Community Living Assistance and Support Services Provider Manual

CLASSPM, Section 1000, Introduction

Revision 17-1; Effective November 1, 2017

 

1000 Introduction

 

The Community Living Assistance and Support Services (CLASS) program provides home and community-based services to people with related conditions as defined in Texas Administrative Code (TAC), Chapter 45, Subchapter A, §45.104. The CLASS program is funded by Title XIX Medicaid through a federal waiver that provides the opportunity for the Texas Health and Human Services Commission (HHSC) to offer specialized services that are not available under the regular Medicaid program. Individuals who receive CLASS program services may not also receive services from a program included in Appendix III, HHSC Operated Program CLASS Mutually Exclusive Services.

HHSC supports the expectation that every person has the opportunity to participate in their community, gain and maintain relationships of their choosing, express preferences, make choices, fulfill goals, and live with dignity and respect. The fundamental framework for delivering program services to individuals is based on tailoring program services to the individual's needs and circumstances. Services offered in the CLASS program supplement, but do not supplant, other Medicaid services, generic services, and other family and community supports to assist individuals successfully live and work in the community.

The goal of the CLASS program is to support individuals with related conditions to achieve their desired lifestyles and to be valued members of the community by:

CLASS program services must:

HHSC obtains Medicaid provider agreements with qualified provider agencies to deliver CLASS program services. The case management agency (CMA) provides case management services and the direct services agency (DSA) provides all other CLASS services, except Support Family Services (SFS), Transition Assistance Services (TAS) and Consumer Directed Services (CDS) delivery options. All provider agencies must work cooperatively to ensure that the individual's needs are met.

Rules governing the CLASS program are in Title 40 of the Texas Administrative Code (TAC), Chapter 45.

 

1100 Complaints and Consumer Rights and Services (CRS)

Revision 17-1; Effective November 1, 2017

 

When to Call HHS CRS

CRS receives complaints from individuals, family members, providers and the public about the care, treatment or services provided to an individual. Individuals receiving services or family members of the individual may prefer to call CRS to assist in resolving an issue rather than speaking with their case manager or DSA representative.

A complaint may be reported by anyone at any time to CRS by calling 1-800-458-9858. A complaint may be made online at crscomplaints@dads.state.tx.us.

Information about CRS can also be located on the HHS website at https://hhs.texas.gov/about-hhs/your-rights/consumer-rights-services/how-do-i-make-a-complaint-about-hhs-service-provider . Click on the relevant topic to obtain the needed information.  You may also direct your web browser to https://hhs.texas.gov/about-hhs/your-rights/consumer-rights-services/how-do-i-make-a-complaint-about-hhs-service-provider/.

Written complaints may be mailed to:

Texas Department of Health and Human Services
Consumer Rights and Services, Mail Code E-249
P.O. Box 149030
Austin, TX 78714

CRS Website

The CRS website provides useful information regarding filing a complaint; locating consumer rights booklets; reporting abuse, neglect and exploitation; and locating community services. Visit the website at https://hhs.texas.gov/about-hhs/your-rights/consumer-rights-services.

Provider Agency Complaint Process

The CLASS provider agencies are required to have processes for receiving and resolving complaints about the provision of CLASS services. The process by which a complaint may be filed with a CLASS provider agency regarding CLASS program services must be provided to the individual/legally authorized representative (LAR) at the time of enrollment and at least annually thereafter.

 

1200 Interest List

Revision 17-1;  Effective November 1, 2017

 

HHSC manages the capacity of the program in accordance with available funding and within federally approved program limits by offering enrollment to individuals registered on the interest list. Individuals interested in receiving services in the CLASS program must register via the CLASS interest list. Individuals may register on the CLASS interest list regardless of whether they meet program eligibility requirements and must participate in financial and functional eligibility assessments as part of the enrollment process. Individuals registered on the CLASS interest list must ensure current address and contact information is on file with HHSC/DADS.

If an applicant is denied waiver enrollment based on diagnosis, level of care, or other functional eligibility requirements, HHSC will place the applicant’s name on all other waiver program’s interest list, using the applicant’s original request date for the CLASS interest list.

To contact the CLASS interest list call 877-438-5658.

 

1300 CLASS Program Eligibility

Revision 17-1; Effective November 1, 2017

 

HHSC approves eligibility for the CLASS program for applicants/individuals with related conditions who meet all of the following eligibility requirements.

CLASS-PM, Section 2000, Case Management Agency (CMA)

Revision 17-1; Effective November 1, 2017

 

 

2100 Case Management Responsibilities

Revision 17-1; Effective November 1, 2017

 

Case management services are provided to all individuals receiving Community Living Assistance and Support Services (CLASS) program and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) services in the CLASS program.  Individuals must select a CMA with a valid provider agreement in the catchment area in which the individual lives. Individuals who receive services in the CLASS program may request to transfer to another CMA at any time.

As outlined in this section, the CMA is required to provide the following case management services on an ongoing basis:

CLASS program services, as a whole, enhance an individual's integration into the community and prevent admission to an institution while maintaining and improving independent functioning.

 

2110 Base of Operation

Revision 11-3; Effective November 18, 2011

 

CLASS program providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program services.

  1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:
    • maintain individual records for the CLASS program contract in the catchment area;
    • maintain personnel records for personnel who provide CLASS program services to individuals served in the catchment area;
    • be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and
    • maintain adequate staff to provide services and to supervise the provision of services within the catchment area.
  2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:
    • post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and
    • leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.

 

2120 CMA Staff Training Requirement

Revision 12-1; Effective January 13, 2012

 

 

2121 Initial Training for Staff with Direct Contact

Revision 17-1; Effective November 1, 2017

 

Direct contact for the purposes of this manual means face to face contact. Upon hire, all CMA staff whose job functions might involve direct contact a minimum of one time per calendar year with individuals receiving Community Living Assistance and Support Services (CLASS) must complete one of the following within 60 calendar days of the employee beginning to provide CLASS program services:

The CMA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. CMA staff who develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training provided by HHSC. The CMA must have a record to verify that the trainer has attended the CLASS Provider Training. The CMA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the CMA.

Documentation of completion of required training must include, at a minimum:

If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and be available to HHS employees during a contract monitoring review.

 

2122 Initial and Annual Training for All CMA Staff

Revision 17-1; Effective November 1, 2017

 

All CMA staff must complete the training described below within 60 calendar days of employment and at least every 12 months thereafter.

If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and available to HHSC employees during a contract monitoring review.

 

2123 CMA Staff Training for Person-Centered Planning

Revision 17-1; Effective November 1, 2017

 

CMA staff responsible for completing Form 8606, Individual Program Plan (IPP) and Form 3629 Individual Program Plan Addendum (IPP-A) must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.

 

2200 Eligibility

Revision 17-1; Effective November 1, 2017

 

The case manager is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met.

The CMA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits. If the CMA receives notice of an individual's impending loss of Medicaid eligibility, the CMA must work proactively with the individual/legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at least every two weeks and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the individual is terminated from the CLASS program.

Program services may be terminated if the individual does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services.

 

2300 Service Planning

Revision 17-1; Effective November 1, 2017

 

The case manager facilitates Service Planning Team (SPT) meetings. The SPT process uses a person-centered planning processes to develop a plan for the provision of supports and services necessary for the individual's functioning and to maintain integration in the community. After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/legally authorized representative (LAR), DSA representative(s) (as defined in Section 3300, Service Planning), and other people requested by the applicant/individual/LAR meet to develop a proposed Form 3621, CLASS/CFC – Individual Plan of Care (IPC). The case manager must use the SPT notes in conjunction with Form 3629, IPP-A to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, legally authorized representative (LAR), the CMA, DSA representative, and others, as requested by the individual or LAR.

