and medical records attached.

When submitting Form 2406 to the state office physician, staff must submit each request in a separate email and must submit it as a secure email. The email's subject line must read: MDCP Form 2406 for XX. The "XX" in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "MDCP Form 2406 for AS."

 

3520.5 Determination of Medical Fragility by the DADS Physician

Revision 15-8; Effective July 31, 2015

 

The DADS physician will determine if the individual meets the medically fragile criteria. State office will respond via email to the regional nurse and the case manager. The response will be either Meets Criteria or Does Not Meet Criteria. The case manager contacts the individual, or the individual's parent or guardian, by phone within three working days of receipt of the DADS state office email to advise the individual of the outcome of the limited stay request. If the state office physician has a comment regarding the information submitted, this will be noted in the state office response to the region. The case manager must include this comment when advising the applicant of the outcome of the limited stay request. If the applicant submits additional documentation, it must be submitted to regional staff with a complete Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and will be considered a new request.

If a limited nursing facility stay is approved, the case manager must stress to the individual, or the individual's parent or guardian, the importance of coordinating the limited stay with the case manager. If the limited nursing facility stay is approved or the individual chooses to transition from a nursing facility, as described in Section 3510, Individuals Currently Residing in a Nursing Facility, the case manager will inform the MDCP supervisor within three working days of being informed of the decision. The MDCP supervisor must notify the Community Services Interest List (CSIL) Unit by email within three working days of being notified by the case manager that the individual meets the medically fragile criteria for the limited stay process and who the MDCP case will be assigned to for processing. After being notified by the MDCP supervisor of the decision, the CSIL Unit will place the individual in a Money Follows the Person (MFP) assigned status in the CSIL database, and the case manager will proceed with the application process.

If the DADS physician determines the individual does not meet the medically fragile criteria, the case manager contacts the individual, or the individual's parent or guardian, by phone within three working days of receipt of the DADS state office email. The case manager will inform him that a limited nursing facility stay is not approved, and the individual has the option to transition from a nursing facility stay, as described in Section 3510,  to access MDCP through the MFP option. If the individual does not choose to complete a nursing facility stay, as described in Section 3510, his name will remain on the interest list.

If the state office physician did not approve a limited nursing facility stay, the individual may re-apply in the future by contacting the case manager and submitting a new Form 2406. Once a determination has been rendered by the DADS state office physician, additional information regarding an individual's condition will not be considered as part of the original request.

 

3520.6 Initial Home Visit for Individuals Approved for a Limited Nursing Facility Stay

Revision 13-1; Effective February 1, 2013

 

The 14-day time frame for completing the initial home visit begins from the date the individual, or the individual's parent or guardian, informs the case manager of the decision to complete a limited nursing facility stay. At the initial home visit, the case manager will inform the individual, or the individual's parent or guardian, of the MDCP eligibility process and that he must present Form 3618, Resident Transaction Notice, to the case manager showing the time and date of the limited stay admission and discharge before MDCP services can be authorized. MDCP services must be authorized within 24 hours of the nursing facility discharge date to meet Money Follows the Person funding requirements.

 

3520.7 Coordination of the Limited Nursing Facility Stay

Revision 15-8; Effective July 31, 2015

 

The case manager must coordinate the limited stay in the nursing facility (NF) with the MDCP applicant or his primary caregiver to ensure the case manager is available to authorize MDCP services within 24 hours after discharge. Case managers must stress that compliance with Money Follows the Person (MFP) policy for continuity of services may be difficult if an applicant chooses to discharge from an NF on a Friday, Saturday, Sunday, or any day preceding or the day of a state holiday. However, if an applicant is unable to conduct a limited NF stay any other day, case managers can coordinate the NF stay and discharge. Case managers must be able to ensure services are authorized within 24 hours after the discharge from the NF.

The case manager must discuss with an applicant the risk of conducting a limited NF stay on a date other than the date coordinated with the case manager. If services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP policy and MDCP services cannot be authorized. However, if an applicant conducts a limited stay on a date other than the date coordinated with the case manager, and the case manager is available to authorize services within 24 hours after discharge, the applicant has met the MFP requirement for continuity of services after the NF discharge.

Case managers must coordinate with the MDCP supervisor to make him aware of all upcoming MFP limited NF stays. If a case manager is out on the date of an arranged NF discharge, MDCP supervisors must make certain that services are authorized within 24 hours after the NF discharge.

The case manager must ensure all eligibility requirements listed in Section 3100, Eligibility Determination, are met prior to the applicant completing the limited stay. The only exception to these requirements is Medicaid approval for MFP applicants approved for a limited stay.

Once the individual has been authorized to receive MDCP services, the MDCP case manager notifies:

The case manager must monitor MDCP services for 30 calendar days after services begin to ensure all necessary services are being provided.

 

3520.8 Delay in Limited Nursing Facility Stay

Revision 13-4; Effective November 1, 2013

 

If the nursing facility (NF) stay cannot be completed within 40 days after the date Form H1200, Application for Assistance-Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD), the case manager must request that MEPD delay certification. The case manager documents the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and submits the forms to MEPD. The case manager should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of waiver services is pending.” The delay request, if approved, will extend the MEPD time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for applicants requiring a disability determination, MEPD will deny the application. Once the case manager confirms the Medicaid denial, he must deny MDCP program eligibility and follow current policy in MDCP handbook Section 9510, Ineligibility.

If the individual, parent or guardian chooses to continue to pursue the Money Follows the Person (MFP) limited stay option after program eligibility has been denied, the MFP limited stay application process must start over. The case manager must follow current policy in Section 3520.1, MFP Procedures for Requesting a Limited NF Stay. The case manager must inform the individual, parent or guardian a new Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed if the physician’s signature date at the bottom of the form is more than 365 days old. If the date is signed within the previous 365 days, the individual, parent or guardian may use the previously submitted Form 2406.

If the new initial home visit is completed within 90 days of the MEPD denial, the case manager may obtain a letter signed by the individual, parent or guardian requesting to reopen the Medicaid application. The request must be sent with Form H1746-A marked “Application.” The MEPD time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to MEPD, the case manager must request that MEPD delay certification. However, MEPD may not approve the additional requests for delay in certification based on the amount of time that has passed since the original application file date. If MEPD denies the request to delay certification due to the age of the application, the case manager must assist the individual, parent or guardian in completing a new Form H1200. If MEPD approves the request for delay in certification, the case manager must proceed with coordination of the NF stay and enrollment procedures.

 

3530 Money Follows the Person Demonstration (MFPD)

Revision 12-3; Effective November 1,2012

 

Effective May 23, 2008, Money Follows the Person Demonstration (MFPD) was implemented for the Medically Dependent Children Program (MDCP). MFPD is intended to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities (NFs) and receive necessary long-term services in the setting of their choice.

MFPD is available to individuals applying for services through the Money Follows the Person (MFP) option who reside continuously in an institutional setting for at least 90 calendar days prior to the waiver program eligibility date and are enrolled from a Medicaid-certified NF. The continuous 90 day requirement must not include any Medicare paid days in an NF including full Medicare payment and Medicaid co-pay. In the Service Authorization System (SAS), an NF Service Authorization record will have a Service Group (SG) 1 and a Service Code (SC) 3A for Part-A full Medicare payments, and SG 1 and an SC 3 for a co-insurance (Medicaid co-pay) record. An NF Service Authorization record will have SG 1 and an SC 1 for a full Medicaid payment record. The SG 1, SC 3A record will always appear if the individual meets the 20 day qualifying stay for Medicare. Staff may have to contact the NF, hospital or other institution to verify the actual Medicare days or other institutional days.

Individuals who participate in MFPD must transition from an NF to the waiver program. For MFPD, an institutional setting is defined as an NF, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), hospital or state hospital. The 90-calendar-day residency rule may be met by a continuous stay in a combination of the settings.

Example: An individual may have resided continuously in an NF for a full month, in a hospital for a full month, and then re-entered the NF for another full month. This would meet the 90-calendar-day residency rule for MFPD.

To verify MFPD institutional residency requirements, the case manager may:

Check SAS for verification of residence in qualified institutional settings. This may include stays in a combination of settings. Applicable settings include:

The case manager must document in the case record the dates of each qualifying institutional stay verified to meet the 90-day continuous stay requirement for MFPD.

The regional MDCP supervisor or designated program manager must contact the state office MDCP policy specialist for procedures when case managers identify potential MFPD participants.

 

3530.1 MFPD 365-Day Entitlement Period

Revision 12-1; Effective May 1,2012

 

Money Follows the Person Demonstration (MFPD) individuals are entitled to participate in the demonstration for 365 days, beginning the date an individual agreeing to participate in the demonstration is enrolled in the waiver program. Tracking of institutional days is required to ensure MFPD individuals receive the full 365-day entitlement period.

The individual's date of entry and date of discharge from a hospital, nursing facility or other institutional setting is included in the number of days the individual is considered to be institutionalized for MFPD tracking purposes.

 

3540 Closing NF Authorizations for Individuals Transitioning to Community Services

Revision 12-1; Effective May 1,2012

 

Closure of nursing facility (NF) records may be necessary when registering an individual plan of care (IPC) in the Service Authorization System (SAS) for an applicant transitioning from an NF to the community.

The case manager must call the Provider Claims Services hotline to close the NF authorization. The hotline number is: 512-438-2200. Select Option 1.

The case manager should call the hotline directly to request the NF record in SAS be closed so Medically Dependent Children Program (MDCP) services can be authorized. The case manager must confirm the individual has been discharged from the NF and MDCP services are negotiated to begin on or after the date of discharge.

When calling the hotline, the case manager must identify himself as a Department of Aging and Disability Services (DADS) employee and report that the individual has discharged from the NF and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SAS, including Service Code 60. The case manager documents the contact in the case record.

 

3550 Accessing Relocation Services

Revision 12-1; Effective May 1,2012

 

If the applicant wants to move to the community but needs help in locating housing or other transition planning and has no other informal supports, the case manager may refer a request for relocation services to relocation contractors. Relocation services consist of, but are not limited to:

The case manager must contact the relocation contractor by telephone and send Form 1579, Referral for Relocation Services, within two working days of the initial interview, if the applicant indicates a need for relocation services.

The case manager must complete Form 1579 in its entirety to document specific details regarding the applicant's needs, resources and plans for relocation. The case manager must include any information that could be helpful to the relocation contractor in assisting the applicant in the relocation process.

The case manager must verbally inform the applicant of the referral to a relocation contractor and document the date and time of contact with the applicant on Form 1579 before sending the form to the relocation services provider. This ensures the opportunity for facilitation of the relocation process for all applicants choosing to return to the community. The case manager files a copy of Form 1579 in the case file.

Some of the relocation contractors may also provide Transition Assistance Services (TAS). If the applicant chooses the relocation contractor as a TAS provider, the case manager completes the TAS authorization for this provider according to the procedures in Section 4150, Transition Assistance Services (TAS), and Section 4220, Provider Notification.

CM-MDCP, Section 4000, Services

Revision 15-8; Effective July 31, 2015

 

 

4100 Medically Dependent Children Program (MDCP) Services

Revision 12; Effective May 1, 2013

 

MDCP provides Respite, Flexible Family Support Services, Minor Home Modifications, Adaptive Aids, Transition Assistance Services and Financial Management Services to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.

 

Utilization of Waiver Services

Federal guidelines require that applicants and individuals must need and use one or more waiver services to qualify and maintain eligibility for MDCP. All applicants and individuals must have a need for and use MDCP services on a monthly basis to qualify for MDCP. The case manager must inform all applicants and individuals that, at a minimum, one MDCP service must be used at least once a month to qualify and maintain enrollment in MDCP.

It is important for the case manager to accurately assess the need for services when developing the individual plan of care (IPC). For this reason, the case manager must identify the applicant's/individual's needs, the primary caregiver's ability to meet those needs, and determine the appropriate service to meet the identified needs.

 

4110 Respite

Revision 13-1; February 1, 2013

 

§51.103

(36) Primary caregiver--A person who:

(A) is legally responsible for an individual's routine daily care, provision of food, shelter, clothing, health care, education, nurturing, and supervision; and

(B) provides daily, uncompensated care for the individual.

(40) Respite services--Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Respite is a service that provides temporary relief from care giving to the applicant's/individual's primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/individual's parent(s), guardian, a family member or spouse, if married.

The case manager reviews the primary caregiver definition with the applicant/individual and the family, and identifies the applicant's/individual's primary caregiver on Form 2410, Medical-Social Assessment and Individual Plan of Care, Page 1, Item 4.

Respite may be delivered by the following providers:

Respite also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option.

Respite delivered by an HCSSA or through the CDS option is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4112, Respite Service Limits. Other community settings could include the park, the respite provider’s home, or a home of the individual’s relative.

Attendant with Delegated Tasks

The case manager may authorize an attendant with delegated tasks provider type to deliver Respite by an HCSSA. The attendant with delegated tasks provider type is not available through the CDS option.

A delegated task is defined in Section 1200, Program Definitions, as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate.

The individual with a skilled task need may use the attendant with delegated tasks provider type if a practitioner or RN delegates the skilled task required to meet the individual's needs.

Example: A three-year-old boy lives at home with his mother who is his primary caregiver. The individual's condition is stable and predictable. He is unable to take food by mouth and receives his entire nutritional intake via a gastrostomy button (G-button). The HCSSA nurse has assessed the individual and, in consultation with the mother, has determined the task of tube feeding this individual meets the Texas Board of Nursing criteria for delegation to an unlicensed person. The HCSSA nurse has instructed the unlicensed person in the tube feeding and has agreed to retain accountability for how the unlicensed person performs the tube feeding. The HCSSA nurse has determined, in consultation with the mother, the level of supervision and frequency of supervisory visits required, taking into account the individual's status and the specific task being delegated.

If the individual does not have a skilled task need for the delivery of Respite, he will not have a need for an attendant with delegated tasks. If the individual or primary caregiver requests the use of an attendant with delegated tasks, but DADS or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the case manager should not authorize an attendant with delegated tasks to deliver Respite. As noted in Section 3130, Individual Plan of Care Development, if there are disagreements regarding the use of provider types that may place the individual at risk, the case manager should convene a meeting to resolve the conflict. The meeting should include the individual, the primary caregiver, the provider or entity that participates in the individual's care, the case manager and the MDCP nurse. If necessary, staff also should involve the individual's physician. The decision reached by DADS staff involved in this consultation is final.

 

4111 Out-of-Home Respite

Revision 12-1; Effective May 1, 2012

 

Respite can be provided out of the home if the physician's order indicates that out-of-home respite is allowed (see Form 2428, Physician's Orders for Licensed Nursing Services).

Out-of-home respite providers are:

The case manager should review Section 4112, Respite Service Limits, when authorizing respite services delivered by a hospital or nursing facility.

 

4112 Respite Service Limits

Revision 15-5; Effective May 8, 2015

 

Texas Administrative Code §51.231, Service Limitations

The case manager may only authorize Respite during the time the primary caregiver would usually provide care to the individual. Therefore, the case manager may not authorize Respite during the time the primary caregiver is at work, attending school or in job training.

The case manager may not authorize the provider to provide respite services to a member of an individual's household who is not eligible to receive Medically Dependent Children Program (MDCP) services. However, if there are two individuals in the household who are receiving MDCP services, the case manager can authorize respite services for both during the same time period using the same provider.

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that MDCP services, including Respite, may not be provided to an individual who is admitted into a hospital or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). The case manager should not confuse this with facility-based respite. If an individual is admitted into the hospital for reasons such as illness, surgery or stabilization/treatments, then Respite may not be provided. The case manager may authorize Respite only if an individual enters an MDCP contracted hospital to receive Respite.

Since Respite is intended to provide relief to the primary caregiver, it may not be delivered while the individual is in school or in a school setting.

Facility-based respite is limited to 29 days per the individual plan of care (IPC) period. The 29-day limit applies to the total number of days an individual receives respite in a hospital or nursing facility.

The individual may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the case manager and the MDCP nurse must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. If there is no danger to the individual’s health and welfare, then staff should approve the request.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide Respite to an individual who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide Respite to an individual receiving out-of-home respite in a nursing facility.

All Respite settings must be located within the state of Texas. The case manager may not authorize Respite for care delivered by:

 

4113 Respite Service Authorizations

Revision 15-5; Effective May 8, 2015

 

 

The case manager follows the Medically Dependent Children Program (MDCP) Respite definition and limitations to review all requests for Respite. The case manager authorizes Respite by completing Form 2065-B, Notification of Waiver Services, and Form 2415, Respite Service Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Respite. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2415 to identify the Respite hours the provider is authorized to deliver. When the case manager authorizes out-of home respite in an approved camp setting, as described in Section 4111, Out-of-Home Respite, the case manager must authorize only the number of hours an individual will utilize while receiving respite service at an approved camp setting. No additional administrative fees can be added to an individual plan of care (IPC). The case manager sends Form 2415 to the provider identified on the form and copies of Form 2415 to the individual. The case manager must complete and send Form 2065-B and Form 2415 within two working days of determining eligibility for the requested service.

The case manager determines how many units of respite to authorize based on the need of the primary caregiver. The case manager must round units per week up to the next quarter-hour on Form 2415 because providers are only able to bill in quarter-hour increments. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour. Example: An individual's primary caregiver requested 15 hours and 20 minutes of respite per week. The case manager would authorize 15.50 hours of respite per week.

Case Manager Follow-up on Provider Response

The case manager must track the provider's response on Form 2415. The case manager must ensure the HCSSA completes this provider requirement. The case manager will submit a referral to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint within five working days if the required signed service authorization form was not submitted to the case manager within 14 working days from the date the provider receives the applicable service authorization form.

The case manager must identify the complaint is regarding a "Medically Dependent Children Program provider" and indicate the HCSSA is not complying with program requirements. The case manager documents the referral to CRS in the case file, using Form 2405, Narrative Notes.

 

4114 Respite Service Schedule Changes

Revision 15-5; Effective May 8, 2015

 

The case manager may inform the individual that the case manager does not need to pre-approve all changes to the Respite service schedule.

The individual may adjust Respite service schedules without prior approval if the change in the schedule does not:

Example: If the case manager authorized 60 monthly hours of Respite services for an IPC beginning February 1, and the individual used:

This individual can use up to 180 hours (60 x 3 = 180) in any month as long the individual has enough unused hours from previous months in the same IPC year. The individual had a total of 150 unused hours (20+40+30+40+20= 150) to be used in any future months of the IPC as of the end of August. The individual used 120 hours in September and 140 in December, which left a total of 10 unused hours. The individual had 10 unused hours in January, which gave the individual a total of 20 unused hours at the end of the IPC. The 20 unused hours do not carry over into the new IPC year.

The case manager must inform the individual that he is responsible for:

If the individual requests a change in the service schedule that results in an increase of 50 percent or more, the case manager may approve the use of the increased number of hours. When the individual requests a schedule change resulting in an increase of 50 percent or more hours from a previous month, the case manager and the Medically Dependent Children Program (MDCP) nurse must review the individual's needs and the primary caregiver's ability to meet those needs, and determine the appropriate MDCP service to meet the identified needs within the IPC cost limit.

The case manager must document all contact with the individual/primary caregiver and MDCP nurse in the case file, using Form 2405, Narrative Notes.

 

4120 Flexible Family Support Services

Revision 13-2; Effective May 1, 2013

 

§51.103

(2) Activities of daily living--Activities that are essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transfer and ambulation, positioning, range of motion, and assistance with self-administered medications.

(4) Adjunct support services--Direct care services needed because of an individual's disability that:

(A) help an individual participate in:

(i) child care;

(ii) post-secondary education; or

(iii) independent living; or

(B) support an individual's move to an independent living situation.

(6) Attendant--An employee of a provider or of an individual who has selected the consumer directed services option who provides direct care to the individual.

(7) Basic child care--Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training, or at school.

§51.221

(a) The individual's parent or guardian must be responsible for basic child care.

Flexible Family Support Services are individualized and disability-related services that support an individual to participate in:

Flexible Family Support Services include personal care supports for basic activities of daily living (ADL) and instrumental ADL, skilled task and delegated skilled task supports.

Examples of basic ADL include:

Instrumental ADL may not be necessary for fundamental self-care, but may be useful for community living. These activities may include:

Flexible Family Support Services promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine.

Flexible Family Support Services may be delivered by the Home and Community Support Service Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option.

Documenting Flexible Family Support Services

The case manager documents the individual's need for Flexible Family Support Services using Form 2405, Narrative Notes, in the case file. The case manager documents specific ADL, instrumental ADL, skilled task, non-skilled task or delegated skilled tasks the individual needs that are not met by the setting in which Flexible Family Support Services are requested. The case manager identifies the amount of units determined to address each of the identified areas of the individual's needs. The case manager uses this information to complete the individual plan of care (IPC) and Form 2414, Flexible Family Support Services Authorization.

Example: A 10-year-old girl has a babysitter in the home while the primary caregiver works. The babysitter is in the home from 3-6 p.m., Monday through Friday and provides general supervision. The individual recently had orthopedic surgery and now has an external orthopedic device on her leg that requires care to the skin that surrounds the pins to the device (pinsite care). In addition, this individual has a feeding tube, and she now requires the administration of prescription medications through the feeding tube. The babysitter is unable to do the pinsite care or administer the prescribed medications. The pinsite care takes approximately 15 minutes and administering the medications takes an additional 15 minutes. The primary caregiver, case manager and MDCP nurse agree an LVN is required to deliver this service. The individual requires one half hour of Flexible Family Support Services delivered by an LVN daily from Monday through Friday.

Attendant with Delegated Tasks

The case manager may authorize an attendant with delegated tasks provider type to deliver Flexible Family Support Services by an HCSSA. The attendant with delegated tasks provider type is not available through the CDS option.

In Section 1200, Program Definitions, a delegated task is defined as a task that a practitioner or RN delegates in accordance with state law. In general, the Texas Board of Nursing defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate.

The individual with a skilled task need may use the attendant with delegated tasks provider type if a practitioner or RN delegates the skilled task required to meet the individual's needs.

Example: A three-year-old boy lives at home with his mother who is his primary caregiver. The individual's condition is stable and predictable. He is unable to take food by mouth and receives his entire nutritional intake via a G-button. The HCSSA nurse has assessed the individual and, in consultation with the mother, has determined the task of tube feeding this individual meets the Texas Board of Nursing criteria for delegation to an unlicensed person. The HCSSA nurse has instructed the unlicensed person in the tube feeding and has agreed to retain accountability for how the unlicensed person performs the tube feeding. The HCSSA nurse has determined, in consultation with the mother, the level of supervision and frequency of supervisory visits required, taking into account the individual's status and the specific task being delegated.

If the individual does not have a skilled task need for the delivery of Flexible Family Support Services, he will not have a need for an attendant with delegated tasks. If the individual or primary caregiver requests the use of an attendant with delegated tasks, but DADS or the HCSSA determines the use of this provider type places the individual's health and welfare at risk, the case manager should not authorize an attendant with delegated tasks to deliver Flexible Family Support Services. As noted in Section 3130, Individual Plan of Care Development, if there are disagreements regarding the use of provider types that may place the individual at risk, the case manager should convene a meeting to resolve the conflict. The meeting should include the individual, the primary caregiver, the provider or entity that participates in the individual's care, the case manager, and the MDCP nurse. If necessary, staff also should involve the individual's physician. The decision reached by DADS staff involved in this consultation is final.

 

4121 Flexible Family Support Services in Child Care

Revision 13-2; Effective May 1, 2013

 

§51.103

(7) Basic child care--Watchful attention and supervision of an individual while the individual's primary caregiver is at work, in job training, or at school.

§51.221

(a) The individual's parent or guardian must be responsible for basic child care.

The individual's parent or guardian is responsible for basic child care either in or out of the individual's home. Flexible Family Support Services support the individual's participation in child care when the service provided by the child care does not support the individual's disability-related needs. If the individual's child care is not able to meet the individual's activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task needs, the case manager may authorize Flexible Family Support Services.

To determine the need for Flexible Family Support Services for participation in child care, the case manager must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the individual's home or both. The delivery of Flexible Family Support Services does not include basic child care, which is watchful attention or supervision of the individual while the primary caregiver is at work, in job training or at school. These remain responsibilities within the service delivered by the child care. The caregiver's cost for child care does not impact the individual's need for Flexible Family Support Services. The case manager must determine the amount of hours needed to support the individual's needs. The case manager should ask the parent or guardian about the individual's personal and skilled task needs and the time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual to address necessary safeguards that ensure the individual's health and welfare.

 

4122 Flexible Family Support Services for Independent Living

Revision 13-2; Effective May 1, 2013

 

An individual may indicate a desire for increased independence as he matures. If the individual needs assistance with activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task, the case manager may authorize Flexible Family Support Services to help the individual with his goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not an MDCP service, an independent living arrangement also can provide life-skills training to assist individuals in acquiring the skills they will need to live independently as adults.

To determine the need for Flexible Family Support Services for independent living, the case manager must discuss the individual's and primary caregiver's plan for independent living. When identifying the individual's need for this service, the case manager should address age appropriateness for the tasks required to meet these needs. The case manager must determine the amount of hours needed to support the individual's needs. The case manager must identify the individual's personal and skilled task needs and the time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual and the appropriateness of the living arrangement and service delivery regarding the individual's age, health and welfare.

As indicated in Section 4124, Flexible Family Support Services Limits, Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training.

 

4123 Flexible Family Support Services in Post-Secondary Education

Revision 13-2; Effective May 1, 2013

 

An individual can access Flexible Family Support Services to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental ADL, skilled task, non-skilled task or delegated skilled task needs. If an individual has an ADL, instrumental ADL, skilled task, non-skilled task or delegated skilled task need prohibiting him from participating in post-secondary education, the case manager may authorize Flexible Family Support Services so the individual may participate in post-secondary education.

An individual may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in college or university. These educational institutions do not follow federal requirements for a free and appropriate education as required of elementary and secondary public schools. Post-secondary institutions can provide academic adjustments, but do not support the individual's personal, skilled and delegated skilled task needs.

To determine the need for Flexible Family Support Services in post-secondary education, the case manager must identify the individual's need for assistance and the amount of hours needed to support the individual's needs. The case manager should identify the individual's personal and skilled task needs and the amount of time needed to address those needs. The case manager and the MDCP nurse also should discuss the skill level required to assist the individual and address necessary safeguards to ensure the individual's health and welfare.

As indicated in Section 4124, Flexible Family Support Services Limits, Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training.

 

4124 Flexible Family Support Services Limits

Revision 15-5; Effective May 8, 2015

 

Texas Administrative Code §51.231, Service Limitations

Flexible Family Support Services may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the case manager may not authorize Flexible Family Support Services during the same time period the individual receives Personal Care Services.

The case manager may not authorize the provider to provide flexible family support services to a member of an individual's household who is not eligible to receive Medically Dependent Children Program (MDCP) services. However, if there are two individuals in the household who are receiving MDCP services, the case manager can authorize flexible family support services for both during the same time period using the same provider.

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that MDCP services, including Flexible Family Support Services, may not be provided to an individual who is admitted into a hospital or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

The case manager may not authorize Flexible Family Support Services during the individual's school hours in primary or secondary educational settings.

4125 Flexible Family Support Services Authorizations

Revision 15-5; Effective May 8, 2015

 

The case manager follows Medically Dependent Children Program (MDCP) Flexible Family Support Services criteria, to review all requests for Flexible Family Support Services. The case manager authorizes Flexible Family Support Services by completing Form 2065-B, Notification of Waiver Services, and Form 2414, Flexible Family Support Services Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Flexible Family Support Services. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2414 to identify the Flexible Family Support Services hours the provider is authorized to deliver. The case manager sends Form 2414 to the provider identified on the form and copies of Form 2414 to the individual. The case manager must complete and send Form 2065-B and Form 2414 within two working days of determining eligibility for Flexible Family Support Services.

The case manager determines how many units of flexible family support services to authorize based on the need of the primary caregiver. The case manager must round units per week up to the next quarter-hour on Form 2414 because providers are only able to bill in quarter-hour increments. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour. Example: An individual's primary caregiver requested 15 hours and 20 minutes of flexible family support services per week. The case manager would authorize 15.50 hours of flexible family support services per week.

Case Manager Follow-up on Provider Response

The case manager must track the HCSSA's response on the Service Authorization form. The case manager will submit a referral to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint within five working days if the required signed service authorization form was not submitted to the case manager within 14 working days from the date the provider receives the applicable service authorization form.

The case manager must identify the complaint is regarding a "Medically Dependent Children Program provider" and indicate the HCSSA is not complying with program requirements. The case manager documents the referral to CRS in the case file, using Form 2405, Narrative Notes.

 

4126 Service Schedule Changes to Flexible Family Support Services

Revision 15-5; Effective May 8, 2015

 

 

Texas Administrative Code §51.237, Service Schedule Changes

The case manager may inform the individual that the case manager does not need to pre-approve all service schedule changes to Flexible Family Support Services.

The individual may adjust service schedules without prior approval if the change in the schedule does not:

Example: If the case manager authorized 60 monthly hours of Flexible Family Support Services for an IPC beginning February 1, and the individual used:

This individual can use up to 180 hours (60 x 3 = 180) in any month as long the individual has enough unused hours from previous months in the same IPC year. The individual had a total of 150 unused hours (20+40+30+40+20= 150) to be used in any future months of the IPC as of the end of August. The individual used 120 hours in September and 140 in December, which left a total of 10 unused hours. The individual had 10 unused hours in January, which gave the individual a total of 20 unused hours at the end of the IPC. The 20 unused hours do not carry over into the new IPC year.

The case manager must inform the individual he is responsible for:

If the individual requests a change in the service schedule that results in an increase of 50 percent or more, the case manager may approve the use of the increased number of hours. When the individual requests a schedule change resulting in an increase of 50 percent or more hours from a previous month, the case manager and the Medically Dependent Children Program (MDCP) nurse must review the individual's needs and the primary caregiver's ability to meet those needs, and determine the appropriate MDCP service to meet the identified needs within the IPC cost limit.

The case manager must document all contact with the individual/primary caregiver and MDCP nurse in the case file, using Form 2405, Narrative Notes.

 

4130 Adaptive Aids

Revision 15-7; Effective June 12, 2015

 

Texas Administrative Code (TAC) §51.103, Definitons

TAC §51.423, Respite and Flexible Family Support Services

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable individuals to:

The case manager informs the applicant of the adaptive aids service at the initial home visit and reviews the service criteria at the annual reassessment or upon the individual's request.

At the initial home visit, the case manager must provide the applicant the Tool for Adaptive Aids, and the Tool for Van Lifts/Vehicle Modifications, found in Appendix II, Medically Dependent Children Program (MDCP) Tools.

The case manager must offer the individual the tool when the service criteria are reviewed at the annual reassessment if the individual requests adaptive aids. Whenever an individual requests an adaptive aid, the case manager must send the Department of Aging and Disability Services (DADS) resources and publications the individual may need to acquire adaptive aids within five working days of the request. The case manager should include the following DADS resources and publications in an MDCP adaptive aid packet:

An individual may take an adaptive aid to an out-of-home respite facility for his/her use while residing there.

 

4131 Individual Role in Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

In the Medically Dependent Children Program (MDCP), the individual, primary caregiver or family assume primary responsibility for obtaining all necessary documentation to request adaptive aids.

The individual is responsible for obtaining written specifications for all requests for adaptive aids. See Section 4131.3, Specifications for Adaptive Aids, for requirements.

The individual is responsible for obtaining three bids for all requests for adaptive aids. See Section 4131.5, Bids for Adaptive Aids, for requirements.

The case manager must ensure the individual is aware of his role in obtaining adaptive aids and should assist the individual in understanding the prior authorization process.

 

4131.1 Third-Party Resources for Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

All individuals have Medicaid and can access medically necessary durable medical equipment (DME) through Medicaid or the Texas Health Steps Comprehensive Care Program (CCP). In Texas, the Texas Medicaid and Healthcare Partnership (TMHP) reviews all requests for durable medical equipment and authorizes items that are medically necessary and allowable under Medicaid. Since TMHP reviews every request for medical necessity, there is no list of automatically approved or denied DME items.

If TMHP requests additional information, the individual or the DME supplier must submit the information to TMHP before the Department of Aging and Disability Services (DADS) reviews a request for adaptive aids.

The case manager must inform the individual of the individual's responsibility for pursuing adaptive aids through available third-party resources and obtaining specifications and bids before the case manager can process the request for adaptive aids. An individual with private insurance must first request adaptive aids from a DME company participating in the individual's insurance plan before requesting adaptive aids as a Medicaid benefit. The case manager must also inform the individual of the individual's responsibility to provide, as needed, hard copies of denials from private insurance, Medicaid or other third-party resources. The case manager must request these denials for items that may address a individual's medical need. An individual is not required to secure a third-party denial letter for a vanlift/vehicle modification request.

The case manager may only accept third-party resource denials that have assessed the individual's need for the item when reviewing a request for adaptive aids. The case manager must not accept third-party resource denial documentation that is not based on an assessment of need. Example: A third-party resource denial due to lack of documentation or failure to provide additional information has not assessed the individual's need for the item and is not an appropriate assessment. In this example, the case manager must request the individual to submit the information to the third-party resource.

DADS reviews the individual's request for an adaptive aid even if a third-party resource denies the request for an item citing a lack of medical need. An individual's lack of medical need for an item does not automatically disqualify the request for DADS review.

For adaptive aids authorized or previously authorized by DADS staff, the individual does not have to submit requests to TMHP for the following:

 

4131.2 Adaptive Aid Bidders

Revision 12-1; Effective May 1, 2012

 

§51.233

(b) If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

The individual may choose a provider from a list of adaptive aid providers or a non-contracted entity to submit a bid. The individual should inform the non-contracted entity that it must apply for a contract with the Department of Aging and Disability Services (DADS) if the individual chooses the non-contracted entity to deliver adaptive aids. The case manager must refer the individual to the Medically Dependent Children Program (MDCP) rules governing provider and service delivery requirements for adaptive aids. The case manager must encourage the individual to refer non-contracted entities to these rules before applying to contract with DADS. MDCP rules are available on the Internet at https://hhs.texas.gov. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:

The case manager must encourage the individual to refer non-contracted entities to the DADS Contracts Unit at telephone 512- 438-5430, to request an adaptive aid contract enrollment packet for MDCP. The case manager may only authorize contracted adaptive aid providers to deliver adaptive aids.

 

4131.3 Specifications for Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

§51.303

(a) An individual must obtain written specifications for each adaptive aid from:

(1) a practitioner;

(2) a physical therapist

(3) an occupational therapist;

(4) a speech pathologist; or

(5) an adaptive aid provider.

(b) The individual must ensure that the written specifications are recorded on a single document that includes:

(1) the name and address of the individual receiving MDCP services;

(2) a description of the adaptive aid being specified;

(3) the written specifications;

(4) the printed name and dated signature of the person preparing the written specifications; and

(5) the individual's dated signature.

§51.305

(b) The individual must make the same specification available to each bidder.

Written specifications are required for all requests for adaptive aids. The Department of Aging and Disability Services (DADS) will accept specifications prepared by the individual's:

On the written specification, the preparer must include the:

In the purpose of the item, the specification must include the expected benefit regarding the individual's:

The specification must also indicate whether the individual needs adaptive aids to complete activities of daily living or to control the environment in which the individual lives. Activities of daily living are basic personal every day activities such as bathing, dressing, transferring, toileting, mobility and eating.

The individual must provide the same written specification to all providers and non-contracted entities submitting bids for adaptive aids.

The case manager must request the individual to submit the specification for adaptive aids to the case manager when submitting the bids for the requested item.

If the specification is incomplete, the case manager identifies the missing information and asks the individual to have the preparer submit the written specification with the missing information.

The case manager must document the specification preparer qualifications using Form 2405, Narrative Notes, or Appendix III, Adaptive Aids (AA) Checklist, in the case file.

Van lifts/vehicle modification specification requirements and procedures are identified in Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications.

 

4131.3.1 Specifications for Adaptive Aids with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

 

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

After determining a request for adaptive aids requires a personal cost contribution from the individual, the case manager informs the individual that updated specifications are needed to continue the service authorization process.

The case manager must inform the individual of the specification items that can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated specifications must meet the criteria listed in Section 4131.3, Specifications for Adaptive Aids, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The items in the updated written specifications should not differ from the ones listed in the original written specification.

The individual must submit the updated written specifications to the case manager to continue the adaptive aids authorization process.

See Section 4134, Individual Personal Costs for Adaptive Aids, for procedures to determine the individual's personal costs.

 

4131.4 Special Requirements for Van Lifts/Vehicle Modifications

Revision 12-1; Effective May 1, 2012

 

§51.301

(a) Before procuring an adaptive aid costing $100 or more, an individual must submit a request for the adaptive aid, including the written specifications and bids, to the case manager for approval.

§51.309

(a) For the purpose of this chapter, vehicle modifications and adaptive equipment are considered adaptive aids, and the individual must follow the procurement procedures for adaptive aids in this division in addition to the requirements of this section.

(b) When requesting a vehicle modification, the individual provides the following information to the case manager:

(1) information on the vehicle to be modified, including:

(A) the year and model of the vehicle;

(B) proof of ownership;

(C) current state inspection and tags;

(D) applicable state insurance; and

(E) mileage;

(2) information on the needed modifications; and

(3) if the individual is not the owner of the vehicle, the individual must provide the vehicle owner's signed and dated written approval for the vehicle modification.

(c) When an individual requests a vehicle modification that costs $1,000 or more and the vehicle has been driven more than 100,000 miles or is more than four years old, the individual must submit to the case manager:

(1) a written evaluation by an experienced mechanic who is not the provider of the requested vehicle modification to document the sound mechanical condition of all major components of the vehicle; and

(2) documentation of the experience of the mechanic who performed the evaluation.

(d) Bids for a vehicle modification must include:

(1) an itemized list of parts and accessories, including their prices;

(2) an itemized list of required labor and charges; and

(3) information on warranty coverage.

All bids for van lifts/vehicle modifications must include:

The individual must provide the same written specification to all providers and non-contracted entities submitting a bid for the van lift/vehicle modification.

The case manager must inform the individual a mechanical evaluation is required for:

The individual must obtain the evaluation from an experienced mechanic who is not the provider selected to complete the van lift/vehicle modification. The evaluation must include a statement indicating the van/vehicle is mechanically and structurally sound for the requested modification and include the mechanic's experience and qualifications. The case manager sends Form 2432, Vehicle Evaluation, to the individual upon the individual's request for a van lift/vehicle modification with the Tool for Van Lifts/Vehicle Modifications, in Appendix II, Medically Dependent Children Program (MDCP) Tools, if a mechanical evaluation is needed.

 

4131.5 Bids for Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

§51.305

(a) An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).

(b) The individual must make the same specifications available to each bidder.

(c) If the individual is unable to obtain three bids, the individual must contact the case manager and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about his efforts to secure three bids.

The Department of Aging and Disability Services requires a minimum of three bids for all requests for adaptive aids. The individual must provide the same written specification to all providers and non-contracted entities submitting bids. The individual is not limited to the list of adaptive aids providers. The individual may obtain bids from non-contracted entities. The case manager sends Form 2435, Adaptive Aids Bid, to the individual upon the individual's request for an adaptive aid.

If the individual is unable to get three bids, the individual must provide specific information to the case manager about his efforts to get the required bids. The case manager must document the individual's reason for obtaining less than three bids in the case file using Form 2405, Narrative Notes.

 

4131.5.1 Bids for Adaptive Aids with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

 

§51.305

(a) An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).

(b) The individual must make the same specifications available to each bidder.

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

After determining a request for adaptive aids requires a personal cost contribution from the individual, the case manager follows procedures in Section 4131.3.1, Specifications for Adaptive Aids with Individual Personal Costs. The individual must also obtain updated bids to reflect the changes in the updated specifications.

The case manager must inform the individual which items in the original bids can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated bids must meet the criteria listed in Section 4131.5, Bids for Adaptive Aids, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The actual bid items should not differ from the ones listed in the original bid.

The individual must submit the updated bids with the updated specifications to the case manager to continue the adaptive aids authorization process.

See Section 4134, Individual Personal Costs for Adaptive Aids, for procedures to determine the individual's personal costs.

 

4132 Service Limits on Adaptive Aids

Revision 15-8; Effective July 31, 2015

Texas Administrative Code §51.231(c), Service Limitations

The service limit on adaptive aids is $4,000 per individual plan of care (IPC) period. The Department of Aging and Disability Services (DADS) does not authorize or reimburse adaptive aids costing less than $100.

Examples of adaptive aids covered in the Medically Dependent Children Program (MDCP) are:

DADS cannot authorize or reimburse adaptive aids that are primarily:

Medical supplies are available as a Medicaid benefit and are not adaptive aids in MDCP.

 

4133 Bid Verification for Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

§51.305

(a) An individual must obtain a minimum of three written bids based on the written specifications described in §51.303 of this chapter (relating to Specifications for Adaptive Aids).

(b) The individual must make the same specifications available to each bidder.

(c) If the individual is unable to obtain three bids, the individual must contact the case manager and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about his efforts to secure three bids.

Upon receipt of appropriate documentation and request for adaptive aids, the case manager must verify all bids are comparable to the written specification. Bids for van lifts/vehicle modifications must include all required documentation identified in Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications.

The case manager must verify all bids match the specifications. The bids must list items separately and include the cost for each item.

 

4134 Individual Personal Costs for Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

§51.307

If the individual wants to proceed with the purchase of an adaptive aid that exceeds the cost or scope of the approved request, the individual is responsible for all costs associated with the enhancement.

An individual may request an item or a combination of items that can either exceed the adaptive aids service limit or include items or options that are not approved by the Department of Aging and Disability Services (DADS).

If an individual requests an item with a cost exceeding the adaptive aids service limit, the case manager will review the request with the DADS nurse. If the DADS nurse approves the request, the case manager will inform the individual DADS will approve the request; however, the individual is responsible for the costs exceeding the adaptive aids service limit.

Example: The individual requests a van lift with a cost of $10,000. The case manager reviews the request with the DADS nurse and approves the request. The case manager completes Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, Section A and Section B, to notify the individual personal costs were identified.

If an individual requests an item (with accessories) that does not follow the adaptive aids service criteria, the case manager will review the request with the DADS nurse. The case manager and DADS nurse may approve the item and necessary accessories, but may not approve accessories that do not meet adaptive aids service criteria. The case manager must notify the individual of the items DADS will approve; however, the individual is responsible for personal costs for items not included in the adaptive aids service criteria.

Example: The individual requests a feeder seat, seat base and tray with a total cost of $1,100. The feeder seat is $300, the seat base is $300, and the tray is $500. The case manager and DADS nurse review the request and determine the feeder seat and seat base follow the service criteria and determine the tray does not. The case manager completes Section A and Section B on Form 2416 to notify the individual personal costs were identified.

 

4135 Adaptive Aids Service Authorization

Revision 12-1; Effective May 1, 2012

 

The case manager may use Appendix III, Adaptive Aids (AA) Checklist, to review the adaptive aid requests to ensure all appropriate documentation requirements are in the case file. The case manager may authorize adaptive aids only after benefits available through Medicare, Medicaid or other third-party resources have been exhausted. The case manager follows adaptive aids criteria to review all requests for adaptive aids, as well as the availability of funds remaining in the current individual plan of care (IPC) period. When a new IPC is developed and approved for the upcoming IPC period, the funds from the previous IPC period are no longer available for approving an adaptive aid.

Within two working days of determining eligibility for the requested items, the case manager must complete and send Form 2065-B, Notification of Waiver Services, and Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, to the individual and the provider to inform both of the case manager's decision and allowable costs covered by the Medically Dependent Children Program.

The case manager's signature on Form 2416 indicates the requested adaptive aid (AA) or minor home modification (MHM) is authorized. This means the request for the AA or MHM met all criteria and the individual submitted the appropriate documentation. If the request for the AA or MHM results in a personal cost, the case manager does not sign the form before sending it to the individual for acknowledgement of personal costs. As indicated in the Form 2416 instructions, if personal costs are identified, the case manager:

Upon return of signed Form 2416 from the individual, the case manager:

The case manager's signature is located in Section C. The individual's acknowledgement of personal costs (when applicable) is required prior to authorizing the requested AA or MHM.

If the request for an item does not meet the adaptive aid criteria, the case manager must deny the individual's request for the service by completing Form 2065-B and documenting the reason for denying the request in the Comments field. The case manager must complete and send Form 2065-B within two working days of determining the request for the service did not meet adaptive aid service criteria.

The Department of Aging and Disability Services requires the provider to sign and return Form 2416 to the case manager within 14 days of receipt of the form. The case manager must file this copy in the case file. If the provider does not return Form 2416, the case manager may follow up with the provider no later than five working days from the date the provider should have returned Form 2416. The case manager must document the action in the case file using Form 2405, Narrative Notes.

From the time the individual submits the written specification and bids, the case manager must review all documentation, adjust the individual plan of care, as needed, and authorize or deny the request within 14 days.