Examples of the discovery process include, but are not limited to:

The person-centered planning process:

Additional guidance and information about person-centered planning can be found on the HHSC website.

Meetings of the SPT to develop the enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home. While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that meeting in the home allows the SPT the opportunity to determine if other needs of the individual may be met by through CLASS or CFC services. The enrollment and renewal IPC must be signed in person by the SPT.

SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. Revisions of the current service plan may be signed by facsimile.

The case manager is required to ensure that the SPT develops a transportation plan if habilitation transportation is included on the IPC. Information on completing Form 3598, Individual Transportation Plan is available in the instructions.

The proposed IPC must specify:

As part of the service planning process, the SPT will also develop an IPP on Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program service listed on the proposed IPC. Each IPP describes:

The IPP-A and SPT notes are created by the case manager during the SPT meeting to document use of person-centered planning processes. The IPP-A and SPT notes summarize the outcome of the meeting and must be included with the IPP-A to provide additional information. The SPT notes must include, at a minimum:

If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by, or contracts with, the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the effective date of the IPC that identifies the individual’s need for the service or continuation of the need for the service by no more than 120 days.  

The case manager is responsible for initiating revisions to the individual's IPC and IPP-A as determined necessary throughout each plan year. The case manager will submit all proposed IPCs and revised IPP-A to HHSC.

On an ongoing basis, the case manager must assist individuals in gaining access to needed CLASS services and other services and supports, including medical, social, and educational resources, regardless of the funding source for the services and supports.

All requests from HHSC related to the UR process must be submitted within the period outlined in Section 5000.

The CMA is responsible for providing a copy of the following documentation to all SPT members within 10 business days from HHSC authorization, including the financial management services agency (FMSA), if the individual receives a service through the Consumer Directed Services option:

 

2310 Enrollment

Revision 17-1; Effective November 1, 2017

 

At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a CMA within 30 calendar days after the date of the written offer. HHSC notifies the selected CMA the applicant has chosen the agency to provide case management services. According to the Selection Determination document the CMA then completes the following:

The case manager must provide the applicant/individual the CLASS Program brochures in English or Spanish, as appropriate.

The case manager should take advantage of this opportunity to describe the person-centered planning process, as described in Section 2300, that will be used to develop the IPP-A.

Upon notification that the applicant has selected the CMA, a case manager must be assigned to the applicant. The CMA must have a written process that ensures case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned, but to whom they may be required to provide case management.

The case manager must complete the following functions within 14 calendar days of the CMA's receipt of the Selection Determination document from HHSC:

The case manager must complete the following functions within two business days following the initial face-to-face assessment:

Within 30 calendar days of notification by the DSA of HHSC approval of diagnostic/functional eligibility for an individual as identified on Form 8578, Intellectual Disability/Related Condition Assessment, the case manager must convene the SPT to develop the enrollment IPC, Form 3621, CLASS/CFC – Individual Plan of Care (IPC) and Form 3629, Individual Program Plan Addendum using a person-centered planning process as described in Section 2300.

The SPT must include, at a minimum, the applicant/LAR, case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the habilitation needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. The SPT may include any other people requested by the individual/LAR. The SPT must make every effort to accommodate these requests by the individual/LAR.

Within 10 business days of HHSC transmission of the authorized enrollment IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

Form Resources

The following forms may need to be completed as part of the enrollment process:

Submission Standard — Enrollment

The following submission standards apply when submitting enrollment paperwork to HHSC:

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrollment efforts to HHSC:

 

2320 Renewal

Revision 17-1; Effective November 1, 2017

 

The case manager must complete the following functions no less than 30 calendar days and no more than 90 calendar days before the end of the current IPC year:

Within 10 business days of HHSC transmission of the authorized renewal IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]) as necessary. The case manager must maintain documentation of transmission of all necessary documents.

The CMA must electronically access MESAV to verify that the services authorized on the renewal IPC are consistent with those authorized in MESAV by HHSC.

At HHSCs request, the CMA must submit additional documentation supporting the proposed renewal IPC to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.

If HHSC notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

Form Resources

The following forms may need to be completed as part of the renewal process:

Submission Standard

The following submission standards apply when submitting renewal paperwork to DADS:

 

2330 Revision

Revision 17-1; Effective November 1, 2017

 

When the case manager is notified of a needed revision to the IPC, the case manager must ensure:

At the request of HHSC, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.

If HHSC notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

Within five business days of HHSC’s transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the following to all members of the SPT:

The case manager must also provide copies of the above documentation within five business days of HHSC’s transmission of the authorized IPC to any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

The CMA must electronically access MESAV to verify that the services authorized on the renewal IPC are consistent with those authorized in MESAV by HHSC.

Submission Standard

The following submission standards apply when submitting revision paperwork to HHSC:

 

2331 Immediate Jeopardy of CLASS Individual

Revision 17-1; Effective November 1, 2017

 

When the CMA receives written documentation from the DSA indicating the DSA provided CFC PAS/HAB, respite, nursing, dental services or an adaptive aid that is not included on the individual's IPC in response to a situation of the individual's immediate jeopardy, the case manager must complete and submit the following to HHSC:

For the above, the CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional CFC PAS/HAB, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

The documentation furnished to the CMA by the DSA must include:

HHSC authorizes the IPC only if, after reviewing the documentation, HHSC determines the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

At HHSC request, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days.

Form Resources

The following forms may need to be completed as part of the revision process:

 

2340 Transfer

Revision 17-1; Effective November 1, 2017

 

When the individual/legally authorized representative (LAR) notifies the case manager they wish to be transferred to a different agency(s), the case manager must:

The current CMA must submit the following to HHSC before the effective date of the transfer:

Form Resources

The following forms may need to be completed as part of the transfer process:

Submission Standard

The following submission standards apply when submitting transfer paperwork to HHS:

 

2350 IPP Service Review

Revision 17-1; Effective November 1, 2017

 

The case manager is responsible for ongoing monitoring of:

The case manager must meet with the individual or LAR in the individual's home, or other location if services are not primarily provided in the individual’s home, to review the IPC and update the IPP-A if needed. CMA Individual Program Plan (IPP) service reviews will occur in accordance with the schedule in Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal IPC. The fourth IPP service review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC. The IPP-A and SPT notes will document the development of the renewal IPC using person-centered planning processes. The case manager must use Form 3595, IPP Service Review, to document the review of the services delivered to the individual since the ninth month IPP service review.

The purpose of meeting the individual or LAR in the setting where services are delivered is to allow the case manager to verify that services listed on the IPC are delivered as described in the Individual Program Plan (IPP). This function is best accomplished by the case manager observing CLASS services in the setting in which they are provided. Since most individuals receive CLASS services in the home setting, the IPP service reviews should occur in the location where the majority of services are delivered.

While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that a complete assessment of services provided to the individual is required to be performed in the setting in which those services are delivered. Case managers must document when and why an individual or LAR refuses to meet in the home setting in the “General Comments” section of Form 3595.

During the IPP service review face-to-face contact with the individual, the case manager must complete Form 3595 to:

The case manager is required to complete all sections of Form 3595 for CLASS services provided to an individual. The case manager may choose to print only those pages that reflect the services reviewed and provide them to the individual, the DSA and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary.

If an individual's IPC includes any nursing services or CFC PAS/HAB, and any of those services are not currently identified as requiring a service backup plan, the case manager must discuss with the individual or LAR whether any of those services may now be critical to the individual's health and safety. If the case manager and individual/LAR determines either service may now be critical to the individual's health and safety, the case manager must convene the SPT to discuss development of a service backup plan.

The case manager must also ask the individual/LAR if a service backup plan was implemented during the most recent review period and discuss the implementation of the service backup plan with the individual/LAR to determine whether or not the plan was effective.

If the service backup plan was implemented and determined to be ineffective, the case manager must convene an SPT meeting to revise the service backup plan.

If a change is requested by the individual during the IPP service review, the case manager is responsible for initiating any change(s) needed and convenes the SPT, as applicable within five business days after becoming aware that the individual's needs have changed. The case manager must also update the IPP-A.

Within five business days of the IPP service review, the case manager is responsible for providing copies of the service review with the updated IPP-A to the individual, DSA and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

Form Resources

The following forms may need to be completed as part of the 90-day service review:

 

2400 Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

 

An individual whose CLASS program or CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

The CMA must obtain written authorization from HHSC for all suspensions of CLASS program or CFC services.

HHSC issues a notice to the CMA of all denials of enrollment or terminations from the CLASS program. The CMA must notify the individual, DSA, FMSA, CFS and SFS provider as applicable.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409.

 

2410 Denial

Revision 17-1; Effective November 1, 2017

 

Denial is a HHSC action that disallows:

Denial of a Request for Enrollment into the CLASS Program

HHSC denies an individual's request for enrollment into the CLASS program if:

If HHSC denies a request for enrollment, HHSC sends a written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with 40 TAC §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

Denial of a CLASS Program Service

HHSC denies a CLASS program service on an individual's IPC if services:

If HHSC denies a CLASS program or CFC service on an individual's IPC, HHSC notifies the CMA in writing. Upon receipt of HHSC written notice of denial of a CLASS program or CFC service, the CMA must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of the denial of the service, copying the individual's DSA and, if selected, FMSA, CFS or SFS provider.

Form Resources

The following forms may need to be completed as part of a suspension denial of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

 

2420 Reduction

Revision 17-1; Effective November 1, 2017

 

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of a service authorized by HHSC on an IPC.

HHSC will perform utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All services and units of service included on a proposed IPC must be justified by the SPT.

HHSC CLASS Program staff review the IPC to ensure the services on the IPC:

The case manager has the responsibility to gather the following information for the HHSC CLASS program staff:

The case manager must summarize this information using the appropriate IPP.

As necessary during the review of a proposed IPC, HHSC CLASS program staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for requested services or does not meet requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information submitted to HHSC by the case manager does not provide sufficient information to justify requested units of services, HHSC will modify the IPC by reducing the number of units of services as necessary and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, the CMA must notify the individual and provide a copy of the notification to the DSA, FMSA and Support Family Services provider, as applicable, of the documentation of the reason for the reduction. Upon receipt of a written notice proposing to reduce a service, the CMA must inform the individual or LAR of the HHSC decision. The CMA informs the individual of the right to request a fair hearing.

The case manager sends written notice on Form 3624, Termination, Reduction or Denial of CLASS, to the individual allowing 12 days for the participant individual to respond before taking any action to reduce services.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS program service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a suspension reduction of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

 

2430 Suspension

Revision 17- 1; Effective November 1, 2017

 

Individuals may not receive CLASS program or CFC services during a period of time in which they are admitted to a facility listed in this section. Individuals must be suspended without prior notification from CLASS program or CFC services until such time as the individual returns to his own or family home or is terminated from the CLASS program. The individual is not eligible for continuation of CLASS program or CFC services until the fair hearing process is completed because suspension of an individual's services is effective the date the individual was temporarily admitted to one of the facilities listed below, or leaves the state and, therefore, the individual is not given advance notice of the suspension.

Within two business days after the CMA becomes aware of a situation that necessitates an individual's CLASS program or CFC services to be suspended, the CMA must send a written request for suspension with written supporting documentation to HHSC CLASS program staff.

HHSC notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS program or CFC services. Suspension is a HHSC action taken:

Upon receipt of a written notice from HHSC authorizing the suspension of CLASS program or CFC services, the CMA must send the written notice of suspension to the individual/ LAR, DSA and FMSA, if applicable. The written notice includes the individual's right to request a fair hearing. The period of suspension is the length of the admission to the facility or the time spent in another state. An individual may remain on suspension from CLASS program or CFC services for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Form Resources

The following forms may need to be completed as part of a suspension of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

 

2440 Termination

Revision 17-1; Effective November 1 , 2017

 

Termination is a HHSC action that results in the loss of the individual's authorized services in the CLASS program and CFC.

 

 

2441 Termination With Advanced Notice

Revision 17- 1; Effective November 1, 2017

 

HHSC terminates an individual's CLASS program and CFC services if:

If termination of services is requested based on a determination by the DSA that it cannot ensure the individual's health and safety, the CMA must include in the request specific reason(s) why the DSA determines it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current selection determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the CMA must initiate a transfer IPC as described in Section 2340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA in writing using Form 3624, Termination, Reduction or Denial of CLASS, or written notice from HHSC, of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of HHSC notification authorizing a proposed termination of CLASS program services, the CMA must send written notice of the termination of CLASS program and CFC services to the individual or LAR within two business days. The CMA must send a copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

In the event CLASS program services are terminated due to an individual's IPC cost being over $114,736.07, HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program services and includes the individual's right to request a fair hearing in the notice. HHSC sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA.

If a CMA becomes aware an individual has not complied with a mandatory participation requirement described in this section, the CMA must immediately attempt to resolve the situation, including facilitating at least one face-to-face meeting with the SPT. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must request in writing that HHSC terminate CLASS program services for the individual. The request must be sent to HHSC within two business days of the CMA's determination the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of:

If an individual's CLASS Program services and CFC services are terminated, the CMA must ensure that the case manager informs the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website.

The CMA will not provide notice of a termination of CLASS program and CFC services to an individual for whom HHSC has terminated due to an IPC cost being over $114,736.07. HHSC will provide notice to individuals in this situation directly.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

 

2442 Termination Without Advanced Notice

Revision 17- 1; Effective November 1, 2017

 

HHSC terminates an individual's CLASS program services without advanced notice if any of the following situations exist:

Within two business days after the CMA becomes aware of a situation such as described above, the CMA must send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by documentation supporting the request.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website at https://hhs.texas.gov/.

HHSC notifies the individual's CMA in writing of whether it authorizes the termination of CLASS program services. Upon receipt of a written notice from HHSC authorizing the termination of CLASS program services, the CMA must send written notice to the individual or LAR of the termination. The CMA must also send a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

 

2443 Immediate Jeopardy of CLASS Providers

Revision 17-1; Effective November 1, 2017

 

HHSC may terminate an individual's CLASS program services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager, CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program services.

Upon receipt of written notice from HHSC authorizing the termination of CLASS program services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the HHS website.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

Form Resources

The following forms may need to be completed as part of termination of services:

Submission Standard — Termination

The following submission standards apply when submitting termination paperwork to HHSC:

Submission Standard — Appeal

The following submission standards apply when submitting a request for an appeal to HHSC:

 

2500 Provision of Direct Services by CMA

Revision 17-1; Effective November 1, 2017


A CMA or any other division of the agency must not provide any other CLASS program services to an individual receiving case management services from the CMA. This interpretation is consistent with CLASS rules in TAC, specifically 40 TAC §45.703(b)(3) that states a case manager is not employed by or contracting with a DSA to provide a direct service to an individual served by the CMA.