For data entry procedures in the Service Authorization System, See Section 4200, Notification and Service Authorization System.

 

4135.1 Approval of Adaptive Aids Not Listed in Section 4132, Service Limits on Adaptive Aids

Revision 12-1; Effective May 1, 2012

 

The list of adaptive aids in Section 4132, Service Limits on Adaptive Aids, is not an all-inclusive list. When a case manager receives a request for an adaptive aid not listed in Section 4132, the case manager must review the request to determine if the request is complete per Section 4131, Individual Role in Adaptive Aids, Section 4131.4, Special Requirements for Van Lifts/Vehicle Modifications, and Section 4131.1, Third–Party Resources for Adaptive Aids. The case manager must also verify all bids submitted are comparable to the written specification per Section 4133, Bid Verification for Adaptive Aids.

If the case manager determines the request is complete, he must forward the request to the regional nurse for review. If the case manager determines the request is incomplete, he must contact the individual by phone to inform him of the actions needed to complete the request. Once the individual completes the request and returns it to the case manager, the case manager will forward the request to the regional nurse for review.

Regional Nurse Responsibilities

The regional nurse will review the request to determine if the adaptive aid request meets the criteria found in Section 4130, Adaptive Aids. If the regional nurse determines the request does not meet the criteria, he must inform the case manager that the request was denied. If the regional nurse determines that the request meets the criteria found in Section 4130, he must inform the case manager that the request was approved.

Once the regional nurse approves or denies an adaptive aid request, the case manager must follow policy found in Section 4135, Adaptive Aids Service Authorization, to ensure appropriate notification, service authorization and all documentation is in the case file.

State Office Consultation

If the DADS regional nurse is unsure about approving items, he may request the state office nurse:

The DADS regional nurse will submit a written request by email to the state office nurse for Community Services Policy and Curriculum Development.

The DADS regional nurse will:

The state office nurse may request additional information if the documentation submitted is not sufficient to make a determination or does not support the regional recommendation. The state office nurse will approve or deny the request in writing to the DADS regional nurse, who will communicate the decision to the case manager.

 

4136 Adaptive Aid Delivery Time Frames and Confirmation

Revision 12-1; Effective May 1, 2012

 

§51.461

(a) The provider must deliver the adaptive aid that meets the written specifications.

(b) The provider must:

(1) deliver the adaptive aid within 30 working days of one of the following dates, whichever is later:

(A) the effective date of the IPC; or

(B) the date the provider receives and date stamps the service authorization form; or

(2) notify the individual and the case manager in writing of any delay in completing delivery of the adaptive aid, the reason for the delay, and the new proposed date of delivery.

(A) The individual and the case manager must receive the notification on or before the 30th working day described in paragraph (1) of this subsection.

(B) If DADS determines the documented reason for the delay is outside the provider's control, the provider is considered to be in compliance with this section.

§51.463

(a) Within seven working days from the date the adaptive aid is delivered, the provider must contact the individual to:

(1) verify the delivery of the adaptive aid;

(2) determine and document the individual's satisfaction or dissatisfaction with the adaptive aid; and

(3) orient the individual on the use of the adaptive aid.

(b) The provider must make a home visit if the individual is dissatisfied with the adaptive aid or needs additional training or orientation on its use. If the provider can resolve the dissatisfaction, the provider must do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, the provider must contact the case manager within seven working days of the home visit.

(c) Within 14 working days of the initial contact required in subsection (a) of this section, the provider must complete the home visit and document delivery of the adaptive aid as described in §51.505 of this chapter (relating to Purchase Completion Documentation).

§51.505

(a) An adaptive aid or minor home modification provider must record the completion of purchase for a minor home modification or an adaptive aid on a single document that includes:

(1) the name of the individual and the individual's parent or guardian, if applicable;

(2) the individual's address;

(3) a description of the modification or adaptive aid;

(4) the date of completion or delivery;

(5) a statement of satisfaction or dissatisfaction with the minor home modification or adaptive aid; and

(6) the provider's name and vendor number.

(c) In addition to the requirements in subsection (a) of this section, the adaptive aid provider must include the following on the purchase completion document:

(1) the name and title of the person completing the orientation on the adaptive aid; and

(2) the date of the orientation on the adaptive aid.

(d) If the provider must make a home visit to the individual due to the individual's dissatisfaction or to provide additional orientation, the provider must send a copy of the purchase completion documentation to the case manager within seven working days of the home visit.

(e) After all purchase completion documentation activities are complete, the provider's representative must sign and date the purchase completion document referenced in subsection (a) of this section and submit it to the case manager within seven working days of the dated signature.

The provider has 30 working days from either the individual plan of care (IPC) effective date or receipt of Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, whichever is later, to deliver the adaptive aid. The case manager and the individual should receive written notification of any delays in meeting the delivery time frame from the provider. The provider should propose a new delivery date in the written notification.

If requested by the individual or if the case manager does not agree with the provider's reason for the delay, the case manager is responsible for taking appropriate steps to address the concerns. Within five working days of receipt of the provider's written notification regarding the delay in delivering the adaptive aid, the case manager must contact the provider to review the proposed delivery date or address the individual's or case manager's concerns.

The case manager must inform the individual of the provider's responsibility to contact the individual within seven working days from the date the adaptive aid is delivered and installed to:

The case manager must also inform the individual the provider must complete a home visit within 14 working days from the date of the contact and obtain the individual's signature acknowledging receipt of the adaptive aid.

The case manager may inform the individual that if the individual is dissatisfied with the adaptive aid, the provider must address the individual's concern within seven working days of the home visit. If the provider can resolve the dissatisfaction, the Department of Aging and Disability Services (DADS) requires the provider to do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, DADS requires the provider to contact the case manager within seven working days of the home visit.

DADS requires the provider to submit purchase completion documentation to the case manager within seven working days of the provider's signature or within seven working days of the home visit when the provider has completed all purchase and delivery activities.

The purchase completion documentation must include the:

Purchase completion documentation does not have to be on Form 8605, Documentation of Completion of Purchase. If the provider does not submit purchase completion documentation within the required time frame, the case manager may follow up with the provider no later than five working days from the date the provider should have submitted the documentation. The case manager must document the action in the case file using Form 2405, Narrative Notes.

 

4140 Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.103

(33) Minor home modification—A physical change to an individual's residence that is needed to prevent institutionalization or to support the most integrated setting for an individual to remain in the community.

A minor home modification is a physical modification to an individual's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the individual or to enable the individual to function with greater independence in his home.

The case manager informs the applicant of minor home modifications at the initial home visit and reviews the service criteria at the annual reassessment or upon the individual's request.

The case manager must provide the applicant the Tool for Minor Home Modifications, found in Appendix II, Medically Dependent Children Program (MDCP) Tools, at the initial home visit.

The case manager must offer the individual the tool when the service criteria are reviewed at the annual reassessment if the individual requests a minor home modification. Whenever an individual requests a minor home modification, the case manager must send Department of Aging and Disability Services (DADS) resources and publications the individual may need to acquire minor home modifications within five working days of the request. The case manager should include the following DADS resources and publications in a minor home modification packet:

 

4141 Individual Role in Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

In the Medically Dependent Children Program, the individual, primary caregiver or family assume primary responsibility for obtaining all documentation needed to request minor home modifications.

The individual is responsible for obtaining written specifications for requests costing more than $1,000 for minor home modifications. See Section 4141.2, Specifications for Minor Home Modifications, for requirements.

The individual is responsible for obtaining three bids for requests costing more than $1,000 for minor home modifications. See Section 4141.3, Bids for Minor Home Modifications, for requirements.

The case manager must ensure the individual is aware of his role in obtaining minor home modifications and should assist the individual in understanding the prior authorization process.

 

4141.1 Minor Home Modification Bidders

Revision 12-1; Effective May 1, 2012

 

§51.233

(b) If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

The individual may choose a provider from a list of minor home modification providers or a non-contracted entity to submit a bid. The individual should inform non-contracted entities that the non-contracted entity must apply for a contract with the Department of Aging and Disability Services (DADS) if the individual chooses the non-contracted entity to complete the minor home modification. The case manager must refer the individual to the Medically Dependent Children Program (MDCP) rules governing provider and service delivery requirements for minor home modifications. The case manager must encourage the individual to refer non-contracted entities to these rules before applying to contract with DADS. MDCP rules are available on the Internet at https://hhs.texas.gov/. The individual may instruct the non-contracted entity to follow these steps to access MDCP rules:

The case manager must encourage the individual to refer non-contracted entities to the DADS Contracts Unit at 512-438-5430, to request a minor home modification contract enrollment packet for MDCP. The case manager may only authorize contracted minor home modification providers to deliver minor home modifications.

 

4141.2 Specifications for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.103

(47) Texas Accessibility Standards—Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.325

(a) For a minor home modification costing $1,000 or more, an individual must obtain written specifications. The individual may obtain separate written specifications when different contractors will complete different parts of the modification.

(b) A person with home modification experience must prepare the written specifications. The individual must document the experience of the person preparing the specifications and submit the documentation to the case manager with the request for the minor home modification.

(c) The individual must record the specifications on a single document that includes:

(1) the individual's name and address;

(2) a description of the home modification being specified;

(3) the written specifications, including any applicable local regulations, any construction requirements, and any applicable Texas Accessibility Standards;

(4) the printed name and dated signature of the person who prepared the written specifications; and

(5) the individual's dated signature.

 

Written specifications are required for minor home modification requests costing $1,000 or more. The Department of Aging and Disability Services will accept specifications prepared by a person with home modification experience.

On a single document, the preparer must include:

The individual must provide the same document to all providers and non-contracted entities submitting bids for minor home modifications.

The case manager must request the individual to submit the documentation with the written specification when submitting bids for minor home modifications.

If the documentation is incomplete, the case manager identifies the missing information and asks the individual to have the preparer submit the completed documentation.

The case manager must document the specification preparer qualifications using Form 2405, Narrative Notes, or Appendix IV, Minor Home Modification (MHM) Checklist, in the case file.

 

4141.2.1 Justifications for Minor Home Modifications Less Than $1,000

Revision 12-1; Effective May 1, 2012

 

The individual is not required to submit specifications for minor home modifications costing less than $1,000. To request a minor home modification costing less than $1,000, the individual must submit documentation that includes:

 

4141.2.2 Specifications for Minor Home Modifications with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

 

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

After determining a request for minor home modifications requires a personal cost contribution from the individual, the case manager informs the individual that updated specifications are needed to continue the service authorization process.

The case manager must inform the individual of the specification items that can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated specifications must meet the criteria listed in Section 4141.2, Specifications for Minor Home Modifications, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The items in the updated written specifications should not differ from the ones listed in the original written specification.

The individual must submit the updated written specifications to the case manager to continue the minor home modification authorization process.

See Section 4144, Individual Personal Costs for Minor Home Modifications, for procedures to determine the individual's personal costs.

 

4141.3 Bids for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.321

(a) Before undertaking a minor home modification, an individual must submit a request for the minor home modification to the case manager. For a minor home modification costing $1,000 or more, the request must include written specifications and bids as described in this division.

§51.329

(a) For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).

(b) The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.

(c) If the individual is unable to obtain three bids, the individual must contact the case manager to provide documentation to support the lack of three bids and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about all efforts to secure three bids.

§51.471

(c) The provider must not hire or reimburse a spouse, parent, or guardian of an individual for work related to the modification, including preparation of the written specifications and the inspection.

The Department of Aging and Disability Services requires a minimum of three bids for minor home modification requests costing $1,000 or more. The individual must provide the same written specification documentation to all providers and non-contracted entities submitting bids. The individual is not limited to the list of minor home modification providers and may obtain bids from non-contracted entities. The case manager sends Form 2436, Minor Home Modification Bid, to the individual upon the individual's request for a minor home modification.

If the individual is unable to get three bids, the individual must provide specific information to the case manager about his efforts to get the required bids. The case manager must document the individual's reason for obtaining less than three bids in the case file using Form 2405, Narrative Notes.

The case manager must inform the individual:

Bids submitted by the individual must include written specification documentation and the cost for the actual work. Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

The case manager must inform the individual the provider cannot hire or pay the individual's spouse, parent or guardian to complete any portion of the modification, written specification completion or inspection.

 

4141.3.1 Bids for Minor Home Modifications Less Than $1,000

Revision 12-1; Effective May 1, 2012

 

The individual is not required to submit three bids for minor home modification requests costing less than $1,000. To request minor home modifications costing less than $1,000, the individual must submit at least one bid to the case manager. The bid must list each item separately and include a list of materials and the cost for each item. The bid should also include costs for labor and builder grade materials.

 

4141.3.2 Bids for Minor Home Modifications with Individual Personal Costs

Revision 12-1; Effective May 1, 2012

 

§51.329

(a) For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).

(b) The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

After determining a request for a minor home modification requires a personal cost contribution from the individual, the case manager follows procedures in Section 4141.2.2, Specifications for Minor Home Modifications with Individual Personal Costs. The individual must also obtain updated bids to reflect the changes in the updated specifications.

The case manager must inform the individual which items in the original bids can be approved by the Department of Aging and Disability Services (DADS) and which items may be purchased by the individual's personal cost contribution.

The updated bids must meet the criteria listed in Section 4141.3, Bids for Minor Home Modifications, and must identify the items that can be approved by DADS and the items to be purchased by the individual as a personal cost. The actual bid items should not differ from the ones listed in the original bid.

The individual must submit the updated bids with the updated specifications to the case manager to continue the minor home modification authorization process.

See Section 4144, Individual Personal Costs for Minor Home Modifications, for procedures to determine the individual's personal costs.

 

4141.4 Home Owner Approval of Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.327

An individual must obtain written approval for a minor home modification from the property owner (if leasing or renting) before submitting the request to the case manager, unless the individual's lease or rental agreement for the property specifically allows for modifications. Owner approval must be recorded on a single document that includes:

(1) the name and address of the person receiving MDCP services;

(2) a description of the minor home modification;

(3) the individual's approval of the modification;

(4) the individual's dated signature;

(5) the property owner's approval or disapproval of the modification as described in the written specifications; and

(6) the property owner's printed name and dated signature.

The individual must obtain written approval for a minor home modification from the property owner (if leasing or renting) before submitting the request to the case manager, unless the individual's lease or rental agreement for the property specifically allows for modifications.

If the individual submits a written approval, the individual must document the owner's approval on a single document that includes the:

The case manager must verify documentation of owner approval before processing the minor home modification request. The documentation required may be either a copy of the homeowner's written approval or a copy of the lease agreement allowing modifications to the property, and is filed in the case file with the minor home modification documentation.

 

4142 Service Limits on Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.103

(47) Texas Accessibility Standards—Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.231

(d) Minor home modifications. The cost ceilings for minor home modifications are:

(1) $7,500 in an individual's lifetime; and

(2) $300 for repairs and maintenance per IPC year.

 

§51.323

(a) Minor home modifications covered under MDCP are limited to:

(1) the purchase and installation of permanent and portable ramps;

(2) widening of doorways;

(3) modifications to bathroom facilities; and

(4) modifications related to the approved installation or modification of ramps, doorways, or bathroom facilities.

(b) A minor home modification must not create a new structure or add square footage to the home.

The minor home modification lifetime limit is $7,500. The case manager may authorize up to $300 per the individual plan of care (IPC) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The case manager does not include a $300 maintenance and repair limit as part of the $7,500 lifetime limit. A minor home modification must not create a new structure or add square footage to the home.

Minor home modifications are limited to:

The Department of Aging and Disability Services will reimburse contracted providers for approved minor home modifications that:

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

 

4143 Bid Verification for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.321

(a) Before undertaking a minor home modification, an individual must submit a request for the minor home modification to the case manager. For a minor home modification costing $1,000 or more, the request must include written specifications and bids as described in this division.

§51.329

(a) For a modification costing $1,000 or more, an individual must obtain a minimum of three written bids based on the written specifications described in §51.325 of this chapter (relating to Specifications for Minor Home Modifications).

(b) The individual must make the same specifications available to each bidder. Multiple modifications may be included in one bid if the same contractor will be doing the multiple modifications as one job.

(c) If the individual is unable to obtain three bids, the individual must contact the case manager to provide documentation to support the lack of three bids and explain why the individual could not obtain three bids. The individual must be prepared to provide specific information about all efforts to secure three bids.

Upon receipt of appropriate documentation and the request for a minor home modification, the case manager verifies all bids are comparable to the written specifications and include all required documentation.

The bids must list each item separately and include a list of materials and the cost for each item. The bid should also include the costs of labor and builder grade materials. Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures. All bids for bathroom modifications must include current and proposed floor plans.

 

4144 Individual Personal Costs for Minor Home Modifications

Revision 12-1; Effective May 1, 2012

 

§51.331

If an individual wants to proceed with a minor home modification that exceeds the cost or scope of the approved request, the individual is responsible for obtaining new written specifications and for all costs associated with the enhancement.

An individual may request a minor home modification or a combination of modifications that can either exceed the service limit or include items or options that are not approved by the Department of Aging and Disability Services (DADS). See Section 4141.2.2, Specifications for Minor Home Modifications with Individual Personal Costs, and Section 4141.3.2, Bids for Minor Home Modifications with Individual Personal Costs.

The individual must obtain the updated specifications and the updated bids before the case manager can complete the minor home modification authorization process.

If an individual requests a minor home modification with a cost exceeding the service limit, the case manager will review the request with the DADS nurse. If the DADS nurse approves the request, the case manager will inform the individual of DADS' approval and the individual is responsible for costs exceeding the minor home modification service limit.

Example: The individual requests a modification to a bathroom facility with a cost of $10,000. The case manager reviews the request with the DADS nurse and approves the request. The case manager must complete Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, Section A and Section B, to notify the individual that personal costs were identified.

If an individual requests a minor home modification with fixtures that do not impact institutional prevention or affect the individual's ability to function with greater independence in his home, the case manager reviews the request with the DADS nurse. The case manager and DADS nurse may approve the minor home modification and fixtures addressing institutional prevention or influence an integrated setting, but the fixtures not meeting the minor home modification criteria may be purchased by the individual.

Example: The individual requests a bathroom modification to convert a tub into a shower. The bid includes tub removal, shower installation, shower rod, curtain, and the inspection fee with a total cost of $7,500. The tub removal and shower conversion are $7,300, the shower rod and curtains are $50, and the inspection fee is $150. The case manager and DADS nurse review the request and determine the tub removal and shower installation are necessary to prevent institutionalization and determine the shower rod and curtain do not meet the service criteria. The case manager must complete Form 2416, Section A and Section B, to notify the individual that personal costs were identified.

 

4145 Minor Home Modification Repairs and Maintenance

Revision 12-1; Effective May 1, 2012

 

§51.479

The provider is responsible for all repairs or replacement of a minor home modification during the first year after completion, unless the individual or the individual's family members caused the need for repair or replacement. If the individual or the individual's family members caused the need for repair or replacement, then the individual or the individual's parent or guardian is responsible for the repair or replacement.

An individual may request maintenance or repair of a previously purchased minor home modification. The case manager must verify the need for the service is not covered by the provider's warranty. The case manager may review the original bid for warranty information, if available, or contact the provider directly. The individual should submit a bid for the repair, but is not required to submit a specification.

If the request for the service is not covered by the provider's warranty, the case manager may authorize up to $300 to the individual's provider of choice. The $300 limit is available per the individual plan of care period for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

 

4146 Minor Home Modification Service Authorization

Revision 12-1; Effective May 1, 2012

 

§51.477

(a) Reimbursement for inspection. The fee for inspecting a minor home modification, not to exceed $150, is reimbursable as part of the modification. The inspection fee must be approved as part of the bid.

The case manager may use Appendix IV, Minor Home Modification (MHM) Checklist, to review minor home modification requests to ensure all appropriate documentation requirements are in the case file. The case manager follows minor home modification criteria to review all requests for minor home modifications. Within two working days of determining eligibility for the requested services, the case manager must complete and send Form 2065-B, Notification of Waiver Services, and Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, to the individual and the provider to inform both of the case manager's decision and allowable costs covered by the Medically Dependent Children Program.

When authorizing minor home modifications, the case manager may authorize the lowest cost of the approved item(s) from the bids submitted or the service limit, whichever is less. Individuals and families have the option to pay the difference as a personal cost to pursue the requested item.

If the provider completed the specification, prepared a bid, included the specification fee in the bid and is the individual's provider of choice, the case manager may authorize no more than $200 for the specification fee. The specification fee is excluded from the total modification cost when determining if the modification is within the $7,500 limit.

The case manager may authorize no more than $150 for the inspection fee. The case manager must include the inspection fee as part of the $7,500 minor home modification lifetime service limit.

If the request for the service does not meet minor home modification criteria, the case manager must deny the individual's request by completing Form 2065-B and documenting the reason for denying the request in the Comments field. The case manager must complete and send Form 2065-B within two working days of determining the request for services did not meet minor home modification criteria.

The Department of Aging and Disability Services requires the provider to sign and return Form 2416 to the case manager within 14 days of receipt of the form. The case manager must file this copy in the case file. If the provider does not return Form 2416, the case manager should follow up with the provider no later than five working days from the date the provider should have returned Form 2416. The case manager must document the action in the case file using Form 2405, Narrative Notes.

From the time the individual submits the written specification and bids, the case manager must review all documentation, adjust the individual plan of care, as needed, and authorize or deny the request within 14 days.

For data entry procedures in the Service Authorization System, See Section 4200, Notification and Service Authorization System.

 

4147 Minor Home Modification Time Frames and Completion Confirmation

Revision 12-1; Effective May 1, 2012

 

§51.103

(47) Texas Accessibility Standards--Texas Department of Licensing and Regulation building standards adopted to meet the provisions of Texas Government Code, Chapter 469, and to meet or exceed the construction and alterations requirements of Title III of the Americans with Disabilities Act (42 U.S.C. §§12181-12189).

§51.473

The provider must:

(1) ensure completion of the minor home modification within 30 working days of one of the following dates, whichever is later:

(A) the effective date of the IPC; or

(B) the date the provider receives and date stamps the service authorization form; or

(2) notify the individual and the case manager in writing of any delay in completion of the modification, the reason for the delay, and the new proposed date of completion.

(A) The notification must be received on or before the 30th working day described in paragraph (1) of this section.

(B) If DADS determines the documented reason for the delay is outside the provider's control, the provider is considered to be in compliance with this section.

§51.475

(a) The provider must ensure that someone who did not complete the minor home modification inspects the minor home modification.

(b) The inspection must be made on-site within seven working days of the completion date to determine whether the modification:

(1) was completed;

(2) is in compliance with Texas Accessibility Standards and any other applicable standards or codes; and

(3) is in compliance with the written specifications, if applicable.

(c) For requirements concerning reimbursement of the inspection fee, see §51.477 of this chapter (relating to Reimbursement of Minor Home Modifications).

(d) Within seven working days of the date a completed minor home modification is inspected, the provider must contact the individual to:

(1) verify the completion of the minor home modification; and

(2) determine and document the individual's satisfaction or dissatisfaction with the minor home modification.

(e) The provider must make a home visit if the individual is dissatisfied with the minor home modification. If the provider can resolve the dissatisfaction, the provider must do so within seven working days of the home visit. If the provider cannot resolve the dissatisfaction, the provider must contact the case manager within seven working days of the home visit.

(f) Within 14 working days of the initial contact required in subsection (d) of this section, the provider must complete the home visit and document the completion and inspection of the minor home modification as described in §51.505 of this chapter (relating to Purchase Completion Documentation).

§51.505

(a) An adaptive aid or minor home modification provider must record the completion of purchase for a minor home modification or an adaptive aid on a single document that includes:

(1) the name of the individual and the individual's parent or guardian, if applicable;

(2) the individual's address;

(3) a description of the modification or adaptive aid;

(4) the date of completion or delivery;

(5) a statement of satisfaction or dissatisfaction with the minor home modification or adaptive aid; and

(6) the provider's name and vendor number.

(b) In addition to the requirements in subsection (a) of this section, the minor home modification provider must include the following on the purchase completion document:

(1) the name and qualifications of the inspector;

(2) whether the minor home modification was:

(A) completed according to Texas Accessibility Standards; and

(B) completed according to any required written specifications;

(3) the inspector's dated signature; and

(4) the individual's dated signature.

(d) If the provider must make a home visit to the individual due to the individual's dissatisfaction or to provide additional orientation, the provider must send a copy of the purchase completion documentation to the case manager within seven working days of the home visit.

(e) After all purchase completion documentation activities are complete, the provider's representative must sign and date the purchase completion document referenced in subsection (a) of this section and submit it to the case manager within seven working days of the dated signature.

The provider has 30 working days from either the individual plan of care (IPC) effective date or receipt of Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, whichever is later, to complete the minor home modification. The case manager and the individual should receive written notification of any delays in meeting the delivery time frame from the provider. The provider should propose a new delivery date in the written notification.

If requested by the individual or if the case manager does not agree with the provider's reason for the delay, the case manager is responsible for taking appropriate steps to address the concerns. Within five working days of receipt of the provider's written notification regarding the delay in completing the minor home modification, the case manager must contact the provider to review the proposed delivery date or address the individual's or case manager's concern.

The case manager must inform the individual the minor home modification must be inspected within seven working days from the modification completion date. The provider must send an inspector, someone who did not complete the modification, to inspect the minor home modification.

The case manager must inform the individual the provider must contact the individual no later than seven working days after the inspection to determine and document the individual's satisfaction or dissatisfaction with the minor home modification.

The case manager must inform the individual the provider must complete a home visit within 14 working days from the date of the contact and obtain the individual's signature acknowledging completion of the minor home modification.

If the individual is dissatisfied with the minor home modification, the case manager may inform the individual the provider must address the individual's concern within seven working days of the home visit.

The Department of Aging and Disability Services (DADS) requires the provider to submit purchase completion documentation when all service delivery activities are complete.

The purchase completion documentation must include the:

The case manager should receive purchase completion documentation within seven working days of the provider's signature on the documentation or within seven working days of the home visit. DADS does not require providers to use Form 8605, Documentation of Completion of Purchase. The case manager must file purchase completion documentation in the case file within two working days of receipt from the provider. If the provider does not submit purchase completion documentation within the required time frame, the case manager may follow up with the provider no later than five working days from the date the provider should have submitted the documentation. The case manager must document the action in the case file using Form 2405, Narrative Notes.

 

4150 Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

 

§51.103

(49) Transition assistance services—One-time service provided to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community to receive MDCP services.

The case manager must advise applicants who reside in a nursing facility (NF) or individuals whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or individual needs assistance in setting up a household when relocating into the community from the NF.

At the initial interview, the case manager will discuss the applicant's or individual's community living arrangement and ask where the applicant or individual intends to live upon discharge from the NF.

The applicant or individual may access TAS if the applicant or individual:

If these or any other situation exists that creates a barrier to the applicant's or individual's transition, the case manager may continue reviewing TAS criteria.

 

4151 Transition Assistance Services (TAS) Description

Revision 12-1; Effective May 1, 2012

 

§62.5

(a) Transition assistance services (TAS) assist Medicaid recipients who are nursing facility residents discharged from the facility to set up a household. TAS are only available to nursing facility residents who are discharged from the facility into a waiver program. TAS are not available to residents moving from a nursing facility who are approved for any of the following waiver services:

(1) assisted living services;

(2) adult foster care services;

(3) support family services;

(4) 24-hour residential habilitation; or

(5) family surrogate services.

 

TAS may be available to pay for non-recurring set-up expenses for applicants transitioning from nursing facilities (NFs) into the Medically Dependent Children Program (MDCP) and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant's or individual's transition into the community to set up a household.

TAS may include, but is not limited to, payment or purchases of:

 

4151.1 Deposits

Revision 12-1; Effective May 1, 2012

 

§62.5

(b) TAS include, but are not limited to:

(1) payment of security deposits required to lease an apartment or home, or to establish utility services for the home

The case manager may authorize Transition Assistance Services (TAS) to pay deposits which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or individual's name.

 

Residential Leases

A security deposit is a one-time expense and the amount may be no more than the equivalent of two months rent. The case manager must not authorize TAS to pay rent.

TAS may be accessed to pay for pet deposits only if the pet is the applicant's or individual's service animal.

 

Household Utilities

TAS may be used to pay for utility deposits to establish accounts in the applicant's or individual's name or to pay for arrears on previous utilities if the account is in the applicant's or individual's name and the applicant or individual will not be able to get the utilities unless the previous balance is paid. The case manager must not authorize TAS for payment toward utilities.

TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The case manager must not authorize TAS to pay for any charges on upgrades.

TAS funds can be used to pay for initial setup or reconnection fees to propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call. The case manager must not authorize TAS to top off a tank with fuel when the applicant's or individual's home is connected and has a supply of butane or propane.

 

4151.2 Essential Furnishings

Revision 12-1; Effective May 1, 2012

 

§62.5

(b) TAS include, but are not limited to:

(2) purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, and food preparation items

 

The case manager may authorize Transition Assistance Services (TAS) to purchase essential furnishings and household items that, if absent, would pose a barrier to the applicant's or individual's transition into the community.

Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

 

Furniture

The case manager may authorize TAS to purchase furniture such as a bed, recliner or dinette if the applicant's or individual's place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

 

Appliances

The case manager may authorize TAS to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or individual identifies these appliances as needed items.

 

Housewares

The case manager may authorize TAS to purchase housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

 

Cleaning Supplies

The case manager may authorize TAS to purchase cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

 

Other

The case manager may authorize TAS to purchase any special request from the applicant or individual not included in the general list that meets the criteria as a basic essential furnishing to transition into the community.

 

4151.3 Moving Expenses

Revision 12-1; Effective May 1, 2012

 

§62.5

(b) TAS include, but are not limited to:

(3) payment of moving expenses required to move into or occupy the home or apartment

The case manager may authorize Transition Assistance Services (TAS) to pay for moving expenses, which may include the cost of moving the applicant's or individual's belongings from the nursing facility to the community residence, or delivery charges on TAS items approved by the case manager.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or individual from the nursing facility to his residence in the community.

 

4151.4 Site Preparation

Revision 12-1; Effective May 1, 2012

 

§62.5

(b) TAS include, but are not limited to:

(4) payment for services to ensure the health and safety of the client in the apartment or home, such as pest eradication, allergen control, or a one-time cleaning before occupancy

The case manager may authorize Transition Assistance Services (TAS) to pay for preparing the applicant's or individual's place of residence for occupancy if the current condition of the residence prevents the applicant's or individual's transition from the nursing facility.

Site preparation purchased with TAS funds may include pest eradication, allergen control and a one-time residential cleaning.

Pest Eradication

The case manager may authorize TAS if the residence has been unattended and is in need of some type of extermination.

 

Allergen Control

The case manager may authorize TAS if the residence has been unattended or the applicant or individual is moving into a place that poses a respiratory health problem.

 

One-time Cleaning

The case manager may authorize TAS if the applicant's or individual's residence has been unattended or the applicant or individual is moving into a private home or apartment where pre-move-in cleaning should not be expected, for example, a family friend has an empty house available but cannot provide the cleaning.

 

4152 Limits on Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

 

§51.231

(e) Transition assistance services:

(1) An individual may access transition assistance services only once in the individual's lifetime; and

(2) The cost ceiling for transition assistance services is $2,500.

 

§62.5

(a) Transition assistance services (TAS) assist Medicaid recipients who are nursing facility residents discharged from the facility to set up a household.

The service limit on TAS is $2,500. An applicant or individual may access TAS only once in his lifetime.

A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services may receive a one-time TAS authorization if the case manager determines that no other resources are available to pay for the basic services or items needed by the applicant or individual.

The case manager may not authorize TAS for:

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications.

TAS is only available to applicants or individuals who are discharged from a nursing facility and require TAS to set up a household.

 

4153 Authorizing Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

 

§62.31

The provider agency must accept all clients of any waiver program whom the Texas Department of Human Services refers to the provider agency for services under this chapter.

§62.33

(a) The provider agency must:

(1) deliver to the client the specific transition assistance service that the case manager authorized in writing;

(2) purchase services for the client within the dollar amount that the case manager authorizes; and

(3) submit a claim for reimbursement to the Texas Department of Human Services only after the purchased services have been delivered to the client.

 

The case manager follows the Medically Dependent Children Program (MDCP) TAS definition and limitations to review all requests for TAS. The case manager authorizes TAS by completing Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The case manager authorizes the provider to deliver TAS on Form 8604. The case manager may estimate the costs of items and services if the actual cost is not known.

The applicant or individual selects a provider from the list of contracted TAS providers. The Department of Aging and Disability Services (DADS) requires TAS providers to accept all applicants and individuals referred by the case manager.

The applicant or individual signs Form 8604 to indicate the items listed are necessary to establish a household in the community and to let the selected provider purchase the approved items and services.

The case manager must inform the applicant or individual that TAS items or services must be purchased and delivered before the applicant or individual leaves the nursing facility. DADS requires the provider to have all services and items completed two days before the applicant's or individual's discharge date.

The case manager must explain to the applicant that the service will not be authorized until the applicant is determined eligible for MDCP services and the applicant is notified in writing of MDCP eligibility. The case manager must contact the applicant before eligibility determination to verify the applicant has arranged for community relocation and has a projected discharge date. The case manager sends Form 8604 to the provider and applicant or individual before the discharge date. At a minimum, the case manager must allow five days between the authorization date and the discharge date. Example: If the applicant's discharge date is Tuesday, the case manager must send the forms to the applicant and provider no later than Wednesday of the previous week.

Upon receipt of Form 8604, if the provider has questions regarding the authorized items or services, DADS requires the provider to contact the case manager by the following working day and before purchasing any items or services. The case manager will contact the applicant or individual, if necessary, to clarify any information. The case manager will revise Form 8604 and send it to the provider and applicant or individual within two working days if the case manager changes any authorized item or service. See Section 4153.1, Changes to Transition Assistance Services (TAS) Authorization.

The case manager must not authorize the full TAS limit of $2,500 without regard to the applicant's or individual's identified needs.

If the applicant's or individual's request for an item or service does not meet the TAS criteria, the case manager must deny the request for TAS.

For an applicant accessing TAS, the case manager delays Service Authorization System (SAS) data entries for all MDCP services included in the initial individual plan of care (IPC) until the applicant has been discharged from the nursing facility. The case manager must data-enter authorized MDCP services in SAS no later than 14 days from the IPC service initiation date.

For an individual accessing TAS, the case manager must create and update SAS records by the effective date of the IPC change if services are utilized during the IPC period. If service delivery coincides with the annual reassessment, the case manager data enters TAS and other MDCP services by the end of the previous IPC period.

 

4153.1 Changes to Transition Assistance Services (TAS) Authorization

Revision 12-1; Effective May 1, 2012

 

If the provider, the applicant or individual identify additional items or services are required after Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, has been sent, the provider should submit a request in writing to update the authorization to the case manager. The case manager must update Form 8604 when a new item is requested or when the cost of items exceeds the previous total authorized amount if the request is within the scope and limit for this service. The case manager must send an updated Form 8604 to the provider within two working days from the date the Department of Aging and Disability Services received the provider's written request.

If a change request is received and the original authorization has been entered into the Service Authorization System (SAS), the case manager modifies the units in the TAS service authorization and the service plan SAS records.

If a provider submits a request to update Form 8604 to change the costs estimated for specific items or services, but the change does not result in exceeding the total TAS amount that was originally authorized, the case manager does not need to update Form 8604.

The case manager must request a review and approval from the Medically Dependent Children Program supervisor to authorize delivery of TAS after the nursing facility discharge date.

 

4154 Transition Assistance Services (TAS) Delivery Time Frames and Confirmation

Revision 12-1; Effective May 1, 2012

 

§62.33

(b) The provider agency must complete the delivery of services to the client at least two days before the client's nursing facility discharge date.

(c) The provider agency may fail to deliver authorized services to the client by the applicable due date described in subsection (b) of this section only if the reason for the delay is beyond the control of the provider agency, and only if the provider agency makes an ongoing effort to deliver the services. The provider agency must document any failure to deliver the authorized services by the applicable due date, including:

(1) a description of the pending services;

(2) the reason for the delay;

(3) either the date the provider agency anticipates it will deliver the pending services or specific reasons why the provider agency cannot anticipate a delivery date; and

(4) a description of the provider agency's ongoing efforts to deliver the services.

(d) The provider agency must orally notify the case manager of any failure to deliver any of the authorized services before the applicable due date described in subsection (b) of this section. Oral notice means directly speaking with the case manager and does not include a message left by voice mail.

The provider purchases the authorized items or services and arranges and pays for the delivery of the purchased items, if applicable. The provider purchases only items or services identified, and within the total dollar amount authorized by the case manager, on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The case manager must inform the applicant or individual that the provider may contact the applicant or individual or the applicant's or individual's authorized representative, if necessary, to coordinate service delivery.

The Department of Aging and Disability Services (DADS) requires the provider to deliver the authorized services by the completion date recorded on Form 8604. DADS requires the provider to give copies of the purchase receipts and any original product warranty information to the applicant or individual. The provider should maintain the original purchase receipts, including sales tax, delivery or installation charges.

The case manager must allow at least five days between the date of authorization and the completion date on Form 8604. The completion or delivery date should be two days before the applicant's or individual's nursing facility (NF) discharge date. The provider should contact the applicant or individual by the completion date to confirm that all authorized items or services were delivered.

If a provider cannot deliver all authorized items or services at least two days before the applicant's or individual's NF discharge date, the provider should directly notify the case manager before the discharge date to give:

DADS requires the provider to orally notify the case manager of any failure to deliver any of the authorized items or services before the due date. Oral notice means directly speaking with the case manager and does not include a message left by voice mail.

The case manager must contact the applicant or individual to inform the applicant or individual of the provider's delay in delivering TAS.

 

4155 Failure to Leave the Nursing Facility

Revision 12-1; Effective May 1, 2012

 

While the case manager makes every effort to confirm the applicant or individual has definite plans to leave the nursing facility (NF), there may be situations when the applicant or individual changes his mind or has a change in his health, making it impossible for him to relocate to the community as planned. In this situation, the case manager notifies the Transition Assistance Services (TAS) provider that the applicant or individual is no longer moving and no further items or services are to be purchased.

The Department of Aging and Disability Services (DADS) requires the provider to attempt to return any item(s) purchased on behalf of the applicant or individual and refund the amount of the purchase. DADS also requires the provider to attempt to recoup security, utility and other deposits paid on behalf of the applicant or individual.

If the provider is unsuccessful in returning the item(s) for the amount of monies paid or the deposits paid on behalf of the applicant or individual cannot be recouped, the provider is entitled to the cost of the item(s) and reimbursement for deposits paid, not to exceed the amount authorized by the case manager. DADS requires the provider to send the case manager written notice stating the item(s) could not be returned or the deposits could not be recouped. DADS staff must contact a local charity to donate the items and must make arrangements for pick-up. The charity must serve individuals whose needs are similar to those of the applicant or individual for whom the items were purchased or must be dedicated to assisting individuals establishing a home. The case manager documents the outcome of the donated items in the case file using Form 2405, Narrative Notes, before closing the case file.

If the provider is able to return the item(s) or receives the deposits back, the provider is not entitled to reimbursement. If the provider recoups part of the monies paid, the provider is entitled to the costs of the item(s) or deposits less any monies recouped. DADS requires providers to adjust any claims filed and paid for items, services or deposits and pay monies back to DADS.

If a service has already been delivered, such as pest eradication, then the provider is entitled to the costs of the service, not to exceed the authorized amount.

If the individual is only in the community for a few days and returns to the NF, the individual keeps the item(s) purchased through TAS.

The provider can bill for the TAS fee in all of the above situations.

DADS will reimburse the provider for any authorized item or service purchased. To data enter TAS and the TAS fee in the Service Authorization System (SAS) for an applicant or individual who is not enrolled in the waiver program, the case manager must select "100 – 100% State" option from the drop down feature in the Fund field and select "Force" in the Service Authorization record. In the Force Comment field, the case manager enters "Forcing 100% state funds for individual not discharged from NF." The case manager must complete all SAS data entries within two working days of notification the applicant/individual will not transition to the community.

 

4160 Financial Management Services

Revision 15-3; Effective March 11, 2015

 

Financial Management Services (FMS) provides assistance to individuals with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers. The FMS provider, referred to as the Financial Management Services Agency (FMSA), also serves as the individual's employer-agent, which is the Internal Revenue Service's (IRS) designation of the entity responsible for IRS-related responsibilities on behalf of the individual. As the employer-agent, the FMSA also files required forms and reports to the Texas Workforce Commission.

The FMSA also:

See Section 8000, Consumer Directed Services, for policy regarding the service delivery option.

 

4170 Employment Assistance (EA)

Revision 14-2; Effective September 1, 2014

Employment services are intended to assist individuals to find employment and maintain employment. Senate Bill 45, passed by the 83rd Legislature, required that all Medicaid waivers offer Employment Assistance (EA) and Supported Employment (SE). DADS is also adding the Consumer Directed Services option for both EA and SE.

 

4171 Process to Authorize EA Services

Revision 14-2; Effective September 1, 2014

For individuals who are competitively or self-employed, the case manager/service coordinator, in consultation with the service planning team (SPT), including the individual, the case manager/service coordinator and any other parties the individual chooses to participate, such as family members and service providers, determine if the individual needs paid supports to sustain employment.

The case manager completes Form 2429, Job Interest Assessment, at the initial face-to-face visit for every individual 18 years of age through 20 years of age. For individuals already enrolled in the Medically Dependent Children Program (MDCP), the case manager completes Form 2429 at the reassessment following the individual’s 18th birthday.

If Form 2429 indicates a "yes" response on all of the last three questions, the case manager uses the "First Steps to Employment for People with Significant Disabilities" tool to guide the individual’s SPT, including the individual, to consider the individual’s interests, strengths and supports available before applying for Department of Assistive and Rehabilitative Services (DARS). While the tool was developed in consultation with DARS, considering these topics should help an individual be successful in employment even if he or she does not receive DARS.

For any individual under age 22, the case manager will ensure that employment services are not available to the individual from the individual’s school district before authorizing waiver Employment Assistance (EA) services. The case manager documents the method by which he or she determined availability of school district-funded employment services.

The case manager refers the individual to DARS within 30 days of completing Form 2429 at the initial face-to-face visit. The case manager should contact the local DARS office to identify the referral process used by that office. Local DARS offices may be located at http://www.dars.state.tx.us/drs/offices/OfficeLocator.aspx or by calling l-800-628-5115.

If an individual refuses to contact DARS, he or she may not receive waiver-funded EA.

An individual who has been referred for DARS or contacted DARS himself is eligible to receive waiver-funded EA until DARS has developed the Individualized Plan of Employment (IPE) and the individual has signed it. The DADS case manager authorizes 10 hours for EA using Form 2430, Employment Assistance and Supported Employment Authorization. Employment assistance can be authorized up to 180 days. The individual or provider may request more hours for EA if needed.

Upon request and with proper authorization for disclosure, the case manager will assist the individual to provide the DARS Vocational Rehabilitation Counselor (VRC) with the following items described in the DARS Guide for Applicants at http://www.dars.state.tx.us/drs/DRSguide.shtml:

If the VRC determines that DARS is not the appropriate resource to meet the individual's needs and does not take an application for services, documentation of this decision in the individual’s record serves as sufficient evidence that DARS is not available and the individual is eligible to receive waiver-funded EA.

DARS will:

If DARS has not notified the individual of an eligibility decision within 60 days of the initial DARS appointment, the individual’s case manager will attempt to contact the assigned DARS VRC to determine the status of the application and document the contact in the narrative notes

The individual’s case manager will ensure that communication is maintained with the assigned DARS VRC regarding waiver-funded services provided between the DARS Vocational Rehabilitation (VR) referral and the "start date" of DARS, as defined in the individual's DARS VR IPE.

The case manager will complete Form 2065-B, Notification of Waiver Services, to notify the individual of the last day EA services will be provided using waiver funds. At the request of an individual determined eligible for DARS, the case manager, along with the individual, will:

 

4180 Supported Employment (SE)

Revision 14-2; Effective September 1, 2014

 

Supported Employment (SE) services provide assistance to help an individual sustain competitive employment or self-employment.

Competitive employment is work:

An integrated setting is a setting typically found in the community in which applicants or eligible individuals interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

Self-employment is work in which the individual:

SE services include:

SE may be provided through the waiver if documentation is maintained in the individual’s record, for an individual under age 22, that the service is not available to the individual under a program funded under the Individuals with Disabilities Education Act (IDEA). (20 U.S.C. §1401 et seq.)

The provider must ensure provision of SE, as needed, for an individual to sustain competitive employment or self-employment, if the services are not available through the local school district for an individual under age 22.

 

4181 Role of the Case Manager

Revision 14-2; Effective September 1, 2014

 

The DADS case manager coordinates with other agencies, including the Texas Health and Human Services Commission, regarding an individual’s continued Medicaid eligibility once he or she begins working. The DADS case manager also coordinates with the Department of Assistive and Rehabilitative Services (DARS) and the local school districts, seeking third party resources before using employment assistance (and supported employment, in the case of school districts).

Activities include:

 

4200 Notification and Service Authorization System

Revision 12-1; Effective May 1, 2012

 

The case manager completes Form 2065-B, Notification of Waiver Services, to document the applicant's initial and individual's ongoing eligibility for Medically Dependent Children Program (MDCP) services and to authorize the provider to deliver MDCP services.

See Section 4231, Service Authorization System (SAS) Data Entry, for procedures for data entering information in SAS.

 

4210 Applicant/Individual Eligibility Notification

Revision 13-2; Effective May 1, 2013

 

Notifications for Program Eligibility

The case manager reviews all eligibility criteria in Section 1300, Eligibility. The applicant is eligible for the Medically Dependent Children Program (MDCP) when all eligibility criteria are met. Since a disability determination is only required at the initial enrollment, the case manager does not assess for a disability at annual reassessments, as directed in Section 1350, Disability. The case manager documents the applicant's/individual's eligibility and authorizes MDCP services by completing Form 2065-B, Notification of Waiver Services. The case manager sends Form 2065-B to the applicant/individual with the case manager's original signature within two working days of determining program eligibility.

In addition to Form 2065-B and also within two working days of determining program eligibility, the case manager completes and sends the following service authorization forms to the applicant/individual, as appropriate:

The applicant/individual is not eligible for MDCP services if the case manager determines he does not meet all eligibility criteria. The case manager documents program ineligibility by completing and sending Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, with the case manager's original signature to the applicant/individual within two working days from the date the case manager determined program ineligibility.

Notifications for Specific Services

If the applicant/individual requests a change to the individual plan of care (IPC) at a time other than the initial or annual reassessment, upon determination the request meets MDCP service criteria, the case manager completes and sends Form 2065-B to the applicant/individual with the case manager's original signature within two working days.

If the applicant/individual requests a specific service and the case manager determines the request does not meet MDCP service criteria but the denial does not affect the applicant's/individual's program eligibility, the case manager must complete and send Form 2065-B to the applicant/individual within two working days from the date the case manager determined the individual's request did not meet MDCP service criteria.

 

4220 Provider Notification

Revision 13-2; Effective May 1, 2013

 

§51.413

(a) A provider must receive the service authorization form from the case manager before delivering services.

(b) Within 14 days after receiving the service authorization form, the provider must send the case manager:

(1) a signed copy of the service authorization form; and

(2) a signed copy of the practitioner's orders. This paragraph applies only to a respite or adjunct support services provider that is:

(A) a home and community support services agency using:

(i) an RN;

(ii) an LVN; or

(iii) an attendant with delegated nursing tasks;

The case manager authorizes providers to deliver services by completing Form 2065-B, Notification of Waiver Services. The case manager sends the appropriate service authorization form and appropriate service plan to each provider. Within two working days of program eligibility determination or approval for a specific service and in addition to Form 2065-B, the case manager sends:

For Respite and Flexible Family Support Services, the case manager may use the comments section of Form 2414 or Form 2415 to give specific instructions to providers about the applicant's/individual's service arrangement. These include specific instructions about unique applicant/individual concerns or the home environment, the requested nurse type or information about qualifications for potential attendants.

By completing Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, the case manager authorizes TAS providers to deliver TAS. The case manager completes and sends Form 8604 to the TAS provider no later than five days before the applicant's/individual's nursing facility discharge date. The case manager does not send a copy of Form 2065-B to TAS providers.

 

4230 Service Authorization System (SAS)

Revision 12-1; Effective May 1, 2012

 

The case manager must data enter individual plan of care (IPC) information in SAS by appropriate time frames and then ensure accuracy of the information submitted. SAS maintains information relevant to the individual's authorized services. The case manager must data enter authorized services into SAS before a provider can receive payment for services delivered to an individual.

 

4231 Service Authorization System (SAS) Data Entry

Revision 13-2; Effective May 1, 2013

 

SAS Data Entry Time Frames

The SAS data entry must be completed at the same time Form 2065-B, Notification of Waiver Services, is completed on initial authorizations, redeterminations or changes, or when Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is completed for a change resulting in denial or termination of MDCP services. When the SAS data entry cannot be completed at the same time Form 2065-B or Form 2065-C is completed, the delay must be documented. There is an exception to this for Money Follows the Person (MFP) certifications.

MFP Certifications

The case manager notifies the individual applying for MDCP services through MFP of MDCP eligibility and the negotiated nursing facility (NF) discharge date, which is the effective date of MDCP services on Form 2065-B.

Completion of SAS data entry must meet the following time frames:

The case manager must verify the information in SAS matches the new or updated plan of care and service authorization forms. The plan of care forms are:

The service authorization forms are:

If the SAS data entry cannot be completed within the identified time frames, the case manager must document the delay and complete the SAS data entry as soon as possible. The case manager must document all SAS data entry delays in the case file using Form 2405, Narrative Notes.

 

4232 Service Authorization System (SAS) Data Entry for Service Reductions, Suspensions, Denials and Case Closures

Revision 13-2; Effective May 1, 2013

 

SAS data entry should be completed at the same time Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is completed, or when federal or state law requires a change resulting in a reduction, denial or termination of MDCP services. When SAS data entry cannot be completed, the delay must be documented.

Below are exceptions to the requirement for completion of Form 2065-B or Form 2065-C, and SAS data entry at the same time.

For case closures, the case manager must enter the appropriate termination code in all active Service Authorization records for Service Group 18. SAS termination codes are found in the drop-down menu in the Service Authorization record "Term Code" field.

The case manager must verify the information in SAS matches the new or updated plan of care and service authorization forms. The plan of care forms are:

The service authorization forms are:

If the SAS entry cannot be completed within the identified time frames, the case manager must document the delay and complete the SAS data entry as soon as possible. The case manager must document all SAS data entry delays in the case file using Form 2405, Narrative Notes.

 

4233 SAS Data Entry Procedures for FMSA Provider Transfers

Revision 15-3; Effective March 11, 2015

 

When completing a provider transfer, the case manager must ensure the Service Authorization System (SAS) Service Authorization record reflects service units available for the new provider and utilized units for the previous provider.

 

To update the Service Authorization record in SAS for the losing provider, the case manager must enter the number of units or the costs of services delivered by the losing provider in the Units field. The case manager enters the day before the individual plan of care (IPC) change is effective in the End Date field.

The case manager creates a new Service Authorization record for the receiving provider and enters the number of units or the cost of services determined for the receiving provider in the Units field. The case manager enters the IPC change effective date in the Begin Date field, which is the date the receiving provider is authorized to deliver services. The case manager enters the end date of the IPC period in the End Date field.

The total number of units or the cost of services for all Service Authorization records must not exceed the total number of units or the cost of services the case manager authorized in the IPC period.

To update the Service Authorization record in SAS for the losing Financial Management Services Agency (FMSA), the case manager enters the dollar amounts reported by the losing FMSA to update the Units field in the Service Authorization record for Respite and/or Flexible Family Support Services for the applicable service code(s).

To update the Service Authorization record for Financial Management Services for the losing FMSA, the case manager enters the day before the transfer date in the End Date field. The case manager creates a new Service Authorization record for the gaining FMSA and enters the date of the transfer date in the Begin Date field and the last day of the IPC period in the End Date field. The case manager does not enter half units or create separate Service Authorization records if the FMSA transfer date occurs on any date other than the first of the month.

SAS Records and Time Frames

If the provider transfer results in a change to the total authorized services cost amount, the case manager must update the new amount in the Service Plan record. The case manager must complete all SAS data entry updates within five working days of the IPC change effective date.

If the losing provider requests additional units/amount added to a closed Service Authorization record after the provider transfer action is completed, the case manager must update SAS to add the additional units/amount to the Service Authorization records for the losing provider, if appropriate.

CM-MDCP, Section 5000, Ongoing Case Management

Revision 15-3; Effective March 11, 2015

 

5100 Changes to the Individual Plan of Care (IPC)

Revision 12-3; Effective November 1, 2012

 

 

5110 Interim Plan of Care

Revision 13-2; Effective May 1, 2013

 

When an individual has a significant change in health during the individual plan of care (IPC) period and requests a change to the IPC, the case manager must complete Form 2411, Interim Plan of Care. A change in the individual's Resource Utilization Group (RUG) value does not automatically necessitate a change to the IPC. The case manager must discuss the individual's change in health with the Medically Dependent Children Program (MDCP) nurse. The MDCP nurse will complete a Significant Change in Status Assessment (SCSA) and transmit the assessment to obtain a RUG for the SCSA. The case manager must review the individual's and primary caregiver's needs and determine if a change to the IPC is needed.

If the individual requests a change to the IPC and the case manager determines an IPC change is needed, the case manager completes Form 2411 within 14 days of the change to the Level of Service (LOS) record in the Service Authorization System (SAS). If the case manager manually updated the previous LOS record, the new RUG will not be recorded in SAS. If the case manager manually updated the LOS record in SAS, the case manager must complete Form 2411 within 14 days from the date an updated RUG is received. If there are no errors to the SCSA fields needed to calculate a RUG, the new RUG is calculated upon assessment transmission. It is important for the case manager and MDCP nurse to coordinate their efforts to obtain the updated RUG.

Completion of Form 2411 requires the case manager to calculate a prorated cost limit for the IPC period. The prorated cost limit for the IPC period documented on Form 2411 is based on the cost of authorized services up to the day before the effective date of change, plus the prorated cost limit amount of the new RUG for the remainder of the current IPC period. The prorated cost limit amount for the remainder of the current IPC period is based on the individual's new RUG cost limit divided by the number of days remaining in the IPC period from the Form 2411 effective date.

Case managers must make the effective date on Form 2411, Form 2065-B, Notification of Waiver Services, and all applicable service authorization forms the date the request is processed and approved by the case manager or later. The effective date of the IPC change is the date the case manager processed the request or the date negotiated with the individual, the individual's caregiver and any other person who participates in the individual's care. The date negotiated cannot be a date prior to the date the request was processed.

For example, if a case manager receives a request that results in a change to the IPC on June 5, 2012, and processes the request on June 10, 2012, the effective date on Form 2411 or Form 2412, Budget

Revision, Form 2065-B, and all applicable service authorization forms must be June 10, 2012, or later. The effective date cannot be before June 10, 2012.

Cost of Authorized Services Up to the Day Before the Effective Date of Change

The case manager determines the cost of all authorized services from the IPC begin date up to the day before the effective date of the change by following the instructions on Form 2411.

For Respite and Flexible Family Support Services, the case manager must determine the cost of authorized services by using the weekly units documented in the service authorization forms and multiplying the amount by the number of weeks before the effective date on Form 2411.

To calculate the cost of authorized services for the period before the Form 2411 effective date, the case manager must follow the steps below.

 

Step 1: Review the service authorization form for the amount of waiver service units per week.
Step 2: Determine the total number of days from the start of the IPC and through the date before the Form 2411 effective date.
Step 3: Divide the total number of days by seven to get the number of weeks for the IPC period before the Form 2411 effective date.
Step 4: Multiply the number of weeks by the weekly amount of authorized waiver services to get the number of units authorized for the period before the Form 2411 effective date.
Step 5: Multiply the amount in Step 4 by the unit rate to get the cost of authorized services for the period before the Form 2411 effective date.

Example: An individual's IPC period is Jan. 1, 2011, through Dec. 31, 2011, and the Form 2411 effective date is Aug. 15, 2011.

Step 1: The weekly amount of authorized Respite on Form 2415, Respite Service Authorization, is 25 units per week.
Step 2: The number of days per month: January = 31, February = 28, March = 31, April = 30, May = 31, June = 30, July = 31, August 1-14 = 14, for a total of 226 days.
Step 3: 226 days ÷ 7 = 32.285 weeks
Step 4: Round 32.285 weeks up to 33 weeks
Step 5: 33 weeks × 25 units per week = 825
Step 6: 825 × $10.86 = $8,959.50

$8,959.50 is the cost of Respite authorized up through the day before the effective date of change.

Prorating the Cost Limit Amount for the New RUG

The prorated cost limit amount for the new RUG is based on the number of days from the Form 2411 effective date through the end date of the IPC period.

To calculate the prorated amount for the new RUG, the case manager must follow the steps below.

 

Step 1: Divide the cost limit of the new RUG by the total number of days in the IPC period.
Step 2: Determine the total number of days between and including the Form 2411 effective date and the IPC period end date.
Step 3: Multiply the figure from Step 1 and the figure in Step 2 to get the prorated amount of the new cost limit.

Note: See Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age, if the individual ages out during the IPC period to determine the daily amount for the new RUG cost limit in Step 1 above.

Example: An individual was assessed and received a PE2 RUG value. An individual's IPC period is Jan. 1, 2011, through Dec. 31, 2011, and the Form 2411 effective date is Aug. 15, 2011. The IPC cost limit for PE2 is $22,101.

 

Step 1: $22,101 ÷ 365 days = $60.55 per day
Step 2: The number of days per month: August 15-31 = 17, September = 30, October = 31, November = 30, December = 31, for a total of 139 days.
Step 3: $60.55 × 139 = $8,416.45

$8,416.45 is the prorated cost limit amount available from Aug. 15, 2011, through Dec. 31, 2011.

The case manager adds the cost of authorized services up to the day before the effective date of change to the prorated cost limit amount of the new RUG to obtain the prorated IPC cost limit for the Interim Plan of Care for the IPC period.

Example: Using the amounts in the examples above, $8,959.50 and $8,416.45, the prorated cost limit for this IPC period is $8,959.50 + $8,416.45 = $17,375.95.

Note: The case manager must not complete Form 2411 if the individual's RUG does not change. The case manager completes Form 2412 if there is no change in RUG and an IPC change is needed. See Section 5120, Budget

Revision. If the individual's request for an IPC change includes a change in providers, follow procedures in Section 5140, Provider Transfers During the IPC Period.

The case manager must send a copy of Form 2411 to all providers affected by the IPC change. The case manager must also document all contact with the individual/primary caregiver in the case file, using Form 2405, Narrative Notes.

The case manager completes applicable service authorization forms and Service Authorization System data entry following procedures in Section 4200, Notification and Service Authorization System.

 

5120 Budget Revision

Revision 13-4; Effective November 1, 2013

 

When a change to the individual plan of care (IPC) needs to be made and there is no change in the individual's Resource Utilization Group (RUG), the case manager must review the individual's and primary caregiver's needs for services.

When the individual requests to add or delete any Medically Dependent Children Program (MDCP) service, the case manager must assess the individual's need for the change and determine if the request for the change meets MDCP service criteria.

If the case manager determines an IPC change is needed, the case manager completes Form 2412, Budget

Revision, within 14 days of the request to change the IPC. The case manager must round the units per week for respite or flexible family support services up to the next quarter-hour on Form 2412. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour.

When making changes to the IPC, case managers must make the effective date on Form 2412, Form 2065-B, Notification of Waiver Services, and all applicable service authorization forms the date the request is processed and approved by the case manager or later. The effective date of the IPC change is the date the case manager processed the request or the date negotiated with the individual, the individual's caregiver and any other person who participates in the individual's care. The date negotiated cannot be a date prior to the date the request was processed.

For example, if a case manager receives a request that results in a change to the IPC on June 5, 2012, and processes the request on June 10, 2012, the effective date on Form 2411 or Form 2412, Form 2065-B, and all applicable service authorization forms must be June 10, 2012, or later. The effective date cannot be before June 10, 2012.

Note: The case manager must not complete Form 2412 if the individual has a change in RUG. The case manager completes, Form 2411, Interim Plan of Care, if the individual has a change in RUG and requests changes to the IPC. See Section 5110, Interim Plan of Care. If the individual's request for an IPC change includes a change in providers, follow procedures in Section 5140, Provider Transfers During the IPC Period.

The case manager must send a copy of Form 2412 to all providers affected by the IPC change. The case manager must also document all contact with the individual/primary caregiver in the case file, using Form 2405, Narrative Notes.

The case manager completes applicable service authorization forms and Service Authorization System data entry following procedures in Section 4200, Notification and Service Authorization System.

 

5130 Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age

Revision 12-1; Effective May 1, 2012

 

Applicants/individuals who turn 21 years of age before the annual reassessment will have services based on a prorated cost (see Form 2410, Medical-Social Assessment and Individual Plan of Care). Minor home modifications and adaptive aids should be pursued before the last individual plan of care (IPC) period, if possible.

The prorated cost is based on the applicant's/individual's cost limit and the total number of days before the applicant's/individual's 21st birthday.

To calculate the prorated cost, the case manager must:

  1. divide the applicant's/individual's cost limit by the total number of days in a year (365 days);
  2. determine the total number of days beginning with the start date of the IPC and ending with the date before the applicant's/individual's 21st birthday; and
  3. multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the IPC period for which the applicant/individual is eligible.

Example: The individual's 21st birthday is July 9, 2012, and his IPC period begins on April 1, 2012, and ends on July 8, 2012. The cost limit is $25,000.

Step 1: $25,000 ÷ 365 days = $68.49 per day
Step 2: The number of days per month: April = 30, May = 31, June = 30, July 1-8 = 8, for a total of 99 days.
Step 3: $68.49 × 99 = $6,780.51

$6,780.51 is the prorated cost limit for the individual for the IPC period.

 

5140 Provider Transfers During the IPC Period

Revision 15-3; Effective March 11, 2015

 

The case manager must follow procedures in Section 5110, Interim Plan of Care, or Section 5120, Budget

Revision, as applicable to complete the provider transfer as a change to the individual plan of care (IPC).

Establishing Effective Dates for Provider Transfers

The case manager must complete the provider transfer within 14 days of the documented date of the individual's request to change providers. The case manager must negotiate the effective date of the change with the individual/caregiver and the providers. If the case manager negotiates a transfer effective date beyond 14 days of the request, the case manager must document the reason on Form 2405, Narrative Notes, and document the individual's/caregiver's participation in the decision regarding the delay. Form 2065-B, Notification of Waiver Services, authorizing the provider transfer, must be signed by the 14th day. Acceptable service authorization delays, such as a delay in receiving information from a contracted provider, must be documented in the case file using Form 2405.

Terminating the Losing Provider's Service Authorization

Upon completion of Form 2065-B authorizing the provider transfer, the case manager must also document the losing provider's authorization termination using:

The case manager may use the service authorization form initially used to authorize the service. The case manager terminates the service authorization by checking the box labeled "Your service authorization is cancelled effective" and adds the date, which must be the day before services begin with the gaining provider. The case manager must cancel the losing provider's authorization within the same 14-day time frame to complete the provider transfer.

Updating Service Authorization System (SAS) Service Authorization Records

When an individual transfers from one provider to another, the case manager must verify the number of units or the cost of services delivered by the losing provider from the authorized start date through the day before the IPC change is effective. The case manager must then determine the number of units or the costs of services that will be delivered by the receiving provider from the effective date of the change to the end of the IPC period.

The case manager must use Form 2067, Case Information, to request the:

The case manager will use the provider's written response to update the SAS Service Authorization records and complete changes to the IPC. If the provider does not respond to the request for information, the case manager must follow up with the provider before the 14th day of the individual's request to change providers. The case manager may follow up with the provider by telephone contact or send an additional Form 2067. See Section 4233, SAS Data Entry Procedures for FMSA Provider Transfers, for SAS procedures.

 

5141 FMSA Transfers During the IPC Period

Revision 15-3; Effective March 11, 2015

 

When an individual requests to transfer Financial Management Services Agency (FMSAs), the case manager must request the following on Form 2067, Case Information, from the losing FMSA for each service delivered through the Consumer Directed Services (CDS) option and each employee type the:

Completing the IPC Change Form

Use Form 2412, Budget

Revision, to complete the provider transfer. If the individual has a change in the Resource Utilization Group (RUG) that coincides with a request to change the FMSA, the case manager must use Form 2411, Interim Plan of Care. On the applicable IPC form, the case manager uses the FMSA response regarding funds allocated in the individual's budget up until the day before the transfer date to complete the information for services authorized before the date of the IPC change. The case manager uses the FMSA response regarding the number of units and the amount of funds remaining in the individual's budget for each service available on and after the scheduled transfer date to complete the information for services authorized on the date of the IPC change.

If the transfer date occurs on any date other than the first of the month, the case manager uses the same procedures above to document Respite and/or Flexible Family Support Services delivered through the CDS option on the IPC form. To document the monthly Financial Management Services (FMS) fee, the case manager must document the number of whole months plus half a unit for the period before the transfer date and after.

Example: An individual whose IPC period is January through December requests an FMSA change effective August 5. On the IPC form, the case manager documents 7.5 units of FMS for the losing FMSA and 4.5 units of FMS for the gaining FMSA.

The sum of both units must equal the total number of calendar months in the individual's IPC period. The case manager does not change the total number of FMS units in the individual's IPC to complete this provider transfer.

The case manager sends the IPC form to the individual/primary caregiver and the gaining FMSA.

Completing Service Authorization Forms

The case manager uses the FMSA response for the number of units and the amount of funds remaining in the individual's budget for each service available on and after the scheduled transfer date to complete Form 2402, Consumer Directed Services Option – Services Authorization, for the period effective the transfer date through the end of the IPC. The case manager completes Form 2065-B, Notification of Waiver Services. In the Beginning on field, the case manager enters the transfer date and in the comments, indicates Change in Financial Management Services Agency. In the Provider Authorization field, the case manager lists the losing FMSA with the date effective the first day of the current IPC the FMSA was authorized to deliver services and the termination date is the day before the transfer date. The case manager lists the gaining FMSA with the effective date the same as the transfer date. The termination date for the gaining FMSA may be left blank or the case manager documents the last day of the current IPC period.

The case manager sends both Form 2402 and Form 2065-B to the individual/primary caregiver and the gaining FMSA. The case manager sends Form 2065-B to the losing FMSA. The case manager does not send Form 2402 to the losing FMSA.

See Section 4233, SAS Data Entry Procedures for FMSA Provider Transfers, for SAS procedures.

 

5142 Assessing an Individual's Satisfaction When a Change in Provider is Requested

Revision 12-1; Effective May 1, 2012

 

When a request to change providers is made, within the 14-day time frame to complete the change to the service plan for provider transfers, the case manager must contact the individual and the provider to determine:

The case manager must first attempt to resolve any problems the individual may have with the current provider before he processes the transfer.

The case manager must consider if the dissatisfaction is due to services not being provided according to the service plan, problems with the attendant, problems with the provider or the individual's failure to comply with the service plan.

The case manager may request a meeting with the individual, primary caregiver and others participating in the individual's care to discuss and find a resolution to the service delivery issues, if possible.

Within the 14-day time frame to process the service plan change, the case manager authorizes the transfer if:

The individual will continue to have the freedom to choose/change providers without restriction. However, the case manager should follow current program procedures to terminate the individual's services if the individual repeatedly refuses to comply with the service delivery provisions by directly, or knowingly and passively, condoning unacceptable behavior of someone in his home.

The case manager must follow Section 5140, Provider Transfers During the IPC Period, for information related to provider transfers and Section 5400, Convening a Meeting to Resolve Issues, for information related to convening a meeting with applicable individuals.

 

5143 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 12-3; Effective November 1, 2012

 

A provider may report it will no longer serve the individual due to health and safety concerns. In some situations, the case manager may initiate services with a new provider. The case manager must make a referral to a new provider and must determine how much information to share with the new provider regarding the previous actions.

The case manager 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.

The case manager must use good judgment in determining the needed information to share and, if in doubt, consult with his supervisor for guidance.

 

5200 Service Delivery Issues Reported to DADS Staff

Revision 15-3; Effective March 11, 2015

 

Case managers must report program provider service delivery issues reported or 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.

Within five working days of receiving a report or becoming aware of service delivery issues, the case manager must respond to the individual and the provider either by phone or face-to-face contact to discuss the issues. The case manager must inform the provider of the service delivery issues and discuss resolutions. The case manager convenes an interdisciplinary team (IDT) meeting, if appropriate. The case manager coordinates with the individual and provider to implement actions required to resolve the issues. The case manager must document the receipt of the report and contacts with the individual and the provider in the case record. The case manager 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 issues 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 manager must:

The case manager must make the report to CRS 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 manager must call CRS as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case manager must also contact Adult Protective Services or Child Protective Services within 24 hours if there is an immediate or imminent threat to the health and safety of the individual. The case manager must continue to work with the individual and provider to resolve the issues within the 10-working-day time frame.

The case manager must identify the specific service the provider is delivering when calling CRS to report a complaint. For example, the case manager identifies the provider as an "MDCP provider" when making a referral to CRS that involves MDCP service delivery issues. The case manager 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 issue. CRS will log the information into the automated system and forward the complaint to the appropriate DADS division for action.

 

5300 Service Delivery Issues Reported by the Provider

Revision 12-1; Effective May 1, 2012

 

§51.417

(a) Required notification. A provider must notify the case manager if:

(1) the individual's primary caregiver refuses to comply with the IPC;

(2) the provider is unable to verify the individual's Medicaid eligibility as required in §51.405 of this chapter (relating to Monitoring Medicaid Eligibility);

(3) the provider is unable to begin services on the service initiation date. This notification must include:

(A) an explanation of why there is a delay in the service initiation date; and

(B) an expected date that services will begin; or

(4) the provider makes any changes in service delivery.

(b) Method and deadline for notification.

(1) The provider must notify the case manager orally or by fax about any circumstance described in subsection (a) of this section no later than one working day after awareness.

(2) If the provider's notification is oral, the provider must speak directly with the case manager. If the provider is unable to speak directly with the case manager, the provider may leave a telephone message. If the provider leaves a telephone message, the provider must document all attempts to meet the deadline and make a follow-up contact with the case manager within one working day.

(3) If the provider's notification is oral, the provider must send written notification to the case manager within five working days of the oral notification.

The Department of Aging and Disability Services (DADS) requires a provider to notify the case manager of issues that impact service delivery. The provider may notify the case manager of any changes either orally or by written documentation. If the provider notifies the case manager orally, the provider must follow up with written documentation.

 

5310 Primary Caregiver Refuses to Comply with the IPC

Revision 12-1; Effective May 1, 2012

 

The provider may notify the case manager if the primary caregiver does not follow the individual plan of care (IPC). The case manager must contact the primary caregiver to discuss the situation within 14 days of receiving a report of service delivery issues from the provider. The case manager must explain Medically Dependent Children Program (MDCP) service criteria if the primary caregiver does not understand the need and use of MDCP services. If the case manager determines a change to the individual's IPC is necessary, the case manager changes the IPC following Section 5100, Changes to the Individual Plan of Care (IPC). If the issue continues after the initial contact, the case manager must convene a meeting to address the issue. See Section 5400, Convening a Meeting to Resolve Issues.

The case manager must document all contact with the primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5320 Provider is Unable to Verify Individual's Medicaid Status

Revision 12-1; Effective May 1, 2012

 

Each month, the Department of Aging and Disability Services (DADS) requires the provider to verify the individual's Medicaid eligibility. The provider may verify the individual's status by using the current systems available through the Health and Human Services Commission (HHSC).

If the provider is unable to access the individual's Medicaid status after attempting the options available to the provider, the case manager may verify the individual's Medicaid status via the Texas Integrated Eligibility Redesign System (TIERS).

If the case manager is unable to determine the individual's Medicaid status through a database inquiry, the case manager must contact the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works staff if the individual's Medicaid eligibility was previously determined by HHSC staff. If the individual's Medicaid eligibility is based on receipt of Supplemental Security Income (SSI), the case manger contacts the individual to determine if there was a change in the individual's SSI.

If the individual lost Medicaid eligibility, the case manager must follow procedures in Section 5500, Loss of Medicaid.

The case manager must send Form 2067, Case Information, to the provider indicating the individual's Medicaid status. The case manager must send Form 2067 within two working days of determining whether or not the individual was Medicaid eligible. The case manager must also inform the provider if an application for Medicaid will be completed. The case manager must not confirm whether or not the individual will retain Medicaid certification.

The case manager must document all contact with the individual/caregiver in the case file, using Form 2405, Narrative Notes.

 

5330 Provider is Unable to Begin Services on the Service Initiation Date

Revision 12-1; Effective May 1, 2012

 

For an individual with an initial individual plan of care (IPC), if the provider is unable to begin delivering services on the service initiation date, the provider must notify the case manager and explain the reason for the delay in service delivery and identify an expected date that services will begin.

The case manager must contact the individual within three working days of notification by the provider and inform the individual of the delay in services. The individual has the right to choose another service provider if he requests a change in the provider.

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5340 Provider Initiated Changes to the Delivery of Services

Revision 13-2; Effective May 1, 2013

 

If the provider notifies the case manager of any changes in service delivery, the case manager must determine if the change in service delivery requires a change to the individual's individual plan of care (IPC). If the change in service delivery does not require a change to the IPC, the case manager documents the provider's reason for the change in the case file. The case manager must contact the individual if the change in service delivery requires a change to the IPC. If the individual agrees with the change, the case manager completes the change to the IPC following procedures in Section 5100, Changes to the Individual Plan of Care (IPC). If the individual does not agree with the change, the case manager must contact the provider and resolve the provider's change in service delivery. The provider may not exceed the amount of services already authorized on the IPC.

If the change in service delivery results in a 50 percent increase of monthly services, the case manager follows procedures in Section 4114, Respite Service Schedule Changes, if the request is for Respite, or Section 4126, Service Schedule Changes to Flexible Family Support Services, if the request is for Flexible Family Support Services. If the individual did not prior request the service schedule change, the provider did not follow the IPC or the service authorization form. If the provider did not follow the IPC or the service authorization form, the case manager follows provider complaint procedures identified in Section 5200, Service Delivery Issues Reported to DADS Staff.

The case manager must resolve all actions including all contacts and any IPC change within 14 days of the provider's first method of notification.

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5400 Convening a Meeting to Resolve Issues

Revision 12-1; Effective May 1, 2012

 

The case manager may request a meeting with the individual, primary caregiver and others participating in the individual's care to resolve issues or concerns regarding the individual's care.

Depending on the nature of the issue or concern, the case manager may:

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5500 Loss of Medicaid

Revision 12-1; Effective May 1, 2012

 

When the case manager is made aware of the individual's loss of Medicaid, the case manager should immediately contact the individual to:

See Section 1340, Financial Eligibility, for financial eligibility criteria. The case manager must determine the reason for the loss of Medicaid and follow the procedures below.

If the case manager is made aware an individual is pending a Medicaid denial, the case manager should immediately inform the individual to submit any necessary documentation to continue Medicaid eligibility to avoid the risk of losing MDCP eligibility.

The case manager must document all contact with the individual/primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

Loss of Medicaid ME-Waivers

An individual who loses Medicaid ME-Waivers eligibility must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. The Department of Aging and Disability Services (DADS) will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on Medicaid ME-Waivers and he loses Medicaid, the individual has two options. The individual may:

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual or contact the Medicaid for the Elderly and People with Disabilities (MEPD) staff to verify this information.

If the individual has Medicaid ME-Waivers financial eligibility determined by MEPD staff and loses the eligibility, the MEPD specialist sends the individual Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, with a copy to the case manager as notification of the Medicaid denial. The case manager must coordinate the MDCP denial date with the Medicaid denial effective date established by the MEPD specialist. MDCP services cannot continue past the last date of Medicaid coverage.

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232, Service Authorization System (SAS) Data Entry for Service Reductions, Suspensions, Denials and Case Closures.

See Section 9611, Case Manager and Designated Data Entry Representative Procedures, and Section 9611.1, Procedures for Loss of Medicaid, for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

The case manager sends Form 2067, Case Information, to the provider(s), indicating MDCP services may continue until a fair hearing decision is made, within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued. See Section 9621.1, Action Taken on Fair Hearing Decision, for procedures after the fair hearing decision.

The case manager should discuss ME-Waivers gaps with the MEPD specialist to determine how long the gap will affect MDCP services. SAS records may remain open if the case manager documents the individual is in the process of providing requested information to MEPD to support continued Medicaid eligibility. If there will be a gap in ME-Waivers coverage, as determined and notified by the MEPD specialist, the case manager follows procedures under Medicaid Recertification below to reinstate MDCP services after the gap period.

The case manager must document all contact with MEPD in the case file, using Form 2405.

Loss of Medicaid Established by MEPD Other than ME-Waivers

When an individual whose MDCP eligibility is based on Medicaid other than ME-Waivers loses Medicaid, he must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. DADS will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on Medicaid other than ME-Waivers and he loses Medicaid, the individual has three options. The individual may:

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual or contact MEPD staff to verify this information.

See Section 9611 and Section 9611.1 for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

The case manager sends Form 2067 to the provider(s), indicating MDCP services may continue until a fair hearing decision is made, within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued. See Section 9621.1.

For an individual whose program eligibility was established by an applicable Medicaid program other than ME-Waivers or Temporary Assistance for Needy Families (TANF), MEPD staff may not know the individual is receiving MDCP services and therefore, may not notify DADS of the loss of Medicaid. The individual may be eligible for TP14/BP13 and a referral may be made to MEPD. When notifying the individual and provider of loss of program eligibility, the case manager must indicate denying services on Form 2065-C in the comments section, and that an application may be submitted to MEPD to determine Medicaid eligibility for MDCP and the possibility of continuation of services once the individual becomes eligible for ME-Waivers. (See below if the individual loses TANF-related Medicaid.)

The case manager must document all contact with MEPD in the case file, using Form 2405.

Loss of Supplemental Security Income (SSI)

If an individual's MDCP eligibility is based on SSI and he loses SSI Medicaid, the individual has two options. The individual may:

An individual who becomes financially ineligible for SSI loses SSI Medicaid. For an individual whose eligibility is based on SSI, the case manager does not complete Form 2065-C when he becomes aware of the loss of SSI.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual, obtain a copy of the letter from the Social Security Administration (SSA) or contact the local SSA office to verify this information.

If the individual accepts the loss of SSI Medicaid and MDCP services, the case manager completes and sends Form 2065-C, notifying the individual of denied MDCP services.

If Medicaid will be reinstated the beginning of the next month without a gap in coverage, no further case manager action is required.

For an individual whose loss of Medicaid will result in a gap or SSI will be denied ongoing, the case manager must immediately begin the ME-Waivers financial eligibility process with MEPD. The case manager must obtain Form H1200, Application for Assistance – Your Texas Benefits, and as much verification documentation as possible and send to the MEPD specialist. No later than the close of business on the second working day following the date of receipt of Form H1200, the case manager must fax or mail Form H1200 to the Midland Document Processing Center (DPC).

If the case manager faxes Form H1200 to DPC, he must not send the original to the DPC. DADS staff must retain the original Form H1200 with the individual's valid signature in the case file. The original form must be kept for three years after the case is denied or closed. Case managers must also retain a copy of the successful fax transmittal confirmation in the case file.

If unusual circumstances exist in which the original must be mailed to DPC after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case file. Scanning Form H1200 and sending by electronic mail is prohibited. The day DADS receives the Medicaid application form is day zero and starts the two working day time frame.

The case manager requests financial eligibility determination for MDCP on Form H1746-A, MEPD Referral Cover Sheet. All available verifications provided by the individual must be attached. The case manager keeps a copy of all documents and documents the date the application was faxed, hand delivered, or mailed in the case file.

When MEPD receives the Medicaid application form, the MEPD specialist will determine ongoing Medicaid eligibility and/or eligibility for the gap period.

If the individual does not have Medicaid during the period MEPD is determining ME-Waivers eligibility or the individual is working with the SSA to reinstate SSI Medicaid, MDCP services are suspended by sending Form 2067 to the MDCP providers. If the ME-Waivers application form is not received from the individual, financial eligibility is denied or SSI Medicaid will not be reinstated, the case manager must:

An individual may appeal the ME-Waivers and MDCP denials; however, MDCP services may not continue during the appeal process due to lack of Medicaid coverage.

SAS records may remain open if the case manager documents the individual is actively in the process of applying for ME-Waivers eligibility or providing requested information to support continued SSI Medicaid eligibility.

Some individuals may be ineligible for SSI for a short period before SSI is reinstated. This might occur when eligibility is based on the parent(s)' earned weekly income, normally with four paychecks although five paychecks are received in some months. In these situations, the case manager must work with the individual and MEPD to prevent a gap in waiver coverage. The case manager must assist the individual in submitting the Medicaid application form. If ME-Waivers eligibility criteria are met, the MEPD specialist will certify the individual for Medicaid for waivers, and notify the case manager of the Medicaid eligibility for the gap in SSI coverage. If an SSI Medicaid gap period reoccurs, MEPD will use the same application to determine eligibility for the subsequent gap periods for up to a year from receipt of the Medicaid application form.

The case manager must document all contact with SSA and MEPD staff in the case file, using Form 2405.

Loss of TANF-Related Medicaid

An individual who loses TANF-related Medicaid must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. DADS will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on TANF-related Medicaid and he loses Medicaid, the individual has three options. The individual may:

Upon notification that an individual was denied or is being denied TANF-related Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. An individual whose eligibility is met with TANF-related Medicaid will not appear in the monthly loss of eligibility reports sent to the region. The case manager may contact the individual, obtain a copy of the denial letter from Texas Works (Form H1017, Notice of Benefit Denial or Reduction, or TF0001, Notice of Case Action), or contact the local Texas Works office to verify this information.

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232.

If TANF-related Medicaid will be reinstated the beginning of the next month without a gap in coverage, follow procedures below regarding Medicaid Recertification.

See Section 9611 and Section 9611.1 for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

Within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued, the case manager sends Form 2067 to the provider(s) indicating MDCP services may continue until a fair hearing decision is made. See Section 9621.1.

For individuals whose loss of TANF-related Medicaid will result in a gap or Texas Works benefits will be denied ongoing, the case manager must immediately begin the ME-Waivers financial eligibility process with MEPD following the procedures identified in Loss of Supplemental Security Income (SSI), above. In the comments section of Form 2065-C denying services, the case manager must inform the individual that an application may be submitted to MEPD to determine Medicaid eligibility for MDCP, and the possibility of continuation of services if the individual is eligible for ME-Waivers.

The case manager must document all contact with Texas Works staff in the case file, using Form 2405.

Medicaid Recertification

Upon notification the individual's Medicaid status is reestablished and provided all eligibility criteria are met, the case manager completes Form 2065-B, Notification of Waiver Services, since Form 2065-C was completed to notify the individual and providers of loss of eligibility. In the comments section of the form, the case manager indicates MDCP services may resume effective the date of the Medicaid recertification effective date. The case manager completes and sends Form 2065-B to the individual and the provider(s) within two working days of verifying Medicaid recertification. The case manager must also send all applicable service authorization forms to the individual and provider(s). The case manager does not change the number of units on the new service authorization form. If the individual had a gap in services due to Medicaid ineligibility, the case manager documents in the comment field services were suspended for the duration the individual did not have Medicaid. Example: Waiver services were suspended from May 1, 2012, to May 31, 2012, due to gap in Medicaid coverage.

If the individual's Medicaid status is re-established due to an appeal, follow procedures in Section 9621.3, Procedures for Reversed Decisions.

 

5510 Coordination of Fair Hearings with the CRU

Revision 12-1; Effective May 1, 2012

 

The Centralized Representation Unit (CRU) represents the Health and Human Services Commission (HHSC) in all Medicaid fair hearings regarding Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works determinations. The CRU replaces the MEPD and Texas Works specialist in specific steps related to denial of Medicaid applications and ongoing cases. The CRU:

The case manager must coordinate all appeals involving loss of Medically Dependent Children Program (MDCP) eligibility due to loss of Medicaid with the CRU.

The following procedures must be used by the case manager to coordinate appeal actions with the CRU in cases for which MEPD or Texas Works staff determine Medicaid eligibility. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

The applicant/individual may appeal a decision orally, in person or in writing. The case manager is responsible for completing Form 4800-D, DADS Fair Hearing Request Summary. DADS staff 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. The case manager must determine if the appealed action is:

If the appealed action is related to a non-Medicaid program denial, the case manager completes Form 4800-D and enters his name as the Agency Representative. In the Other Participants field, DADS staff enter the CRU supervisor and CRU administrative assistant. The CRU supervisor and assistant names must be entered by using the MOR Search function. This will assure that all of the correct information is populated in TIERS and CRU staff will receive the notice of appeal.

If the appealed action is a program denial based on Medicaid financial eligibility, the case manager completes Form 4800-D. In Section 6 of Form 4800-D, DADS staff must select Yes to the question, "Are you an OES Texas Works or MEPD employee?" (DADS staff are responding to this question on behalf of the CRU.) On the Agency Representative page, select Yes in the drop down. Failure to answer yes to this item will result in the CRU not being notified of the fair hearing. DADS staff continue completing Form 4800D and enter the CRU supervisor as the Agency Representative. DADS staff must enter this information through the MOR Search function for the CRU to receive the fair hearing information. DADS staff must list the case manager's name and title in the Other Participants section. The case manager does not enter the name of the local MEPD or Texas Works specialist on Form 4800-D for MEPD financial appeals. DADS staff must include the job title, such as DADS case manager or DADS supervisor. Enter the DADS staff email address and include the CRU administrative assistant in Other Participants. The CRU administrative assistant's information must be entered through the MOR Search function.

When Form 4800-D is sent to the designated data entry representative, DADS staff send an email notification to the CRU supervisor with a copy to the CRU administrative assistant regarding the request for an appeal to the CRU.

The email must include the:

Upon receipt of notification of an appeal, the CRU requests the Medicaid evidence packet from the local MEPD or Texas Works specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent HHSC at the fair hearing, if required, and takes steps to ensure the appropriate Medicaid financial case action is taken once a fair hearings officer's decision is rendered.

When an MDCP denial fair hearings decision is rendered by the fair hearings officer, DADS staff (staff name entered as Agency Representative) will be notified via email of the decision by the fair hearings officer. Based on the fair hearings decision, the case manager determines the appropriate action for MDCP services according to specific time frames. The case manager may need to coordinate effective dates of reinstatement with the CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. DADS staff report the implementation of the fair hearings decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

For individuals with Medicaid ME-Waivers, the local MEPD specialist will continue to notify DADS staff if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to the CRU to handle during the appeal process. Once the appeal decision regarding the Medicaid eligibility is rendered by the fair hearings officer, the CRU will notify DADS staff via email of the fair hearings decision, including decisions that are sustained, reversed or withdrawn. Based on the fair hearings decision, the case manager determines the appropriate action for MDCP. The email sent by the CRU will include:

DADS staff must not put an applicant/individual back on the MDCP interest list while a Medicaid denial is in the appeal process. The case manager must take appropriate action to certify or deny the case, or resume services once the Medicaid fair hearings decision is rendered. The individual may choose to be added back to the MDCP interest list once the case manager denies MDCP.

 

5520 Case Manager Responsibilities and Effective Dates of Appeal Decisions

Revision 12-1; Effective May 1, 2012

 

Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must verify the fair hearings officer's decision by obtaining a copy of the decision that is to be filed in the case file.

Sustained Appeal Decisions

When the fair hearings officer's decision sustains the denial of Medically Dependent Children Program (MDCP) services, the case manager must:

Do not send another Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to notify the individual of the sustained denial.

Sustained Appeal Decisions – Effective Dates

When services are terminated at the annual reassessment due to the individual not meeting financial eligibility criteria and services are continued until the appeal decision is known, the MDCP termination date is:

When services are denied during the IPC period, the MDCP termination date is the effective date of the fair hearings officer's decision as recorded on Page 1 of Form H4807.

Reversed Appeal Decisions

When the fair hearings officer's decision reverses the MDCP denial, the case manager must:

Reversed Appeal Decisions – Effective Dates

The fair hearings officer's decision date recorded on Form H4807 is considered the eligibility or effective date of MDCP services for all reversed decisions involving services:

 

5600 Change of Address

Revision 13-1; February 1, 2013

 

For an individual receiving Supplemental Security Income (SSI) with a change in address, the case manager must inform the individual or his primary caregiver to contact the Social Security Administration (SSA) to request the residence address change. DADS staff must not send address change requests for SSI recipients to the Midland Document Processing Center (DPC).

If the individual does not have SSI Medicaid, the case manager must correct the individual’s address in the Service Authorization System (SAS). See Section 11210, Address Area – Initial Service Authorization, for a change of address request for an individual with Medicaid other than SSI.

 

5700 Change in Primary Caregiver

Revision 13-3; August 1, 2013

 

If an applicant’s/individual’s primary caregiver changes after the initial visit, the case manager must contact the new primary caregiver and schedule a face-to-face visit with the new primary caregiver within 14 calendar days of receiving the notification of this change. The case manager must review Medically Dependent Children Program (MDCP) services with the new primary caregiver during the face-to-face visit and evaluate the need for services based on the criteria found in Section 4100, Medically Dependent Children Program (MDCP) Services. The need for services may change and must be assessed while taking into account the new primary caregiver’s schedule. The case manager must assess the individual’s living arrangement to ensure it meets policy outlined in Section 1380, Living Arrangement.

The case manager does not need to coordinate the visit with the nurse. There is no need for the nurse to collect additional medical information or submit a new Medical Necessity and Level of Care (MN/LOC) unless the change in primary caregiver also coincides with a significant change in health status of the individual or an annual reassessment.