Title 42 of the Code of Federal Regulations (CFR) in 42 CFR §441.301(c)(1)(vi) specifies providers of home and community-based services for the individual, or those who have an interest in or are employed by a provider of home and community-based services for the individual must not provide case management or develop the person-centered service plan. After reviewing the CLASS waiver application, HHSC has determined the Centers for Medicare and Medicaid Services (CMS) intends to maintain CMA services and DSA services separate. CMS has had concerns in other Texas 1915(c) waivers regarding conflict of interest.

CLASS-PM, Section 3000, Direct Services Agency (DSA)

Revision 17-1; Effective November 1, 2017

 

3100 DSA Responsibilities

Revision 17-1; Effective November 1, 2017

 

All individuals who receive Community Living Assistance and Support Services (CLASS) program services and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) must choose a direct services agency (DSA) with a valid provider agreement that operates in the catchment area in which the individual lives. Individuals who receive services through the CLASS program may request to transfer to another DSA at any time.

A DSA provides CLASS program services, CFCPAS/HAB services, and CFC emergency response services (ERS) to the individual as outlined in their Individual Plan of Care (IPC), the Individual Program Plan (IPP) for that service, and Individual Program Plan Addendum (IPP-A). An individual may elect to have some or all CLASS program and CFC services delivered by the DSA. Select services may be chosen for self-direction by the individual or legally authorized representative (LAR) using the Consumer Directed Services (CDS) option. For a complete list of CLASS and CFC services available using the CDS option, refer to Section 4000, Consumer Directed Services (CDS).

As outlined in this section, the individual's selected DSA is required to perform the following tasks on behalf of an individual in CLASS on an ongoing basis:

CLASS program and CFC services, as a whole, enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

 

3110 Base of Operation

Revision 17-1; Effective November 1, 2017

 

CLASS program and CFC providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program and CFC services.

  1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:
    • maintain individual records for the CLASS program contract in the catchment area;
    • maintain personnel records for personnel who provide CLASS program and CFC services to individuals served in the catchment area;
    • be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and
    • maintain adequate staff to provide services and to supervise the provision of services within the catchment area.
  2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:
    • post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and
    • leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.

 

3120 DSA Staff Training Requirement

Revision 17-1; Effective November 1, 2017

 

 

 

3121  Initial Training for Direct Contact Staff

Revision 17-1; Effective November 1, 2017

 

Direct contact for the purposes of this manual means face-to-face contact with a CLASS individual a minimum of one time per calendar year. A DSA program director(s) and any DSA staff person who has direct contact with an individual receiving services through the CLASS program must complete one of the following within 60 calendar days of the employee beginning to work with the CLASS program:

The DSA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. The DSA must have a record to verify that the trainer has attended the CLASS Provider Training. The DSA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the DSA.

Documentation of completion of required training must include, at a minimum:

If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. Verification of the DSA training instructor's completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review.

 

3121.1  Initial Training for CFC PAS/HAB or CLASS Transportation-Habilitation and Respite Service Providers

Revision 17-1; Effective November 1, 2017

 

The DSA must ensure CFC PAS/HAB or CLASS habilitation and respite  service providers:

The information specific to related conditions above is contained in the list of ICD-10 approved diagnostic codes for persons with related conditions is located on the HHSC website at: /sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf.

Annual evaluations by the supervisor that take place with the individual/LAR ensures that the needs of the individual are being met. Form 3599 is used to document this evaluation, as stated in the instructions for the form. Documentation of transportation-habilitation, prevocational, and respite service provider training outlined above or any training of CFC PAS/HAB provider requested by the individual or LAR must include a signed certificate of completion stating:

 

3122  Initial and Annual Training for All DSA Staff

Revision 17-1; Effective November 1, 2017

 

Within 60 calendar days of the employee beginning to work with the CLASS program and every 12 months, all DSA staff must receive training on:

DSA staff that develop the curriculum used for initial and annual training must have attended and successfully completed the CLASS Provider Training. Verification of a DSA training instructor’s completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review. If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review.

Any DSA staff person who is responsible for developing the IPP-A, a service IPP, or the, PAS/Habilitation Plan - CLASS/DBMD/CFC must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.

 

3123  Types of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

The two types of CFC PAS/HAB or CLASS transportation-habilitation service providers are:

 

3124  Qualifications of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

CFC PAS/HAB or CLASS transportation-habilitation services are performed by service providers who:

 

3125  Required Training for CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

Before services begin, the CFC PAS/HAB or CLASS transportation-habilitation service provider must meet the supervisor or other staff member qualified to train the habilitation service provider in the specific needs of the individual at the individual’s home. The CFC PAS/HAB or CLASS transportation-habilitation service provider receives a general orientation with the full participation of the individual, if possible, in the CFC PAS/HAB or CLASS transportation-habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

 

3125.1 Required Training for Certain Special CFC PAS/HAB or Special Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

 

Special transportation-habilitation service providers or special CFC PAS/HAB providers who have six continuous months of experience in delivering CFC PAS/HAB or CLASS transportation-habilitation services in any Medicaid program or a program that primarily serves individuals with intellectual disabilities can receive the orientation from the supervisor or other appropriate DSA staff by phone rather than in person.

The individual receiving CFC PAS/HAB services should participate in providing special CFC PAS/HAB providers any training on the activities necessary to meet the needs and characteristics of the individual and the specific needs of the individual at the individual’s home. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

After the first orientation to the special CFC PAS/HAB or special CLASS transportation-habilitation activities necessary to meet the needs and characteristics of an individual, the special CFC PAS/HAB or special CLASS transportation-habilitation service provider does not need to be reoriented if the individual’s condition, tasks and hours remain unchanged. There are no limits on the length of time a special CFC PAS/HAB or special CLASS transportation-habilitation service provider may be used. The special CFC PAS/HAB or special CLASS transportation-habilitation service provider may serve the individual without retraining, as long as the individual’s condition, tasks and hours remain unchanged. In addition, there are no restrictions with respect to the amount of time between the service provider’s assignments.

 

3126 Documentation of Required Experience for Special Service Provider Exception

Revision 17-1; Effective November 1, 2017

 

Records provided by the employee, or records provided by a former or current employer that document the time the employee delivered direct care services, may be used to establish that a special CFC/PAS/HAB or special habilitation service provider meets requirements.

 

3200 Eligibility

Revision 17-1; Effective November 1, 2017

 

The DSA is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met:

Individuals who receive CLASS program and CFC services must maintain continuous eligibility as outlined above. The DSA must assess the individual at the time of enrollment, at least annually, and as necessary when an individual's situation changes that may result in the individual no longer meeting all CLASS eligibility criteria.

The DSA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The DSA must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the DSA and available for review by HHSC staff. If an individual is found to be ineligible for Medicaid, the DSA must notify the case manager no later than the next business day. The DSA must maintain verifiable evidence of notifying the case manager.

CLASS program and CFC services may be terminated if the individual does not meet all eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. For more information regarding termination of services, see Section 3400, Denial, Reduction, Suspension and Termination.

See Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs.

 

3300 Service Planning

Revision 17-1; Effective November 1, 2017

 

A DSA must ensure a representative from its agency participates as a member of an individual's SPT. A DSA representative must be a:

Meetings of the SPT to develop the IPP-A, the IPP, enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home and the meeting must be at a time and location that is mutually agreed upon by all mandatory members.

The case manager must use Form 3629, Individual Program Plan Addendum to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, LAR, the CMA, DSA representative and others, as requested by the individual or LAR.
Examples of the discovery process include, but are not limited to:

The person-centered planning process

Additional guidance and information about person-centered planning can be found at The Learning Community.

The SPT should include, at a minimum, the individual/applicant or LAR, the case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. If licensed or certified professionals attend the SPT meeting, this may be billed as a professional service only when the individual has an identified need for the service, and for actual time spent in the capacity of the respective discipline. The SPT may include any other people requested by the individual or LAR. The SPT will make every effort to accommodate these requests by the individual or LAR.

SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. If the individual/LAR requests an in person meeting, SPT members must make every effort to accommodate the request. Participation in an SPT via conference call is not reimbursable to the DSA using CFC PAS/HAB or CLASS transportation-habilitation.

An IPC must be signed in person by the SPT at enrollment and renewal SPT meetings. Revisions of the current service plan may be signed by facsimile.

After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/LAR, DSA representative(s) and other persons as requested by the applicant/individual/LAR must meet to develop Form 3629, Individual Program Plan Addendum and a proposed Form 3621, CLASS/CFC – Individual Plan of Care.

The proposed IPC must specify:

The SPT will develop Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program and CFC service listed on the proposed IPC. Each IPP describes:

If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by or contracts with the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the date of the IPC that identifies the individual’s need for the service or continuation of the need for the service by no more than 120 days.

Each CLASS program and CFC service must be provided to an individual in accordance with the IPP-A, the individual's IPC and the individual's IPP for that service. A DSA must inform the individual's case manager throughout the IPC year of changes needed to the individual's IPP-A, IPC or IPPs.

On an ongoing basis, the DSA's responsibilities include:

 

3310 Enrollment

Revision 17-1; Effective November 1, 2017

 

At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a DSA within 30 calendar days after the date of the written offer from HHSC. HHSC notifies the selected DSA the applicant has chosen the agency to provide direct services according to the HHSC Selection Determination document.

Within 14 calendar days after receiving Form 3657, Pre-Enrollment Assessment, from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA a DSA staff person must complete an initial face-to-face, in-home visit with the individual/LAR to inform the individual and LAR or person actively involved with the individual, orally and in writing, of the process by which they may file a complaint regarding CLASS Program services or CFC services provided by the DSA.

A DSA representative must also provide the following information regarding required use of the Electronic Visit Verification (EVV).

If the individual has additional questions, the DSA representative must provide any requested additional information on how EVV works.
Within 14 calendar days after receiving Form 3657 from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must assign a registered nurse or an appropriate licensed professional to perform and complete the following functions:

To determine an individual’s adaptive behavior level as part of establishing an individual’s enrollment level of care (LOC), the DSA must complete one of the following ABL assessments according to the publisher's instructions:

The DSA must ensure:

Form Resources

The following forms may need to be completed as part of the enrollment process:

Submission Standard — ID/RC

The following submission standards apply when submitting ID/RC paperwork to HHSC:

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrolment efforts to HHSC:

 

3320 DSA Renewal of Level of Care

Revision 17-1; Effective November 1, 2017

 

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an annual nursing assessment of the individual using the Form 6515, CLASS/DBMD Nursing Assessment form, Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, Form 8662, Related Conditions Eligibility Screening Instrument (RCESI) (these documents must be completed every year), and an adaptive behavior level (ABL) assessment if the current one is greater than five years old, or is no longer valid.

Form 8578, Form 8662 and results of the current ABL assessment must be sent to HHSC at least 60 calendar days, but no more than 120 calendar days, before the expiration of an individual's IPC to establish that an individual continues to meet diagnostic/functional eligibility criteria. Once HHSC informs the DSA of the approval of diagnostic/functional eligibility, the DSA must submit a copy of the approved ID/RC and the completed CLASS/DBMD Nursing Assessment to the CMA by the next business day.

If an individual's ABL assessment is more than five years old or the individual's needs significantly change, the DSA must complete one of the following ABL assessments according to the publisher's instructions:

A DSA representative, as defined in Section 3300, Service Planning, must participate as a member of the SPT to develop:

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

The DSA is responsible for assisting and providing documentation, as requested by the CMA.

A DSA is responsible for verifying in MESAV that each individual’s enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

Form Resources

The following forms may need to be completed as part of the renewal process:

Submission Standard

The following submission standards apply when submitting ID/RC paperwork to HHSC:

 

3330 Revision

Revision 17-1; Effective November 1, 2017

 

When the DSA is notified of a needed revision to the IPC, the DSA representative must contact the CMA within one business day. The DSA is responsible for assisting and providing documentation, as requested by the CMA to ensure:

Within five business days after receipt of the IPP-A, IPP and IPC from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must sign and return the IPP-A, IPP and IPC to the CMA. If any revised services provided by the DSA affect the service backup plan, PAS/Habilitation Plan - CLASS/DBMD/CFC  plan or the IPP-A, the DSA must revise the existing plan to reflect these changes to program services.

A DSA is responsible for verifying in MESAV that each individual’s enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

 

3331 Immediate Jeopardy of CLASS Individual

Revision 17-1; Effective November 1, 2017

 

Immediate jeopardy is interpreted as a crisis situation in which the health and safety of an individual is at risk.

During circumstances when the individual's health and safety is placed in immediate jeopardy the DSA must provide the following services:

These services must be provided even if they are not included on the individual's IPC. The DSA must, within seven calendar days after providing the service, submit to the CMA:

The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitation, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

Form Resources

The following forms may need to be completed as part of the revision process:

 

3340 Transfer

Revision 15-2; Effective November 20, 2015

 

If an individual plans to move to another CLASS provider, the case manager must provide the individual the most current Selection Determination document for the applicable catchment area. The requirements for the transferring DSA and receiving DSA are provided below.

 

3341 Transferring DSA

Revision 17-1; Effective November 1, 2017

 

The transferring DSA must provide the receiving DSA with the current balance of each service category based on most current CLASS/CFC IPC authorized and actual delivery up to the transfer effective date — Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

Copies of the identified records must be delivered by the transferring DSA to the receiving DSA within five calendar days of notification by the case manager of the individual's decision to transfer to a different DSA. The records that must be provided include:

The transferring DSA is required to maintain documentation of the specific records that were delivered to the receiving DSA, as well as the date of the delivery.

 

3342 Receiving DSA

Revision 11-1; Effective June 13, 2011

 

The receiving DSA must initiate services on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the receiving DSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

The receiving DSA must develop a Form 3628, Provider Agency Model Service Backup Plan, for those services requiring a backup plan as indicated on the IPC.

 

3350 IPP Service Summaries

Revision 17-1; Effective November 1, 2017

 

CLASS service provider(s) must evaluate the effectiveness of CLASS program and CFC services delivered by the DSA. The DSA is responsible for providing an IPP Service Summary to the CMA in accordance with the schedule in Appendix X, Service Summary/Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal CLASS/CFC IPC. The final review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC and update the IPP-A. The case manager is responsible for documenting the service summary provided by the DSA since the preceding review. The evaluation must include an assessment of the individual's progress, evolving needs and plans to address those needs. The IPP Service Summary must document the service provider’s review of the individual's progress toward achieving the goals and objectives, as described on the IPP for each CLASS program and CFC service listed on the individual's IPC. There is not a HHSC form for the IPP Service Summary; however, the DSA must provide this information in a written format.

A DSA is required to ensure that each CLASS program and CFC service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application, available on the CLASS website at https://hhs.texas.gov/laws-regulations/policies-and-rules/waivers/class-waiver-applications.

An IPP is developed to describe the goals and objectives to be met by the provision of each CLASS program and CFC service on an individual's IPC that are supported by justifications, are measurable, and have timelines. Additionally, a DSA must ensure CLASS program and CFC services are documented in the individual's record, including the progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed.