The case manager must present Form 2121, Long Term Services and Supports, to the new primary caregiver and complete the following forms with the new primary caregiver:

The case manager must present the Consumer Directed Services (CDS) Option to the new primary caregiver following policy in Section 2400, Initial Presentation of the Consumer Directed Services Option.

Since the new primary caregiver’s schedule and need for services may differ from previously authorized services, a change to the individual plan of care (IPC) may be necessary. The case manager must follow policy in Section 5100, Changes to the Individual Plan of Care, if a change to the IPC is required.

Note: DADS staff must not discard the original Form 2408, Individual Plan of Care (IPC) Service Review, Form 2410, Medical-Social Assessment and Individual Plan of Care, or any other form or document completed during the face-to-face visit. The case manager must file the original handwritten document in the case file even the form is typed after returning to the office.

 

5800 Use of Services Outside the Provider's Contracted Service Delivery Area

Revision 14-1; Effective February 3, 2014

 

Services Outside of the Contracted Service Delivery Area

When an individual makes a request for services outside the contracted service delivery area to the provider, the provider may accept or decline this request. If the provider accepts the individual’s request, the provider may provide the allowed service to the individual during a period of no more than 60 consecutive days. The provider is not required to pay for expenses incurred by the provider’s employee who is delivering services outside the contracted service delivery area. Within three working days after the provider begins providing services outside the contracted service delivery area, the provider is required to send a written notice to the case manager notifying him:

• the individual is receiving services outside the provider’s contracted service delivery area;
• the location where the individual is receiving services;
• the estimated length of time the individual is expected to be outside the provider’s contracted service delivery area; and
• contact information for the individual.

The case manager will receive written notification from the provider when the individual has returned to the provider’s contracted service delivery area within three working days after the provider becomes aware of the individual's return.

If the provider declines the individual's request for services outside the service delivery area, the provider will inform the individual or his primary caregiver, parent, guardian or responsible party, orally or in writing, of the reason(s) for declining the request. The provider’s notice will also indicate that the individual or his primary caregiver, parent, guardian or responsible party may request a meeting with the case manager and the provider to discuss the reasons for declining the request. The provider will also inform the case manager in writing, within three working days after declining the request, that the request was declined and the reason(s) for declining the request.

If the individual requests an interdisciplinary team (IDT) meeting, the case manager must convene an IDT meeting with the provider and the individual or his primary caregiver, parent, guardian or responsible party to discuss delivery of services outside the provider’s contracted service delivery area and possible resolutions. The case manager must document the contacts with the individual and the provider in the case record. If a resolution cannot be reached, the case manager must offer the individual choice of providers or the Consumer Directed Services (CDS) option for respite following current procedures.

Out of Area Service Limitations

If an individual receives services outside the provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that service delivery area before the provider may agree to another request from the individual for the provision of services outside the provider's contracted service delivery area.

If the individual intends to remain outside the provider's contracted service delivery area for a period of more than 60 consecutive days, the case manager must follow current procedures and transfer the individual to a provider selected by the individual that has a contracted service delivery area that includes the area in which the individual is receiving services.

CM-MDCP, Section 6000, Monitoring Services

Revision 15-3; Effective March 11, 2015

 

 

6100 Monitoring Services and Follow-up Contacts

Revision 14-2; Effective September 1, 2014

 

The case manager is responsible for assessing how well services are meeting the individual's needs and enabling the individual to achieve the goals described in the individual plan of care (IPC). The case manager monitors implementation of the IPC at regular intervals by contacting the individual and the primary caregiver.

Due to the frequency of contacts in the Medically Dependent Children Program (MDCP), the case manager must emphasize to the individual the importance of:

MDCP contacts are required according to the following time frames:

The case manager must document all follow-up contacts in the case file, using Form 2408, Individual Plan of Care (IPC) Service Review.

If the case manager identifies service delivery issues regarding the provider, the case manager follows Consumer Rights and Services (CRS) procedures in Section 5200, Service Delivery Issues Reported to DADS Staff.

Note: DADS staff must not discard the original Form 2408 or any other form or document completed during the face-to-face visit. The case manager must file the original handwritten document in the case file even if the form is typed after returning to the office.

 

6110 Monitoring Transition Assistance Services (TAS)

Revision 12-1; Effective May 1, 2012

 

The case manager must contact the individual within three working days of the nursing facility discharge date to assure all authorized TAS items and services have been received. If the individual reports items or services were not delivered, the case manager must contact the provider by telephone and follow up with written documentation to request the reason and status of the items or services that were not delivered.

Once the case manager has confirmed delivery of all authorized TAS items and services, the case manager must end the TAS Service Authorization record in the Service Authorization System using the date the case manager confirmed delivery of TAS as the end date.

 

6120 30-Day Contact

Revision 15-3; Effective March 11, 2015

 

The case manager must contact the individual by telephone or conduct a face-to-face visit within 30 days of the initial individual plan of care (IPC) effective date, or from the Financial Management Services (FMS) service authorization date, to ensure service initiation.

If services have not been initiated by the 30th day of the IPC start date, the case manager must contact the Financial Management Services Agency the next working day to determine the reason for the delay in service initiation.

If applicable, the case manager follows procedures in Section 5200, Service Delivery Issues Reported to DADS Staff, or Section 5300, Service Delivery Issues Reported by the Provider, to determine the appropriate steps for addressing the delay.

 

6130 IPC Service Monitoring

Revision 13-3; Effective August 1, 2013

 

The case manager reviews service delivery and implementation of the individual plan of care (IPC) by telephone or in person with the individual or the primary caregiver at least every six months. The case manager monitors implementation of the IPC at regular intervals by contacting the individual or the primary caregiver.

If the individual or primary caregiver does not have a telephone or contact cannot be made by telephone, a face-to-face visit is required. The case manager may have to make a face-to-face contact if:

The case manager must complete the first IPC service monitor within six months from the initial 30-day service review completed after the initial IPC effective date. See Section 6120, 30-Day Contact. The case manager must review the Respite and/or Flexible Family Support Services schedule with the individual or primary caregiver to determine if service schedule adjustments or changes to the IPC are needed.

The case manager is also responsible for determining if any existing situations jeopardize the individual's health and welfare. The case manager may schedule a face-to-face visit less than six months from the previous visit if health and safety or service delivery issues cannot be resolved adequately by telephone contact.

If the case manager identifies problems with waiver service delivery or the implementation of the IPC, the case manager may counsel the individual or primary caregiver regarding the IPC. If necessary, the case manager may convene a meeting following procedures in Section 5400, Convening a Meeting to Resolve Issues. The case manager must follow procedures in Section 5200, Service Delivery Issues Reported to DADS Staff, if the case manager identified service delivery or IPC implementation issues regarding the provider's performance.

The regional nurse may complete the IPC service monitoring review in place of the case manager, if needed. If this occurs, the regional nurse must complete Form 2408, Individual Plan of Care (IPC) Service Review, when completing the monitoring contact and file it in the case file. The regional nurse must coordinate with the case manager if changes to the IPC are needed.

Outbreak of Transmittable Disease in the General Population

During the time when Texas experiences an increase in serious transmittable diseases in the general population, certain precautions are necessary to ensure the health and welfare of the case manager who may come in contact with an individual reporting he has a contagious illness.

While it is important that service monitoring reviews are performed on a timely basis, there may be circumstances that could place the case manager at risk for contracting contagious illnesses.

If a case manager contacts an individual to schedule a monitoring face-to-face visit and the individual states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the face-to-face visit, including the stated illness. If possible, the case manager should schedule a future date for the visit when the individual thinks he will be better or complete the service monitoring review by telephone. If unable to schedule the visit for a future date, the case manager must contact the individual at least weekly until the service monitoring review can be completed.

Each contact must be documented in the case file on Form 2405, Narrative Notes. This documentation will be considered as an acceptable reason for delaying a service monitoring review.

CM-MDCP, Section 7000, Annual Reassessment

Revision 15-3; Effective March 11, 2011

 

 

7100 Annual Reassessment Overview

Revision 14-1; Effective February 3, 2014

 

The case manager will coordinate with the Medically Dependent Children Program (MDCP) nurse to complete a face-to-face visit 60 to 90 days prior to the end date of the Individual Plan of Care (IPC) to reassess the individual's needs, redetermine MDCP eligibility and develop a new IPC. If the case manager and nurse cannot visit the individual on the same day, they may conduct separate face-to-face visits to prevent delays in redetermining MDCP eligibility. During the annual reassessment, the case manager must review service options and limitations of MDCP services. The case manager must review the Electronic Visit Verification (EVV) information on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and adequately explain the EVV requirements to the individual. Refer to Section 2370, Explaining Electronic Visit Verification Requirements, for talking points on explaining EVV requirements to the individual.

Note: DADS staff must not discard the original Form 2408, Individual Plan of Care Service Review, Form 2410, Medical-Social Assessment and Individual Plan of Care, or any other form or document completed during the face-to-face visit. The case manager must file the original handwritten document in the case file even if the form is typed after returning to the office.

Outbreak of Transmittable Disease in the General Population

During the time when Texas experiences an increase in serious transmittable diseases in the general population, certain precautions are necessary to ensure the health and welfare of the case manager who may come in contact with an individual reporting he has a contagious illness.

While it is important that a required face-to-face visit is performed on a timely basis, there may be circumstances that could place the case manager at risk for contracting contagious illnesses.

If a case manager contacts an individual to schedule a visit and the individual states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the visit, including the stated illness. If possible, the case manager 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 manager must contact the individual at least weekly until the visit can be made. The visit must be conducted in time for the case manager to redetermine MDCP eligibility and develop a new IPC prior to the end date of the current IPC.

Each contact must be documented in the case file on Form 2405, Narrative Notes. This documentation will be considered as an acceptable reason for delaying a required face-to-face visit.

 

7100.1 Opportunity to Register to Vote

Revision 14-1; Effective February 3, 2014

 

In addition to being offered voter registration assistance, as required by the National Voter Registration Act, at the time an individual applies for services, he must be offered this opportunity when he is reassessed annually for services. He must be given the opportunity to:

If the individual wishes to complete Form 0030 during the annual reassessment, DADS staff 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, DADS staff will ask him to complete Form 0030. DADS must transmit Form 0030 to the appropriate county voter registrar within five working days of the signature by the individual.

If the individual does not wish to complete Form 0030, the individual must complete and sign Form 1019, Opportunity to Register to Vote/Declination. If the individual refuses to sign the declination form, DADS staff must enter on the form a notation of that fact. DADS staff shall preserve in the individual's case record each declination form for at least 22 months after the date of signing.

The case manager must inform the individual of the option of requesting a ballot by mail if the individual is:

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.

 

7110 Annual Eligibility Requirements

Revision 12-2; Effective August 1, 2012

 

§51.203 To be eligible to participate in MDCP, a person must:

(1) live in Texas;

(2) be:

(A) a citizen of the United States (U.S.);

(B) an alien who entered the U.S. before August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1641(b) or (c); or

(C) an alien who entered the U.S. on or after August 22, 1996, who has lived in the U.S. continuously since entry, and who meets the definition of a qualified alien at 8 U.S.C. §1612(b) and §1613;

(3) be under 21 years of age;

(4) meet the financial Medicaid eligibility criteria described in Texas Administrative Code, Title 1, Chapter 358 (relating to Medicaid Eligibility), based on the person's income and resources;

(5) for initial enrollment only, meet at least one of the disability criteria described in §51.205(b) of this chapter (relating to Disability Criteria);

(6) meet medical necessity as described in §51.207 of this chapter (relating to Medical Necessity);

(7) have an IPC with a cost for MDCP services at or below 50 percent of the reimbursement rate that would have been paid for the same individual to receive nursing facility services considering all other resources, including resources described in §40.1 of this title (relating to Use of General Revenue for Services Exceeding the Individual Cost Limit of a Waiver Program); and

(8) if the person is under 18 years of age, reside:

(A) with a family member; or

(B) with a foster family that includes no more than four children unrelated to the individual.

The individual is eligible for the Medically Dependent Children Program (MDCP) when all eligibility criteria are met. The case manager reviews the eligibility criteria during the annual reassessment with the exception of the disability criteria. A disability determination is only required at the initial enrollment; the case manager does not assess for the disability criteria at the annual reassessment. The case manager must verify and document applicable eligibility requirements on Form 2405, Narrative Notes.

If the individual does not meet eligibility requirements at the annual reassessment, the case manager must notify the individual of ineligibility following procedures in Section 9510, Ineligibility.

The case manager must complete the following before determining individual eligibility during the annual reassessment:

 

7111 Financial Reassessments

Revision 13-3; Effective August 1, 2013

 

Health and Human Services Commission (HHSC) Medicaid for the Elderly and People with Disabilities (MEPD) redetermines financial eligibility annually for individuals receiving ME-Waivers Medicaid.

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, the case manager must provide the individual with an explanation of the changes. Previously, the envelopes contained the following wording, “Important Insurance Information.” The envelopes now state the following:

Image of Time Sensitive Stamp

The case manager must take examples of the envelopes to the face-to-face visit so the individual can become familiar with the new appearance of the envelopes. The case manager can make copies of the envelope examples located in Appendix XXII, Examples of HHSC Envelopes, to provide to the individual at the face-to-face visit. The case manager must discuss with the individual at the face-to-face visit the importance of returning Form H1200, Application for Assistance-Your Texas Benefits, or Form H1200-A, Medical Assistance Only (MAO) Recertification, 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 or Form H1200-A. The individual will receive Form H1200-SR instead of Form H1200 or H1200-A. 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.

The case manager 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. The individual may only return Form H1010 thinking this form will suffice for all services the individual is receiving. The case manager must inform the individual Form H1200, H1200-A, or H1200-SR and Form H1010 must both be completed and returned to HHSC. The case manager must make the individual aware he can track the status of his application using the “HHSC Your Texas Benefits” website at www.yourtexasbenefits.com, or by calling 211.

 

7120 Medical Necessity Determination

Revision 14-1; Effective February 3, 2014

 

§51.207

(a) An entity contracted by HHSC determines medical necessity.

(b) A determination that an individual meets medical necessity is valid for one year. An individual must receive a determination of medical necessity annually to remain eligible for MDCP.

The individual must receive a medical necessity (MN) determination annually to remain eligible for the Medically Dependent Children Program (MDCP). The MDCP nurse is responsible for completing the Medical Necessity and Level of Care (MN/LOC) Assessment during the annual reassessment face-to-face visit.

To obtain a medical necessity determination at the annual reassessment, the MDCP nurse must:

Within three working days of the visit, the MDCP nurse must complete and transmit the MN/LOC Assessment to TMHP for review for MN redetermination. The MDCP nurse must ensure the MN/LOC Assessment is entered into TMHP at least 60 days prior to the end of the Individual Plan of Care (IPC).

If the nurse is unable to submit the MN/LOC Assessment within three working days due to situations out of the nurse's control, the nurse must notify the case manager either on Form 2067, Case Information, or by phone, reporting the reason for the delay and the date the nurse anticipates this task will be completed.

Within three working days of TMHP's decision regarding the MN/LOC Assessment, the MDCP nurse must send a copy of the signed and dated Page 1 of Form 2410, and the Document Locator Number (DLN) associated with the MN/LOC Assessment, to the case manager.

If the nurse is unable to send a signed and dated copy of page 1 of Form 2410, and the MN/LOC DLN to the case manager within three working days of TMHP's decision regarding the MN/LOC Assessment due to situations out of the nurse's control, the nurse must notify the case manager either on Form 2067 or by phone, reporting the reason for the delay and the date the nurse anticipates this task will be completed.

The case manager may, at any time following TMHP's decision, retrieve a copy of the MN/LOC Assessment by accessing the TMHP web-based portal.

 

7130 Individual Plan of Care Development

Revision 14-1; Effective February 3, 2014

 

The case manager and the Medically Dependent Children Program (MDCP) nurse coordinate the development of a new Individual Plan of Care (IPC) at least annually based on the annual reassessment. The case manager and regional nurse must complete the annual reassessment 60 to 90 days prior to the end of the current IPC in order to ensure all annual reassessment activities are completed timely. The regional nurse must continue to enter the Medical Necessity and Level of Care (MN/LOC) Assessment into the Texas Medicaid and Healthcare Partnership (TMHP) online portal within three working days of the visit. If the individual or individual’s parent or guardian does not participate in the development of the IPC 60 to 90 days prior to the end of the current IPC, the case manager must deny MDCP program eligility.

The case manager must contact the provider of choice by phone to discuss the draft IPC developed at the annual reassessment. The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion with the provider must occur in time to authorize services before the end of the current IPC. Once all parties agree with the draft IPC, the service initiation date must be negotiated with the provider. The case manager should also include the MDCP nurse in the discussion, as appropriate, for any proposed changes to the IPC.

The case manager must document all dates of contact with the provider on Form 2405, Narrative Notes. The documentation must include details of the case manager's efforts to coordinate the IPC development and any concerns the provider may have regarding the draft IPC.

The case manager must complete all procedures necessary to authorize waiver services and enter the new IPC into the Service Authorization System (SAS) before the expiration date of the current IPC. The effective date of the new reassessment IPC is the first day of the new IPC period, which is the day after the last day of the previous IPC. The effective dates are the same on Form 2410 and Form 2065-B, Notification of Waiver Services. The case manager signature date and the date at the top of Form 2065-B must be the same date. This signature date and the date at the top of the form is the date the case manager completes the form and must be before the IPC expires. The date at the top of the form does not take into consideration the mail date of the form. Applicants and individuals must be notified within required time frames.

The case manager must not enter an annual reassessment IPC in SAS unless the individual meets all eligibility criteria.

Coordinating Multiple Services

When the case manager is evaluating the need for MDCP services for an individual receiving nursing or attendant services through programs other than MDCP, he must first evaluate if there is a need for MDCP services based on the criteria found in Section 4100, Medically Dependent Children Program (MDCP) Services. He must also determine if MDCP services are needed at least monthly, as required by the MDCP waiver and that there is no duplication in services.

The primary caregiver identified on the IPC is ultimately responsible for providing care to the individual, regardless of whether there is a service provider in the home. Therefore, a caregiver could feasibly need respite during the time another service provider is in the home, provided there is no duplication of services.

Example: A Comprehensive Care Program (CCP) private duty nurse is in the home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing personal care services to the individual to relieve the caregiver of tasks he or she would normally be responsible for performing.

The only exception to the no duplication of services policy would be instances requiring two-person transfers. In that scenario, the CCP private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

 

7131 Setting Funds Aside in the IPC

Revision 12-1; Effective May 1, 2012

 

During the development of the Individual Plan of Care (IPC), an individual may wish to set funds aside for future service requests, such as adaptive aids or minor home modifications.

The case manager may document future service requests under "Comments" in Fields 47a through 47f of Part II C – Individual Plan of Care Summary on Form 2410, Medical-Social Assessment and Individual Plan of Care. As indicated in the form instructions, these fields are completed when the applicant/individual/family is selecting to use the service during the IPC period. The case manager must not document funds that are set aside for future service requests in Part III – MDCP Applicant/Consumer Plan of Care/Budget Worksheet. Information in Part III must reflect authorized services for the IPC period.

 

7132 Completing the Annual Reassessment IPC

Revision 15-3; Effective March 11, 2015

 

To complete the annual reassessment Individual Plan of Care (IPC), the case manager must complete all of the following activities before the expiration of the current IPC:

The case manager must document on Form 2410 if the individual is using Aid and Attendance (A&A) or Housebound Benefits (HB) from Veterans Affairs to purchase respite care or flexible family support services. The use of these funds and services purchased must be considered in the development of the IPC.

If the annual reassessment IPC is submitted and current MN information is not found in SAS, the IPC will suspend. The IPC will also suspend if the Texas Integrated Eligibility Redesign System (TIERS) records do not reflect eligibility for a correct Medicaid type program at the time the IPC annual reassessment is data entered.

For individuals who appeal the denial of their annual reassessment IPC timely, MDCP services can be continued into the reassessment period, if requested by the individual. However, the case manager must complete the reassessment IPC and it must be registered into the SAS system. The case manager will notify the providers via Form 2067, Case Information, to continue services until the outcome of the appeal is determined.

When completing the annual reassessment for individuals receiving services in dual households, refer to Section 3136, Individual Residing in Dual Households.

Any gaps in concurrent coverage of the MN/LOC Assessment or the IPC will cause the loss of payment to the providers and unnecessarily jeopardize the care of the individual.

 

7133 Personal Care Services

Revision 12-1; Effective May 1, 2012

 

Personal Care Services (PCS) are available to Medicaid recipients under the age of 21 who are eligible for Texas Health Steps (THSteps).

PCS provides assistance with activities of daily living (ADL), instrumental ADL and health-related functions due to a physical, cognitive or behavioral limitation related to a disability or chronic health condition. The PCS program is administered by the Texas Health and Human Services Commission; however, the Department of State Health Services determines eligibility for services.

Medically Dependent Children Program (MDCP) individuals may receive services from PCS, in addition to receiving services from MDCP. Since PCS addresses different needs than those met by MDCP services, the individual's decision to access PCS should not affect the MDCP services authorized by Department of Aging and Disability Services (DADS) case managers. The DADS case manager must document in the case file the individual was referred to PCS on the Individual Plan of Care (IPC) or on Form 2405, Narrative Notes.

For individuals receiving services from both PCS and MDCP, close coordination between DADS and PCS case managers is necessary to ensure the IPC accurately reflects all services being received.

 

7133.1 PCS Data Reports

Revision 12-1; Effective May 1, 2012

 

Department of Aging and Disability Services (DADS) case managers are required to coordinate services with Personal Care Services (PCS) case managers for individuals who are receiving both PCS and DADS waiver services. PCS data reports are available online at: ftp://dads4svtuvok/PCS.

DADS case managers will access the PCS data reports before annual reassessments to determine if coordination of services with PCS case managers is needed.

 

7133.2 Using the PCS Data Reports

Revision 12-1; Effective May 1, 2012

 

After clicking the link ftp://dads4svtuvok/PCS, Department of Aging and Disability Services (DADS) case managers will find a zipped folder named PCS Files SFY10 Q3.zip. Double click that folder to access three excel spreadsheets: PCS Match File 1 FY10 Q3, PCS Match File 2 FY10 Q3 and PCS Match File 3 FY10 Q3.

Note: The fiscal year and quarter will change as warranted.

PCS Match File 1 FY10 Q3 lists individuals currently receiving both waiver services and PCS, and is utilized at annual reassessments.

PCS Match File 2 FY10 Q3 lists individuals receiving PCS who are being released from a waiver interest list, and is utilized at initial assessments.

PCS Match File 3 FY10 Q3 is used by the Department of State Health Services to identify individuals receiving waiver services.

DADS case managers must review PCS Match File 1 FY10 Q3 prior to conducting an annual reassessment to search for individuals receiving PCS. DADS case managers open the PCS Match File by double clicking the file, and may search in column A by Medicaid number or column B by name for individuals being assessed. If the individual is found in PCS Match File 1 FY10 Q3, DADS case managers must coordinate with PCS case managers to evaluate the level of PCS being delivered and the need for DADS waiver services.

 

7133.3 Procedures for Individuals Not Receiving PCS

Revision 15-3; Effective March 11, 2015

 

The Department of Aging and Disability Services (DADS) case manager must explain Personal Care Services (PCS) and give the individual the Texas Medicaid & Healthcare Partnership (TMHP) toll-free PCS Line (1-888-276-0702). TMHP will forward referral information to the appropriate Department of State Health Services staff. The DADS case manager must review the status of PCS eligibility at the following six-month monitor. The DADS case manager continues with Medically Dependent Children Program (MDCP) eligibility re-determination and documents the PCS program referral in the case file.

If the individual contacts the PCS case manager and requests PCS, the PCS case manager will provide PCS information describing the benefits of the program available to the individual. The PCS case manager will inform the individual that both the PCS case manager and the DADS case manager must work together to coordinate the delivery of PCS and MDCP services. The PCS case manager will contact the DADS case manager to request the Individual Plan of Care (IPC). The DADS case manager must fax the individual's IPC and provider names, including the Financial Management Services Agency, and contact information using Form 2067, Case Information, to the PCS case manager within five working days of the request.

Once the individual is determined PCS eligible, the PCS case manager will provide a copy of the final Personal Care Assessment Form to the DADS case manager with the PCS case manager's name and contact information.

 

7134 Coordinating with IDD Services During the Development of the Annual IPC

Revision 12-2; Effective August 1, 2012

 

Home and Community-based Services (HCS), Texas Home Living (TxHmL) and Local Authority (LA) general revenue services are intellectual developmental disability (IDD) services that must not be accessed in coordination with Medically Dependent Children Program (MDCP) services. In order to prevent dual enrollment with these programs, the MDCP case manager or intake screener must check the Client Assignment and Registration (CARE) System to see if an individual is receiving LA services, which could be mutually exclusive with other DADS services. The DADS case manager checks the mutually exclusive chart for programs that are not mutually exclusive. The chart is in Appendix V, Mutually Exclusive Services.

 

7135 FMS for the MDCP Individual Accessing CDS

Revision 12-2; Effective August 1, 2012

 

If the individual is using the Consumer Directed Services (CDS) option and wants to continue to use the option for both Personal Care Services (PCS) and the Medically Dependent Children Program (MDCP), the individual must use only one CDS agency for both programs. If the individual has a CDS agency serving both programs, the individual may continue to use the current CDS agency. If the individual has a CDS agency that does not contract to deliver Financial Management Services for both programs, the individual must select a CDS agency that serves both PCS and MDCP.

 

7136 Coordination of Services in the MDCP IPC and the Personal Care Assessment Form

Revision 13-2; Effective May 1, 2013

 

Although Respite and Flexible Family Support Services have different service criteria and are authorized to address different needs than Personal Care Services (PCS), coordination of service delivery is required of both the Department of Aging and Disability Services (DADS) case manager and the PCS case manager. Duplication of services will not be permitted. Duplication is defined as two different services providing an individual the same assistance at the same time without the presence of an unmet need. Both case managers must review the needs of the individual/primary caregiver and reach an agreement on the individual plan of care (IPC) for service delivery for the Medically Dependent Children Program (MDCP) and PCS.

The DADS case manager may contact the Department of State Health Services (DSHS) for information for current PCS individuals at the following telephone numbers:

DSHS Region 1
806-655-7151

DSHS Region 2/3
817-264-4627

DSHS Region 4/5 N
903-533-5231

DSHS Region 6/5 S
713-767-3111

DSHS Region 7
254-778-6744

DSHS Region 8
210-949-2155

DSHS Region 9/10
915-834-7682

DSHS Region 11
956-423-0130

DSHS regions differ slightly from DADS. To determine which DSHS office to call, the DADS case manager may access a list of DSHS regional offices and a DSHS County/Region map located at www.dshs.state.tx.us/regions/default.shtm.

The DADS case manager must document all verbal communication with the PCS case manager in the case file, using Form 2405, Narrative Notes.

 

7140 Notifications for Program Eligibility and Service Authorizations

Revision 14-1; Effective February 3, 2014

 

The case manager documents the individual's eligibility and authorizes Medically Dependent Children Program (MDCP) services by completing Form 2065-B, Notification of Waiver Services. Within two working days of determining program eligibility, the case manager sends Form 2065-B with the case manager's original signature, to the individual, provider and Medicaid for the Elderly and People with Disabilities (MEPD) specialist, when applicable.

In addition to Form 2065-B and also within two working days of determining program eligibility, the case manager completes and sends the following service authorization forms to the individual/employer and provider, as appropriate:

The case manager must apply the adverse action period when reducing or terminating a service across Individual Plan of Care (IPC) years. For example, if an individual was receiving 20 hours per week of respite but will only receive 15 hours per week in the new IPC year, the case manager must notify the individual of the reduction in respite when sending Form 2065-B. The case manager does not need to indicate one-time purchased items, such as adaptive aids, authorized in the current IPC that are not requested on the new annual reassessment IPC on Form 2065-B. In order for the case manager to establish if an adverse action period is needed, the case manager must finalize the IPC at least 30 days prior to the end of the current IPC.

When a service is reduced from one IPC year to the next, the case manager must document the reduction in the comments section on Form 2065-B.

Example: The individual currently receives 40 hours per week of respite and received an adaptive aid during the current service plan. The individual’s annual reassessment service plan includes a reduction in respite from 40 hours per week to 20 hours per week. No adaptive aid is requested on the new service plan. When the case manager sends Form 2065-B to the individual advising him of his continued eligibility, the case manager documents the following statement in the comments section: “Your respite has been reduced from 40 hours per week to 20 hours per week.” The case manager does not need to comment about the adaptive aid because it was a one-time purchased item on the previous service plan.

 

7141 Respite Service Authorizations

Revision 13-4; Effective November 1, 2013

 

The case manager follows the Medically Dependent Children Program Respite definition and limitations to review all requests for Respite. The case manager authorizes Respite by completing Form 2065-B, Notification of Waiver Services, and Form 2415, Respite Service Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Respite. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2415 to identify the Respite hours the provider is authorized to deliver. The case manager must follow procedures in Section 4113, Respite Service Authorizations, for rounding respite units per week up to the next quarter-hour on Form 2415. The case manager sends Form 2415 to the provider identified on the form and copies of Form 2415 to the individual. The case manager must complete and send Form 2065-B and Form 2415 within two working days of determining eligibility for the requested service.

 

7142 Flexible Family Support Services Authorizations

Revision 13-4; Effective November 1, 2013

 

The case manager follows Medically Dependent Children Program Flexible Family Support Services criteria to review all requests for Flexible Family Support Services. The case manager authorizes Flexible Family Support Services by completing Form 2065-B, Notification of Waiver Services, and Form 2414, Flexible Family Support Services Authorization. The case manager completes Form 2065-B to inform the individual of eligibility for the requested service and to authorize the provider to deliver Flexible Family Support Services. The case manager sends Form 2065-B to the individual and copies of Form 2065-B to the providers. The case manager completes Form 2414 to identify the Flexible Family Support Services hours the provider is authorized to deliver. The case manager must follow procedures in Section 4125, Flexible Family Support Services Authorizations, for rounding flexible family support services units per week up to the next quarter-hour on Form 2414. The case manager sends Form 2414 to the provider identified on the form and copies of Form 2414 to the individual. The case manager must complete and send Form 2065-B and Form 2414 within two working days of determining eligibility for Flexible Family Support Services.

 

7143 Practitioner's Orders or Form 2428 for Respite or Flexible Family Support Services

Revision 13-2; Effective May 1, 2013

 

The Home and Community Support Services Agency (HCSSA) must determine if skilled tasks will be delivered. No practitioner's orders are required for services delivered by an attendant (Service Code 11). The delivery of skilled tasks is not required when an individual uses a registered nurse (RN) or licensed vocational nurse (LVN) to deliver Respite or Flexible Family Support Services; however, the state has two reimbursement rates for Respite delivered by attendants dependent on the delivery of skilled tasks.

In brief, practitioner's orders are required when skilled tasks are delivered by an:

Practitioner's orders are not required when non-skilled tasks are delivered by an:

The HCSSA is not required to use Form 2428, Physician's Orders for Licensed Nursing Services, if the practitioner's orders are recorded on an HCSSA form or one from the practitioner's office. The practitioner order requirement only applies to HCSSA Respite providers and does not apply to any other Respite provider.

Practitioner's orders submitted to the case manager by an HCSSA must be signed by the individual's practitioner, as defined in 40 Texas Administrative Code (TAC) §51.103, (35), which defines a practitioner as:

Neither a Consumer Directed Services (CDS) agency nor CDS employer is required to submit practitioner's orders to the case manager for individuals using the CDS option.

Case Manager Follow Up on Provider Response

The case manager must track the provider's response on Form 2414, Flexible Family Support Services Authorization, or Form 2415, Respite Service Authorization. The case manager must ensure the HCSSA completes this provider requirement. The case manager will submit a referral to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858 to register a complaint within five working days if the required signed service authorization form with practitioner’s orders, as applicable, were not submitted to the case manager within 14 working days from the date the provider receives the applicable service authorization form.

The case manager must identify the complaint is regarding a "Medically Dependent Children Program provider" and indicate the HCSSA is not complying with program requirements. The case manager documents the referral to CRS in the case file, using Form 2405, Narrative Notes.

If the case manager receives the applicable service authorization form indicating skilled tasks will be delivered within 14 working days from the date the provider receives a service authorization form, but no signed practitioner’s orders are received, the case manager contacts the HCSSA and gives the provider until the 14th working day from the date the provider receives the service authorization form to submit practitioner’s orders. If practitioner’s orders are not received within 14 working days from the date the provider receives the service authorization form, the case manager must make a referral to CRS.

If the case manager authorized Respite or Flexible Family Support Services to be delivered by an attendant with delegated tasks, the case manager must review the HCSSA response regarding the delivery of skilled tasks. If the HCSSA indicates the individual does not require skilled tasks, the case manager must change the provider type to an attendant. The case manager must update the Individual Plan of Care (IPC), Form 2414 or Form 2415, and the Service Authorization System (SAS) data records. This change is not a service reduction, service denial or case closure, and therefore does not require a 30-day notification time frame. The case manager may indicate the HCSSA determined no skilled tasks will be delivered in the Comment section on Form 2414 or Form 2415. The case manager must contact the individual/primary caregiver to inform the individual/primary caregiver of the change in provider type before sending the updated Form 2414 or Form 2415.

In SAS, the case manager must cancel the Service Authorization record for the attendant with delegated tasks and create a new Service Authorization record with the appropriate service code using the same begin and end dates. Cancellation and creation of Service Authorization records must occur on the same day to avoid a gap in services and potential reimbursement recoupment. SAS data entries due to changes to the IPC must be processed following the time frames in Section 4230, Service Authorization System (SAS).

The case manager applies the same procedures if an attendant provider type was authorized and the HCSSA response indicates skilled tasks will be delivered. If the change from an attendant to an attendant with delegated tasks results in a service reduction, the 30-day notification time frame applies. For this reason, the case manager must make every effort to discuss the appropriate use of an attendant with delegated tasks with the individual/primary caregiver when developing the IPC. See Section 4110, Respite, or Section 4120, Flexible Family Support Services.

No additional follow up is needed if the HCSSA indicated no skilled tasks will be delivered on Form 2414 or Form 2415 for RN or LVN provider types.

If the request for assistance does not meet Respite or Flexible Family Support Services criteria, the case manager denies the individual's request for the service.

 

7144 Program Ineligibility at Annual Reassessment

Revision 14-1; Effective February 3, 2014

 

If the individual does not meet eligibility criteria at the annual reassessment, the case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations/Codes (see the Form 2065-C instructions) to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination to the individual and providers. The case manager must send Form 2065-C to the individual no later than 30 days before the end of the individual's Individual Plan of Care (IPC) period. The day the case manager completes Form 2065-C is day zero and starts the 30-day time frame for the notification period.

The case manager does not complete any service authorization forms when denying Medically Dependent Children Program (MDCP) services for an individual at the annual reassessment.

For case closures resulting from loss of Medicaid, see Section 5500, Loss of Medicaid.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center by fax within two working days of the program ineligibility determination.

If the individual or individual’s parent or guardian does not participate in the development of the IPC 60 to 90 days prior to the end of the current IPC, the case manager must deny MDCP program eligibility. The case manager must mail Form 2065-C to the individual at least 30 days prior to the end of the current IPC and list the last day of the current IPC as the last day the individual is eligible to receive services.

 

7150 Service Authorization System Data Entry

Revision 13-2; Effective May 1, 2013

 

The case manager must data enter the Individual Plan of Care (IPC) developed during the annual reassessment in the Service Authorization System (SAS) by the end of the previous IPC period. SAS maintains information relevant to the individual's authorized services. The case manager must data enter authorized services into SAS before a provider can receive payment for services delivered to an individual.

If the SAS data entry cannot be completed within the identified time frame, the case manager must document the delay in the case file using Form 2405, Narrative Notes, and complete the SAS data entry as soon as possible.

The case manager must document all delays if SAS data entry cannot be completed at the same time as completion of:

The case manager must verify the information in SAS matches the new plan of care and service authorization forms. The plan of care form is Form 2410, Medical-Social Assessment and Individual Plan of Care, used for initial enrollments or annual reassessments.

The service authorization forms are:

CM-MDCP, Section 8000, Consumer Directed Services

Revision 16-1; Effective May 3,2016

 

 

8100 Overview

Revision 15-3; Effective March 11, 2015

 

The Consumer Directed Services (CDS) option was codified in Section 531.051 of the Government Code and expanded by the 79th Legislature to provide more options for individuals to direct their Long-term Services and Supports (LTSS). The rules for the CDS option are found in Texas Administrative Code Title 40, Chapter 41.

§41.107 — Overview of the CDS Option.

(a) An individual or LAR may elect the CDS option if:

(1) the individual's program offers the CDS option;

(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;

(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;

(4) the individual or LAR selects a CDSA to provide FMS; and

(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:

(1) selects a CDSA to provide FMS;

(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and

(3) recruits, screens, hires, trains, manages, and terminates service providers.

(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities.

CDS is a service delivery option in which an individual or legally authorized representative (LAR) employs and retains service providers and directs the delivery of Respite Services and Flexible Family Support Services.

An individual participating in the CDS option is required to use a Financial Management Services Agency (FMSA) chosen by the individual or LAR to provide financial management services (FMS). FMS is defined as services delivered by the FMSA to an employer such as an initial orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the employer.

 

8110 Definitions

Revision 15-3; Effective March 11, 2015

 

The following terms, when used in reference to the Consumer Directed Services (CDS) option, have the following meanings:

Budget — A written projection of expenditures for each program service delivered through the CDS option.

Designated Representative (DR) — A willing adult appointed by the employer of record to assist with or perform the employer's required responsibilities to the extent approved by the employer. The DR is not the employer of record. The DR is not paid.

Employee — A person employed by the individual or LAR through a service agreement to deliver program services, who is paid an hourly wage for those services.

Employer of Record — The individual or LAR who chooses to participate in the CDS option and, therefore, is responsible for hiring and retaining service providers to deliver program services.

Financial Management Services (FMS) — Financial management services delivered by the FMS agency (FMSA) to the individual or LAR such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the individual or LAR.

Legally authorized representative (LAR) — A person authorized by law to act on behalf of an individual with regard to matters described in the CDS option, including a parent, guardian, managing conservator of a minor, or the guardian of an adult.

Service Back-up Plan — A documented plan to ensure that critical services delivered through the CDS option are provided to an individual when normal service delivery is interrupted or there is an emergency.

 

8200 Individual Choice in the CDS Option

Revision 13-2; Effective May 1, 2013

 

All individuals will continue to be assessed for financial and functional eligibility under the guidelines currently in use.

There is no change in eligibility determination. Individuals have the option of using a personal attendant for flexible family support or respite services delivered through a contracted home health agency or using the Consumer Directed Services (CDS) option, in which they hire and manage their own personal attendant.

Individuals currently receiving MDCP services may call and request to change to the CDS option at any time during the individual plan of care year.

 

8210 Initial Presentation of the CDS Option

Revision 15-6; Effective May 20, 2015

 

Texas Administrative Code §41.109, Enrollment in the CDS Option.

The case manager is responsible for presenting the Consumer Directed Services (CDS) option to individuals applying for MDCP services and individuals already receiving MDCP services. The case manager will review the CDS option annually during the reassessment. Unless an individual selects a different option from the initial choice, a new Form 1584, Consumer Participation Choice, is not required. Refer to Section 2370, Explaining Electronic Visit Verification Requirements, for talking points on explaining Electronic Visit Verification requirements to the applicant or individual requesting the CDS option.

The individual's signature on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, is acknowledgement of the presentation of the CDS option information. The case manager is also responsible for discussing Form 1581, Consumer Directed Services Option Overview, with the individual. If the individual is not interested in the CDS option, the individual signs Form 1584 and the case manager:

If the individual is interested in the CDS option, the case manager must present Form 1582, Consumer Directed Services Responsibilities, which includes the following information:

In completing the individual self-assessment portion of the form with the individual, the case manager:

The case manager presents the list of contracted FMSAs to the individual to select an FMSA.

The case manager may also inform the individual that The Department of Aging and Disability Services (DADS) website provides a choice list of FMSAs for individuals using the CDS option. The list, which allows individuals to search for FMSAs by county, can be accessed at: hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds.

Under the CDS menu, select CDS Agencies and a list of DADS programs will appear. When a program is selected, on the top of the page is a drop-down list of Texas counties. After selecting a county, click the button labeled “Search for FMSAs”. This will create a list of FMSAs serving the selected county.

Declining the CDS Option

If the individual or legally authorized representative (LAR) declines or is not ready to select the CDS option after Form 1582 is shared, the case manager:

The case manager must ensure the individual understands the CDS option is always available, and that the individual may call the case manager to request a change to the CDS option at any time.

Form 1584 is signed by the individual when a different service delivery option is chosen. For exceptions, see Section 8600, Transfer Procedures.

 

8220 CDS Option for Ongoing Individuals

Revision 12-1; Effective May 1, 2012

 

After the initial presentation, the individual signs Form 1584, Consumer Participation Choice, and the case manager files it in the case file.

The case manager will review the CDS option annually during the reassessment. The information is presented on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual. Unless an individual selects a different option from the initial choice, a new Form 1584 is not required.

 

8300 Developing the Individual Service Plan

Revision 13-2; Effective May 1, 2013

 

§41.111. Service Planning in the CDS Option

(a) Service planning for an individual who chooses to participate in the CDS option is completed in accordance with the rules and requirements of the individual's program in the same manner as if services are delivered through a program provider. Service planning includes:

(1) determining the individual's needs;

(2) determining service levels;

(3) justifying changes to the service plan;

(4) maintaining costs and cost ceilings;

(5) reviewing services; and

(6) obtaining approval for planned services.

(b) A case manager or service coordinator must adhere to rules and requirements of the individual's program and in Subchapter D of this chapter (relating to Enrollment, Transfer, Suspension, and Termination) if the individual's services or a request for services is recommended for:

(1) denial;

(2) reduction;

(3) suspension; or

(4) termination.

(c) A case manager or service coordinator must provide an oral explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided orally and in accordance with the individual's program requirements.

Case managers continue to determine eligibility and develop a service plan using current policy. All financial and non-financial eligibility requirements apply. Consumer Directed Services (CDS) is not a different service; it is a service delivery option.

The individual using the CDS option must have a back-up system to assure the provision of authorized Respite and Flexible Family Support Services deemed critical to the health and welfare of the individual. The individual or legally authorized representative must develop and receive approval from the case manager for each required service back-up plan in order to participate in the CDS option. Refer to Section 8420, Service Back-up Plans.

 

8400 Initiation and Transition to the CDS Option

Revision 15-3; Effective March 11, 2015

 

§41.401. Enrollment Process

The enrollment process is conducted in accordance with §41.109 of this chapter (relating to Enrollment in the CDS Option). Within five working days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible individual or LAR, or upon receipt of Form 1584 and within five working days after eligibility determination for an applicant applying for program services, a case manager or service coordinator must provide the following documentation to the Financial Management Services Agency (FMSA):

(1) Form 1584;

(2) the individual's authorized service plan;

(3) the individual's plan of care; and

(4) if not provided in paragraph (1)-(3) of this section:

(A) the date the employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;

(B) the date the employer may begin delivery of program services through the employer's service providers;

(C) the number of units, the approved rate, or the amount authorized in the individual's service plan for each service to be delivered through the CDS option;

(D) the total funds authorized for each program service to be delivered through the CDS option; and

(E) the authorized schedule of service delivery per day, week, month, or other time frame specific to the service.

Individuals choosing the Consumer Directed Services (CDS) option must be Medicaid eligible or will become Medicaid eligible by the individual plan of care (IPC) service initiation date.

Within five working days after the applicant has met all MDCP eligibility criteria and has requested enrollment into the CDS option via Form 1584, Consumer Participation Choice, case managers must send a referral to the applicant's chosen financial management service (FMS) provider.

The referral packet will include:

The case manager must refer to Section 3130 and Section 7130, Individual Plan of Care Development, at initials and annual reassessments for rounding respite or flexible family support services units per week up to the next quarter-hour on the IPC. The case manager also sends Form 2067, Case Information, to the agency to advise that the individual has selected the CDS option and requests that training be delivered to the individual. The agency is required to respond to the case manager on Form 2067 within 30 days to advise that the training and transition planning has been completed and the individual is ready to negotiate a start date for CDS.

If the agency is unable to complete the training within the required time frames, an explanation must be provided on Form 2067. If the case manager has not heard from the individual and FMSA in 30 days, the case manager should contact the individual regarding the delay.

For MDCP Applicants using the Money Follows the Person (MFP) option whose Medicaid Eligibility will not be determined until 30 Days after the Nursing Facility (NF) Admission Date

Case managers must inform MFP applicants who are not yet Medicaid eligible when discharged from the NF that MDCP services must be delivered through the provider service delivery model until Medicaid eligibility is determined. Case managers follow current policy and enroll applicants using the provider service delivery model. Once applicants have been certified for Medicaid, case managers must add FMS as a change to the IPC and change the respite authorization to CDS.