The DSA must provide the case manager with the IPP Service Summaries from each service listed below provided by the DSA documenting the individual's progress and needs. The service provider of each service listed below completes a service summary for each individual

Within five business days of the service provider completing the IPP service summary, the DSA is responsible for providing copies of the summaries to the case manager, as evidenced by the fax transmittal date on the documents provided to the CMA. The DSA must maintain documentation of transmission of all necessary documents. An IPP service summary for each service listed below must be prepared based on the schedule in Appendix X from the effective date of the most recent enrollment or renewal IPC. The DSA verbally updates the case manager during the renewal SPT meeting with any relevant information regarding services delivered in the last quarter of the IPC year.

The summaries must include quarterly reports from providers of the following services:

Each IPP Service Summary completed by the service provider must include all of the elements listed below:

Form Resources

The following forms may need to be completed as part of the summary:

 

3400 Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

 

An individual who has been denied enrollment or terminated from the CLASS program and CFC services, or an individual whose CLASS program and CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409

 

3410 Denial

Revision 17-1; Effective November 1, 2017

 

Denial is an HHSC action that disallows:

 

3411 Denial of a Request for Enrollment into the CLASS Program

Revision 17-1; Effective November 1, 2017

 

HHSC denies an individual's request for enrollment into the CLASS program if:

If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, Financial Management Services Agency (FMSA).

 

3412 Denial of a CLASS Program or CFC Service

Revision 17-1; Effective November 1, 2017

 

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

HHSC denies a CLASS program or CFC service on an individual's IPC if services:

If HHSC determines one or more of the CLASS program or CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

Form Resources

The following forms may need to be completed as part of a denial of services:

 

3420 Reduction

Revision 17-1; Effective November 1, 2017

 

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of CLASS program or CFC services not authorized by HHSC on a prior IPC.

HHSC will perform a utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All CLASS program or CFC services and units of service included on a proposed IPC must be justified by the SPT.

HHSC staff review the IPC to ensure the services on the IPC:

As necessary during the review of a proposed IPC, HHSC staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for a proposed CLASS program and CFC service(s). If information submitted to HHSC by the case manager does not provide sufficient information to justify requested CLASS program and CFC services or amounts of CLASS program and CFC services, HHSC will reduce the number of units of CLASS program and CFC services, as necessary, and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, CMA notifies the DSA in writing describing HHSC’s reason for the reduction. The CMA also notifies the DSA if and when the individual chooses to appeal the decision. If the individual or LAR requests a fair hearing within 10 days from date of notification, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a reduction of services:

 

3430 Suspension

Revision 17-1; Effective November 1, 2017

 

Suspension is an HHSC action that results in temporary loss of the individual's authorized CLASS program or CFC services. An individual may remain on suspension from CLASS for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Suspension is an HHSC action taken because of:

Within two business days of learning of a situation that necessitates an individual's CLASS program and CFC services to be suspended, the DSA must send the CMA written notification using Form 2067, Case Information, including any supporting documentation.

Form Resources

The following forms may need to be completed as part of a suspension of services:

 

3440 Termination

Revision 11-7; Effective November 1, 2017

 

Termination is an HHSC action that results in the loss of the individual's eligibility for authorized services in the CLASS program and CFC services.

 

3441 Termination With Advanced Notice

Revision 11-7; Effective November 1, 2017

 

HHSC terminates an individual's CLASS program and CFC services if:

Within two business days after the DSA learns of one of the situations described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation. The DSA is responsible for making reasonable attempts to accommodate a face-to-face meeting with the SPT as scheduled by the CMA.

If termination of services is requested based on a determination by the DSA on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence, the DSA must provide specific reason(s) to the CMA regarding why the DSA determined it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current Selection Determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the DSA must assist the CMA to develop a transfer IPC as described in Section 3340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If CLASS program and CFC services are terminated due to an individual's IPC cost being over $114,736.07,  HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program and CFC services and includes in the notice the individual's right to request a fair hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program and CFC services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

 

3442 Termination Without Advanced Notice

Revision 17-1; Effective November 17, 2017

 

HHSC terminates an individual's CLASS program and CFC services without advanced notice if any of the following situations exist:

Within two business days after the DSA becomes aware of a situation such as described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

HHSC may terminate an individual's CLASS and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the case manager or a service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

Form Resources

The following forms may need to be completed as part of termination of services:

 

3500 Service Initiation

Revision 17-1; Effective November 1, 2017

 

A DSA must ensure each CLASS and CFC service is provided to an individual in accordance with the individual's IPP-A, IPC and IPP for each service.

A DSA must have a written process that ensures staff members are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide a CLASS and CFC service.

A DSA must inform the individual's case manager of changes needed to the individual's IPC or IPPs.

 

3510 Immediate Jeopardy of CLASS and CFC Providers

Revision 17-1; Effective November 1, 2017

 

HHSC may terminate an individual's CLASS program and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or DSA service provider in immediate jeopardy, the CMA or DSA must:

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of a written notice from HHSC authorizing the termination of CLASS program and CFC services, the CMA must, no later than the date of the termination of services, send a written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

 

3520 Adaptive Aids Costing Less than $500

Revision 17-1; Effective November 1, 2017

 

Once the DSA determines the cost of the requested adaptive aid, the DSA must request in writing that the case manager initiate an IPC revision. The DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 14 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for completion of purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, a DSA must ensure the individual receives the medical supply as follows:

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

If the DSA cannot provide an adaptive aid that is a medical supply and is not immediately necessary by the individual, the DSA must:

 

3530 Adaptive Aid Costing $500 or More

Revision 17-1; Effective November 1, 2017

 

Once the SPT has agreed the individual is in need of an adaptive aid with an anticipated cost that is more than $500, the DSA must request in writing that the case manager initiate an IPC revision including funds for obtaining an assessment of the individual by the appropriate licensed professional as described in Appendix I of CLASS Provider Manual. The assessment must include a description and a recommendation for an adaptive aid that meets the individual’s need(s). This assessment must identify how this adaptive aid will meet the needs of the individual and must include consideration of other alternatives known to the appropriate licensed professional to meet the individual’s need(s). Detailed descriptions, to the extent possible, must accompany the licensed professional’s recommendation for adaptive aids when the cost is more than $500.

After HHSC authorizes the proposed IPC for payment of the adaptive aid assessment, the DSA must obtain the assessment from the appropriate licensed professional that describes the adaptive aid within 30 calendar days. The assessment by the licensed professional that describes the specific need(s) of the individual must include recommendations for the adaptive aid that, in the opinion of the licensed professional, will best meet the needs identified in the assessment.

Based on the recommendations contained in the assessment, the DSA will consult with the appropriate vendor  to determine the most cost-effective item(s) that meet the recommendations in the assessment. The description of the item(s) as contained in the assessment must be used to develop the specifications to obtain bids from all vendors. The DSA must obtain comparable bids for the requested adaptive aid from three vendors within 60 calendar days of obtaining the specifications.

A bid obtained must be based on the specifications and include:

The DSA must:

For purchases of an adaptive aid or medical supply costing over $500, the CMA, DSA and individual/legally authorized representative must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

The DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

A bid obtained must be based on the specifications and include:

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests to purchase an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

Requests for interpreter services or specialized training for augmentative communication devices must include:

If the requested adaptive aid is a vehicle modification, a DSA must obtain proof the individual or individual's family member owns the vehicle for which the vehicle modification is requested. Requests for vehicle modifications to accommodate modifications or additions to the primary transportation vehicle must include an assessment by the appropriate licensed professional as indicated in Appendix I. Additionally, if the vehicle is more than five years old or the mileage on the vehicle odometer exceeds 50,000 miles, the vehicle must pass an inspection performed by an automotive technician certified by The National Institute for Automotive Service Excellence (ASE).