For Individuals Choosing the CDS Option at the Annual Reassessment

The case manager may also enroll MDCP Individuals into the CDS option at the annual reassessment. Once an Individual has met all ongoing MDCP eligibility criteria and requests enrollment into the CDS option, case managers must send a referral to the applicant's chosen FMS provider within five working days, as described above.

FMSAs that do not Accept Referrals

FMSAs are not required to provide services to all referred individuals. In rare instances, such as anticipation of contract termination or placement on vendor or individual hold, an FMSA may not accept referrals.

If the selected FMSA is not able to provide services to the individual, the FMSA must send the case manager written notification using Form 2067. Receipt of this written notification will prompt the case manager to offer the individual another choice of FMSA and to provide the newly selected FMSA with the required documentation, following the same procedures outlined above.

 

8410 Initial Orientation of the Employer

Revision 16-1; Effective May 3,2016

Texas Administrative Code §41.207, Initial Orientation of an Employer

Employers of Record for Individuals Using the CDS option

Texas Administrative Code Chapter 41 rules regarding the Consumer Directed Services (CDS) option define a parent as a natural, legal, foster, or adoptive parent of a minor. A legally authorized representative (LAR) is a person authorized or required by law to act on behalf of an individual, including a parent, guardian, managing conservator of a minor, or the guardian of an adult. An applicant or individual age 18 and over who does not have an LAR to sign CDS forms is the employer of record, and may designate a representative to assist with the CDS option.

Upon receipt of the CDS referral from the case manager, the Financial Management Services Agency (FMSA) completes the initial employer orientation with the individual, LAR or designated representative (DR) in the individual's residence. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the employer and the FMSA.

The individual, LAR or DR signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five calendar days after the date of initial orientation.

The individual and FMSA notify the case manager when all initiation activities are complete.

 

8420 Service Back-Up Plans

Revision 15-3; Effective March 11, 2015

 

§41.217. Service Back-up Plan

(a) An employer or DR must develop and document a service back-up plan for each service to be delivered through the CDS option that the individual's service planning team has determined to be critical to the health and welfare of the individual.

(b) An individual's service planning team must describe:

(1) which services are critical; and

(2) the length of time that constitutes a service interruption or an emergency for the individual.

(c) An employer or DR must develop a service back-up plan that:

(1) ensures the provision of services when the employer's regular service provider is not available to deliver the service or in an emergency; and

(2) may include the use of:

(A) paid service providers;

(B) unpaid service providers, such as family members, friends, or non-program services; or

(C) use of respite, if included in the authorized service plan.

The case manager must discuss with the individual, legally authorized representative (LAR) or designated representative (DR) the services delivered through Consumer Directed Services (CDS) that are critical to the individual's health and welfare and inform the individual, LAR or DR to develop a service back-up plan to ensure the health and safety of the individual when regular service providers are not available to deliver services or in an emergency. The individual, LAR or DR must develop a back-up system to assure the provision of all authorized services without a service break.

The individual, LAR or DR, with the assistance of the case manager if needed, develops a service back-up plan. The service back-up plan must list the steps the individual, LAR or DR will implement in the absence of the service provider. The service back-up plan may include the use of paid service providers, or unpaid service providers such as family members, friends or non-program services, or Flexible Family Support Services if included in the authorized service plan. The individual, LAR or DR is responsible for implementation of the service back-up plan in the absence of the employee.

Service back-up plans are submitted by the individual, LAR or DR to the case manager. The back-up plan is approved as being viable in the event a service provider is absent by:

The case manager, individual and the primary caregiver must approve each service back-up plan, as well as any

Revision, before implementation by the individual, LAR or DR. The case manager approves the service back-up plan by signing and dating the plan and returning a copy of the plan to the individual, LAR or DR.

The individual, LAR or DR is required to:

The FMSA must assist an individual, LAR or DR, as requested, to revise budgets to meet service back-up plan strategies approved by the individuals specified in the previous paragraph, reimburse documented, budgeted, allowable expenses incurred related to implementing service back-up plan strategies; and retain a copy of service back-up plans received from the individual, LAR or DR.

 

8430 Corrective Action Plans

Revision 15-3; Effective March 11, 2015

 

§41.221. Corrective Action Plans

(a) A written corrective action plan may be required from an employer or DR if the employer or DR:

(1) hires an ineligible service provider;

(2) submits incomplete, inaccurate, or late documentation of service delivery;

(3) does not follow the budget;

(4) does not comply with program requirements related to the CDS option; or

(5) does not meet other employer responsibilities.

(b) An employer must provide written corrective action plans to the person requiring the plan within 10 calendar days after receiving the request. Corrective action plans may be requested in writing by:

(1) a FMSA, related to employer responsibilities;

(2) a case manager or service coordinator;

(3) a service planning team; or

(4) a DADS representative.

(c) A written corrective action plan must include:

(1) the reason the corrective action plan is required;

(2) the action to be taken;

(3) the person responsible for each action; and

(4) the date the action must be completed.

(d) An employer or DR may request assistance in the development or implementation of a corrective action plan from:

(1) the FMSA or others if the plan is related to employer responsibilities, as described in this subchapter;

(2) if applicable, the support advisor as described in Subchapter F of this chapter (relating to Support Consultation Services and Support Advisor Responsibilities); and

(3) the case manager, service coordinator, or others if the corrective action plan is related to program rules or requirements.

The individual, legally authorized representative (LAR) or designated representative (DR) must provide written corrective action plans to the person requiring the plan within 10 calendar days after receiving the request to provide a plan. Corrective action plans may be requested in writing by a:

The written corrective action plan, Form 1741, Corrective Action Plan, must include the:

The individual, LAR or DR may request assistance in the development or implementation of a corrective action plan from the:

FMSA Quarterly Reports

§41.317. CDSA Reports

(1) compile a report in accordance with the format provided by DADS addressing each service delivered through the CDS option, including the actual number of hours or units of service delivered;

(2) provide the report no less than quarterly, and monthly if requested, to:

(A) the employer or DR; and

(B) the case manager or service coordinator; and

(3) provide a copy of the report to DADS, upon request by a DADS representative.

The FMSA must provide the budget status report at least quarterly to the individual or LAR and case manager. The individual or LAR may request the FMSA provide the budget report on a monthly basis. The individual or LAR must initiate budget

Revisions if needed to ensure sufficient funds and units of a service are available through the end date of the individual plan of care.

 

8500 Employer Difficulty Managing the CDS Option

Revision 15-3; Effective March 11, 2015

 

If during the 30-day contact or individual plan of care (IPC) service monitor review, it is evident the Consumer Directed Services (CDS) employer is having difficulty in the management of services under the CDS option, the case manager may consult with the Financial Management Services Agency (FMSA).

Examples of CDS employer difficulty in managing services under the CDS option:

The case manager may recommend additional training for the CDS employer in certain areas or relay concerns on budget management.

Problems with the FMSA should be resolved following procedures in Section 5200, Service Delivery Issues Reported to DADS Staff.

Problems noted with services delivered through the CDS option should be sent to the FMSA via Form 2067, Case Information. The case manager may recommend additional training for the individual, LAR, or DR in certain areas or relay concerns on fiscal management. The case manager may request a corrective action plan. Refer to Section 8430, Corrective Action Plans.

Problems with the FMSA should be noted and resolved with the FMSA, or sent to Consumer Rights and Services.

 

8600 Transfer Procedures

Revision 15-3; Effective March 11, 2015

 

The case manager follows normal agency transfer procedures. If issues with the current agency cannot be resolved, the individual has the right to transfer.

The individual has the right to transfer to a different Financial Management Services Agency (FMSA) or request a transfer back to the Home and Community Support Services Agency (HCSSA) option at any time.

If the individual chooses to transfer back to the HCSSA option, the case manager negotiates a transfer date not to exceed 14 days to begin flexible family support or respite services through the HCSSA.

The case manager sends both the FMSA and the HCSSA a new service authorization, with one showing an end date another showing a start date.

In addition, the case manager is responsible for arranging for services as quickly as possible and assisting individuals in exploring other resources, as necessary.

 

8610 Termination of Participation in the CDS Option

Revision 15-3; Effective March 11, 2015

 

§41.407. Termination of Participation in the CDS Option

(a) An employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. The termination must last at least 90 calendar days.

(b) An individual may be involuntarily terminated from participation in the CDS option in accordance with the requirements of the individual's program.

(c) FMS and, if applicable, support consultation, are terminated in the individual's service plan when participation in the CDS option is terminated.

The Financial Management Services Agency (FMSA) is responsible for:

The case manager is responsible for:

With supporting documentation from the FMSA, the case manager can recommend to the individual that he voluntarily request to change to the Home and Community Support Services Agency (HCSSA) option.

The case manager transfers the individual back to the HCSSA option. Form 2065-B, Notification of Waiver Services, is sent to the individual to notify of the termination of the CDS option.

Issues of non-compliance with CDS option requirements may result in the termination of an individual's participation in the CDS option. The case manager, in consultation with the primary caregiver, may recommend immediate termination of participation in the CDS option when the:

Before an FMSA recommends involuntary termination of participation in the CDS option to the case manager, the FMSA must:

The individual, LAR or DR must be given the opportunity to implement interventions to:

The case manager must provide assistance to the individual with accessing supports, developing and implementing a corrective action plan, and documenting interventions utilized by the individual, LAR, or DR to eliminate the noncompliance with the CDS option.

The case manager meets with the individual, the primary caregiver and any other individual participating in the care of the individual to:

If the primary caregiver and other individuals participating in the individual's care recommend termination of participation in the CDS option, the case manager sends Form 2065-B to notify the individual of termination of participation in the CDS option. The individual has the right to appeal. Form 2065-B must include the:

The case manager must also document in the case record:

When an individual's participation in the CDS option is terminated, the case manager must take steps and interventions in accordance with the requirements of the Medically Dependent Children Program to:

The FMSA must provide a final report to the individual or LAR and the case manager within five working days after the individual's termination. The FMSA must provide copies to the individual or LAR of documentation as received and filed on behalf of the individual following the individual's termination from the CDS option and submit a satisfaction survey to the employee.

For involuntary termination, the individual cannot be re-enrolled in the CDS option until he has met the time frame and conditions established by the:

The case manager is required to complete Form 1584, Consumer Participation Choice, any time the individual chooses a different service delivery option.

If the individual is being involuntarily terminated from the CDS option and the case manager is unable to get Form 1584 signed, the case manager must document the reason in the case file.

 

8620 Re-enrollment in the CDS Option

Revision 16-1; Effective May 3,2016

Texas Administrative Code §41.409, Re-enrollment for Participation in the CDS Option

Upon receipt of request from an individual to re-enroll in the Consumer Directed Services (CDS) option after a suspension or termination of the CDS option, the case manager determines if established criteria to return to the CDS option is met in consultation with the:

The case manager reviews the reason for the suspension or termination, determines if any issues relating to the suspension or termination are still unresolved, and verifies time frame requirements.

If an individual's request for re-enrollment in the CDS option is approved, the case manager revises the service plan, ensures service back-up plans are in place and authorizes the CDS option.

The case manager follows routine transfer procedures to refer the individual to the Financial Management Services Agency (FMSA) and sends Form 2065-B, Notification of Waiver Services, to notify the individual, Home and Community Support Services Agency (HCSSA) and the FMSA of the transfer of the individual back to the CDS option.

If a request for re-enrollment is not approved, the case manager sends Form 2065-B to notify the individual the request is not approved. The case manager must notify the individual of the reason the request for re-enrollment is not approved and assist the individual in resolving any issues that prohibit re-enrollment.

If the individual requests re-enrollment after a suspension, the case manager is not required to complete Form 1584, Consumer Participation Choice. CDS forms currently on file in the case record are still applicable upon reactivation of the CDS option. The case manager should complete new CDS forms only if the form requires a change related to the delivery of services, such as Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services.

If the individual requests re-enrollment after a termination, the case manager shares the information on Form 1584 and obtains the individual's or legally authorized representative's (LAR's) signature documenting the choice to receive services through the CDS option. Form 1581, Consumer Directed Services Option Overview, Form 1582, Consumer Directed Services Responsibilities, Form 1583, Employee Qualification Requirements, and Form 1733 must be completed with the individual before returning to the CDS option.

If approved for re-enrollment, the FMSA must provide the individual, LAR or designated representative (DR) with an initial orientation if the current individual, LAR or DR has not received an initial orientation.

The FMSA must also notify the individual, LAR or DR, and the individual's case manager in writing within two working days after any repeat of prior noncompliance or additional noncompliance with program requirements.

 

8700 CDS Contact Chart

Revision 15-3; Effective March 11, 2015

 

Due to the involvement of different entities in the provision of Consumer Directed Services (CDS), it is sometimes difficult to determine who is responsible for responding to questions asked by an applicant, individual or the applicant’s or individual’s family.

The table below was developed for the DADS case manager to use when making this determination.

If an individual asks the case manager a question related to CDS that falls under the Financial Management Services Agency (FMSA) purview to answer, the case manager must refer the individual to the FMSA rather than attempting to answer the question himself. He can also contact the FMSA for the individual. If the case manager has a general non-individual specific question about the CDS option, the case manager must contact the regional CDS liaison rather than contacting an FMSA. If the regional CDS liaison cannot answer the question, the question is forwarded to state office.

CDS Contact Chart

Issue or Question Related to: Contact:
  • Service authorization
  • Rates for CDS services (unrelated to wages)
  • Offering the CDS option upon enrollment and annually thereafter
  • CDS backup service plan request and approval
  • Approving or requesting a corrective action plan for an individual who is having difficulty with the CDS option
  • Program rules, including those specifically related to the CDS option
  • Service plan (including related forms)
  • Convening all interdisciplinary team meetings, including those meetings needed to address CDS issues
  • Change in service delivery option at the individual’s request or through involuntary termination of the CDS option
  • Change in FMSA
  • Non-CDS services
Case manager contacts regional CDS liaison

 

Regional CDS liaison contacts state office – Ginny Grote
ginny.grote@dads.state.tx.us

  • Initial CDS orientation
  • Employer-related paperwork
  • Issues with service delivery
  • Ongoing training and support related to employer issues
  • CDS budget
  • Criminal history checks
  • Verification of licensing credentials of potential service providers
  • Payroll withholdings, deposits, reporting, timesheets, receipts, invoices and payment to service providers
  • Budget status report
  • Support consultation
  • Support advisor
Case manager refers individual to FMSA

FMSA contacts CDS program coordinator in the Center for Policy and Innovation via email only

  • Billing and payment issues
Case manager contacts regional CMS coordinator
  • FMSA contract issues, including difficulty locating contract numbers in the Service Authorization System (SAS) and choice list issues
Case manager contacts regional CDS liaison

Regional CDS liaison contacts state office Community Services Contracts Unit:
paul.straka@dads.state.tx.us
misti.ackermann@dads.state.tx.us
communityservicescontracts@dads.state.tx.us

CDS website: hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds

CM-MDCP, Section 9000, Service Reductions, Suspensions, Denials, Case Closures, Appeals and Fair Hearings

Revision 15-9; Effective December 15, 2015

 

 

9100 Notification Forms for Service Reductions, Suspensions, Denials and Case Closures

Revision 13-4; Effective November 1, 2013

 

The case manager completes Form 2065-B, Notification of Waiver Services, to:

The case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to:

The date at the top of Form 2065-B and Form 2065-C is the date the case manager completes the form. The date at the top of the form does not take into consideration the mail date of the form. The case manger must still ensure applicants and individuals are notified within required time frames. For situations requiring adverse action, the case manager must complete the notification in a timely manner to ensure the individual is given the full adverse action time period.

As applicable, the case manager must update or complete service authorization forms for active waiver services authorized in the Individual Plan of Care (IPC) after determining a service reduction, suspension, denial or case closure is needed. The service authorization forms are:

Policy in the following sections directs the case manager to the appropriate form(s) to use for specific case actions.

 

9110 Exceptions to the 30-day Notification Time Frame

Revision 12-1; Effective May 1, 2012

 

§51.243

(d) Notifications.

(1) The effective date of the service reduction, service denial, or case closure is 30 days after the date on the individual's notification letter.

(2) DADS notifies the individual in writing of the process to appeal the service reduction, service denial, or case closure as described in §51.251 of this chapter (relating to Appeals).

In most situations, the case manager must provide 30 days notification to the individual for any case action that is a service reduction, service denial or case closure. The intent of the 30-day notification time frame is to allow the individual and primary caregiver sufficient time to adjust to DADS decision.

In some instances, delaying denial or reduction of services for 30 days may have an adverse effect on the individual. In these instances, DADS may provide less than 30 days notification for service reductions, service denials or case closures. These instances may include:

If the individual/primary caregiver requests the case action occur before the 30-day notification time frame, the case manager must inform the individual/primary caregiver that he:

Within two working days of receiving a request to waive the 30-day notification for a service reduction, service denial or case closure, the case manager must send the individual, or the individual's parent or guardian, Form 1574. Form 1574 must be completed and returned to the case manager before the date of the required 30-day notification of a service reduction, service denial or case closure.

If Form 1574 is not returned to the case manager before the date of the required 30-day notification of a service reduction, service denial or case closure, the case manager must send the notification for the service reduction, service denial or case closure 30 days in advance of the effective date.

When an individual, or the individual's parent or guardian, requests a service reduction or case closure with an effective date that is less than 30 days from the request date, Form 1574 must be returned before the effective date of the requested service reduction or case closure.

The case manager must complete the change to the IPC within two working days of receipt of a completed Form 1574. The two-working-day time frame for the change to the IPC is specific for case actions in which the individual/primary caregiver requested to waive the 30-day notification period. The case manager must also negotiate the effective date for the case action with the individual/primary caregiver and the provider. It is important to include the provider in the negotiation of the effective date to prevent unauthorized service delivery after the IPC effective date.

Service Reduction Notification

The case manager must complete Form 2065-B, Notification of Waiver Services, when adding and reducing services in this case action. The case manager must complete and send Form 2065-B and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of completing the IPC.

Case Closure Notification

In a case closure due to voluntary withdrawal from the program, the termination date is the last date the individual/primary caregiver requests MDCP services. The case manager may negotiate the date if the individual/primary caregiver did not identify a specific date.

In situations in which the individual/primary caregiver does not know the last day in which MDCP services are needed, the case manager may not be able to negotiate the effective date of the case action. In these cases, the MDCP case closure date is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver. The case manager must contact the provider at least two working days before the case closure effective date to prevent the provider from delivering services to the individual after the case closure date. The contact may be by telephone or on Form 2067, Case Information.

The case manager must complete Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for case closures. The effective date of Form 2065-C, and applicable service authorization forms identified in Section 9100, is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver program or the last day of MDCP services requested by the individual/primary caregiver. The case manager must complete and send Form 2065-C and applicable service authorization forms to the individual and the provider within two working days of determining program ineligibility.

If the case manager is unsure when an individual's written request is needed, he may consult with the MDCP supervisor.

The case manager must document all telephone contacts, dates of contact and outcome with the individual/primary caregiver and provider in the case file using Form 2405, Narrative Notes.

 

9200 Service Reductions

Revision 15-3; Effective March 11, 2015

 

§51.243 Denials, Terminations, and Service Reductions

A reduction in services means a decrease in the amount of previously authorized MDCP services. Not all changes to the individual's individual plan of care (IPC) are considered a reduction in services. Example: An individual may have a change from receiving Respite delivered by a registered nurse (RN) to Respite delivered by a licensed vocation nurse (LVN). The cost of waiver services decreased but there was no change to the hours authorized to the individual. In this case, the individual did not have a service reduction.

The case manager must assess third-party resources (TPRs) to determine if MDCP services must be reduced. It is possible an individual may have a TPR identified during the IPC development or one may become available during the IPC period. If the TPR changes the individual's/caregiver's need for waiver services, the case manager must reduce services in the IPC. Note: The availability of a TPR does not necessarily impact the individual's/caregiver's need and use for MDCP services.

Other situations may cause a reduction in services, such as an individual's request to decrease services.

Provider Information for Completing Service Reductions

When the case manager plans a change to the IPC for a service reduction, it may be necessary to obtain service delivery information from providers to complete the change. When this occurs, the case manager must verify the number of units or the cost of services delivered by the provider from the authorized start date through the day before the IPC change is effective. The case manager will use that information to plan the impact of the service reduction for the remainder of the IPC period.

The case manager must use Form 2067, Case Information, to request the total:

The case manager must complete and send Form 2065-B, Notification of Waiver Services, and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of completing the service reduction to the IPC. The effective date of Form 2065-B and applicable service authorization forms for a service reduction is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period. See Section 9110, Exceptions to the 30-Day Notification Time Frame.

The case manager must follow procedures in Section 5110, Interim Plan of Care, or Section 5120, Budget

Revision, as applicable to complete the reduction in services as a change to the IPC. The effective date of an IPC change resulting from a service reduction is 30 days from the date on Form 2065-B.

The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry procedures for service reduction case actions. Consult the SAS help file for SAS record data entry procedures for service reduction actions.

 

9300 Denying Requests for Specific Services

Revision 12-1; Effective May 1, 2012

 

When an individual or caregiver requests a waiver service, the case manager must determine if the need for the service falls within the service criteria. See Section 4100, Medically Dependent Children Program (MDCP) Services, for a review of waiver service criteria. If the request for a specific waiver service does not meet the service criteria, the case manager denies the request using Form 2065-B, Notification of Waiver Services, and uses information found in Attachment A, MDCP Comments for Denying Requests for Specific Services, of the form instructions to complete the Comments part of the form.

The case manager must complete and send Form 2065-B to the individual within two working days of determining the request for the waiver service did not meet waiver service criteria. The case manager does not send Form 2065-B denying requests for specific services to providers.

The case manager must not cancel an active service authorization form identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, when the case manager completes Form 2065-B to deny a request for a service that did not meet the waiver service criteria.

 

9400 Service Suspensions

Revision 12-1; Effective May 1, 2012

 

§51.241

(a) DADS or a provider must suspend an individual's MDCP services if or when:

(1) the individual is admitted for purposes other than respite services to:

(A) a hospital (if an RN or an LVN provides the services);

(B) a nursing facility (if an RN or an LVN provides the services);

(C) a state mental retardation facility;

(D) a state mental health facility;

(E) a rehabilitation hospital; or

(F) an intermediate care facility for persons with mental retardation or related conditions; or

(2) the individual or someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider, or another person in the residence.

(b) DADS or a provider may suspend an individual's MDCP services if the individual or someone in the individual's residence discriminates against a provider or a DADS employee.

The case manager or a provider may suspend an individual's MDCP services during the individual plan of care (IPC) period. The case manager or the provider must suspend MDCP services when the individual:

An individual or someone in the individual's residence may exhibit behavior that constitutes imminent danger or a threat to the health or safety of the individual or another person. Examples include, but are not limited to:

Imminent danger in the context of requiring a suspension is not to be treated lightly, nor is it to be used loosely. Example: A medically fragile individual threatening to harm or kill someone when there are no weapons in the home and it would be physically impossible for the individual to carry out these threats, is not imminent danger and is not a cause for suspension. However, an individual or another person in the individual's residence brandishing a weapon, or having a history of physical violence and making threats that the individual or other person in the individual's residence is clearly capable of carrying out, may be imminent danger.

If, during any contact, the case manager perceives an individual's/family's comment or behavior to be threatening, hostile or of a nature that would cause concern for the safety of the individual, a provider employee or the case manager, he must immediately notify his supervisor. Regional management will review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the individual's safety may be at risk, the case manager must contact the Department of Family and Protective Services and the police, if appropriate, the same day the case manager is aware of the suspension. If the case manager believes there is a potential threat to others, regional management should determine the best method for notifying the provider and for addressing the individual's needs without placing the case manager at risk.

An individual who threatens his own health or safety or that of others should be considered for referral to the Local Authority and the police, if appropriate.

If a placement in an institution is determined to be permanent, the case manager must deny MDCP services following Section 9500, Service Denials and Case Closures.

The case manager may suspend MDCP services up to 180 days.

The case manager must document all contact with the individual, primary caregiver and provider using Form 2405, Narrative Notes, in the case file.

 

9410 Notification of Service Suspensions

Revision 12-3; Effective November 1, 2012

 

§51.419

(a) Required service suspensions. A provider must suspend services to an individual if or when:

(1) the individual is admitted for purposes other than respite services to:

(A) a hospital (if the services are provided by an RN or an LVN);

(B) a nursing facility (if the services are provided by an RN or an LVN);

(C) a state mental retardation facility;

(D) a state mental health facility;

(E) a rehabilitation hospital; or

(F) an intermediate care facility for persons with mental retardation or related conditions; or

(2) someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider, or another person. If this occurs the provider must make an immediate referral to:

(A) DFPS or other appropriate protective services agency;

(B) local law enforcement; and

(C) the case manager.

(b) Other service suspensions. A provider may suspend services to an individual if the individual or someone in the individual's residence discriminates against a provider or a DADS employee.

(c) Notification of service suspension. The provider must notify the case manager orally or by fax about a service suspension no later than one working day after services are suspended. If the provider's notification is oral, the provider must send written notification to the case manager within five working days of the first notification.

(d) Notification requirements. The notification must include:

(1) the date of service suspension;

(2) the reason for the suspension;

(3) the duration of the suspension, if known; and

(4) an explanation of the provider's attempts to resolve the problem that caused the suspension, including the reason why the problem was not resolved. This subparagraph applies only to circumstances described in subsections (a)(2) and (b) of this section.

DADS requires the provider to notify the case manager no later than one working day after services are suspended of the reason for the suspension, the effective date of the suspension and the duration, if known, for service suspensions initiated by the provider. An explanation of the provider's attempts to resolve the issues that initiated the suspension must be included.

When a case manager receives notice from the provider that services are suspended due to imminent danger to the health and safety of the service provider's staff, a referral to the Department of Family and Protective Services and the police (if appropriate) must be made the same day the case manager is aware of the suspension. By the next working day, the individual must be notified of the temporary suspension by means of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. This notice must include a reference to 40 Texas Administrative Code §51.241(b), the effective date, which is the date the case manager became aware of the action, as well as a clear statement in the comments, such as "Your Medically Dependent Children Program services have been temporarily suspended due to ... You will be contacted by your case manager to determine if this problem can be resolved." The case manager must contact the individual and try to resolve the problem within 12 days from the date on the Form 2065-C. If the problem cannot be resolved, the provider may report to DADS that it will no longer serve the individual due to health and safety concerns. DADS may initiate services with a new provider or terminate the individual’s services.

For any situation requiring waiver service suspension, the case manager notifies the individual and provider by completing Form 2065-C using applicable citations in Attachment F, MDCP Suspension Citations/Codes, by the next working day upon becoming aware of the need for the suspension. If the individual or provider is aware of the return date from an institution, the case manager identifies the duration of the suspension on the comments section of Form 2065-C.

 

9420 Extension of Suspension

Revision 12-1; Effective May 1, 2012

 

MDCP services must be suspended as outlined in Section 9410, Notification of Service Suspensions. DADS may extend a suspension for an additional 30 days if the reason for the individual's suspension will exceed 180 days.

If the individual or family member clearly indicates the wish for MDCP services to resume, the case manager must review the reasons for the request to determine if an exception should be submitted to state office staff. Reasons or conditions that may be included in a request to continue MDCP services will depend on the reason for the suspension. Some examples of reasons for extending the suspension period for individuals:

If, in the case manager's judgment, there is clear and convincing evidence the individual can resume service within 30 days after he exceeds the 180-day suspension period, the case manager may request an exception by submitting a letter outlining the request and the circumstances to the unit manager, Community Services Policy and Curriculum Development Unit, Community Services and Program Operations Section, Mail Code W-351.

 

9430 Resuming Services

Revision 12-1; Effective May 1, 2012

 

§51.419

(e) Resuming services after a suspension. The provider must resume services after a suspension:

(1) on the date specified in writing by the case manager;

(2) upon the individual's return home from an institution listed in subsection (a)(1) of this section; or

(3) on the date the provider becomes aware of the individual's return home.

The duration of the suspension may depend on the reason for the suspension, such as the individual requiring an extended stay in a hospital or nursing facility. If the case manager was not aware or documented the duration of the suspension on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, as indicated in Section 9410, Notification of Service Suspensions, the case manager must communicate with the provider or individual to obtain a date to resume services.

DADS requires providers resume services after a suspension:

The case manager must complete Form 2065-B, Notification of Waiver Services, to notify the individual and provider to resume services if the case manager does not document the duration of the suspension on Form 2065-C. The case manager completes and sends Form 2065-B to the individual and provider within two working days:

If the individual's services are suspended when the annual reassessment is due, the case manager may conduct the annual reassessment with the individual and primary caregiver if it is likely participation in MDCP will continue. The case manager develops the annual reassessment individual plan of care (IPC) and applies the end date as if there had been no suspension and MDCP services were continued. Example: The IPC period is June 1, 2010, through May 31, 2011. The individual's services are suspended on April 15, 2010, and are reinstated July 10, 2011. The new IPC period is July 10, 2011 through May 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

The case manager must document all contact with the individual, primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

9440 Procedures for Temporary Nursing Facility Admissions

Revision 12-1; Effective May 1, 2012

 

When an individual enters a nursing facility (NF) and the facility submits admission paper work, the transmission will automatically populate an end date in the Service Authorization record in the Service Authorization System (SAS). The end date is date of the NF admission. The case manager must determine if the individual's admission is temporary by contacting the primary caregiver. If it is likely the individual's NF admission is for long-term care, see Section 9541, Additional Procedures for Permanent Nursing Facility Admissions, to initiate case closure procedures. If the individual's NF admission is temporary, the case manager must data enter Code 35 for a temporary NF stay in the Termination Code field in all Service Authorization records.

MDCP Service Authorization records in SAS may be closed by an automated process before the case manager learns of and updates SAS records. When the NF submits Form 3618, Resident Transaction Notice, and the Minimum Data Set (MDS) for an MDCP individual, all MDCP Service Authorization records are updated with the new end date. The automated batch process runs five times weekly and uses the date on Form 3618, Item 11, to close the MDCP Service Authorization records effective the date of NF entry. A daily report is posted to the Claims Management Project Documents website at: http://dadsview.dads.state.tx.us/cms/projectdocs/Production/CS%20SRV%20Ended%20by%20NF%20 Enrollment.txt?PROJ_ID=T2R&DocTyp=Reports&s_PROJ_ID=T2R. Regional Claims Management System (CMS) coordinators will access the reports and notify MDCP case managers of individuals whose Service Authorization records are closed by the batch process.

Although Service Authorization records will be closed by the automated batch process, the case manager must still complete the Code 35 SAS action, which includes an additional manual step to prorate units before submitting the Service Authorization record. The case manager must follow procedures in Section 5140, Provider Transfers During the Plan of Care (IPC) Period, to update the number of units in the Service Authorization records for the period before the NF admission. The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry time frames.

Upon discharge from the NF, the case manager creates new Service Authorization records with the remaining authorized service units. The begin date is the date of the NF discharge and the end date is the same as the IPC period. The total units entered in SAS for the IPC period must not exceed the IPC cost limit. The case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan.

Example: An applicant is certified for services effective May 15, 2010, through May 31, 2011. He enters an NF on Feb. 25, 2011. The NF submits Form 3618 and the MDS and SAS automatically end dates MDCP Service Authorization records effective Feb. 25, 2011. The case manager enters Code 35 in the Termination Code field in SAS and updates the Units field with information given by providers. The individual remains in the NF through March 31, 2011. The case manager will create new Service Authorization records with a begin date of March 31, 2011, and end date May 31, 2011, with the remaining balance of authorized service units.

Developing an Annual Reassessment During the Suspension Period

The individual may be residing in the NF when the annual reassessment is due. In this circumstance, the case manager may conduct the annual reassessment in the NF without considering this a new enrollment provided all program requirements are met. The case manager must meet with the individual and primary caregiver to assure the appropriateness of the IPC. Service coordination is essential to assure the new IPC is adequate to meet the individual's needs in the community and is within the cost limit. If the individual is discharged from the NF after the IPC expires, the effective date of the IPC is the date of discharge. The IPC end date remains the same as if the IPC had not expired and MDCP services were continued.

Example: The IPC period is Feb. 1, 2010, through Jan. 31, 2011. The individual enters the NF on Dec. 15, 2010, and is discharged March 10, 2011. The individual meets all MDCP criteria on the discharge date of March 10, 2011. The new IPC period is March 10, 2011 through Jan. 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

A Code 35 SAS action is not required for an individual whose services are suspended for other reasons identified in Section 9400, Service Suspensions.

 

9500 Service Denials and Case Closure

Revision 12-1; Effective May 1, 2012

 

§51.243

(b) Service denials. DADS may deny services to an individual when:

(1) the individual no longer meets the eligibility requirements described in §51.203 of this chapter (relating to Eligibility Requirements);

(3) the individual's primary caregiver does not participate in the development of the IPC; or

(4) budgetary constraints require cost reductions

(c) Case closure. DADS closes an individual's case if:

(1) the individual no longer meets the eligibility requirements described in §51.203 of this chapter;

(2) the individual dies;

(3) the individual enters an institution for long-term care purposes;

(4) the individual starts receiving services through another §1915(c) waiver program;

(5) the individual does not use MDCP services for 60 or more consecutive days without prior approval from the case manager;

(6) the individual's primary caregiver does not participate in the development of the individual's IPC; or

(7) the individual request that services end.

The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry procedures for case closures. Consult the SAS help file for SAS record data entry procedures for termination actions.

 

9510 Ineligibility

Revision 12-1; Effective May 1, 2012

 

An applicant may be denied MDCP services if he does not meet the established eligibility criteria noted in Section 1300, Eligibility. An individual may also be denied MDCP services if he no longer meets the same eligibility criteria in Section 1300 with the exception of disability criteria in Section 1350, Disability, as determined through the annual reassessment process.

If the applicant does not meet the initial eligibility criteria, the case manager notifies him of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment D, MDCP Application Denial Citations, of Form 2065-C instructions to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination.

If the individual does not meet eligibility criteria at the annual reassessment, the case manager notifies him and providers of program ineligibility by completing Form 2065-C. The case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination to the individual and providers. The case manager must send Form 2065-C to the individual no later than 30 days before the end of the individual's IPC period. The day the case manager completes Form 2065-C is day zero and starts the 30-day time frame for the notification period.

The case manager does not complete any service authorization forms when denying MDCP services for an initial application or for an individual at the annual reassessment.

For case closures resulting from loss of Medicaid, see Section 5500, Loss of Medicaid.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center by fax within two working days of the program ineligibility determination.

 

9520 Failure to Maintain Enrollment

Revision 15-5; Effective May 8, 2015

 

Texas Administrative Code §51.219, Maintaining Enrollment

An individual may lose eligibility for the Medically Dependent Children Program (MDCP) if the individual or the individual's parent/guardian does not:

Maintaining enrollment requirements are addressed in Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and are essential for the development and implementation of services for the individual and primary caregiver. Individual and family responsibilities promote service planning and IPC implementation.

If the individual or the individual's parent/guardian does not fulfill the maintaining enrollment responsibilities, the case manager must attempt to resolve the issue, which may place the individual's MDCP eligibility at risk. The case manager must inform the individual or the individual's parent or guardian failure to maintain enrollment actions significantly impact service planning or IPC implementation and will place the individual at risk for losing MDCP services.

The case manager must document all contacts and attempted contacts to the individual/family in the case file on Form 2405, Narrative Notes. The case manager must consult with his supervisor to determine if case closure procedures should be implemented. If continuation of actions impact the case manager's responsibility to develop a service plan or the individual goes without services due to the failure to maintain enrollment, the case manager may proceed with denial of MDCP services. The case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations and Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of determining loss of eligibility due to failure to maintain enrollment. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

 

9530 Death of Individual

Revision 12-1; Effective May 1, 2012

 

After learning of the death of an individual, the case manager must send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and all applicable service authorization forms, to the provider within two working days of verifying the case should be closed. A copy of Form 2065-C must be sent to the MEPD staff, if appropriate. The case manager must not send a denial notification to the family or primary caregiver. The effective date on Form 2065-C and service authorization forms is the individual's date of death.

If the individual was receiving Supplemental Security Income (SSI) and the eligibility records reflect that the SSI has been denied, the case manager uses the same effective date of denial as the SSI denial date. If the eligibility records reflect the SSI is still active, the case manager must contact the Social Security Administration to notify it of the date of the individual's death.

 

9540 Institutional Placement

Revision 12-1; Effective May 1, 2012

 

When an individual is admitted in an institution for long-term care purposes, he is no longer eligible for MDCP services and services must be terminated. An institution may be:

The case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of determining loss of eligibility due to institutional placement. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

The case manager does not update or complete any service authorization forms when denying MDCP services for an individual in an institution if the effective date of the denial coincides with the end of an individual plan of care (IPC) period.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) by sending Form H1746-A, by fax within two working days of the program ineligibility determination. The case manager must indicate on Form H1746-A the individual lost eligibility based on institutional placement and include a copy of Form 2065-C.

 

9541 Additional Procedures for Permanent Nursing Facility Admissions

Revision 12-1; Effective May 1, 2012

 

When an MDCP individual enters a nursing facility (NF) and the facility submits admission paper work, the transmission will automatically update the end date field in all MDCP Service Authorization records in the Service Authorization System (SAS). The end date is date of the NF admission. The case manager must determine if the individual's admission is for long-term care purposes by contacting the primary caregiver. If it is likely the individual's NF admission is temporary, see Section 9410, Notification of Service Suspensions, and Section 9440, Procedures for Temporary Nursing Facility Admissions, for suspension procedures. If the individual's admission is for long-term care purposes, the case manager will data enter Code 03, Admitted to Institution, in the termination field in all Service Authorization records and initiate case closure procedures.

The case manager notifies the individual and providers of program ineligibility following procedures in Section 9540, Institutional Placement; however, the effective date of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and applicable service authorization forms is the day of the NF admission.

MDCP Service Authorizations records in SAS may be closed by an automated process before the case manager learns of the individual's NF admission. When the NF submits Form 3618, Resident Transaction Notice, and the Minimum Data Set for an MDCP individual, all MDCP Service Authorization records are updated with the new end date. The automated batch process runs five times weekly and uses the date on Form 3618, Item 11, to close the MDCP Service Authorization records effective the date of NF admission. A daily report is posted to the Claims Management System (CMS) Project Documents website at: http://dadsview.dads.state.tx.us/cms/projectdocs/Production/CS%20SRV%20Ended%20by%20NF%20 Enrollment.txt?PROJ_ID=T2R&DocTyp=Reports&s_PROJ_ID=T2R. The Regional CMS coordinator will access the report and notify the case manager of individuals whose Service Authorization records are closed by the batch process.

Although Service Authorization records will be closed by the automated batch process, the case manager must still enter termination Code 03 to all MDCP Service Authorization records.

Reinstating MDCP Services Before the IPC Expires

If services were terminated when the individual entered the NF but the individual was discharged after fewer than 180 days and requests MDCP services again before the current IPC period would have ended, the case manager may reinstate MDCP services without considering this a new enrollment provided all program requirements are met. The case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan and is within the cost limit.

The case manager must update the Units field in the Service Authorization records for the periods before the NF admission and create new Service Authorization records for the period after the NF discharge. The total units entered in SAS for the individual plan of care (IPC) period must not exceed the IPC cost limit. The case manager must follow procedures in Section 5140, Provider Transfers During the IPC Period, to determine the number of units to enter in the Service Authorization records for the period before the NF admission.

Reinstating MDCP Services After the IPC Expired

If services were terminated when the individual entered the NF but the individual was discharged after fewer than 180 days and requests MDCP services again after the current IPC period expired, the case manager may reinstate MDCP services without considering this a new enrollment provided all program requirements are met. The case manager must meet with the individual and primary caregiver to assure the appropriateness of the service plan.

The case manager develops the IPC and applies the end date as if there had been no NF admission and MDCP services were continued. Example: The IPC period is Feb. 1, 2010, through Jan. 31, 2011. The individual enters the NF on Dec. 15, 2010, and is discharged March 10, 2011. The individual meets all MDCP criteria on the discharge date of March 10, 2011. The new IPC period is March 10, 2011, through Jan. 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

Re-enrolling Into MDCP on or After 180 Days From the NF Admission

If services were terminated due to the NF admission and the individual was discharged on or after 180 days from the admission date and requests MDCP services, the case manager may re-enroll the individual following procedures in Section 3500, Money Follows the Person Option.

 

9550 Aging Out

Revision 13-2; Effective May 1, 2013

 

§51.203

To be eligible to participate in MDCP, a person must:

(3) be under 21 years of age;

In Section 1330, Age, an applicant/individual must be under the age of 21 to be eligible for MDCP services. If the case manager is in the process of enrolling an applicant who will turn 21 before the end of the individual plan of care (IPC) period, the case manager must inform the applicant of the transition process. On the day of the individual's 21st birthday, he ages out of MDCP and is no longer eligible. The individual may receive MDCP services through the day before his 21st birthday.

An applicant in a non-managed care area who is not enrolled in MDCP before his 21st birthday is not eligible to transition into the Community Based Alternatives (CBA) program.

An applicant in a managed care area who has not been Medicaid certified and is not enrolled in MDCP before his 21st birthday is not eligible to transition into the STAR+PLUS Waiver (SPW) program.

An applicant in a managed care area who is Medicaid certified has two options to enroll into the SPW program. An applicant with Medicaid may voluntarily enroll in STAR+PLUS to receive acute care services (including attendant and Day Activity and Health Services) and request SPW services after his 21st birthday. If the applicant does not voluntarily enroll in STAR+PLUS before his 21st birthday, he will be automatically enrolled on his 21st birthday. The applicant may then request SPW services. In a managed care area, SPW services are only available to Medicaid recipients age 21 or over. An applicant in a managed care area may have a delay in receiving SPW services after his 21st birthday if he is not enrolled directly from MDCP.

For these reasons, DADS staff must make every effort to timely process an enrollment for a 20-year old applicant. During the application process, the case manager must inform the applicant of the transition process. The case manager must also inform the designated regional complex needs coordinator as soon as possible when enrolling an applicant who will age out in less than 12 months.

An individual may apply to either the CBA or SPW programs, depending on the individual's service area. The individual may transition into the CBA or SPW program if he meets the eligibility requirements. The transition process to the CBA or SPW program begins one full year before the individual's 21st birthday. At age 21, individuals are not eligible for MDCP and will no longer be eligible for Private Duty Nursing (PDN), Skilled Nursing (SN) or Personal Care Services (PCS) through the Texas Health Steps (THS) Comprehensive Care Program (CCP). The case manager must inform the complex needs coordinator of an applicant or individual who may have high nursing needs as soon as possible.

State office will furnish a list of individuals turning 21 in the proceeding 18 months to regional directors who will distribute it to the regional complex needs coordinator and designated staff as applicable. The list includes MDCP individuals as well as Medicaid recipients who receive PDN, SN and PCS through CCP. The complex needs coordinator or other designated staff will identify all MDCP individuals aging out one full year before their 21st birthday. At any time during the transition process, the complex needs coordinator may request documentation and assistance from the case manager.

In order to assist the individual/family with the transition to CBA or SPW, the case manager must monitor the transition every three months during the year before the transition while the individual is enrolled in MDCP. The case manager must complete the transition monitor contact within the calendar month of the three-month time frame. It is possible the transition planning process may not coincide with the individual's IPC period and service monitoring schedule. See Section 9551, Aging Out to the Community Based Alternatives (CBA) Program, or Section 9552, Aging Out to the STAR+PLUS Waiver Program, for transition procedures.

Since the individual's 21st birthday is known, the case manager must notify him of loss of program eligibility due to age by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations and Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C to the individual no later than 35 days before the individual's 21st birthday. The effective date of Form 2065-C is the day before the individual's 21st birthday.

Example: An individual's 21st birthday falls on June 29. The last day of MDCP eligibility is June 28th. The case manager completes Form 2065-C indicating the individual will no longer be eligible for MDCP services after June 28 of the current year and mails the form no later than May 24 of the current year.

The case manager does not need to send a copy of Form 2065-C or applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the provider(s). The end date of the notification forms and applicable service authorization forms for the current IPC period must be the day before the individual's 21st birthday.

The case manager may remind providers by telephone or by sending a copy of Form 2065-C or Form 2067, Case Information, of the individual's program ineligibility due to age.

The case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) staff when a Medicaid ME-Waivers individual ages out of MDCP. The case manager must notify MEPD by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center for an individual whose Medicaid eligibility is established by MEPD. The case manager must include the date of enrollment into CBA or SPW, as applicable. The case manager must notify MEPD the same day the case manager sends the aging out notification to the individual.

 

9551 Aging Out to the Community Based Alternatives (CBA) Program

Revision 12-2; Effective August 1, 2012

 

An individual who is aging out of the program and lives in a non-managed care area may apply for the CBA program to continue to receive community services and avoid institutionalization on or after his 21st birthday. The transition planning begins one year before the individual's 21st birthday. The MDCP case manager, the CBA case manager and the DADS regional nurse conduct a home visit to review services available through CBA. With the active assistance from the MDCP case manager, the CBA case manager will facilitate the individual's transition to the CBA program.

The CBA case manager will follow slightly different transition procedures for individuals identified as a "high needs individual" based on nursing needs and projected cost of CBA services. The MDCP case manager must participate in any team meetings to facilitate the high needs individual's transition to CBA. The MDCP case manager must assist the CBA case manager as needed for both the high needs and non-high needs individual.

Prior to the 12-month visit, the MDCP case manager must send the individual the Initial Age-out Letter found in Appendix XIX, Age Out Timeline, Progress Logs, Letters and Talking Points. This letter will serve as an introduction to the process and advise the individual/parent to expect the contact from DADS staff to schedule the 12-month visit. Also before the 12-month CBA transition home visit, the MDCP case manager must forward a copy of the individual's Form 2410, Medical-Social Assessment and Individual Plan of Care, as well as Form 2411, Interim Plan of Care, and/or Form 2412, Budget

Revision, if an IPC change was completed, and the individual's most recent Medical Necessity and Level of Care (MN/LOC) Assessment to the CBA case manager.

12 Months Before the Individual's 21st Birthday

One year before the MDCP individual's 21st birthday, the CBA case manager will contact the MDCP case manager and DADS regional nurse to coordinate the home visit. At the home visit, the CBA case manager will review CBA services and advise the individual/family the CBA intake process will begin six months before the individual's 21st birthday.

Nine Months Before the Individual's 21st Birthday

The MDCP case manager must contact the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed and discussed at the 12-month home visit with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns. The Follow-up Letter, found in Appendix XIX, is sent to any individuals who have 50 or more hours of skilled nursing services weekly. This letter will be sent to the individual by the CBA case manager assigned to the individual as a reminder that the aging out application process will begin six months prior to the individual’s 21st birthday.

Six Months Before the Individual's 21st Birthday

The CBA case manager will begin the CBA intake process. It is at this contact the CBA case manager may initiate the high needs process.

The MDCP case manager contacts the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed and discussed at the 12-month home visit or issues identified in the previous contact with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns.

Three Months Before the Individual's 21st Birthday

The MDCP case manager must contact the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed or discussed from the previous contacts with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns.

Before Aging Out of MDCP

The MDCP case manager notifies the individual of MDCP ineligibility due to aging out following procedures in Section 9550, Aging Out.

The case manager must document all required contacts during the age out of an individual on the Age Out Timeline and Progress Log found in Appendix XIX, and include it in the case file. The case manager must document any additional contacts with the individual/family, CBA case manager, and complex needs coordinator using Form 2405, Narrative Notes, and file in the case file.

 

9552 Aging Out to the STAR+PLUS Waiver Program

Revision 12-2; Effective August 1, 2012

 

An individual who is aging out and living in a managed care service area may apply for services through the Star+PLUS Waiver (SPW) program to continue to receive community services and avoid institutionalization on or after his 21st birthday. It is the case manager's responsibility to facilitate the individual's transition to the SPW program.

Before Initial Transition Home Visit

Prior to the 12-month visit, the MDCP case manager must send the individual the Initial Age-out Letter found in Appendix XIX, Age Out Timeline, Progress Logs, Letters and Talking Points. This letter will serve as an introduction to the process and advise the individual/parent to expect the contact from DADS staff to schedule the 12-month visit. Also before the face-to-face visit to begin the transition process, the case manager must request SPW enrollment packets from the STAR+PLUS Support Unit (SPSU). If multiple transition visits are planned, the case manager should identify the number of enrollment packets needed.

12 Months Before the Individual's 21st Birthday

The case manager must schedule a face-to-face visit with the DADS regional nurse, the individual and primary caregiver to initiate the transition process.

During the home visit to the individual and his family, the case manager must present an overview of SPW and the changes that will take place on the individual's 21st birthday. The case manager must present and review Appendix XIX with the individual/family. The points to be discussed are:

The provider will assist the individual in determining the services needed within this service array to meet his needs and ensure health and safety. For example: If other needs are met, but the individual primarily requires nursing, then a plan can be developed with the maximum number of nursing hours within the cost limit while the individual's other needs are met through other resources.

Reassure the family that every effort will be made to help them make a successful transition to SPW and develop a plan that will meet the individual's needs.

During the transition process, the case manager will:

Nine Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed and discussed at the 12-month face-to-face visit with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns. The Follow-up Managed Care/STAR+PLUS Waiver Letter, found in Appendix XIX, is sent to any individuals in managed care areas who have 50 or more hours of skilled nursing services weekly and will be assessed for SPW. This letter will be sent to the individual by the MDCP case manager assigned to the individual as a reminder that the aging out application process will begin six months prior to the individual’s 21st birthday.

Six Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed and discussed at the 12-month face-to-face visit or issues identified in the previous contact with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns.

The case manager must make a referral to the SPSU six months before the individual's 21st birthday. To refer the individual, the case manager must complete Form 2067, Case Information, and include the following information:

The SPSU will:

SPSU Responsibilities Five Months Before the Individual's 21st Birthday

Within 30 days following the SPSU's initial telephone contact, the SPSU contacts the individual/family to obtain the name of the selected MCO.

If the individual/family has selected an MCO, the individual/family should inform the SPSU of their choice. SPSU will inform the:

If the individual/family has not selected an MCO, the SPSU will inform the individual/family if an MCO is not selected within seven calendar days, one will be assigned. If the individual/family does not make a selection within the seven calendar days, the SPSU will select an MCO for the individual by rotational basis. The SPSU will inform the individual/family:

The SPSU will also inform the MCO of the individual's choice.

The MCO will schedule a home visit with the individual/family within 14 days of the SPSU notification of choice of MCO.

Three Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed or discussed from the previous contacts with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns. If the individual/family did not select an MCO and one was assigned, the case manager must inform the individual/family they may change the assigned MCO after the first calendar month.

Before Aging Out of MDCP

The case manager notifies the individual of MDCP ineligibility due to aging out following procedures in Section 9550, Aging Out.

The case manager must document all required contacts during the age out of an individual on the Age Out Timeline and Progress Log, found in Appendix XIX, and include it in the case file. The case manager must document any additional contacts with the individual/family, SPSU, and complex needs coordinator using Form 2405, Narrative Notes, and file in the case file.

 

9560 Interest List Releases to Other Waiver Programs

Revision 12-1; Effective May 1, 2012

 

§51.211

(g) An individual may be enrolled in only one §1915(c) waiver program at a time.

An individual may be registered on other waiver program interest lists and may be released from the interest list before the individual ages out of MDCP. When an individual is enrolled in another 1915(c) waiver program, he is no longer eligible for MDCP services. In Texas, the following are 1915(c) waiver programs:

When notified the individual is in the enrollment process for another waiver, the MDCP case manager must work with the enrolling case manager/service coordinator to minimize the risk of service gaps. Once the enrollment date into the other waiver program is determined, the MDCP case manager must close the case. The effective date of MDCP case closure is one day before the enrollment date of the other waiver program. The MDCP case manager notifies the individual and MDCP providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The MDCP case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The MDCP case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the MDCP provider within two working days of determining loss of eligibility due to enrollment into another waiver program. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

If the enrollment date into the other waiver program does not allow for the 30-day notification time frame for a case closure action, the MDCP case manager may follow Section 9110, Exceptions to the 30-day Notification Time Frame.

The MDCP case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) when a Medicaid ME-Waivers individual enrolls into another waiver program. The MDCP case manager must send Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center to notify MEPD that the individual is terminating from MDCP and enrolling into another waiver program. The MDCP case manager must identify the other waiver program. The MDCP case manager must notify MEPD the same day the case manager sends the notification to the individual.

 

9570 Transfer of an Individual to Another Service Area

Revision 12-1; Effective May 1, 2012

 

When an active individual moves from one MDCP service area to another, the case must remain open and the existing individual plan of care (IPC) remain in effect until a new plan is implemented. The case manager in the service area of origin is the "original" case manager and the case manager in the new service area is the "new" case manager.

Due to unknown factors that may arise in the process of transferring an individual from one service area to another, coordination between the original and new case manager is important. As information affecting the individual's transfer becomes available, both case managers must keep each other and other entities informed. For this reason, direction in Section 9571, Procedures for the Original Case Manager, and Section 9572, Procedures for the New Case Manager, provide a general chronological guideline, except as noted, to assist the original and new case manager. Every effort must be made to minimize a gap in service delivery.

 

9571 Procedures for the Original Case Manager

Revision 12-1; Effective May 1, 2012

 

When the individual notifies the case manager that he is moving to another service area, the case manager must request a projected date of transfer and any information the individual may have to assist with the case transfer process, such as the new address, telephone number or a point of contact for the individual in the new service area. It is the case manager's responsibility to:

The case manager must provide the individual with the new case manager's name and telephone number. The case manager must inform the individual he may elect to remain with the current provider, if available in the new service area, or provide the individual with the provider choice list and have the individual select a new provider. The case manager must also notify the individual if a provider is not chosen quickly and it is near the end of the IPC period, a gap in services may occur.

When the case manager receives the projected date of transfer, the case manager must follow procedures in Section 5140, Provider Transfers During the IPC Period, to obtain the amount of services the provider will deliver up to the date of transfer. The case manager must complete and send Form 2065-B, Notification of Waiver Services, to terminate the provider's service authorization. The case manager must also update applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures. The termination date of Form 2065-B and cancellation date on applicable service authorization forms is the date before the transfer date. The case manager must complete and send Form 2065-B and applicable service authorization forms to the individual and the provider within two working days of receipt of service delivery information from the losing provider.

Once the individual has selected a provider for service delivery in the new service area, it is the case manager's responsibility to:

For an individual accessing the Consumer Directed Services (CDS) option, the case manager and the new case manager must coordinate service delivery in the new service area with the existing CDS agency. It is possible the CDS agency may serve the new service area or may address service delivery for a temporary transfer directly with the CDS employer. The individual transfer procedure may vary based on the type of transfer and the needs of the caregiver in the new service area.

Service Authorization System (SAS) Records

The case manager must update all applicable SAS records except as noted below. The case manager must use the information provided by providers to update the Units and End Date fields for all Service Authorization records (if there is a change in providers). The case manager must update the End Date field in the Authorizing Agent record. The end date is the day before the transfer date.

The case manager must obtain the provider information from the new service area and use the remaining units in the service plan to create new Service Authorization records. Consult the SAS help file for Provider Transfers to update Service Authorization records for case transfer actions.

Unless information is incorrect, the case manager does not need to update the following SAS records:

The case manager must document all contact with the individual/primary caregiver, provider(s) and new case manager using Form 2405, Narrative Notes, in the case file. The case manager must mail the case file to the new case manager within three working days of confirming the move.

 

9572 Procedures for the New Case Manager

Revision 12-1; Effective May 1, 2012

 

When the case manager is notified an individual is moving or has moved to the new service area, it is the case manager's responsibility to:

The case manager will contact the individual/family in the new service area to assess for any changes that might affect service delivery. If an individual transfers from one service area to another to spend time with a non-custodial parent or other relative, the new case manager must contact the parent or relative to establish primary caregiver status, review MDCP services and identify if an individual plan of care (IPC) change is needed.

If a change to the service plan is needed, the case manager may complete Form 2411, Interim Plan of Care, or Form 2412, Budget

Revision. If a change in the IPC is needed, the effective date of the IPC change is the date of transfer.

Once the case manager has negotiated the start of care, the case manager must complete Form 2065-B, Notification of Waiver Services, to the individual and providers. The case manager must also complete applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures. The effective date of Form 2065-B and applicable service authorization forms is the transfer date.

The case manager must complete and send Form 2065-B, applicable service authorization forms, Form 2410, Medical-Social Assessment and Individual Plan of Care, Form 2411 (if applicable) and Form 2412 (if applicable) to the individual and the provider within two working days of receipt of service delivery information from the losing provider.

If the change to the IPC results in a reduction in services, the case manager follows procedures in Section 9200, Service Reductions. If the change to the IPC results in a case closure, the case manager follows procedures in Section 9500, Service Denials and Case Closure.

For an individual accessing the Consumer Directed Services (CDS) option, the case manager and the original case manager must coordinate service delivery in the new service area with the existing CDS agency. It is possible the CDS agency may serve the new service area or may address service delivery for a temporary transfer directly with the CDS employer. The individual transfer procedure may vary based on the type of transfer and the needs of the caregiver in the new service area.

For the individual whose financial eligibility is determined by Medicaid for the Elderly and People with Disabilities (MEPD), the case manager must notify MEPD of the individual's transfer by sending Form H1746-A, MEPD Referral Cover Sheet. The case manager must notify MEPD staff of all case transfers whether permanent or temporary.

For the individual whose financial eligibility based on Temporary Assistance for Needy Families (TANF)-related Medicaid determined by Texas Works staff, the household must report a change in address within 10 days from knowing of the change. All households are required to report residence changes. The case manager may assist the individual in reporting this change by completing Form H1019, Report of Change, and sending it to the local Texas Works office. The case manager may assist the individual notify Texas Works staff of all case transfers whether permanent or temporary.

Service Authorization System (SAS) Records

The case manager must access SAS to confirm the current service plan. The case manager must update the following SAS records:

If the transfer results in an IPC change, the case manager follows Section 5100, Changes to the Individual Plan of Care (IPC).

The case manager must document all contact with the individual/primary caregiver, provider(s), MEPD staff, Texas Works staff and original case manager using Form 2405, Narrative Notes, in the case file. If the individual is receiving SSI, the case manager will request the individual/family contact the Social Security Administration to report a change of address.

 

9600 Appeals and Fair Hearing Procedures

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.251, Appeals

An applicant/individual may appeal a Department of Aging and Disability Services (DADS) action, including suspensions, reductions in service, service denials or case closures. An applicant/individual may request an appeal to the case manager either orally or in writing within 90 days from the date of the notification. If the individual submits an oral request, the individual must submit a written request to the case manager within five working days after the date of the oral request. If the request is submitted orally, DADS considers the date of the oral request as the date the request is submitted. The individual is no longer required to request continued services. The case manager must continue services if the individual files the appeal before the effective date of the case action unless services cannot continue due to required suspensions or program termination due to loss of Medicaid. The case manager must continue to follow policy in Section 5500, Loss of Medicaid, for terminations due to loss of Medicaid. If an individual chooses not to receive services while a fair hearing is pending, he must provide a clear, written statement requesting services stop. The individual will continue to have up to 90 days from the date of the notification to appeal the decision.

If the follow-up written request for appeal is not received within five working days, the case manager must send Form H4800-A, Fair Hearing Request Summary (Addendum), with a notation that the individual did not follow up with a written request for appeal to the hearings officer for consideration. The hearings officer's name is found on Form H4803, Notice of Hearing. The appeal ID number assigned by the Texas Integrated Eligibility Redesign System must be written at the top of Form H4800-A.

The case manager must explain the applicant's/individual's right to appeal by reviewing Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, along with the right for others to represent the applicant/individual, including legal counsel at the initial assessment and at each annual reassessment. The applicant/individual must sign a copy of the Form 2417 for the case file. The case manager must provide a copy of Form 2417 to the applicant/individual. The case manager may inform the applicant/individual to keep the copy in the in-home record.

 

9610 Appeals Process

Revision 12-1; Effective May 1, 2012

 

Upon notification of a request for a fair hearing, the case manager must initiate procedures to generate the fair hearings process detailed in Section 9611, Case Manager and Designated Data Entry Representative Procedures, Section 9611.1, Procedures for Loss of Medicaid, and Section 9611.2, Procedures for Medical Necessity (MN) Denials, through the Texas Integrated Eligibility Redesign System (TIERS). Each region must designate a data entry representative who is responsible for entering all fair hearings information into the TIERS Fair Hearings and Appeals System. The case manager must work with the regional representative to ensure the applicant's/individual's request is submitted timely.

 

9611 Case Manager and Designated Data Entry Representative Procedures

Revision 13-3; Effective August 1, 2013

 

Upon receipt of the fair hearings request from an applicant/individual, the case manager completes Form 4800-D, DADS Fair Hearing Request Summary. The case manager will send the form to the regional data entry representative and the supervisor within three 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 Texas Integrated Eligibility Redesign System (TIERS).

When the case manager completes Form 4800-D, all questions in Section 3, “Appellant Details - Programs,” must be answered. In Subsection D, “Summary of Agency Action and Citation,” the case manager must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

The case manager must indicate the Individual Plan of Care (IPC) begin and end dates, as applicable, in Section 3.D., “Summary of Agency Action and Citation.” The begin and end dates must also be mentioned during the fair hearing so the hearings officer is aware of when the IPC year ends when rendering a decision.

The case manager must indicate the names and titles, addresses and telephone numbers of all persons or their designees who will attend the hearing on Form 4800-D. Depending on the issue being appealed, the following persons must attend:

Within two days of receipt of Form 4800-D, the data entry representative must enter the information into the TIERS Fair Hearings and Appeals System. The TIERS Fair Hearings and Appeals System will assign an appeal identification (ID) number when all the information is data entered. The data entry representative must document the appeal ID number as directed by the form instructions.

With the exception of Section 9611.1, Procedures for Loss of Medicaid, Section 9611.2, Procedures for Medical Necessity (MN) Denials, and Section 9611.3, Procedures for Utilization Review Findings, the case manager is the agency representative and the case manager's supervisor is the agency representative supervisor. These fields are used to send out the notification of the fair hearings schedule.

 

9611.1 Procedures for Loss of Medicaid

Revision 14-1; Effective February 3, 2014

 

The Centralized Representation Unit (CRU) represents the Health and Human Services Commission (HHSC) in all Medicaid hearings regarding Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works determinations. The CRU replaces the MEPD and Texas Works specialist in specific steps related to denial of Medicaid applications and ongoing cases. The CRU:

The case manager must coordinate all appeals involving loss of MDCP eligibility due to loss of Medicaid with the CRU.

The following procedures must be used by the case manager to coordinate appeal actions with the CRU in cases for which MEPD or Texas Works staff determine Medicaid eligibility. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

The case manager completes Form 4800-D, DADS Fair Hearing Request Summary, following policy in Section 9611, Case Manager and Designated Data Entry Representative Procedures. The case manager must determine if the appealed action is:

If the appealed action is related to a non-Medicaid program denial, the case manager completes Form 4800-D and enters his name as the agency representative. In the Other Participants field, DADS staff enter the CRU supervisor and CRU administrative assistant. The CRU supervisor and assistant name must be entered by using the Model Office Resources (MOR) Search function. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System (TIERS) and CRU staff will receive the notice of the appeal.

If the appealed action is a program denial based on Medicaid financial eligibility, the case manager completes Form 4800-D. In Section 6 of Form 4800-D, DADS staff must select YES to the question: "Are you an OES Texas Works or MEPD employee?" (DADS staff are responding to this question on behalf of the CRU.) On the Agency Representative page, select Yes in the dropdown. Failure to answer Yes to this item will result in the CRU not being notified of the hearing. DADS staff continue completing Form 4800-D and enter the CRU supervisor as the agency representative. DADS staff must enter this information through the MOR Search function for the CRU to receive the hearing information. DADS staff must list the case manager's name and title in the Other Participants section. The case manager does not enter the name of the local MEPD or Texas Works specialist on Form 4800-D for MEPD financial appeals. The DADS staff must include his title, such as DADS case manager or DADS supervisor. Enter the DADS staff email address. Also include the CRU administrative assistant in Other Participants. The CRU administrative assistant's information must be entered through the MOR Search function.

When Form 4800-D is sent to the designated data entry representative, DADS staff send an email notification to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which is monitored by CRU staff and can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings, regarding the request for an appeal. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID (include Appeal ID number). In an attachment to the email, DADS staff must include a copy of the DADS notification form sent to the applicant or individual.

The body of the email must include the:

Upon receipt of notification of an appeal, the CRU requests the Medicaid evidence packet from the local MEPD or Texas Works specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent HHSC at the hearing, if required, and takes steps to ensure the appropriate Medicaid financial case action is taken once a hearings officer's decision is rendered.

When an MDCP denial hearings decision is rendered by the hearings officer, DADS staff (staff name entered as agency representative) will be notified via email of the decision by the hearings officer. Based on the hearings decision, the case manager determines the appropriate action for MDCP services according to specific time frames. The case manager may need to coordinate effective dates of reinstatement with the CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. DADS staff reports the implementation of the hearings decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

For individuals with ME-Waivers, the local MEPD specialist will continue to notify DADS staff if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to the CRU to handle during the appeal process. Once the appeal decision regarding the Medicaid eligibility is rendered by the hearings officer, the CRU will notify DADS staff via email of the hearings decision, including decisions that are sustained, reversed or withdrawn. Based on the hearings decision, the case manager determines the appropriate action for MDCP. The email sent by the CRU will include:

DADS staff must not put an applicant/individual back on the MDCP interest list while a Medicaid denial is in the appeal process. The case manager must take appropriate action to certify or deny the case, or resume services once the Medicaid hearings decision is rendered. The individual may choose to be added back to the MDCP interest list once the case manager denies MDCP.

 

9611.2 Procedures for Medical Necessity (MN) Denials

Revision 12-1; Effective May 1, 2012

 

Texas Medicaid & Healthcare Partnership (TMHP) is the designated agency representative for all fair hearings resulting from a denied MN. A TMHP staff member will be designated as the contact person and will handle the assignment for fair hearings.

The case manager completes Form 4800-D, Fair Hearing Request Summary, and enters the TMHP contact as the Agency Representative. The case manager must check with the supervisor for the name of the current TMHP representative. DADS staff must enter this information through the Model Office Resources (MOR) Search function. No other information is required for Section 6, Agency Representative or Section 7, Agency Representative Supervisor, as these will be automatically populated. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System and TMHP staff will receive the notice of the appeal. The case manager's name, title and email address and the case manager's supervisor's information are entered in Section 8, Other Participants, along with any other participants.

 

9611.3 Procedures for Utilization Review Findings

Revision 13-2; Effective May 1, 2013

 

When an applicant/individual appeals an action as a result of utilization review (UR) findings, the case manager 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.

On Form 4800-D, DADS Fair Hearing Request Summary, the case manager will list the UR nurse in Section 6, Agency Representative, and UR regional manager in Section 7, Agency Representative Supervisor. The case manager will be listed in Section 8, Other Participants. The case manager must confirm the correct UR nurse and UR regional manager to list on the form. The case manager includes the UR nurse whose name is located in Section A of the utilization review tool. The case manager 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 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 the Texas Integrated Eligibility Redesign System and forward a copy of the fair hearing evidence packet to the applicant/individual.

The evidence packet submitted by the case manager will include the applicable notification form. If available, the case manager includes the signed notification form returned by the applicant or individual. The case manager does not include any other documentation in the evidence packet. The designated Data Entry Representative (DER) will be responsible for uploading the case manager’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system.

The UR nurse, UR regional manager (optional) and case manager will participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony regarding the case action.

 

9612 Sending Additional Information

Revision 14-1; Effective February 3, 2014

 

When an applicant or individual requests a fair hearing, the burden of proof to uphold the DADS decision rests with DADS. The fair hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is, therefore, crucial that staff complete and organize all fair hearing packets in order to support DADS decision.

If Form 4800-D, DADS Fair Hearing Request Summary, has already been submitted into the Texas Integrated Eligibility Redesign System (TIERS), and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for the fair hearing, the case manager must use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all documentation to the fair hearings officer. The appeal identification (ID) number assigned by the Texas Integrated Eligibility Redesign System (TIERS) must be written on Form H4800-A. The fair hearings officer's contact information is located on Form H4803, Notice of Hearing.

The case manager will review the request to determine the appropriate documentation to submit to the fair hearings officer as the fair hearings packet. Examples of additional information and who is responsible for submitting that information to the fair hearings officer and appellant include, but are not exclusively limited to:

The case manager must identify the information presented to the fair hearings officer as "submit as evidence" specifying policy or rule citation. The fair hearings officer may not be familiar with policy and may not have time or resources to read through lengthy documentation. The designated data entry representative must upload in TIERS all supporting documentation no later than 10 calendar days prior to the fair hearing date.

Regional Responsibilities

TIERS generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case manager and the case manager's supervisor receive a copy of Form H4800 and the letter identifying the fair hearings officer assigned, and the time and location of the fair hearing. The staff or designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent DADS during the fair hearings process.

Each entity involved in the fair hearing is responsible for preparing its fair hearings packet and forwarding it to both the fair hearings officer identified on Form H4800 and the appellant no later than 10 calendar days prior to the hearing date. All documentation must be neatly and logically organized, and all pages numbered.

Scanning the Evidence

All fair hearings packets must be scanned into the TIERS Fair Hearings and Appeals System. The designated data entry representative uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the fair hearings officer. The appeal ID number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 working days before the fair hearings date, the case manager:

No later than 10 calendar days prior to the fair hearing date, the designated data entry representative:

The data entry representative then sends the fair hearings officer an email with Form H4800-A attached. The data entry representative must enter the appeal ID in the subject line. The email must also inform the fair hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The case manager and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the designated 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 the information, the data entry representative sends Form H4800-A directly to the fair hearings officer’s email address. The data entry representative must enter the appeal ID in the subject line.

Presentation of the Evidence

Documentation contained in the fair hearings 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 the contents of the packet.

Example: I want to offer the following packet as evidence in the appeal filed on the behalf of (appellant's name). Pages 1-10 contain information relating to the completion of Form 2410, Medical-Social Assessment and Individual Plan of Care. Pages 11-15 contain policy from the Case Manager Medically Dependent Children Program Handbook, which relate directly to the issue in question. Pages 16-17 contain documents signed by the appellant related to rights and responsibilities. Page 18 contains Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, which was mailed to the appellant on (date).

The fair hearings officer may ask the appellant if he received the fair hearings packet. If not, the fair hearings officer may attempt to determine why. If no effort was made to send a copy of the fair hearings 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 as evidence.

The fair hearings officer may ask for objections and allow all admissible documents into evidence. Any documents admitted by the fair 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 fair hearings officer will explain the reasons for excluding the material.

 

9613 Request to Withdraw an Appeal

Revision 13-3; Effective August 1, 2013

 

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. The case manager should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts the case manager regarding the withdrawal, the case manager 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 the case manager, the case manager must forward this written request to the hearings office. A fair hearing will not be dismissed based on a DADS 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 DADS 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.

 

9614 Appeals and Continuation of Services

Revision 14-1; Effective February 3, 2014

 

Service Reductions or Service Terminations During an Individual Plan of Care (IPC) Period

When the reduction or termination of specific services is taken during the IPC period, the case manager must include comments on Form 2065-B, Notification of Waiver Services, explaining the reason for the service reduction or termination. The case manager must continue services at the current level when an individual files an appeal before the effective date of the reduction or termination until the hearings officer’s decision is rendered.

Example: During the IPC period, the case manager determines Flexible Family Support Services (FFSS) must be reduced from 20 hours a week to 10 hours a week due to a change in the primary caregiver’s work schedule. The case manager sends Form 2065-B to the individual and Home and Community Support Services Agency (HCSSA) as notification of the reduction in FFSS. The individual appeals before the effective date of the reduction. The case manager authorizes FFSS at 20 hours a week until the hearings officer’s decision is rendered.

IPC Changes or Service Terminations at Annual Reassessment

When an individual remains eligible at the annual reassessment, but some of the services in the new IPC are reduced or terminated, the case manager must continue services that were reduced or terminated at the current level if the individual files an appeal before the effective date of the reduction or service termination until the hearings officer’s decision is rendered. The case manager must document the individual’s disagreement in the case narrative. The individual can request new or increased services other than those being appealed while the fair hearing is pending. The case manager processes the new requests following established procedures.

Example: At the annual reassessment, the individual continues to be eligible for MDCP, but Respite hours are reduced from 40 to 20 hours a week. The individual signs Form 2410, Medical-Social Assessment and Individual Plan of Care, but does not agree with the reduction in Respite hours. The case manager sends Form 2065-B and Form 2410 to the individual and MDCP providers. The individual appeals before the effective date of the reduction. The case manager authorizes Respite at 40 hours per week pending the hearings officer’s decision. The individual later requests an adaptive aid while the appeal is pending and the case manager processes the request following established policy.

Program Terminations

When an individual is terminated from the program, such as at the annual reassessment, the case manager must continue services at the current level if the individual files an appeal before the effective date of the termination until the hearings officer’s decision is rendered. The case manager must not authorize any new or increased services or items until the hearings officer’s decision is rendered. If the individual requests to add or increase services, the case manager must complete and send Form 2065-B to notify the individual that the request for additional services or items pending the hearings officer’s decision cannot be processed. The case manager explains that new or increased services or items may be reviewed for authorization once the hearings officer’s decision is rendered.

Example: At the annual reassessment the individual has been denied Medical Necessity (MN) and the case manager sends Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual and the MDCP provider as notification of the termination of services. The individual appeals by the effective date of the program termination. The case manager authorizes services at the same level as authorized on the current IPC pending the hearings officer’s decision. The individual later requests an adaptive aid that is not on the current IPC. The case manager completes and sends Form 2065-B to notify the individual the request will not be processed pending the hearings officer’s decision.

When an individual determined ineligible at the annual reassessment files an appeal before the effective date of the termination and the hearings officer’s decision will not be made until after the IPC expires, the case manager must enter the current level of services in the Service Authorization System (SAS) for a full IPC year, effective the first day following the end of the current IPC period. The IPC entered into SAS must reflect services authorized at the same level of the current IPC and must not increase, decrease, add or terminate any service. Exception: The case manager does not include one-time items or services from the current IPC, such as adaptive aids or minor home modifications. The case manager must not use the new annual reassessment IPC for services continued pending the outcome of the fair hearing.

For an individual denied MN at the annual reassessment, the case manager will not create an approved MN record and will leave the denied MN in the MN record. The case manager must manually enter a Level of Services (LOS) and Diagnosis record from the previous Medical Necessity and Level of Care (MN/LOC) Assessment for the new IPC period. This ensures the MDCP provider can be paid for services delivered after the expiration date of the current IPC and until the outcome of the fair hearing.

Provider Notifications

Within three working days after an individual appeals a reduction or termination of a service during an IPC period and services will continue, the case manager must notify authorized MDCP providers using Form 2067, Case Information, to provide services at the current IPC level until the hearings officer’s decision is rendered.

Within three working days after an individual appeals a termination of program eligibility and services will continue, such as at the annual reassessment, the case manager must notify authorized MDCP providers using Form 2067 to provide services at the current IPC level until the hearings officer’s decision is rendered. The case manager must also state on Form 2067 that IPC change requests received while the fair hearing is pending will not be processed. If an MDCP provider submits a change request while a fair hearing is pending, the case manager returns the request to the MDCP provider with Form 2067 stating a fair hearing regarding the individual’s eligibility is pending. The case manager completes and sends Form 2065-B to the individual to notify the individual the request will not be processed pending the fair hearing officer’s decision.

When an individual submits a written statement requesting services to stop, the case manager must send Form 2067 to the MDCP provider with an effective date to stop service delivery. The case manager does not send another Form 2065-B or Form 2065-C to the individual or MDCP provider. Refer to Section 9621, Fair Hearing Decision, for information related to effective dates.

 

9620 Fair Hearing

Revision 12-1; Effective May 1, 2012

 

A fair hearing is an informal proceeding held before an impartial HHSC fair hearings officer in which an applicant/individual appeals a DADS action. Unless the DADS action is based on federal or state law, an MDCP applicant/individual has a right to a fair hearing for:

The applicant/individual has the right to appeal an action within 90 days from the date on the notice of DADS action.

At the fair hearings officer's discretion, the fair hearing may be conducted by telephone or in person.

 

9621 Fair Hearing Decision

Revision 12-1; Effective May 1, 2012

 

After the fair hearing is held, the fair hearings officer will send a decision letter to the MDCP applicant/individual and send copies to the case manager and the unit supervisor. Notification is sent via email to those participants with an email address. Decisions to dismiss and withdraw the fair hearings request can be viewed in the History Correspondence tab of the TIERS Fair Hearings and Appeals System. The fair hearings decision can also be viewed under the Decision tab. Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must place a copy of the decision in the case file and ensure a copy of Form 4807-D, DADS Action Taken on Hearing Decision, is entered into the Fair Hearings and Appeals System. Follow procedures in Section 9611.1, Procedures for Loss of Medicaid, to coordinate hearing decisions with Medicaid for the Elderly and People with Disabilities and Texas Works staff.

If the appellant applicant/individual is not satisfied with the fair hearings officer's decision, the applicant/individual may request the fair hearings officer conduct an administrative review. Administrative review of any fair hearings officer's decision provided in the fair hearings rules must be initiated by the appellant applicant/individual. DADS staff may disagree with the hearings officer's decision; however, in most cases the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by DADS staff to management for further review. See Section 9622, Fair Hearing Exception, for procedures to request program management review of a hearings officer's decision.

 

9621.1 Action Taken on Fair Hearing Decision

Revision 12-1; Effective May 1, 2012

 

Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must verify the fair hearings officer's decision by obtaining a copy of the decision that is to be filed in the case file.

 

9621.2 Procedures for Sustained Decisions

Revision 14-1; Effective February 3, 2014

 

When the fair hearings officer's decision sustains the denial of MDCP services, the case manager must:

When the fair hearings officer's decision sustains the reduction or termination of specific services during the individual plan of care (IPC) period or at the annual reassessment when the individual remains eligible for MDCP, the case manager must:

The case manager must not complete or send an additional Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to an applicant/individual confirming a fair hearings officer's decision to sustain a DADS action.

The fair hearings officer will send the applicant a copy of the decision sustaining a denial of MDCP eligibility. The case manager is not required to send by any additional notification.

Sustained Decisions – Effective Dates

When services are terminated at the annual reassessment due to the individual not meeting eligibility criteria, including medical necessity, and services are continued until the appeal decision is known, the MDCP termination date is:

When services are denied or reduced during the IPC period, the MDCP termination or reduction in service effective date is the effective date of the fair hearings officer's decision as recorded on the decision letter.

When an applicant is denied MDCP services, the effective date is the date of the fair hearings officer's decision as recorded on the decision letter.

 

9621.3 Procedures for Reversed Decisions

Revision 14-1; Effective February 3, 2014

 

When the fair hearings officer's decision reverses DADS case action on an MDCP applicant/individual, or the reduction in services during the individual plan of care (IPC) period, the fair hearings officer sends Form H4807, Action Taken on Hearing Decision. The fair hearings officer specifies the corrective action to be taken and a 10-day time frame for completing the action. The case manager actions required by the fair hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals System within the 10-day time frame.

The case manager must complete and send Form 4807-D, DADS Action Taken on Hearing Decision, recording case actions taken, to the supervisor for review and signature. The supervisor will forward the form to the designated data entry representative for data entry. DADS staff have 10 days from the date DADS received the fair hearings officer's decision to enter the information into the TIERS Fair Hearings and Appeals System. The 10-day time frame includes at least two days for the data entry representative to enter the information into the system. The case manager and supervisor must coordinate form completion efforts to have the information available for the data entry representative to ensure DADS meets the 10-day time frame.

If the action cannot be taken by the time frame designated by the hearings officer, Section C, “Implementation Delays,” on Form 4807-D is completed and sent to the supervisor and data entry representative within the 10-day time frame providing a reason for the delay. Acceptable reasons are listed on the form and the begin delay date and the end delay date must be included.

If the hearings officer reverses the decision to reduce or terminate a service, the case manager continues authorization of the higher level of services. The case manager must provide a copy of the correct authorization to the MDCP provider.

If the hearings officer reverses the decision to terminate program eligibility, the case manager must:

If the SAS data entry cannot be completed at the same time Form 2065-B is signed, the delay must be documented in the case file.

Reversed Decisions – Effective Dates

The fair hearings officer's decision date recorded on the decision letter or Form H4807 is considered the eligibility or effective date of MDCP services for all reversed decisions involving services denied:

Refer to Section 9621.4, Procedures When Medical Necessity (MN) Denied is Overturned, for procedures regarding medical necessity denial.

 

9621.4 Procedures When Denied Medical Necessity (MN) is Overturned

Revision 12-1; Effective May 1, 2012

 

Upon receipt of an email from the fair hearings officer notifying Texas Medicaid & Healthcare Partnership (TMHP) of an overturned medical necessity (MN) decision, the TMHP representative will:

The case manager must complete Form 4800-D, DADS Fair Hearing Request Summary, to be entered into the Texas Integrated Eligibility Redesign System (TIERS). The case manager's and supervisor's name, title and email address must be entered in the Other Participants section of Form 4800-D and entered appropriately into TIERS. If there is no name, title or email address in TIERS, TMHP will not be held responsible for forwarding information to the case manager and supervisor. See Form 4800-D instructions for additional instructions to correctly enter all information on the form and in TIERS.

Upon receipt of the second email from TMHP, the case manager must implement the overturned decision and complete Form 4807-D, DADS Action Taken on Hearing Decision, and submit to the data entry representative for data entry into TIERS.

The entry into TIERS must be completed within seven days from the receipt of the second email from TMHP. (This is 10 days from the fair hearings officer sending the decision to TMHP.) The day TMHP receives the decision is considered "Day 0" and TMHP has three days to reverse the MN assessment in the portal and notify DADS. When the notification is received, the case manager must complete and send Form H4807-D to the data entry representative, allowing two days for data entry.

Reversed Decisions – Effective Date

The effective date for reversals related to MN denials is the date TMHP received the MN/LOC Assessment.

 

9621.5 Procedures When a New Assessment is Required by a Fair Hearing Decision

Revision 13-3; Effective August 1, 2013

 

When the fair hearings officer’s final decision orders completion of a new Medical Necessity and Level of Care Assessment (MN/LOC), the hearing is closed as a result of this ruling. The case manager must notify the individual of the results of the new assessment on Form 2065-B, Notification of Waiver Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, the case manager must indicate in Section 3.D. “Summary of Agency Action and Citation,” of Form 4800-D, DADS Fair Hearing Request Summary, 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 and services are continued, DADS continues services until the second fair hearing decision is implemented.

Example: An individual is denied medical necessity (MN) at an annual reassessment and requests a fair hearing and services are continued. The case manager would continue services at the level the individual was receiving prior to the MN denial. The hearings officer then orders a new MN/LOC assessment which results in another MN denial. The case manager sends a notice to the individual informing him of the MN denial. The individual then requests another fair hearing and services are continued pending the second fair hearing decision. The case manager would continue services at the same level services were continued prior to the first fair hearing. If the new assessment results in MN approval but a lower resource utilization group level resulting in a reduction in services and the individual requests a fair hearing, the case manager would continue services at the same level services were continued prior to the first fair hearing.

 

9622 Fair Hearing Exception

Revision 12-1; Effective May 1, 2012

 

To help ensure that HHSC policy is consistently applied by DADS staff and fair hearings officers, the fair hearings exception process may be used when a fair hearings decision seems to be in conflict with DADS policy.

 

9622.1 Fair Hearing Exception Process

Revision 12-1; Effective May 1, 2012

 

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.

If the case manager disagrees with the fair hearings decision, the case manager discusses the decision and all the applicable policy with the supervisor. If the supervisor agrees with the case manager, then the supervisor submits a fair hearing exception request, using Form 1590, Request for a Fair Hearing Exception, outlining the details of the hearing decision and all the relevant rules/policy citations from the rules and handbook, to the regional director (RD).

The documentation must include:

The RD reviews the information and if not in agreement with the request, indicates that decision and sends an appropriate response back to staff. If the RD is in agreement with the request for the exception, the RD 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 of the hearing decision. A copy of the form is kept in the regional files, not in the case record.

 

9622.2 Community Services Policy Staff Actions

Revision 13-2; Effective May 1, 2013

 

Upon reviewing the region's exception request, the Community Services Policy (CSP) Unit manager will decide whether to forward the exception request for consideration by the Health and Human Services Commission (HHSC). If the CSP unit manager (or designee):

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.

If the exception request was sent to HHSC, the case manager must send Form 1015/1015-S, Fair Hearing Exception Letter, to notify the applicant/individual that DADS sent an exception request regarding a fair hearing decision to HHSC. The case manager 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 filed in the case file.

The fair hearings manager conducts a preliminary review of the decision w with input from relevant stakeholders. If the fair hearings manager agrees with the exception request and does not uphold the hearing decision, a response is sent back to the CSP Unit manager who forwards the information to the regional director (RD), along with any additional instruction regarding necessary case actions.

If the fair hearings manager upholds the hearing decision and if the CSP Unit manager and policy staff still disagree with the hearing decision, the information is sent to the DADS attorney for review and additional rule and policy citation. If the DADS attorney agrees to uphold the hearing decision, the information is sent back to the RD noting the rule and policy citations. If the DADS attorney does not agree to uphold the hearing decision and determines that a correct decision was made by DADS staff, then the CSP Unit manager prepares a response containing the information from the DADS attorney regarding the policy. This final decision memorandum is signed and sent to the:

The exception process ensures that policy has been interpreted correctly, provides feedback to regional staff and allows for communication with the Fair Hearings Division. While the outcome of the fair hearing may not change, this process provides guidance for the fair hearings officer and regional staff with correct policy and procedures for future decisions.

CM-MDCP, Section 10000, Case Management Procedures for Utilization Review

Revision 13-3; Effective August 1, 2013

 

 

10100 Medically Dependent Children Program Utilization Review

Revision 12-3; Effective November 1, 2012

 

On March 1, 2009, the Department of Aging and Disability Services (DADS) implemented processes for utilization review (UR) in the Medically Dependent Children Program (MDCP). The UR process includes concurrent reviews of a random sample of existing MDCP cases.

 

10110 New Service Limit Exception Procedures and Utilization Review

Revision 12-3; Effective November 1, 2012

 

The utilization review (UR) process ensures the appropriateness of services in service plans.

If concurrent UR findings result in an increase in services over the new service limit, the case manager checks Yes in the New Service Limit Exceeded Due to UR box on Form 2444, New Service Limit Exception Criterion, and processes the individual plan of care (IPC) following current procedures.

If the concurrent UR finding reduces a service that was previously authorized, including authorized services that were granted an exception, the case manager follows current procedures for the IPC change. The case manager must not complete Form 2444 if the UR finding reduces the amount of an authorized service to an amount below the new service limit.

 

10200 Concurrent Reviews

Revision 12-3; Effective November 1, 2012

 

The utilization review (UR) nurse completes concurrent reviews on a random sample of individuals receiving services. The UR nurse will contact the case manager and request all or a portion of the case file documentation that supports authorization of Medically Dependent Children Program (MDCP) services. The case manager will provide the documentation within seven calendar days of the request. Depending on available information, the UR nurse will complete a desk review and may conduct a visit to the individual’s home, the Home and Community Support Services Agency (HCSSA), or both.

The UR documentation, the referral packet and UR nurse observations will be reviewed by the UR nurse manager, if a concurrent UR finding:

Concurrent UR with Findings

If the UR nurse manager concurs with the UR nurse observations, he will indicate recommended changes on the UR tool Summary page and email the UR tool to the regional director or his designee of the region where the individual resides.

The regional director or designee will review the case file and will contact the UR nurse manager, state office UR manager, or both, for any additional UR finding information needed. UR staff will immediately provide additional requested information to the regional director. If the regional director agrees with the UR finding, within one working day he will direct the case manager to implement the UR finding.

Concurrent UR with No Findings

The UR nurse will contact the case manager via telephone or email to inform the case manager there were no findings.

 

10210 When a Fair Hearing is Pending

Revision 13-3; Effective August 1, 2013

When a case file is selected for concurrent review and a fair hearing is pending, the case manager must inform the utilization review (UR) nurse that a fair hearing is pending. The case manager does not submit the case file for concurrent review. UR will then replace the case with another randomly selected case record for concurrent review.

 

10220 When a Fair Hearing Has Been Rendered

Revision 13-3; Effective August 1, 2013

When a case file is selected for concurrent review and a fair hearing decision has been rendered during the current individual plan of care (IPC) year, the case manager must inform the utilization review (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 manager must provide specific information to the UR nurse about the service(s) appealed and the actions the case manager took to implement the hearings officer’s decision. The case manager submits the case record for concurrent review.

 

10300 Utilization Review Observations and Findings

Revision 12-3; Effective November 1, 2012

 

 

10310 Reporting Observations by the Utilization Review Nurse

Revision 12-3; Effective November 1, 2012

 

When the Utilization Review (UR) nurse is ready to present initial observations to the case manager, the UR nurse contacts the case manager by phone. If the case manager is not immediately available at the first contact, a request for the case manager to contact the UR nurse is left in a phone mail message and is sent via email with a copy to the supervisor and program manager. The case manager notifies the supervisor and program manager when contact with the UR nurse has been made. If the case manager is available to hear UR observations by phone or in person, the case manager notifies the supervisor and program manager via email of receipt and content of the UR observations. If the case manager is not available, a regional staff member (i.e., supervisor or program manager) should contact the UR nurse by close of business the same day, but no later than close of business the second day following the date of the attempted UR contact.