A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

The DSA must request in writing the case manager initiate an IPC revision. At this point, the DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC once submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 30 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, the DSA must ensure the individual receives the medical supply as follows:

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

For an adaptive aid that is a medical supply and not immediately needed by the individual, the DSA must:

 

3540 Minor Home Modification

Revision 17-1; Effective November 1, 2017

 

Once the SPT has agreed the applicant/individual might require a minor home modification, the DSA must request in writing that the case manager initiate an IPC revision that includes funds for obtaining an assessment of the individual by the appropriate licensed professional to determine the specific minor home modification necessary to meet the needs of the individual, as defined in the assessment.

Once HHSC notifies a DSA through the electronic billing system of a service authorization for an assessment by the appropriate licensed professional of the individual’s need(s), the DSA must obtain the assessment within 30 calendar days after the date HHSC authorizes the IPC.

After HHSC authorizes the proposed IPC for payment for the assessment of the individual, the DSA must obtain the specifications from a person who has experience in home modifications within 30 calendar days.

The DSA must:

The CMA, DSA and individual/LAR must complete and sign Form 3849-A to signify agreement with the specifications.

The DSA must obtain comparable bids for a minor home modification from three vendors if the modification costs more than $1,000, within 60 calendar days after obtaining the specifications.

A bid obtained must be based on the specifications and include:

A DSA may obtain one bid or two comparable bids for a minor home modification if the DSA has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.

If a DSA requests to purchase a minor home modification that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

The person who developed the specifications may also offer one of the bids. A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

After the DSA has successfully obtained a sufficient number of bids, the DSA must:

Once HHSC notifies a DSA through the electronic billing system of a service authorization for a planned minor home modification and the cost of the inspection of the modification, the DSA must direct the vendor to begin construction of the modification within seven calendar days after the date HHSC authorizes the proposed IPC; or the effective date of the IPC as determined by the SPT (whichever is later).

A DSA must ensure a minor home modification is completed within 60 calendar days after the date HHSC authorizes the proposed IPC that includes the cost of the modification and inspection or the effective date of the IPC as determined by the SPT (whichever is later).

If the DSA determines the minor home modification will not be completed within the time frame required, the DSA must notify the individual or LAR in writing of a new proposed date of completion. The proposed date may not exceed 30 calendar days after the date outlined before.

The DSA must conduct an in-person inspection of the minor home modification within seven business days after it receives information the modification is completed. The inspection may be performed by the person who developed the specifications unless that person is affiliated with the vendor who completed the minor home modification. The inspection will determine if the:

If the DSA determines the minor home modification meets the conditions of the inspection, the DSA must send a completed Form 8605, Documentation of Completion of Purchase, to the individual's CMA within seven business days after completion of the inspection.

If the DSA determines the minor home modification does not meet the conditions of the inspection, the DSA must ensure the vendor meets the conditions within 30 calendar days after the DSA's determination.

 

3600 CFC PAS/HAB or CLASS Transportation-Habilitation Services Documentation

Revision 17-1; Effective November 1, 2017

 

If the individual receives CFC PAS/HAB or CLASS transportation-habilitation services as part of their service plan, the DSA must document and maintain the following in the individual record (except for items that are not relevant):

Tasks performed by CFC PAS/HAB or CLASS transportation-habilitation provider  must be provided with proper regard for the individual's health, safety, welfare and personal autonomy. CFC PAS/HAB must be performed in a manner that comports with the individual’s personal, cultural or religious preferences.

The DSA must provide CFC PAS/HAB services that meet the individual's needs as specified in the IPC and IPP. The individual or LAR must be afforded an informed choice of settings, techniques and objectives. The individual or LAR may request CFC PAS/HAB services be modified to accommodate individual needs.

CFC PAS/HAB must be provided in community settings; that is, places where the individual lives or works and in settings similar to these. The training must teach skills the individual can practice and apply in daily life.

If any of the following services are provided, the DSA must evaluate and document the effectiveness at least once per quarter:

The evaluation must include an assessment of the individual's progress, evolving needs and plans to address identified needs.

The DSA must also inform the case manager of any significant changes in the service plan and provide the case manager with service summaries of the individual's progress and needs.

Form Resources

The following forms may need to be completed:

 

3700 Money Management/Trust Fund

Revision 17-1; Effective November 1, 2017

 

The SPT will address the individual's need for money management assistance. If an individual requires assistance with money management, this can be addressed during completion of Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC.

Individuals receiving CLASS and CFC services will be encouraged to practice responsible personal money management. If the DSA maintains the individual's finances, it must do so in a way that protects the financial interests of the individual receiving CLASS and CFC services.

Individuals receiving CLASS and CFC services will be encouraged and allowed to manage their own finances, whenever possible.

Individuals who are capable of managing their own finances will:

If the individual does not manage their own funds, the DSA must explain in writing why the individual is unable to perform the activity and what steps are being taken to increase the individual's independence. The provider must also maintain the funds in accordance with trust fund requirements as noted in 40 TAC §19.405, Additional Requirements for Trust Funds in Medicaid-certified Facilities.

 

3800 Changes in Individual Status

Revision 11-1; Effective June 13, 2011

 

The DSA must report changes in an individual's status within 24 hours of awareness of the change to the case manager on Form 2067, Case Information.

The following are examples of changes in the individual's condition or circumstances that require notification to the case manager:

CLASS-PM, Section 4000, Consumer Directed Services (CDS)

Revision17-1; Effective November 1, 2017

 

 

4100 Overview of CLASS Services Available Through the CDS Option

Revision17-1; Effective November 1, 2017

 

In the Community Living Assistance and Support Services (CLASS) program, the Consumer Directed Services (CDS) option is available to individuals who choose to self-direct one or more of the following program services:

When individuals select the CDS option, they are required to use Financial Management Services (FMS). Individuals may also access support consultation if it is determined to be a necessary support to assist the individual in successfully using the CDS option.

A Financial Management Services Agency (FMSA) chosen by the individual or legally authorized representative (LAR) provides FMS. FMS includes processing payroll and payables on behalf of the CDS employer. This includes serving as the CDS employer's fiscal/employer agent to ensure that federal, state and local employment taxes and labor and workers' compensation requirements are implemented in an accurate and timely manner. FMS also includes orientation, training, support and assistance with and approval of CDS employer budgets.

Support consultation is an optional service provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and successfully deliver program services. Individuals may choose a support advisor from the list of support advisors who have met Texas Health and Human Services Commission (HHSC)  support advisor training requirements, located on the HHSC website at apps.hhs.texas.gov/providers/CDS/advisors.cfm. The FMSA must make a qualified support advisor available to individuals to whom they provide FMS. The CDS employer may choose to receive support consultation services from the support advisor associated with their FMSA or another qualified support advisor. Payment for support consultation is budgeted within the CDS portion of the individual's budget and is not a separate and distinct service on the Individual Plan of Care (IPC). Support consultation is available for CDS employers who choose additional support for hiring, dismissing, and training attendants. Support consultation provides more extensive training than CFC support management described below.

Community First Choice (CFC) support management offers training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. Support Management is a voluntary training benefit rather than a service. There is no reimbursement rate.  A Direct Services Agency (DSA) and a FMSA are required to offer support management. DSAs and FMSAs will provide the CFC Support Management Handout (PDF) |Spanish (PDF), along with a verbal explanation, to individuals whose service plan includes support management.