At the time of regional contact, the UR nurse will share observations. The region is offered an opportunity to provide additional information, documentation, or both, preferably by close of business the same day, but no later than close of business the second business day following the date of contact with the UR nurse. If the UR nurse recommends changes to the individual’s individual plan of care (IPC) that is not supported by policy, the case manager must inform the UR staff of the reason prohibiting implementation of the recommendation. For example, if the UR nurse recommends a minor home modification (MHM) when the individual has already exhausted the MHM service limit, the case manager must inform the UR nurse the individual has reached the service limit and no additional MHM funds are available to implement the recommendation.

Within four working days of receiving feedback from the case manager and Home and Community Support Services Agency (HCSSA), the UR nurse will complete the review and forward the preliminary tool with observations to the UR nurse manager.

An observation by the UR nurse is not considered a finding to be referred until:

 

10320 Utilization Review Finding Reports to the Regional Director

Revision 12-3; Effective November 1, 2012

 

Within seven working days of receiving the file from the utilization review (UR) nurse, the UR nurse manager will:

 

10330 Regional Director Response to Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

The regional director has five working days following receipt of information from the utilization review (UR) nurse manager to respond to the UR finding. During this time, the regional director may:

If no formal exception is filed and the UR finding recommends a change to the existing service plan, the five-working-day time frame is part of the 14-calendar-day time frame a case manager has to complete a change request.

If the regional director attempts to contact the UR nurse manager by phone to discuss the findings in an informal exception process, and the UR nurse manager is not available, the UR nurse manager or designee will return the contact within two business days. If discussion (informal exception process) between the UR nurse manager and the regional director results in changes to the UR finding, the UR nurse manager makes the changes on the electronic version of the UR tool and emails the final copy of the revised tool to the regional director or his designee. If the UR finding is not changed through the informal exception process and the regional director disagrees with the final findings, the region can either:

 

10340 Final Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

A utilization review (UR) finding will be considered final when:

Note: Agreement or disagreement with the UR finding is focused on decisions made about the individual’s condition or circumstances at the time of the UR, not to service authorization decisions necessitated by changes to the individual’s condition or circumstances that occur after the UR.

 

10350 Exception Process for Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

If the regional director disagrees with utilization review (UR) finding, he will refer the UR finding via email and telephone within five working days to the designated state office Community Services and Program Operations (CSPO) staff. All requests for formal exceptions must include appropriate supporting documentation.

The state office CSPO staff will then make a final decision on whether to implement, revise or reverse the UR finding. State office CSPO staff will issue a decision within seven working days of receipt of the exception and notify the regional director and designated state office staff within one working day of the decision.

 

10400 Implementation of Utilization Review Observations, Recommendations and Findings

Revision 12-3; Effective November 1, 2012

 

When a case manager or alternate regional staff is notified by the utilization review (UR) nurse of an informal observation, before a UR finding is finalized related to case manager compliance with policy (for example, no documentation of medical necessity, delinquent assessment, etc.) and the regional staff agree with the UR observation, the regional staff may make corrections at the time of initial notification by the UR nurse and inform the UR nurse what actions have been taken.

The 14-calendar-day time frame for the case manager to complete a change request begins on the date:

If necessary, the case manager notifies the Home and Community Support Services Agency (HCSSA) of needed changes and coordinates with the HCSSA to make changes.

Once the UR is complete, UR staff send the review tool documenting the finding to the regional director. The regional director or designee notifies the case manager to implement the UR finding and provides the date for completion and any specific instructions regarding the UR finding.

Under no circumstances should the entire UR tool be filed in the case record. The case manager follows the following for UR documentation in the case record:

UR Finding Case Record Contents
Concurrent review with no findings The UR tool will not be forwarded to the case manager and no documentation is required in the case record.
Concurrent review with findings A copy of the Summary page(s) and all service planning documents completed by the UR nurse must be filed in the case record.

 

10410 Implementation of Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

Once the regional director or designee notifies the case manager to implement the utilization review (UR) finding, and within 14 days of the date the UR nurse notifies the regional director or designee of the UR finding, the case manager must complete the case action. The case action may include adding, increasing, decreasing, terminating MDCP services or documenting the individual did not agree with the addition/increase of services. For the addition/increase of adaptive aids or minor home modifications, the case manager must contact the primary caregiver within the 14-day time frame to initiate the procurement process for these services. The primary caregiver remains responsible for obtaining written specifications and bids.

 

10420 Case Manager Procedures for Completing Changes

Revision 12-3; Effective November 1, 2012

 

The case manager follows policy in Section 5100, Changes to the Individual Plan of Care (IPC), to complete changes resulting from a utilization review (UR) finding. The case manager must complete the change within 14 calendar days of the date the UR nurse manager notifies the regional director. The case manager:

The case manager must ensure all service criteria for items/services are met when completing changes.

 

10430 Individual’s Agreement/Disagreement with the IPC Change

Revision 12-3; Effective November 1, 2012

 

The individual/primary caregiver may agree or disagree with the utilization review (UR) finding when the case manager reviews the change request with the individual. The case manager completes the change action using the following guidelines:

 

10440 Exception to Implementing Termination/Decrease of Services from the Utilization Review Finding

Revision 12-3; Effective November 1, 2012

 

An exception to implementing the decrease or termination of services from the utilization review (UR) finding is allowable if the individual has experienced a change in condition or environment since the UR visit and the change in services would result in a risk to the individual’s health and welfare.

There may be instances where the individual’s or caregiver’s condition or circumstances change, without a threat to his health and welfare, since the UR visit and the individual's individual plan of care (IPC) must be revised to meet the current needs for waiver services or the primary caregiver’s need for respite. The case manager takes appropriate action to address the individual’s or primary caregiver’s current needs.

 

10450 Notifications

Revision 13-2; Effective May 1, 2013

The case manager completes Form 2065-B, Notification of Waiver Services, for reductions, addition or increase in services and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for program terminations. The case manager must also update or complete applicable service authorization forms. The case manager documents the effective date of the individual plan of care change 30 days from the date of the notification form for service reductions or program terminations. The case manager documents the appropriate handbook/rule citation and also adds a comment to the notification form that the decision is based on the utilization review finding, as appropriate for the change.

If the applicant/individual requests a fair hearing, the case manager must inform the utilization review (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 manager must follow policy in Section 9611.3, Procedures for Utilization Review Findings, when processing the request for a fair hearing.

CM-MDCP, Section 11000, Service Authorization System Help File

Revision 14-2; Effective September 1, 2014

 

 

11100 Medically Dependent Children Program (MDCP)

Revision 13-1; Effective February 1, 2013

 

The Service Authorization System (SAS) online application is used to create the authorizations for all Long-term Services and Supports (LTSS). The Claims Management System cannot pay a provider if a valid Service Authorization record does not exist in SAS.

 

11200 Create an Initial Service Authorization for MDCP

Revision 13-1; Effective February 1, 2013

 

These areas must be completed to create an Initial Service Authorization for MDCP:

 

11205 Client – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The Client Details record is system generated with information from the Texas Integrated Eligibility Redesign System (TIERS) database or from information entered in the Create New Client record.

The Client Details record is read-only and is updated with new TIERS identifying information on a monthly basis, a few days after cutoff.

 

11210 Address Area – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The address area contains the individual’s addresses. Create separate address records to record an individual’s home or mailing address (if different than home address), a responsible party’s address, and/or an executor’s address.

Changes: When an address changes, add a new Address record. The system will read the latest record as the current address.

To Register a Home or Mailing Address:

Note: If the address Type selected is 1, 2, 3 or Executor, the screen will display an Address4 field in place of the Tel.No. If the address Type selected is 4 or 5, the screen will display Tel.No.

  1. Select the Address area in the Client Functional area.
  2. Select Add and a blank Address Details record will appear.
  3. Select the Type Code from the drop-down menu in the Type field. The system defaults to 05 - MAILING/HOME.
  4. Type the Effective Date of the address in the Begin Date field, which is the first day of the Initial Individual Plan of Care (IPC). Changes: When an address changes, type the Effective Date of the new address in the Begin Date field.
  5. Type the address in the Address field. If using the primary caregiver or executor, use “C/O” for “in care of.”
  6. Type the phone number of the primary caregiver, if it is different from the individual’s, or the executor in the Phone field. Do not type the individual’s phone number here.
  7. Type the city in the City field.
  8. Select the state from the drop-down menu in the State field. The system defaults to TX-TEXAS.
  9. Type the ZIP code in the Zipcode field.
  10. Select the Save button

To Register a Responsible Party's (RP's) Address:

  1. Select the Address area in the Client Functional area.
  2. Select Add and a blank Address Details record will appear.
  3. Select the Type Code 04 – RESPONSIBLE PARTY from the drop-down menu in the Type field. The system defaults to 05 - MAILING/HOME.
  4. Type the Effective Date of the address in the Begin Date field, which is the first day of the Initial IPC. When an address changes, type the Effective Date of the new address in the Begin Date field.
  5. Type the following in the Address lines:
    1. Address1 – Enter the RP’s name, First, Middle, Last. Start this line with “C/O” (for “in care of”) before the first name.
    2. Address2 – Enter the first line of the RP’s address (usually a street number or a P.O. Box).
    3. Address3 – Enter the second line of the RP’s address (if needed, such as for an apartment number).

    Note: Do not enter identifiers, such as “parent,” directions to the home or any other miscellaneous text in any of these fields.

  1. Type the phone number of the RP in the Tel.No. field, including the area code. Do not use parentheses. For example, enter 555-123-4567.
  2. Type the city in the City field.
  3. Select the state from the drop-down menu in the State field. The system defaults to TX-TEXAS.
  4. Type the ZIP code in the Zipcode field.
  5. Select the Save button.

By adding the Address record, the Location record will be created automatically.

 

11215 Location – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The Location Summary record is used to register the county and region in which an individual resides.

The Location record is system generated from the information on the Texas Integrated Eligibility Redesign System (TIERS) or from the Create New Client function. If the county code on TIERS is actually the guardian’s county, or if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or Social Security Administration (SSA) worker has not updated the county code for an individual, the case manager must register the county where the individual resides on the Service Authorization System (SAS) Online.

Warning: To avoid creating duplicate Location Summary records, the case manager should never add a Location Details record before the Initial Individual file is submitted to the Department of Aging and Disability Services (DADS) database.

If the county identified in the Location Summary record is incorrect (because the county in TIERS is actually the guardian’s county, the individual has moved, the MEPD specialist or SSA worker has not updated the county code, or any other reason), the location information must be corrected. TIERS updates SAS every month on the day after TIERS cutoff. Therefore, the most effective way to correct the county is to correct the county in TIERS. Since most of these corrections must be done by the MEPD specialist, SSA worker or Texas Works staff, timely updates to TIERS may not be possible. The case manager can correct the county information in SAS. However, the corrected record must be Forced or TIERS will rewrite the information at the next TIERS/SAS reconciliation.

To Correct Location Information:

  1. Select the Location area in the Client Functional area.
  2. Select the check box for the latest record listed on the screen.
  3. Select the Modify button.
  4. Move to the End Date field and enter the date before the new county will be registered.
  5. Select the Save button.
  6. Select Add and a blank Location Details record will appear.
  7. Select the appropriate county from the drop-down menu in the County field.
  8. Move to the Begin Date field and enter the date the new county is being registered. Leave the End Date field blank.
  9. Select the Save button.

    In order for TIERS to not overwrite this record, move to the Force field and set the Force Flag. Enter comments explaining why the record is being forced.

 

11220 Other Information

Revision 13-1; Effective February 1, 2013

 

The Other Information area contains additional information about the individual.

  1. Select the Other Information area in the Client Functional area.
  2. Select the individual’s marital status from the drop-down menu in the Marital Status field.
  3. Select the language requiring translation from the drop-down menu in the Translation Needs field, if applicable.
  4. Type directions to the individual’s residence in the Directions field.
  5. Select the Update button.

 

11225 Phone – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The Phone area is used to document an individual's phone number or the phone number of a relative or friend.

To Register Phone Information for an Initial Service Authorization:

  1. Select the Phone area in the Client Functional area.
  2. Select Add and a blank Phone Details record will appear.
  3. The Type field defaults to HO - HOME which is OK if registering a phone number for an individual. Select OT - OTHER if registering a phone number for a relative or friend. There can be multiple records with phone listings, depending on the number of contacts documented in a case.
  4. Move to the Begin Date field and type the date the phone number is valid. This can be the same date as the Begin Date for Enrollment.
  5. Move to the Phone No. field and type the appropriate phone number.
  6. Select the Save button.

To Remove a Telephone Record:

  1. Select the Phone area in the Client Functional area.
  2. Select the check box for the Phone record to be removed.
  3. Select the Remove button.
  4. Select Submit to SAS.
  5. Select Outbox and then the Inbox to ensure the case processed accurately.

 

11230 Authorizing Agent – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

Only one Authorizing Agent record is required for MDCP, however more than one can be created.

To Register the Authorizing Agent for an MDCP Individual:

  1. Select the Authorizing Agent area in the Case Worker Functional area.
  2. Select Add and a blank Authorizing Agent Details record will appear.
  3. Move to the Type field and select CM - CASE MANAGER from the drop-down menu.
  4. Move to the Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  5. Move to the Send to TMHP field and select Y - YES.
  6. Move to the Begin Date field and type the earliest date the MDCP individual is authorized to receive services. Leave the End Date field at the default blank.
  7. Move to the Autho. Agent ID field and type the MDCP case manager’s budgeted job number (BJN).
  8. The Agency field is read-only at 324 - DHS.
  9. Move to the Name field and type the name of the MDCP case manager.
  10. Move to the Phone [Ext] field and type the phone number of the MDCP case manager.
  11. Move the Mail Code field and type the Mail Code of the MDCP case manager.
  12. Select the Save button.

When the Case Manager Changes

When the individual is assigned to another case manager, enter an End Date in the existing Authorizing Agent record and create another record with the new information using these same instructions. To avoid gaps or overlaps in the Authorizing Agent records, the End Date of the existing record should be one day before the Begin Date of the new record.

Currently, although SAS will accept multiple Authorizing Agent records, Texas Medicaid & Healthcare Partnership (TMHP) will only accept two Authorizing Agent records when a SAS file is transmitted to TMHP. Therefore, select NO in the SEND TO TMHP field for all updates.

 

11235 Enrollment – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

To Register the Initial Enrollment for an MDCP Individual:

  1. Select the Enrollment area in the Program and Service Functional area.
  2. Select Add and a blank Enrollment Details record will appear.
  3. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu. This drop-down menu also contains entries for noting the individual is being enrolled while in a CHILDREN’S FOSTER CARE Level 1 or 2 situations.

    Note: Select 12 - MONEY FOLLOWS THE PERSON for individuals who are enrolling in MDCP under MFP provisions. Do not select “Nursing Facility” for these individuals.

  5. Move to the Living Arrangement field, and select the appropriate Community-Based Living Arrangement from the drop-down menu.
  6. Move to the Begin Date field and type the Effective Date of the IPC period.
  7. Enter the day before the 21st birthday in the End Date field.

    Note: If the child leaves the program earlier than the day before the 21st birthday, change the End Date field to the actual day the child is leaving the program.

  8. Leave the Termination code and Waiver Type at the default.
  9. Select the Save button.

 

11240 Service Plan – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The Initial Service Plan record is used to register an Individual Plan of Care (IPC) for an MDCP individual. The Initial Service Plan record includes the total estimated cost of MDCP services taken from the individual's IPC form.

To Register a Service Plan for an Initial MDCP Individual:

  1. Select the Service Plan area in the Program and Service Functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  5. Move to the Ceiling field and type the Annual MDCP IPC Cost Limit for the assigned Resource Utilization Group (RUG) Value from the Medical Necessity/Level of Care (MN/LOC) Assessment.
  6. Move to the Begin Date field and type the Effective Date of the IPC period.
  7. Move to the End Date field and type the last day of the IPC period.
  8. Move to the Amount Authorized field and enter the Total Estimated Cost of All MDCP Services Authorized for the current IPC period.
  9. Leave the Units Authorized field at the default 0.00.
  10. Select the Save button.

 

11245 Level of Service – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

All MDCP individuals must have a Resource Utilization Group (RUG) registered on a Level of Service record. Texas Medicaid & Healthcare Partnership (TMHP) will determine the RUG value based on information on the Medical Necessity/Level of Care (MN/LOC) Assessment. RUG values are calculated and assigned electronically by the automated system when DADS nurses submit the MN/LOC Assessment to TMHP.

To Register the Level of Service RUG for an Initial MDCP Individual:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CP - MDCP RUG from the drop-down menu.
  4. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  5. Leave Contract field blank.
  6. Move to the Level field and type the RUG Value from the MN/LOC Assessment.
  7. Move to the Begin Date field and type the Effective Date of the IPC period.
  8. Move to the End Date field and type the last day of the IPC period.
  9. Select the Save button.

 

11250 Diagnosis – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The Diagnosis Codes listed on the MN/LOC Assessment are registered on SAS Online.

To Register Diagnosis Code(s) for an Initial MDCP Individual:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM from the drop-down menu.
  4. Move to the Begin Date field and type the Effective Date of the IPC period.
  5. Move to the End Date field and type the last day of the IPC period.
  6. Move to the Diagnosis fields and enter the numeric code(s) for the individual's diagnosis, without decimals. Up to five diagnosis codes can be entered.
  7. Move to the Version field and leave at the default 09 - ICD-9-CM CODE.
  8. Select the Save button.

 

11255 Medical Necessity – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

The MDCP Medical Necessity determination is registered on SAS Online.

To Register Medical Necessity Information for an Initial MDCP Individual:

  1. Select the Medical Necessity area in the Medical Functional area.
  2. Select Add and a blank Medical Necessity Details record will appear.
  3. Leave the Medical Necessity field at the default selection Y - YES.
  4. Leave the Permanent field at the default selection N - NO.
  5. Move to the Begin Date field and type the Effective Date of the IPC period.
  6. Move to the End Date field and type the last day of the IPC period.
  7. Select the Save button.

    Note: If the End Date of the Medical Necessity (MN) record does not match the IPC period, add a record with a Begin Date that is the day after the current MN End Date and an End Date that matches the IPC End Date. This process covers the gap.

 

11260 Service Authorization – Initial Service Authorization

Revision 14-2; Effective September 1, 2014

To Register a Service Authorization for Each Service Code on the IPC for an Initial MDCP Individual:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Leave the MHMR Case No. field blank.
  4. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  5. Move to the Service Code field and select the appropriate Service Code from the drop-down menu.
  6. Leave the Fund and Term Code at the default.
  7. The Agency field is read-only at 324-DHS.
  8. Move to the Unit Type field and select 4 - PER AUTHORIZATION from the drop-down menu for all MDCP services, except for the Consumer Directed Services (CDS) Monthly Administrative Fee, select 2-MONTH.
  9. Move to the Units field and type the following entries for the MDCP services authorized in the IPC period.
    If the Service Code is: Enter the following:

    Respite – In-Home (11)
    Respite – Nursing Facility (11F)
    Respite – Camp (11G)
    Respite – Day Care/Licensed Child Care Facility (11H)
    Respite-Licensed Special Care Facility or Host Families (11J)
    Respite-Hospital (11L)
    Respite-HCSS (RN/LVN) (11M)
    Specialized Respite – HCSS (RN/LVN) (11MS)
    Respite-Pas Delegated (11Q)
    FFSS-HCSS (RN/LVN) (11R)
    Specialized FFSS – HCSS (RN/LVN) (11RS)
    FFSS-PAS HCSS (11U)
    FFSS-PAS Delegated (11V)
    Supported Employment (37)
    Employment Assistance (54)

    Total Estimated Annual Hours

    CDS FFSS PAS HCSS (11UV)
    CDS Respite – Specialized RN (11PSV)
    CDS Respite – RN (11PV)
    CDS Respite – LVN (11NSV)
    CDS Respite – LVN (11NV)
    CDS FFSS Support Services Specialized RN (11TSV)
    CDS FFSS Support Services – RN (11TV)
    CDS FFSS Support Services Specialized LVN (11SSV)
    CDS FFSS Support Services – LVN (11SV)
    CDS MDCP Respite-in-Home (11ZV)
    CDS Supported Employment (37)
    CDS Employment Assistance (54)

    Total Annual Cost

    Adaptive Aids/DME (15)
    Minor Home Modifications (16)

    Total Estimated Annual Cost

    TAS (53)

    Total Amount Authorized

    TAS Requisition Fee (53A)

    1

    CDS Monthly Administrative Fee (63V)

    1
  10. Move to the Begin Date field and type the Effective Date of the IPC period.
  11. Move to the End Date field and type the last day of the IPC period.
  12. Move to the Contract No field and type the correct Provider Contract Number for each service.
  13. The NPI field is read-only.
  14. Select the Save button.

Service Code 60, Unlimited Prescriptions

The Service Authorization record for Service Code 60, Unlimited Prescriptions is system-generated. Enter the day before the individual’s 21st birthday in the End Date field.
Repeat Steps 1-14 to create an individual Service Authorization record for each Service Code authorized.

  1. Select Submit to SAS from the toolbar to submit the information when all the required records have been completed.
  2. Select Outbox and then Inbox to ensure the case processed accurately.

 

11265 Consumer Directed Services (CDS) Calculation of the Individual Plan of Care (IPC)

Revision 13-1; Effective February 1, 2013

 

The SAS Unit equals the dollar amount for services delivered in CDS. The case manager determines SAS Units by multiplying the number of hours of CDS services times the number of weeks remaining in the IPC. This total is then multiplied by the rate to get a dollar amount. A separate Service Authorization record is completed for the Monthly Administrative Fee.

 

11270 Service Authorization for CDS Option – Initial Service Authorization

Revision 13-1; Effective February 1, 2013

 

To Register a Service Authorization for the Consumer Directed Services (CDS) Option for an MDCP Individual:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Leave the MHMR No. blank.
  4. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  5. Move to the Service Code field and select the appropriate Service Code from the drop-down menu (11UV; 11PSV; 11PV; 11NSV; 11NV; 11TSV; 11TV; 11SSV; 11SV; and 11ZV).
  6. Leave the Fund field and Term Code field at the defaults.
  7. The Agency field is read-only at 324-DHS.
  8. Move to the Unit Type field and select 2 - MONTH from the drop-down menu.
  9. Move to the Units field and enter the dollar Amount.

    Note: For Code 63V, enter the number of months in the Units field.

  10. Move to the Begin Date field and type the Effective Date of the IPC period.
  11. Move to the End Date field and type the last day of the IPC period.
  12. Move to the Contract No. field and type the Provider Contract Number for each service.
  13. The NPI field is read-only.
  14. Select the Save button.

 

11300 Reauthorize MDCP Services for Another IPC Period

Revision 13-1; Effective February 1, 2013

 

Search the Service Authorization System (SAS) database using the SAS Individual Number. Check the Client Details record to ensure you have the correct individual.

 

11310 Address, Location, Phone and Authorizing Agent – Reassessment

Revision 13-1; Effective February 1, 2013

 

Check the Address, Location, Phone and Authorizing Agent-Reassessment records for accuracy and update, as necessary, using the instructions for changes in Create an Initial Authorization.

 

11320 Enrollment – Reassessment

Revision 13-1; Effective February 1, 2013

 

Check the Enrollment record to be sure the End Date is the day before the individual’s 21st birthday. If it is not, change the End Date to the day before the individual’s 21st birthday.

 

11330 Service Plan – Reassessment

Revision 13-1; Effective February 1, 2013

 

To Register a Service Plan for Another IPC Period:

  1. Select the Service Plan area in the Program and Service Function area.
  2. Check the existing record to ensure that an End Date was previously entered.
  3. If not, select the check box for the existing record for the current IPC period.
  4. Select the Modify button.
  5. Enter the End Date for the current IPC period.
  6. Select the Save button.
  7. Select Add and a blank Service Plan Details record will appear.
  8. Leave the Type field at the default selection AN - ANNUAL PLAN.
  9. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  10. Move to the Ceiling field and type the Annual MDCP IPC Cost Limit for the RUG Value from the MN/LOC Assessment.
  11. Move to the Begin Date field and type the Effective Date of the new IPC period.
  12. Move to the End Date field and type the last day of the new IPC period.
  13. Move to the Amount Authorized field and enter the Total Estimated Cost of All MDCP Services Authorized for the new IPC period.
  14. Leave the Units Authorized field blank.
  15. Select the Save button.

 

11340 Service Authorization – Reassessment

Revision 13-1; Effective February 1, 2013

 

Create a Service Authorization record for each Service Code for the new IPC period, using the same instructions used for Initial Authorizations. If the same Service Code is approved for the next year, the Begin Date of the Service Authorization record for the new IPC period is the day after the End Date of the current IPC period. This prevents a gap in service.

Service Code 60, Unlimited Prescriptions

The Service Authorization record for Service Code 60, Unlimited Prescriptions, is system generated. Enter the day before the individual’s 21st birthday in the End Date field. At the annual review, check to see that the correct information was entered during the Initial Authorization.

 

11350 Level of Service – Reassessment

Revision 13-1; Effective February 1, 2013

 

To Register a Level of Service RUG Value for Another IPC Period:

  1. Select Level of Service area in the Medical Functional area.
  2. Check the existing record to ensure that an End Date was previously entered.
  3. If not, select the check box for the existing record for the current IPC period.
  4. Select the Modify button.
  5. Enter the End Date for the current IPC period.
  6. Select the Save button.
  7. Select Add and a blank Level of Service Details record will appear.
  8. Move to the Type field and select CP - MDCP RUG from the drop-down menu.
  9. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  10. Leave the Contract field blank.
  11. Move to the Level field and type the RUG value from the MN/LOC Assessment.
  12. Move to the Begin Date field and type the Effective Date of the new IPC period.
  13. Move to the End Date field and type the last day of the new IPC period.
  14. Select the Save button.

 

11360 Diagnosis – Reassessment

Revision 13-1; Effective February 1, 2013

 

To Register Diagnosis Code(s) for Another IPC Period:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Check the existing record to ensure that an End Date was previously entered.
  3. If not, select the check box for the existing record for the current IPC period.
  4. Select the Modify button.
  5. Enter the End Date for the current IPC period.
  6. Select the Save button.
  7. Select Add and a blank Diagnosis Details record will appear.
  8. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP).
  9. Move to the Begin Date field and type the Effective Date of the new IPC period.
  10. Move to the End Date field and type the last day of the new IPC period.
  11. Move to the Diagnosis fields and enter the numeric code(s) for the individual's diagnosis with no decimals. Up to five diagnosis codes can be entered.
  12. Leave the Version field at the default 09 - ICD-9-CM CODE.
  13. Select the Save button.

 

11370 Medical Necessity – Reassessment

Revision 13-1; Effective February 1, 2013

 

To Register Medical Necessity Information for Another IPC Period:

  1. Select Medical Necessity area in the Medical Functional area.
  2. Check the existing record to ensure that an End Date was previously entered.
  3. If not, select the check box for the existing record for the current IPC period.
  4. Select the Modify button.
  5. Enter the End Date for the current IPC period.
  6. Select the Save button.
  7. Select Add and a blank Medical Necessity Details record will appear.
  8. Leave the Medical Necessity field at the default selection Y - YES.
  9. Leave the Permanent field at the default selection N - NO.
  10. Move to the Begin Date field and type the Effective Date of the new IPC period.
  11. Move to the End Date field and type the last day of the new IPC period.
  12. Select the Save button.

 

11400 Terminations

Revision 13-1; Effective February 1, 2013

 

The Enrollment and all Service Authorization records must be closed when all services for an existing MDCP individual are terminated in SAS Online. When enrollment is terminated, change the End Date to the Effective Date of the termination, Select Save, and manually terminate active Service Authorization records for each MDCP Service Code.

Individual Service Authorization records can be terminated for specific Service Codes on SAS Online also. See Section 11420, Terminating a Specific Service Code.

 

11410 Terminating All Services

Revision 13-1; Effective February 1, 2013

 

To Terminate All Services for an Existing MDCP Individual:

  1. Open the file and the Client Details record will appear.
  2. Move to the Enrollment area in the Program and Service Functional area.
  3. Select the check box for the appropriate record from the list.
  4. Select the Modify button.
  5. Move to the End Date field and type the Effective Date of the termination.
  6. Move to the Termination Code field and select the appropriate code from the drop-down menu.
  7. Select the Save button.
  8. Move to the Service Authorization area in the Program and Service Functional area.
  9. Select the check box for the appropriate record from the list.
  10. Select the Modify button.
  11. Move to the Term. Code field and select the appropriate code from the drop-down menu.
  12. Move to the End Date field and enter the Effective Date of the termination.
  13. Select the Save button.

Repeat Steps 1-13 to terminate each active Service Authorization record.

  1. Select Submit to SAS from the toolbar to submit the information.
  2. Select Outbox and then Inbox to ensure the case processed accurately.

It is permissible, however, not necessary, to close all other existing records for the individual (Diagnosis, Medical Necessity, Service Plan, Address, Authorizing Agent, Location and Level of Service) unless the individual will transfer to another Service Group. If this happens, the Effective Date of termination is used in the End Date fields.

 

11420 Terminating a Specific Service Code

Revision 13-1; Effective February 1, 2013

 

To Terminate a Specific Service Code for an Existing MDCP Individual who is Still Eligible for the Program:

  1. Open the file and the Client Details record will appear.
  2. Move to the Service Authorization area in the Program and Service Functional area.
  3. Select the check box for the appropriate record from the list.
  4. Select the Modify button.
  5. Move to the Term. Code field and select the appropriate code from the drop-down menu.
  6. Move to the End Date field and enter the last day of the Service Code.
  7. Select the Save button.
  8. Select Submit to SAS from the toolbar to submit the information.
  9. Select Outbox and then Inbox to ensure the case processed accurately.

 

11500 Individual Plan of Care (IPC) Changes

Revision 13-1; Effective February 1, 2013

 

 

11510 Provider Transfers

Revision 13-1; Effective February 1, 2013

 

When an individual transfers from one provider to another, the MDCP case manager must verify the number of units or the cost of services delivered from the time the individual was certified until the change is effective. Then, the case manager must calculate the estimated number of units or the cost of services that will be delivered by the new provider from the effective date of the change to the end of the IPC period.

To Register an IPC When a MCDP Individual Transfers Between Providers:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for each Service Authorization record for the Service Codes currently authorized.
  3. Select the Modify button.
  4. In each Service Authorization record, move to the Units field and type the number of units or the cost of services delivered by the losing provider. Change the End Date to the last day the losing provider is authorized to deliver services.
  5. Select the Save button.
  6. Select Add and a blank Service Authorization Details record will appear.
  7. Leave the MHMR Case No. field blank.
  8. Move to the Service Group field and select 18 – MEDICALLY DEPENDENT CHILDREN PROGRAM (MDCP) from the drop-down menu.
  9. Move to the Service Code field and select the appropriate Service Code from the drop-down menu.
  10. Leave the Fund and Term Code at the default.
  11. The Agency field is read-only at 324-DHS.
  12. Move to the Unit Type field and select 4 - PER AUTHORIZATION from the drop-down menu for all MDCP services, except for the CDS Monthly Administrative Fee, select 2 - MONTH.
  13. Move to the Units field and type the number of units or the cost of services that will be delivered by the new provider.
  14. Move to the Begin Date field and type the date the new provider is authorized to deliver services.
  15. Move to the End Date field and type the last day of the IPC period.
  16. Move to the Contract No field and type the provider contract number for each service.
  17. The NPI field is read-only.
  18. Select the Save button.
  19. When all appropriate services are changed and saved, select Submit to SAS from the toolbar.
  20. Select Outbox and then Inbox to ensure the case processed accurately.

 

11520 Service Plan – IPC Changes

Revision 13-1; Effective February 1, 2013

 

Adjust the Service Plan record if the provider transfer results in a change to the Amount Authorized field.

 

11530 All Other IPC Changes

Revision 13-1; Effective February 1, 2013

 

To process a change to the IPC, the MDCP case manager must calculate the number of units or cost of services previously authorized or obtain utilized units plus the number of units or cost of services necessary to complete the IPC period. The new projected annual units and cost of services must be registered on SAS when the IPC is changed.

To Register an IPC Change:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for the Service Authorization record(s) for the Service Code(s) being changed.
  3. Select the Modify button.
  4. Move to the Units field and type the new number of units. Do not make any other changes to the record, unless existing information is incorrect.
  5. Select the Save button.
  6. Select the Service Plan area from the Program and Service Functional area.
  7. Select the check box for the Service Plan you wish to change.
  8. Select the Modify button.
  9. Move to the Amount Authorized field and type the new Total Cost of Services Authorized on the IPC. Do not make any other changes to the record.
  10. Select the Save button.
  11. Select Submit to SAS from the toolbar to submit the information.
  12. Select Outbox and then Inbox to ensure the case processed accurately.

CM-MDCP, Appendices

CM-MDCP, Appendix I, Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits

CM-MDCP, Appendix II, Medically Dependent Children Program (MDCP) Tools

Revision 12-1; Effective May 1, 2012

 

For information about document accessibility, contact HHS at handbookfeedback@hhsc.state.tx.us

Tool for Adaptive Aids
Tool for Adaptive Aids (Spanish)

Tool for Van Lifts/Vehicle Modification
Tool for Van Lifts/Vehicle Modifications (Spanish)

Tool for Minor Home Modification
Tool for Minor Home Modifications (Spanish)

CM-MDCP, Appendix III, Adaptive Aids (AA) Checklist

Revision 12-1; Effective May 1, 2012

 

 

For information about document accessibility, contact HHS at handbookfeedback@hhsc.state.tx.us

Appendix III

CM-MDCP, Appendix IV, Minor Home Modification (MHM) Checklist

Revision 10-1; Effective March 12, 2010

 

For information about document accessibility, contact HHS at handbookfeedback@hhsc.state.tx.us

Appendix IV

CM-MDCP, Appendix V, Mutually Exclusive Services

CM-MDCP, Appendix VII, Monthly Income/Resource Limits

CM-MDCP, Appendix VIII, Additional Non-Waiver Services

CM-MDCP, Appendix IX, Instructions and Access to CARE

CM-MDCP, Appendix X, Long Term Care Online Portal - Status Messages, Common Scenarios and Workflow

Revision 12-1; Effective May 1, 2012

 

Long Term Care (LTC) Online Portal – Status Messages

Status messages are produced in the LTC Online Portal when the Medical Necessity and Level of Care (MN/LOC) Assessment is submitted and cannot be processed in Service Authorization System (SAS). Following is a non-inclusive draft list of status messages.

All assessments that were successfully processed by SAS will generate a message to the workflow. This message does not require additional steps in SAS or the LTC Online Portal and informs staff that the automation process did not encounter any problems.

  • The request was successfully processed in SAS and the SAS records were synchronized with Texas Medicaid & Healthcare Partnership’s (TMHP) Centers for Medicare and Medicaid Services (CMS) Database.

Messages in the workflow resulting from an Admission, Annual or Significant Change in Status Assessment (SCSA):

  • There is no open Enrollment record for the individual in SAS (Admission Assessment submitted out of sequence).
  • The request cannot be processed because MN has been denied (requires case manager investigation).
  • The request cannot be processed because the Annual Assessment is being submitted more than 90 days prior to the Service Plan or Individual Plan of Care (IPC) end date.
  • The Annual Assessment has been submitted more than 132 days after the end of the last Service Plan. (The nurse may need to inactivate and then submit an Admission Assessment, or the case may have been denied.)
  • A previous Service Plan cannot be found.
  • An open Level of Service (LOS) record for the consumer cannot be found.
  • One or more of the consumer’s SAS records associated with this request has been changed.
  • The request cannot be processed because an open Diagnosis (DIA) record for the consumer cannot be found.
  • The request cannot be processed because an open MN record for the consumer cannot be found.
  • The request cannot be processed because there is not an open Service Plan record for the consumer.
  • The request cannot be processed because the SCSA assessment is being submitted more than 30 days after the Service Plan end date.
  • The SCSA resulted in a denied MN and must be processed manually.

Messages in the workflow resulting from any assessment:

  • The request was successfully processed in SAS but the SAS records were not successfully synchronized with TMHP’s CMS database.
  • The request was successfully processed in SAS but the SAS records have not yet successfully synchronized with TMHP’s CMS database.
  • The request cannot be processed because the Service Group on the request is not one that the Minimum Date Service Authorization System (MDSAS) can process.
  • The request cannot be processed because the consumer does not exist in SAS.
  • The request cannot be processed because the consumer’s eligibility record cannot be found.
  • The request cannot be processed because of data integrity problems with the consumer’s data in SAS.
  • The request cannot be processed because of the following SAS Rules Engine Error: Service Authorization — Does not have any active Applied Income/Copay.
  • The request cannot be processed because of a SAS Rules Engine Error.
  • The request cannot be processed because of the following SAS Rules Engine Error: Authorizing Agent — Active record not found for service authorization date range.
  • The request cannot be processed because of the following SAS Rules Engine Error: Diagnosis — Active record not found for service authorization Begin Date range.
  • The request cannot be processed because of the following SAS Rules Engine Error: Level of Service Begin Date must be <= End Date.
  • The request cannot be processed because of the following SAS Rules Engine Error: Level of Service — Active record not found for service authorization Begin Date range.
  • The request cannot be processed because of the following SAS Rules Engine Error: Medical Necessity — Begin Date overlap with other Medical Necessity record.
  • The request cannot be processed because of the following SAS Rules Engine Error: Service Authorization does not exist.
  • The request cannot be processed because of the following SAS Rules Engine Error: Service Authorization — Does not have an active Medical Necessity record.

Common Scenarios and Workflow

The following scenarios may appear that require the Medically Dependent Children Program (MDCP) case manager actions related to MN. Each scenario describes the case action and provides information related to:

  • Existing SAS Records – MN, LOS and DIA records in SAS;
  • New SAS Records – System-generated changes in SAS resulting from processing the MN/LOC Assessment by TMHP and the Department of Aging and Disability Services (HHS);
  • SAS Actions – Case manager actions in SAS;
  • Case Actions – Non-SAS case manager actions, including eligibility decisions; and
  • Workflow Action – LTC Online Portal messages that identify that automation successfully processed the information from the MN/LOC Assessment or messages that identify errors in SAS that prohibit automation from processing the assessment.

General Processing Rules

Certain principles apply to process MN/LOC Assessments through automation. The list below is not all-inclusive.

  • MN records cannot overlap.
  • MDCP LOS and DIA records cannot overlap.
  • An Annual MN/LOC Assessment can be submitted up to 90 days prior to the end of the IPC.
  • An Annual MN/LOC Assessment cannot be submitted without a previous open/active SAS Enrollment record.
  • A new MN record, approved or denied, will be created for the Annual MN/LOC Assessment.
  • An SCSA must not be submitted more than 30 days after the end date of the IPC in which the SCSA applies.
  • SAS will not update records that have been manually updated. All submittals will be referred to the workflow if the case manager has manually updated MN, LOS or DIA records.
  • To preserve history, submittals will not overwrite original entries.
  • Corrections to most entries in the MN/LOC Assessment can be made within the first 14 days from the day that TMHP received a complete assessment.
  • Unlimited corrections to MN/LOC Assessments may be made within the 14 days for any form status or type submission.
  • If an assessment being inactivated has not been submitted to SAS, TMHP will change the assessment status to inactive. If the assessment has been submitted to SAS, TMHP will change status to inactive and send a message to the workflow. The case manager must take appropriate case action.

Enrollment – Scenario

Initial Enrollment from Community; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
None New MN, LOS and DIA records are auto-populated:
  • Begin Date: The day TMHP received a complete assessment.
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month. If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.
Manually create new MN, LOS and DIA records
  • Begin Date: The day after the End Date of the auto-populated record.
  • End Date: The IPC end date.
The case manager will need to create records to cover the gap from the end date of the auto-populated record to the IPC end date.
The applicant has met MN. Continue enrollment for MDCP. Check the workflow for messages and correct any errors.

Notes: The End Date on the auto-populated SAS records will probably not cover the entire IPC period. The case manager must not change the end dates of the auto-populated records. The case manager must add new records to cover the gap until the end of the IPC period.

Enrollment – Scenario

Initial Money Follows the Person (MFP) enrollment with a limited stay; HHS nurse completed an Admission MN/LOC Assessment; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
None New MN, LOS and DIA records are auto-populated:
  • Begin Date: The day TMHP received a complete assessment;
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month. If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.
Manually create MN, LOS and DIA records to cover the remainder of the IPC period:
  • Begin Date: The day after the end date of the auto-populated record.
  • End Date: The IPC end date.
The case manager will need to create records to cover the gap from the end date of the auto-populated record to the IPC end date.
The applicant has met MN. Continue enrollment for MDCP. Check the workflow for messages and correct any errors.

Notes: The end date in the auto-populated SAS records will probably not cover the entire IPC period. The case manager must not change the end dates of the auto-populated records. The case manager must add new records to cover the gap until the end of the IPC period. If the nursing facility (NF) submits an NF admission form after the individual’s MDCP service initiation date, SAS will close the MN record that resulted from the MDCP MN/LOC Assessment and all MDCP Service Authorization records. The case manager must add new LOS and DIA records with a begin date that equals the day after the previous records ended and an end date that equals the IPC end date. The case manager does not close the MN record that resulted from the NF admission form.

Enrollment – Scenario

Initial Enrollment Nursing Facility (NF) - NF Permanent Medical Necessity (PMN) on File

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The MN, LOS and DIA records associated with the NF are in SAS None Manually create LOS and DIA records for MDCP:

 

  • Begin Date: The IPC service initiation date.
  • End Date: The IPC end date.
Do not modify existing NF PMN, LOS or DIA records. The PMN record remains untouched and open-ended for the initial IPC period only.
Use the current NF PMN to establish MDCP eligibility. The applicant meets MN. Continue enrollment for MDCP. Use the NF Resource Utilization Group (RUG). Check the workflow for messages and correct any errors.

Notes: Per MDCP policy, the NF MN record may be used to establish MDCP MN eligibility; an Admission MN/LOC Assessment by the HHS nurse is not required. If an MN record is on file in SAS when the HHS nurse submits an Admission MN/LOC Assessment, a new MN record will not be auto-populated in SAS. Case managers must verify the MN/LOC Assessment information in the LTC Online Portal to determine appropriate case action and manually create LOS and DIA records.

Enrollment – Scenario

Initial enrollment from NF, Current Approved NF MN on File; HHS nurse submits an MN/LOC Assessment; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records associated with the NF MN are in SAS. New LOS and DIA records are auto-populated:

 

  • Begin Date: The day TMHP received a complete assessment.
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month. If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.

 

A new MN record will not be auto-populated as a result of an assessment submitted by the HHS nurse.
Manually create new LOS and DIA records:
  • Begin Date: The day after the end date of the auto-populated record.
  • End Date: The IPC end date.
NF MN records that are not PMN are time-limited. Manually create a new MN record:
  • Begin Date: The day after the NF MN record.
  • End Date: The IPC end date.
Do not modify existing NF MN, LOS or D
Use the current NF MN to establish MDCP eligibility. The applicant meets MN. Continue enrollment for MDCP. Use the NF RUG or, if the new RUG increases IPC cost limit or the provider's reimbursement rate, use the new RUG. Check the workflow for messages and correct any errors.

Notes: Per MDCP policy, the NF MN record may be used to establish MDCP MN eligibility; an Admission MN/LOC Assessment by the HHS nurse is not required. If an MN record is on file in SAS when the HHS nurse submits an Admission MN/LOC Assessment, a new MN record will not be auto-populated in SAS. Case managers must verify the MN/LOC Assessment information in the LTC Online Portal to determine appropriate case action and manually create MN, LOS and DIA records. The End Date on the auto-populated SAS records will probably not cover the entire IPC period. The case manager must not change the end dates of the auto-populated records. The case manager must add new records to cover the gap until the end of the IPC period.

Enrollment – Scenario

Initial Enrollment from NF, Current Approved NF MN on File; HHS nurse submits an MN/LOC Assessment, MN Not Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records associated with the NF MN are in SAS. None Manually create new LOS and DIA records:

 

  • Begin Date: The IPC service initiation date.
  • End Date: The IPC end date.

NF MN records that are not PMN are time-limited. Manually create a new MN record:

  • Begin Date: The day after the NF MN record.
  • End Date: The IPC end date.
New MN, LOS and DIA records will not be auto-populated as a result of the assessment submitted by the HHS nurse. Do not modify existing NF MN, LOS or DIA records.
Use the current NF MN to establish MDCP eligibility. The applicant meets MN. Continue enrollment for MDCP. Use the NF RUG. Check the workflow for messages and correct any errors.

Notes: This scenario only applies to an applicant that has an MN determination and is residing in the NF at the time the request for MFP is made and remains in the NF until all MDCP eligibility criteria are met. This scenario does not apply to an applicant using the MFP process who does not reside in the NF at the time the HHS nurse completes the MN/LOC Assessment. Per MDCP policy, the NF MN record may be used to establish MDCP MN eligibility; an Admission MN/LOC Assessment by the HHS nurse is not required. If an MN record is on file in SAS when the HHS nurse submits an Admission MN/LOC Assessment, a new MN record will not be auto-populated in SAS. Case managers must verify the MN/LOC Assessment information in the LTC Online Portal to determine appropriate case action and manually create MN, LOS and DIA records.

Annual – Scenario

Annual Assessment completed and submitted before the IPC end date; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MDCP MN, LOS and DIA records are in SAS and the end dates match the end of the current IPC. New MN, LOS and DIA records are auto-populated:

 

  • Begin Date: The day after the current LOS record ends.
  • End Date: See below.

If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month.

If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.

If needed, manually create new MN, LOS and DIA records:

 

  • Begin Date: The day after the end date of the auto-populated record.
  • End Date: The IPC end date.

The case manager will need to create an MN record to cover the gap from the end date of the auto-populated record to the IPC end date.

Determine continued MDCP eligibility based on the auto-populated MN record. The individual meets MN. Continue eligibility determination for MDCP. Check the workflow for messages and correct any errors.

Notes: For most Annual Assessment transmissions, the previous MN record end date will be the same as the IPC end date. If the previous MN record end date is not the same as the IPC end date, the case manager must create a new record to cover the gap.

Annual – Scenario

Annual Assessment completed and submitted before the IPC end date; NF PMN in SAS; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current LOS and DIA records are in SAS and the end dates match the end of the current IPC. The NF PMN record is open ended. The NF PMN record is closed:
  • End Date: The day the current LOS record ends.
New MN, LOS and DIA records are auto-populated:
  • Begin Date: The day after the current LOS record ends.
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month. If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.
If needed, manually create new MN, LOS and DIA records:
  • Begin Date: The day after the end date of the auto-populated record.
  • End Date: The IPC end date.
The case manager will need to create an MN record to cover the gap from the end date of the auto-populated record to the IPC end date.
Determine continued MDCP eligibility based on the auto-populated MN record. The individual meets MN. Continue eligibility determination for MDCP. Check the workflow for messages and correct any errors.

Notes: SAS will close the NF PMN record. For most Annual Assessment transmissions, the previous MN record end date will be the same as the IPC end date. If the previous MN record end date is not the same as the IPC end date, the case manager must create a new record to cover the gap.

Annual – Scenario

Annual Assessment completed and submitted before the IPC end date; MN Not Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records are in SAS and the end dates match the end of the current IPC. A new MN record is auto-populated:

 

  • Begin Date: The day after the current LOS record ends.
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month. If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.
None Determine MDCP eligibility based on the auto-populated MN record. The individual does not meet MN eligibility. Deny MDCP. Check the workflow for messages and correct any errors.

Note: When MN is denied, new LOS and DIA records will not be auto-populated.

Annual – Scenario

Annual Assessment completed and submitted before the IPC end date; NF PMN in SAS; MN Not Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current LOS and DIA records are in SAS and the end dates match the end of the current IPC.

 

The NF PMN record is open ended.
A new MN record is auto-populated:

 

  • Begin Date: The day after the current LOS record ends.
  • End Date: See below.
If the MN Begin Date is the first day of the month, the end date is the last day of the following 11th month.

If the MN Begin Date is any other day of the month, the end date is the last day of the following 12th month.

None Determine MDCP eligibility based on the auto-populated MN record. The individual does not meet MN eligibility. Deny MDCP. Check the workflow for messages and correct any errors.

Note: When MN is denied, new LOS and DIA records will not be created. The NF PMN record will be closed.

Annual – Scenario

Annual Assessment completed before IPC end date, submitted after but within 132 days of current IPC end date, MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The MN, LOS and DIA records for the previous IPC period are in SAS. New MN, LOS and DIA records are auto-populated:

 

  • Begin Date: The day TMHP received a complete assessment.
  • End Date: One year minus one day from the end date of the expired LOS record.
SAS actions will be based on the reason for the delay. If the individual began receiving services after the suspension ended but before the assessment was submitted, then the case manager must create MN, LOS and DIA records to cover the period before the auto-populated MN, LOS and DIA records.

 

  • Begin Date: The day after the MDCP suspension.
  • End Date: One day before the auto-populated MN, LOS and DIA record begin dates.
Determine MDCP eligibility based on the auto-populated MN record. Check the workflow for messages and correct any errors.

Notes: This scenario applies to individuals that were institutionalized or suspended from MDCP at the time of the annual review. Case managers may not authorize MDCP services to individuals while institutionalized or suspended from MDCP. If the individual was admitted to an NF, SAS may have an MN record resulting from an NF assessment. If SAS shows NF records, case managers may not change the NF records. Case managers must create MN records for MDCP to cover any gap before the IPC end date.

Annual – Scenario

Annual Assessment completed and submitted after the IPC end date but within 132 days of current IPC end date, MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The MN, LOS and DIA records for the previous IPC period are in SAS. New MN, LOS and DIA records are auto-populated:

 

  • Begin Date: The day TMHP received a complete assessment.
  • End Date: One year minus one day from current LOS End Date.
SAS actions will be based on the reason for the delay. If the individual began receiving services after the suspension ended but before the assessment was submitted, then the case manager must create MN, LOS and DIA records to cover the period before the auto-populated MN, LOS and DIA records.

 

  • Begin Date: The day after the MDCP suspension.
  • End Date: One day before the auto-populated MN, LOS and DIA record begin dates.
Determine MDCP eligibility based on the new auto-populated MN record. Check the workflow for messages and correct any errors.

Notes: This scenario applies to individuals that were institutionalized or suspended from MDCP at the time of the annual review. Case managers may not authorize MDCP services while individuals are institutionalized or suspended from MDCP.

Some of the above Annual MN/LOC Assessment scenarios apply to SAS Termination Code 35, Temporary Nursing Facility Stay, other allowable suspensions, or appeals when services are not continued and the Annual MN/LOC Assessment is submitted past the IPC end date, within or after the 132 day period. If the suspension exceeds the 132 day period and a new MN determination is needed, the MDCP nurse must submit an Enrollment MN/LOC Assessment to obtain a new MN determination. The individual's IPC period would not change.

Significant Change in Status Assessment (SCSA) – Scenario

Current Approved MN on File; SCSA Submitted; RUG or DIA; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current auto-populated MN, LOS and DIA records are in SAS. The existing LOS and/or DIA records are closed:

 

  • End Date: One day before the nurse signed that the assessment was completed.

If the RUG changed, a new LOS record is auto-populated. If the diagnosis changed, a new DIA record is auto-populated.

New LOS and/or DIA records:

  • Begin Date: the day the nurse signed that the assessment was completed.
  • End Date: The same end date as the original auto-populated LOS and/or DIA records.
If the change in RUG increased the individual's IPC cost limit or the provider's reimbursement rate, no SAS action is required from the case manager.

 

If the change in RUG decreased the individual's IPC cost limit or the provider's reimbursement rate, the case manager must cancel the LOS record with the new RUG. The case manager must create a new LOS record with the RUG from the previous assessment:

  • Begin Date: One day after the end date of the LOS record that was closed as a result of the SCSA.
  • End Date: The same end date as the LOS record that was closed as a result of the SCSA.
Continue MDCP eligibility using the current approved MN record on file in SAS. If the new RUG does not lower the IPC cost limit or decrease the provider reimbursement rate, take appropriate case action to process the IPC using the new RUG documented in the LOS record. Check the workflow for messages and correct any errors.

Notes: A new MN record will not be auto-populated as a result of the SCSA. If the Annual Assessment for the next IPC period has already been submitted and MN, LOS and DIA records were auto-populated for the next IPC period, changes to the RUG and DIA resulting from the SCSA of the current IPC period will close all future LOS and DIA records that resulted from the Annual Assessment, and new LOS and DIA records for the next IPC period will be auto-populated.

SCSA – Scenario

Current Approved MN on File; SCSA Submitted; RUG or DIA changed; MN Approved; Manual updates recorded in SAS

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records are in SAS but one or more have been manually updated or created by the case manager. None If the RUG changed which increased the individual's IPC cost limit or the provider's reimbursement rate, the case manager will need to create a new LOS record. If the DIA changed or if more were added, the case manager will need to create a new DIA record. Close previous LOS and/or DIA records that were manually updated:

 

  • End Date: One day before the day that the nurse signed the SCSA assessment was completed.

Manually create new LOS and/or DIA records:

  • Begin Date: The day the nurse signed that the assessment was completed.
  • End Date: The same end date as the LOS and/or DIA records that were manually updated.
Continue MDCP eligibility using the current approved MN record on file in SAS. If the new RUG does not lower the IPC cost limit or decrease the provider reimbursement rate, take appropriate case action to process the IPC using the new RUG documented in the LOS record. Check the workflow for messages and correct any errors.

Notes: A new MN record will not be auto-populated as a result of the SCSA. SCSA results are not used if the change to the RUG will decrease the individual’s IPC cost limit or provider’s reimbursement.

SCSA – Scenario

Current Approved MN on File; SCSA Submitted; No change in RUG or DIA; MN Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records are in SAS. None None Continue MDCP eligibility using the current approved MN record on file in SAS. Check the workflow for messages and correct any errors.

Note: New MN, LOS and DIA records will not be auto-populated as a result of the SCSA.

SCSA – Scenario

Current Approved MN on File, SCSA submitted before the Annual Assessment for the next IPC period; MN Not Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records are in SAS. None None Do not deny services based on the SCSA. Continue MDCP eligibility using the current approved MN, LOS and DIA records on file in SAS. Check the workflow for messages and correct any errors.

Note: New MN, LOS and DIA records will not be auto-populated as a result of the SCSA.

SCSA – Scenario

Current Approved MN on File; SCSA submitted after the Annual Assessment for the next IPC period; MN Not Approved

Existing SAS Records New SAS Records SAS Actions Case Actions Workflow Action
The current MN, LOS and DIA records are in SAS.

 

The auto-populated MN, LOS and DIA records for the next IPC period resulting from the Annual Assessment are in SAS.

The future MN, LOS and DIA records that resulted from the Annual Assessment are cancelled. None Deny MDCP services at the end of the current IPC period. Check the workflow for messages and correct any errors.

Note: New MN, LOS and DIA records are not auto-populated as a result of the SCSA but all future records are cancelled for the next IPC period that resulted from the Annual Assessment.

CM-MDCP, Appendix XI, Cost Determination Process

CM-MDCP, Appendix XII, Reimbursement Methodology

Revision 05-1; Effective February 1, 2005

 

§355.507 Reimbursement Methodology for Medically Dependent Children Program

This rule is available on the Secretary of State's Texas Administrative Code website at
http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

 

To access Texas Health and Human Services Commission rules, click on Title 1, Administration, then Part 15. Click on Chapter 355, Reimbursement Rates, then Subchapter E, Community Care for Aged and Disabled, to access this rule.

CM-MDCP, Appendix XIII, Reimbursement Methodology for Transition Assistance Services

CM-MDCP, Appendix XIV, MDCP Frequently Asked Questions

Revision 13-2; Effective May 1, 2013

 

What is the Medically Dependent Children Program?

The Medically Dependent Children Program (MDCP) is a 1915(c) Medicaid waiver program that provides a variety of services that allow individuals under age 21 to live at home and avoid nursing facility placement by providing temporary relief to the primary caregiver. MDCP provides respite care, flexible family support services, minor home modifications, adaptive aids and transition assistance services. Individuals eligible for MDCP also receive services through the state Medicaid program.

 

What happens when my/my child's name reaches the top of the interest list?

Initial Contact with a Case Manager: A case manager will contact you within 14 days to determine if you wish to apply for services and, if so, to schedule a home visit.

Determine Eligibility: A home visit will be conducted, at which time the case manager and nurse will collect information on the condition and service needs of the individual applying for MDCP services. Financial eligibility will be determined based on the income and resources of the individual applying for MDCP.

Develop a Service Plan: The case manager and nurse will provide an overview of services offered through MDCP, as well as other resources that may benefit the individual. A medical and social assessment will be conducted at the home visit to assess the individual's condition and the skilled services that the individual needs for services. With your participation, and the help of the case manager and the nurse, an Individual Plan of Care (IPC) will be developed that best meets the needs of the individual and the primary caregiver.

Choose a Provider: The case manager will provide a list of MDCP service providers in your area. It is your responsibility to select a provider for MDCP services.

If you prefer to select an agency not on the provider list, the agency may apply to deliver MDCP services by contacting the Department of Aging and Disability Services, Community Care Contracting Unit, at 512-438-2080.

Start Services: The case manager will inform you whether or not the individual applying for MDCP has met all of the eligibility requirements. The case manager will sign the finalized IPC and assist in negotiating a start date with the provider(s) of your choice.

CM-MDCP, Appendix XV, Medicaid Program Actions

CM-MDCP, Appendix XVI, Specialized Nursing Criteria

Revision 13-3; Effective August 1, 2013

 

The Texas Department of Aging and Disability Services (HHS) implemented specialized nursing rates and rate criteria for Respite and Flexible Family Support Services delivered by nurses to Medically Dependent Children Program (MDCP) individuals who receive ventilator or tracheostomy care.

Individuals must be unable to provide self-care and require at least one of the following therapeutic interventions:

  • daily skilled nursing to cleanse, dress and suction a tracheostomy, as documented with a check mark in Item O0100E, Tracheostomy care, and with a value of 3-7 in S6a., Tracheostomy care; or
  • daily skilled nursing assistance with ventilator care, as documented with a check mark in O0100F, Ventilator or respirator, and with a value of 3-7 in S6b., Ventilator/respirator.

HHS providers must initiate the request for the specialized nursing rate. The case manager may discuss the specialized nursing rate with the provider when sending the draft Individual Plan of Care (IPC) to determine if the specialized nursing rate is needed when the individual meets the specialized nursing criteria. The case manager must document any discussion with the provider regarding the specialized nursing rate in the case file. Once the Home and Community Support Services Agency (HCSSA) submits a request for the specialized nursing rate, the case manager may authorize this rate when the individual meets the specialized nursing criteria. The provider may request the specialized nursing rate after reviewing the draft IPC at initial enrollment or annual reassessment or during the IPC year. If the specialized nursing rates are authorized, the case manager must authorize all Respite and Flexible Family Support Services units delivered by nurses with the specialized nursing rate.

The case manager must process changes to the individual plan of care (IPC) as requested, complete the appropriate authorization form and data enter the information in the Service Authorization System (SAS) within 14 days of the initial request for the specialized nursing rate. When completing the SAS Service Authorization records for the specialized nursing rate, the case manager uses the date he signed the service authorization form as the begin date. The case manager must also document the new Authorized Amount field in the SAS Service Plan record. The change in Respite or Flexible Family Support Services rates is not retroactive.

For future IPC development for individuals meeting the specialized nursing rate, the case manager will apply the specialized nursing rate for all annual reassessments or changes to the IPC if the individual’s Medical Necessity (MN) assessment documentation continues to meet the specialized nursing criteria.

The case manager will document the authorization on Form 2414, Flexible Family Support Services Authorization, or Form 2415, Respite Service Authorization, and Form 2065-B, Notification of Waiver Services. If the specialized nursing rates are applicable, the case manager must authorize all Respite and Flexible Family Support Services units delivered by nurses with the specialized nursing rate.

CM-MDCP, Appendix XVII, Nursing Facility Respite Rate Criteria and Rates

Revision 12-1; Effective May 1, 2012

 

The Texas Department of Aging and Disability Services (HHS) implemented rates and rate criteria for out-of-home respite provided in a nursing facility to Medically Dependent Children Program (MDCP) individuals who require ventilator or tracheostomy care. The case manager uses the criteria listed below to determine which rate to use when developing the individual plan of care (IPC).

Service Code 11F — Respite-Nursing Facility

Case managers use this service code/rate when there is no check mark in P1a.j., Tracheostomy care, and when there are no values identified in S6b., Ventilator/respirator, in the Medical Necessity and Level of Care (MN and LOC) Assessment.

Service Code 11FA — Respite-Nursing Facility/24-Hour Ventilator Care

Case managers use this service code/rate when documentation on the MN and LOC Assessment includes a check mark in Item P1a.j., Tracheostomy care, and a value of 7 in S6b., Ventilator/respirator.

Service Code 11FB — Respite-Nursing Facility/Less than 24-Hour Ventilator Care

Case managers use this service code/rate when documentation on the MN and LOC Assessment does not have a check mark in Item P1a.j., Tracheostomy care, and a value of 1-7 in S6b., Ventilator/respirator.

Service Code 11FC — Respite-Nursing Facility/Pediatric Tracheostomy

Case managers use this service code/rate when documentation on the MN and LOC Assessment includes a check mark in Item P1a.j., Tracheostomy care, and a value of 1-6 in S6b., Ventilator/respirator.

Nursing Facility Respite Hourly Rates
RUG Service Authorization System (SAS) Code
11F 11FA 11FB 11FC
RAD $6.06 $9.95 $7.62 $8.39
RAC $5.38 $9.27 $6.93 $7.71
RAB $5.06 $8.95 $6.62 $7.45
RAA $4.48 $8.37 $6.03 $6.86
SE3 $7.20 $11.09 $8.75 $9.58
SE2 $6.14 $10.03 $7.70 $8.53
SE1 $5.36 $9.25 $6.92 $7.74
SSC $5.24 $9.13 $6.80 $7.62
SSB $4.96 $8.86 $6.52 $7.35
SSA $4.95 $8.85 $6.51 $7.34
CC2 $4.32 $8.21 $5.87 $6.70
CC1 $4.10 $7.99 $5.66 $6.48
CB2 $3.98 $7.87 $5.53 $6.36
CB1 $3.81 $7.70 $5.36 $6.19
CA2 $3.62 $7.52 $5.18 $6.01
CA1 $3.42 $7.31 $4.98 $5.80
IB2 $3.63 $7.52 $5.19 $6.01
IB1 $3.40 $7.29 $4.96 $5.78
IA2 $3.12 $7.01 $4.68 $5.51
IA1 $2.97 $6.86 $4.53 $5.35
BB2 $3.57 $7.46 $5.13 $5.95
BB1 $3.25 $7.14 $4.81 $5.63
BA2 $3.07 $6.96 $4.62 $5.45
BA1 $2.79 $6.69 $4.35 $5.18
PE2 $3.83 $7.72 $5.38 $6.21
PE1 $3.63 $7.52 $5.19 $6.01
PD2 $3.68 $7.57 $5.23 $6.06
PD1 $3.47 $7.37 $5.03 $5.86
PC2 $3.39 $7.28 $4.94 $5.77
PC1 $3.26 $7.15 $4.81 $5.64
PB2 $3.17 $7.07 $4.73 $5.56
PB1 $3.03 $6.92 $4.59 $5.41
PA2 $2.85 $6.75 $4.41 $5.24
PA1 $2.76 $6.65 $4.31 $5.14

CM-MDCP, Appendix XVIII, Service Authorization System (SAS) Service Codes

Revision 15-8; Effective July 31, 2015

 

Respite

Service Code Policy Description
11 Home and Community Support Services (HCSS) Attendant
11F Nursing Facility
11FA Nursing Facility/24-hour Ventilator Care
11FB Nursing Facility/Less than 24-hour Ventilator Care
11FC Nursing Facility/Pediatric Tracheostomy
11G Camp
11H Child Care
11J Special Care Facility
11J Host Family
11L Hospital
11M HCSS Registered Nurse (RN)/Licensed Vocational Nurse (LVN)
11MS HCSS RN/LVN-Specialized Nursing Rate
11NSV Consumer Directed Services (CDS) Specialized LVN
11NV CDS LVN
11PSV CDS Specialized RN
11PV CDS RN
11Q HCSS Attendant with Delegated Tasks
11ZV CDS Attendant

 

Flexible Family Support Services

Service Code Policy Description
11R HCSS RN/LVN
11RS HCSS RN/LVN-Specialized Nursing Rate
11SSV CDS Specialized LVN
11SV CDS LVN
11TSV CDS Specialized RN
11TV CDS RN
11U HCSS Attendant
11UV CDS Attendant
11V HCSS Attendant with Delegated Tasks

 

Adaptive Aids

Service Code Policy Description
15 Adaptive Aids

 

Minor Home Modifications

Service Code Policy Description
16 Minor Home Modifications

 

Transition Assistance Services

Service Code Policy Description
53 Transition Assistance Services
53A Transition Assistance Services Fee

 

Financial Management Services

Service Code Policy Description
63V Financial Management Services Fee

 

Employment Assistance

Service Code Policy Description
37 Employment Assistance
37V CDS Employment Assistance

 

Supported Employment

Service Code Policy Description
54 Supported Employment
54V CDS Supported Employment

CM-MDCP, Appendix XIX, Age Out Timeline, Progress Logs, Letters and Talking Points

For information about document accessibility, contact HHS at handbookfeedback@hhsc.state.tx.us

Age Out Timeline and Progress for the Community Based Alternatives (CBA) Applicant

Age Out Timeline for the STAR+PLUS Waiver (SPW) Applicant

STAR+PLUS Waiver (SPW) Applicant Home Visit Talking Points

STAR+PLUS Waiver (SPW) Applicant Home Visit Talking Points - Spanish

 

Age-out Transition Letters

The age-out transition letters are used as part of the process for applicants aging out (turning age 21) from the Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP) Private Duty Nursing (PDN) into the Community Based Alternatives (CBA) program.

It is important to explain the aging out process to the applicant, his responsible party, or both, so they understand that current services will no longer be available and to introduce the options available at age 21.

The Initial Age-out Letter is sent prior to the 12-month visit by the staff assigned for the applicant. This letter serves as an introduction to the process and advises the applicant to expect contact from HHS staff to schedule the 12-month visit.

The Follow-up Letter is sent to applicants who have 50 or more hours of skilled nursing services weekly. This letter is sent out nine months prior to the applicant's 21st birthday as a reminder that the aging out application process will begin six months prior to his 21st birthday. The letter is sent by the assigned case manager.

Initial Age-out Letter

Initial Age-out Letter – Spanish

Follow-up Letter

Follow-up Letter – Spanish

The Follow-up Managed Care/STAR+PLUS Waiver Letter is sent to applicants who have 50 or more hours of skilled nursing services weekly through CCP-PDN in a managed care area. This letter is sent out nine months prior to the applicant's 21st birthday as a reminder that the aging out application process will begin six months prior to his 21st birthday. The letter is sent by the assigned case manager.

Follow-up Managed Care/STAR+PLUS Waiver Letter

Follow-up Managed Care/STAR+PLUS Waiver Letter – Spanish

CM-MDCP, Appendix XX, Medical Necessity Determination and Resource Utilization Group Value Calculation Explanation

Revision 12-4; Effective December 3, 2012

 

During fair hearings in which medical necessity (MN) determination or resource utilization group (RUG) value change or calculation is in question, such as fair hearings due to MN denials or reduction in services due to a decrease in the cost limit, Department of Aging and Disability Services (DADS) staff present information to the hearings officer and applicant or individual to explain the MN determination or RUG value calculation process. Regional staff present these processes to the hearings officer and applicant or individual by using the script below.

The MN determination and RUG value explanation scripts are for regional staff to use during fair hearings for MN denials or a change in the RUG value. Regional staff must provide testimony utilizing the script to give a general explanation of how the RUG value is determined.

Texas Medicaid & Healthcare Partnership (TMHP) is the DADS agency representative in fair hearings for MN denials. Regional staff must ensure adequate testimony is provided regarding the processes and entities involved in making the MN determination. The script will assist in providing this information. During fair hearings in which the validity of the MN is in question, regional staff have the option of utilizing the script since TMHP will present information on the Medical Necessity and Level of Care (MN/LOC) Assessment. TMHP staff do not participate in fair hearings to explain RUG value differences for an applicant or individual.

Regional staff should always include the script with the agency evidence packet submitted to the hearings officer and the applicant or individual prior to the fair hearing if the fair hearing is related to either the MN determination or RUG value calculation.

MDCP Script

CM-MDCP, Appendix XXI, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

CM-MDCP, Appendix XXII, Examples of HHSC Envelopes

CM-MDCP, Appendix XXIII, Notification and Effective Dates

Revision 15-7; Effective June 12, 2015

 

Case Action Date Form is Mailed/Given to Individual Date to be Entered on Form
If the application is denied: Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, is mailed/given the same date as the Department of Aging and Disability Services (HHS) staff member signs it.

 

Time Frame: Within 30 days of receipt of the initial home visit.

Effective Date: Not applicable for denied applications.
If the application is certified: Form 2065-B, Notification of Waiver Services, is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: The case manager sends Form 2065-B to the applicant/individual with the case manager's original signature within 30 calendar days of the initial home visit. Limited Stay: Form 2065-B must be completed within 24 hours of discharge from the nursing facility (NF).
Eligibility Date: Same date as the HHS staff member's signature. All eligibility factors are in place.

Effective Date: Same date as the HHS staff member's signature or future negotiated date.

Medicaid Eligibility Date (MED): Date of the certification of the Medicaid Assistance Only (MAO) case; cannot be after the eligibility date.

Money Follows the Person: The applicant must remain in the NF until Medically Dependent Children Program (MDCP) eligibility is established. Form 2065-B may first be sent notifying the applicant of the eligibility and MED. A second Form 2065-B must be sent notifying of the effective date when a discharge date is established.

Limited Stay:  The applicant must remain in the NF at least part of two days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services (and establish Medicaid in an NF).

If the case is recertified at annual reassessment: Form 2065-B is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: The case manager must finalize the individual plan of care (IPC) at least 30 days prior to the end of the current IPC.

Eligibility Date: Not applicable for reassessments.

Effective Date: First date of the new IPC year, unless the IPC expires before all eligibility factors are in place.

MED: Not applicable for reassessments.

Room and Board/Copayment Effective Dates: The initial date is the first date of the new IPC; the ongoing date is the first day of the next month after the IPC begin date.

If the case is terminated at annual reassessment: Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: The case manager must finalize the IPC at least 30 days prior to the end of the current IPC.
Effective Date: The date after the 30-day adverse action period.
If there is:

 

  • an increase in units;
  • an addition of a service;
  • a decrease in copayment; and/or
  • a change in providers such as a transfer from one Home and Community Support Services Agency (HCSSA) to another:
Form 2065-B is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within 14 calendar days of receipt of the change request.
Effective Date: The date the change goes into effect.

Routine Changes: Same as the date the HHS staff member signs Form 2065-B.

Copayment Changes: Always effective on the first day of the month. A decrease in copayment can be effective the first day of the month after the notification is sent, even if the 30-day adverse action period has not expired.

Provider Changes or Transfer from One Setting to Another: This may be a negotiated date or a date determined by a mass provider transfer or contract cancellation/assignment.

If services are reduced because of:

 

  • a decrease in units;
  • a removal of specific services; 
  • an increase in copayment; and/or
  • the Resource Utilization Group (RUG) value is lowered either due to a utilization review or an annual reassessment:
Form 2065-B is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within 14 calendar days of the receipt of change request.

Effective Date: The first day after the last day of the 30-day adverse action.

Copayment Changes: Always effective on the first day of the month. An increase in copayment must be effective the first day of the month after the 30-day adverse action has expired.

If all services are terminated because of death: Form 2065-C is not sent to the individual. Form 2065-C is sent to MDCP providers and mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within 14 calendar days of receipt of the change request, within two workdays of determining the need to close the case.
Date of Death: Provider Authorization block is completed. Comments should include death as the reason for termination.
If all services are terminated because the individual moves to a skilled or intermediate care facility, or any other facility where 24-hour supervision is available and the stay is permanent: Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within 14 calendar days of receipt of the change request, within two workdays of determining the need to close the case.
Effective Date: The last day of the 30-day adverse action period and the date the individual entered the facility. The comments section must include a statement providing the date of NF entry. The Provider Authorization termination date is the date of NF entry.
If all services are terminated because of:

 

  • individual out of state more than 90 days;
  • refusal to comply with service requirements;
  • refusal by the HCSSA to serve the individual;
  • refusal to pay room and board or copayment,
  • refusal to pay Qualified Income Trust (QIT) payments;
  • patterns of verbal abuse or discrimination; or
  • presence or use of illegal drugs in the home within the sight of the service provider:
Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within 14 calendar days of receipt of the change request, within two workdays of determining the need to close the case.
Effective Date: The last day of the 30-day adverse action period.
If only one service is terminated, Form 2065-B is sent. The effective date is the first day after the 30-day adverse action period.
If all services are terminated because the individual loses Medicaid: Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Within two workdays of the date the case manager receives the information.
Effective Date: The last day of eligibility for Medicaid.
If all services are terminated because the individual loses medical necessity at reassessment: Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: Before the IPC expiration date.
Effective Date: The last date of the IPC or last day of the 30-day adverse action period if the IPC expires before the 30-day adverse action period ends.
If services are suspended due to reckless behavior of the individual or someone in the individual's home threatens the department staff or provider's health and safety: Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: By the next HHS workday of becoming aware of the reckless behavior suspension.
Effective Date: The date the case manager becomes aware of the action. Comments must include a statement, such as "Your MDCP services have been temporarily suspended due to . . . If this situation is not resolved within 30 calendar days, your services will be denied. You will be contacted by your case manager to determine if this problem can be resolved."
If all services are terminated because:

 

  • reckless behavior of the individual or someone in the individual's home threatens the department staff or provider's health and safety; and
  • a resolution could not be reached within the 12 calendar days of suspension:
Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Time Frame: At the end of the suspension.
Effective Date: The date services were initially suspended. Services do not continue pending the outcome of an appeal, even if the individual appeals within the 30-day adverse action period.
If services are reduced or terminated and:

 

  • a HHS staff member receives a clear written statement signed by the individual that states he no longer wishes services; or
  • the individual gives information that requires termination or reduction in services and indicates that he understands that this must be the result of supplying the information; or
  • the operating agency or its designee establishes the fact that the individual has been accepted for Medicaid services by another state:
Form 2065-C is mailed/given the same date as the HHS staff member signs it.

 

Note: Form 2065-B is used for reduction of services; Form 2065-C is used for termination of all services. Time Frame: Within two workdays of determining the need to close the case.
Effective Date: For reduction of services, the first day after the last day of the 30-day adverse action.
For termination of services, the effective date is the same date as the HHS staff member's signature.
When the individual signs the front of Form 2065-B or Form 2065-C to verify that he has orally requested his services be reduced or terminated, the individual's reason is documented in the comments section.
If services are reduced or terminated and the individual's whereabouts are unknown and the post office returns agency or designee mail directed to the individual indicating no forwarding address: Do not send Form 2065-B or Form 2065-C when an individual’s forwarding address is unknown, such as situations in which there is prior notice from the post office that the individual left no forwarding address. Effective Date: None.
If services are reduced or terminated for any reason not given above: Form 2065-B or Form 2065-C is mailed/given the same date as the HHS staff member signs it. Effective Date: The 30-day adverse action period must be allowed and the appropriate effective date provided on the form.

CMMDCP, Forms

 

Form Title
0003 Authorization to Furnish Information
0030 Informacion en espanol Application for Voter Registration
1019 Informacion en espanol Opportunity to Register to Vote/Declination
1025 Request for Information Medicare Advantage Coordination
1027 Informacion en espanol Caregiver Status Questionnaire
1574 Informacion en espanol Exception to the 30-Day Notification
1579 Informacion en espanol Referral for Relocation Services
1580 Informacion en espanol Texas Money Follows the Person Demonstration Project Informed Consent for Participation
1581 Informacion en espanol Consumer Directed Services Option Overview
1582 Informacion en espanol Consumer Directed Services Responsibilities
1583 Informacion en espanol Employee Qualification Requirements
1584 Informacion en espanol Consumer Participation Choice
1590 Request for a Fair Hearing Exception
1740 Informacion en espanol Service Backup Plan
1741 Informacion en espanol Corrective Action Plan
1745 Service Delivery Log with Written Narrative/Written Summary
2065-B Notification of Waiver Services
2065-C Notification of Ineligibility or Suspension of Waiver Services
2067 Case Information
2076 Informacion en espanol Authorization to Release Medical Information
2097 Provider Contract Assignment Notification Letter
2113 Community Services Interest List Registration and Follow-Up
2121 Long Term Services and Supports (English/Spanish)
2401 Qualified Income Trust (QIT) Co-Payment Agreement
2402 Consumer Directed Services Option - Services Authorization
2403 Case Manager 3/9 Month Telephone Contact Guide
2405 Narrative Notes
2406 Informacion en espanol Physician Recommendation for Length of Stay in a Nursing Facility
2408 Individual Plan of Care (IPC) Service Review
2409 Application Supplement
2410 Medical-Social Assessment and Individual Plan of Care
2411 Interim Plan of Care
2412 Budget Revision
2414 Flexible Family Support Services Authorization
2415 Respite Service Authorization
2416 Minor Home Modifications and Adaptive Aids Service Authorization
2417 Rights and Responsibilities of Families/Primary Caregivers/Independent Individual
2419 Community Services Interest List (CSIL) Closure Communication
2420 Your Appeal Rights
2421 Informacion en espanol In-Home Record Review Follow-Up
2422 Case Closure
2423 Informacion en espanol Request for Medical Evidence
2425 In-Home Record Review
2426 Pending Extension Request/Overdue Case Update
2428 Physician's Orders for Licensed Nursing Services
2430 Employment Assistance and Supported Employment Authorization
2432 Vehicle Evaluation
2435 Adaptive Aids Bid
2436 Minor Home Modification Bid
2438 Applicant Eligibility Checklist
2439 Informacion en espanol Selection Acknowledgement
2440 Informacion en espanol Release from the MDCP Interest List
2441 Release from the MDCP/CLASS Program Interest Lists
2442 Notification of Interest List Release Closure
2444 New Service Limit Exception Criterion
3618 Resident Transaction Notice
3653 Cover Letter for the Physican Signature Page
4800-D DADS Fair Hearing Request Summary
4800-DA 4800-D Addendum
4807-D DADS Action Taken on Hearing Decision
8604 Transition Assistance Services (TAS) Assessment and Authorization
8605 Documentation of Completion of Purchase
H1027-A Medicaid Eligibility Verification
H1200 Application for Assistance - Your Texas Benefits
H1746-A MEPD Referral Cover Sheet
H1746-B Batch Cover Sheet
H3034 Informacion en espanol Disability Determination Socio-Economic Report
H3035 Informacion en espanol Medical Information Release/Disability Determination
H4800-A Fair Hearing Request Summary (Addendum)

Informacion in espanol = form also available in Spanish.

CMMDCP, Revisions

CMMDCP, 16-1, Miscellaneous Changes

Revision Notice 16-1; Effective May 3, 2016

 

The following changes were made:

Section Title Change
3100 Interests Lists Revises the 30-day deadline to complete and return the enrollment packet to 60 days. Updates Texas Administrative Code (TAC) references and language about adding names to the interest list. Clarifies Texas Department of Aging and Disability Services local staff assisting individuals with placement on the interest list and removing the individual’s name from the interest list.
3110.2 Coordination of Disability Determinations Replaces the Medicaid Type Programs (TP) Category 2 chart.
8410 Initial Orientation of the Employer Updates TAC reference.
8620 Re-enrollment in the CDS Option Updates TAC reference and replaces a reference to Form 1585 with Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services.
Appendix XV Medicaid Program Actions Updates appendix with current types of assistance and program names in the Texas Integrated Eligibility Redesign System (TIERS).

CMMDCP, 15-9, Miscellaneous Changes

Revision Notice 15-9; Effective December 15, 2015

 

The following changes were made:

Section Title Change
1200 Program Definitions Adds definitions to match Chapter 51 of the Texas Administrative Code (TAC).
2100 Initial Requests Updates TAC references and adds information about adding and removing the individual’s name from the interest list.
2110 Interest List Release and Notification Revises language to reflect current policy.
2200 Initial Contact Updates TAC references.
2210 Scheduling a Home Visit Revises the 30-day period to 60 days for the individual to make decisions if accepting the Medically Dependent Children Program (MDCP).
2210.1 Scheduling a Home Visit after the Release Closure Date Revises the time period for the case manager to meet with the applicant from the 31st day after release to the 61st day after release.
2230 Failure to Contact the Individual Revises the 30-day period to 60 days for the case manager contacting the individual before closing the release from the interest list.
2310.1 Individual is Still Unsure about Applying for MDCP Services Revises the response time from 30 to 60 days from the date on Form 2440, Release from the MDCP Interest List.
2310.2 Explaining Long Term Services and Supports Moves the information previously in Section 2310.3 and deletes the section, Opportunity to Register to Vote.
2540 Adding Names Back to CSIL Updates TAC references.
9600 Appeals and Fair Hearing Procedures Adds if the follow-up written request for appeal is not received within five working days, the case manager must send Form H4800-A, Fair Hearing Request Summary (Addendum), with a notation that the individual did not follow up with a written request for appeal to the hearings officer.

CMMDCP, 15-8, Miscellaneous Changes

Revision Notice 15-8; Effective July 31, 2015

 

The following changes were made:

Section Title Change
3520.1 MFP Procedures for Requesting a Limited Nursing Facility Stay Updates procedures for the Community Services Interest List (CSIL) and the Medically Dependent Children Program (MDCP) interest list.
3520.2 Case Manager Receipt of Form 2406 Updates procedures if the limited nursing facility stay is approved or the individual chooses to transition from a nursing facility.
3520.3 Regional Nurse Approved Makes minor corrections.
3520.5 Determination of Medical Fragility by the DADS Physician Updates procedures if the limited nursing facility stay is approved or the individual chooses to transition from a nursing facility.
3520.7 Coordination of the Limited Nursing Facility Stay Updates the case manager’s responsibilities once the individual has been authorized to receive MDCP services.
4132 Service Limits on Adaptive Aids Adds repairs to adaptive aids that have been purchased with MDCP funds.
Appendix XVIII Service Authorization System (SAS) Service Codes Adds Employment Assistance Service Codes and Supported Employment Service Codes.

CMMDCP, 15-7, Section 4130 Change and New Appendix

Revision Notice 15-7; Effective June 12, 2015

 

The following changes were made:

Section Title Change
4130 Adaptive Aids Adds references and links to the Texas Administrative Code. Adds an individual may take an adaptive aid to an out-of-home respite facility for his/her use while residing there.
Appendix XXIII Notification and Effective Dates Adds a new appendix.

CMMDCP, Policy Updates

The purpose of this section is to make the most current policy and procedures readily available via a single resource. Memoranda containing policy or procedural information will be placed on this list at the time of distribution. They will remain on the list until the information contained is completely incorporated into the handbook.

 

Release Date Title
01-15-16 LTSS 16-01-002 - Consumer Directed Services Option Procedural Changes for Abuse, Neglect, and Exploitation Allegations in the Medically Dependent Children Program
09-02-15 LTSS 15-08-002 - Rate Changes Effective September 1, 2015 for Medically Dependent Children Program
06-04-15 LTSS 15-06-004 - How Implementing Community First Choice in Personal Care Services Affect the Medically Dependent Children Program
04-24-15 LTSS  15-04-005 - Medically Dependent Children Program Referrals for Disability Determination to Disability Determination and Medicaid for the Elderly and People with Disabilities Involving Category 02 and MA Coverage-Type Medicaid Recipients
  Attachment - Category 02 and MA coverage-type Medicaid Programs
04-01-15 LTSS 15-04-003 - Changes to Form 2412, Budget Revision, in the Medically Dependent Children Program
  Attachment 1 - Form 2412 Budget Revision - First Change
Attachment 2 - Form 2412 Budget Revision - Second Change
Attachment 3 - Form 2412 Budget Revision - Third Change
01-13-15

LTSS 15-01-001 - Health and Human Services Commission Electronic Visit Verification Initiative – Statewide Expansion.

12-03-14

LTSS 14-12-021 - New Requirements for Backup Plans and Change in the Definition of Primary Caregiver

12-01-14

LTSS 14-12-020 - Approval of Service Backup Plans for Individuals in the Medically Dependent Children Program using the Consumer Directed Services Option

11-24-14

LTSS 14-11-019 – Midland Document Processing Center Move to Austin

10-13-14

LTSS 14-09-017 – Completing a home visit for a service monitor or annual reassessment for Medically Dependent Children Program with delay due to unsafe environmental circumstances

10-03-14

LTSS 14-09-014 – Rate Changes Effective September 1, 2014 for Medically Dependent Children Consumer Directed Services Option

09-08-14

LTSS 14-09-012 – Diagnosis Codes in the State Authorization System Online

09-02-14

LTSS 14-09-009 – Rate Changes Effective September 1, 2014 for Medically Dependent Children Agency Option

08-06-14

LTSS 14-06-006 - Transferring Individuals Due to Provider Contract Terminations or Contract Assignments

01-16-14

LTSS 14-01-001 - Deletion of Health Insurance Portability and Accountability Act, (HIPAA) Privacy Notice, Explanation of Health Information Privacy Rights and Notice of Privacy Practices, Forms 0401, 0401-S, 0403, 0405 and 0405-S

12-16-13

CSPO 13-12-003 - Fair Hearing Requests After 90 Days

12-16-13

CSPO 13-12-002 - Mandatory Completion of Form 1740, Service Backup Plan, for All Individuals Selecting the Consumer Directed Services Option in the Medically Dependent Children Program

12-16-13

CSPO 13-12-001 - Process for Reporting Suspected Fraud by an Individual, Employer or Employee in the Consumer Directed Services Option

01-15-13

CSPO 13-01-007 – Medicaid Program Action Changes for Community Medical Assistance Only to Waiver Medicaid

12-27-11

CSPO 11-12-010 – CBA and MDCP Referrals for Medicaid Waiver Coverage to Medicaid for the Elderly and People with Disabilities Involving Assessment of Category 02 and MA Coverage-Type Medicaid Recipients

 

CMMDCP, Nurse Memos

The purpose of this section is to make the most current policy and procedures affecting regional nurses readily available. Memoranda containing policy or procedural information will be placed on the list for the program that it impacts at the time of distribution. They will remain on the list until the information contained is completely incorporated into the handbook.

 

Release Date Title
07-06-15 LTSS 15-7-001 - International Classification of Disease Transition, and Changes to the Medical Necessity/Level of Care Assessment and Transition Submission Instructions
12-01-10 RLS#10–12–001 - Obtaining Medical Necessity and Level of Care Data From Other Sources
01-13-10 RLS#10–01–006 - Regional Nurse Use of Form 3653, Cover Letter for the Physician Signature Page, for the Medically Dependent Children Program (MDCP)
02-25-09 RLS#09–02–007 - Coding Therapies and Nursing Rehabilitation/Restorative Care on the Medical Necessity and Level of Care Assessment

 

CMMDCP, Form Updates

Date No. and Title Change
November 1, 2016 Form 1579, Referral for Relocation Services, Form 1579-S, and Instructions Adds the Medically Dependent Children Programs.
November 1, 2016 Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, Form 1580-S, and Instructions Adds the Medically Dependent Children Programs.
November 1, 2016 Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, Form 2406-S, and Instructions Updates the information for Texas Health and Human Services Commission to include STAR Kids.
November 1, 2016 Form 2442, Notification of Interest List Release Closure, Form 2442-S, and Instructions Adds drop-down menus for selecting programs.
February 4, 2016 Form 2440, Release from the MDCP Interest List, Form 2440-S (Spanish), and Instructions Adds a field for Interest List Number and Release Date. Includes a phone number for the Community Services Interest List.
December 30, 2015 Form 2410, Medical-Social Assessment and Individual Plan of Care, and Instructions Removes personal care services and adds Community First Choice. Adds check boxes for weekly, bi-weekly or monthly in Fields 42b and 44b.
November 6, 2015 Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and Instructions Adds Home and Community-based Services.

CMMDCP, Glossary

Revision 12-1; Effective May 1, 2012

 

C D E S T

 

CBA — Community Based Alternatives, a DADS administered adult waiver.

CCP — Comprehensive Care Program, a package of Medicaid services that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps benefit.

CFR — Code of Federal Regulations, a federal document that describes Medicaid services and waiver services.

CLASS — Community Living Assistance and Support Services, a DADS waiver.

CMS — Center for Medicare and Medicaid Services, the federal agency that administers Medicare and Medicaid (formerly called the Health Care Financing Association, or HCFA).

Case Manager — The human services specialist; case workers for MDCP.

 

C D E S T

 

DADS — Texas Department of Aging and Disability Services

DSHS — Texas Department of State Health Services

 

C D E S T

 

EPSDT — Early and Periodic Screening, Diagnosis and Treatment, a federal Medicaid benefit for individuals under 21 years (called Texas Health Steps in Texas).

 

C D E S T

 

SSA — Social Security Administration, a federal agency that authorizes Medicaid and waiver services.

 

C D E S T

 

TAC — Texas Administrative Code, the state rules that implement programs and services.

THSteps — Texas Health Steps, the EPSDT benefit in Texas.

THSteps — Medical case management (MCM) available for all Medicaid children under 21.

CMMDCP, Contact Us

For questions about the Case Manager Medically Dependent Children Program Handbook, email: mdcppolicy@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: handbookfeedback@hhsc.state.tx.us