 

4110 Offering the CDS Option

Revision 17-1; Effective November 1, 2017

 

The individual's CLASS case manager at the case management agency (CMA), is required to offer the CDS option at the time of CLASS program enrollment, at least annually, and at any other time upon request of the individual or LAR.

Individuals have a choice in how their services are delivered:

The service delivery option individuals select is based on their own preferences, as discussed during the service planning process. It is important to tell individuals they may switch service delivery options at any time. It is possible to have some services delivered through the CDS option and have other services delivered through the agency option. If they select the CDS option, they can switch to the agency option at any time. However, if an individual switches from the CDS option to the agency option, they must wait 90 days before switching back to CDS.

The CLASS case manager offers the CDS option by reviewing the following HHSC forms with the individual.

Form 1581, Consumer Directed Services Option Overview — The purpose of Form 1581 is to introduce the CDS option. Form 1581 gives an overview of the differences between the CDS option and the agency option. This form, when signed, provides acknowledgement the CLASS case manager has provided, both orally and in writing, an overview of the benefits and responsibilities of the CDS option in CLASS.

Form 1582, Consumer Directed Services Responsibilities — The purpose of Form 1582 is to provide more detailed information to the individual or LAR about the responsibilities assumed if the CDS option is selected. It concludes with the CDS Consumer Self-Assessment. If the individual or LAR (the employer) is not able to complete the Consumer Self-Assessment, a person appointed by the employer to be the employer's Designated Representative (DR) must be able to complete the Consumer Self-Assessment for the individual receiving services to participate in the CDS option. Form 1720 designates a representative for employer duties. The purpose of the self-assessment is to:

The self-assessment may not be used to determine that an individual/LAR cannot use the CDS option. If the individual or their LAR has difficulty responding to the self-assessment questions, they probably will need a designated representative (DR) to help them implement the CDS option. It is the FMSA's responsibility to assist them with appointing a DR.

Form 1583, Employee Qualification Requirements — The purpose of Form 1583 is to provide important definitions of terms used with CDS. This form includes information about who can be the CDS employer, who can be a DR, and who can and cannot be hired as an employee in the CDS option for CLASS.

Form 1584, Consumer Participation Choice — The purpose of Form 1584 is to document the individual's/LAR's choice of service delivery option. If the individual or LAR is selecting the CDS option, the individual also must select an FMSA of his or her choice.

The case manager will provide a list of FMSAs serving the individual's CLASS catchment area. The FMSA choice list is available at apps.hhs.texas.gov/providers/cds/cdsas/CLASS.cfm.

To locate FMSAs serving the individual's local area, type in the county in which the individual resides. The case manager should encourage the individual or LAR to call and interview several FMSAs before selecting one.

Important: FMSAs are not required to be located in the same town in which the individual resides. FMSAs provide FMS. This service does not require ongoing face-to-face contact. While FMSAs are required to make one visit to the individual's home to conduct the CDS orientation before service initiation, the FMSA conducts the remainder of their business via email or fax with the individual or LAR, or DR if one has been appointed.

Form 1586, Acknowledgement of Information Regarding Support Consultation Services — The purpose of Form 1586 is to provide information to the individual or LAR regarding the availability of support consultation in the CLASS program. The use of support consultation is optional. If the individual or LAR requests support consultation during the service planning process, this service must be included in the IPC. During the development of the IPC, the number of units of support consultation must be determined for inclusion in the IPC. The amount and duration of support consultation needed by the individual will vary. Since payment for support consultation is drawn from the CDS employer's service budget, there are no additional funds available to pay for support consultation.

Support consultation provides practical skills training, coaching, and assistance related to employer responsibilities, including:

A support advisor provides support consultation. FMSAs are required to make support advisors available through their agency.

The individual or LAR may select a qualified support advisor provided by his or her FMSA, or may opt to choose a certified support advisor who is not associated with the FMSA from the list of qualified support advisors.

The list of support advisors who completed the required support advisor training is available on the HHSC website at apps.hhs.texas.gov/providers/CDS/advisors.cfm.

Form 1720, Appointment of a Designated Representative

The purpose of Form 1720 is to appoint a representative to perform specific employer tasks delegated by the Individual or LAR. The individual or LAR will choose a designated representative to perform certain employer tasks. If the designated representative is not a relative, the FMSA must conduct a criminal conviction check using the Texas Department of Public Safety public website.

Form 1735, CLASS, Service Provision Requirements Addendum

The purpose of Form 1735 is to provide program specific information about the services that can be self-directed, the provider qualifications, service delivery documentation and training requirements. By signing and dating Form 1735-CLASS, the CDS employer (individual or LAR) or DR certifies that they have read, understood, and agreed to comply with the CLASS program requirements.

 

4120 Service Backup Plans

Revision 17-1; Effective November 1, 2017

 

The CDS employer (individual or LAR) is responsible for developing a backup plan for self-directed CFC PAS/HAB and nursing services. CLASS Transportation - Habilitation  services do not require a service backup plan. CDS service backup plans are documented on Form 1740, Service Backup Plan. The CDS employer's plan must be reviewed and approved by the SPT.

It is the case manager's responsibility during each IPP Service Review to review a CDS employer's backup plan to determine whether the strategies are reasonable and viable contingencies in the event an individual is unable to receive a critical program service by their regular service provider. If the case manager determines the strategies are not reasonable and viable, the case manager may support the CDS employer as needed to develop a viable plan. The case manager may also suggest the CDS employer consider using support consultation to assist in the development of a backup plan.

The CDS employer is responsible for providing the FMSA with the copy of each service backup plan within five working days after it has been approved by the SPT.

Backup plan strategies may include both formal and informal supports. If backup services are to be purchased from a CLASS DSA, the CDS employer must include such costs in the CDS budget. In addition, people who are paid to provide backup services must pass all criminal history and registry checks. Funds must be allocated in the individual's budget for criminal history checks of backup service providers.

 

4130 Service Planning

Revision 17-1; Effective November 1, 2017

 

The SPT consists of the case manager, the applicant/individual/LAR, DSA representative(s), and other people requested by the applicant/individual/LAR to develop a proposed IPC, using Form 3621, CLASS/CFC – Individual Plan of Care. The FMSA does not play a role in the CLASS service planning process. FMSA staff does not attend SPT meetings, unless requested by the individual. The CDS employer is responsible for developing the PAS/Habilitation Plan - CLASS/DBMD/CFC in conjunction with the SPT. Any change in the amount of a service delivered through the CDS option must be discussed and justified by the SPT as part of the SPT process.

HHSC may, at any time, request documentation to justify a service. If HHSC requests this documentation for a service the individual or LAR has chosen to self-direct using the CDS option, the CDS employer is responsible for providing the documentation to HHSC. The CDS employer may request support from the case manager to provide this documentation for HHSC.

The SPT must revise the IPC to include any change in the amount of a service(s). For all IPC revisions, the case manager must provide a copy of the IPC to the FMSA within five business days of HHSC transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents.

A support advisor may participate in service planning meetings if requested by the individual or LAR. A support advisor must notify the individual's case manager:

The individual or LAR (that is, "employer") is responsible for:

A support advisor may provide coaching in any of the areas listed above.

 

4200 Enrolling the Individual in the Consumer Directed Services Option

Revision 17-1; Effective November 1, 2017

 

To enroll an individual in the CDS option, the case manager sends the following documents to the FMSA:

The FMSA needs the proposed IPC in order to conduct the required CDS orientation with the individual or LAR before services delivered via the CDS option can begin.

During the CDS orientation, several key activities must occur before services starts. The FMSA will:

The FMSA will need to know the number of hours of CFC PAS/HAB or CLASS habilitation, respite, nursing, physical therapy, occupational therapy, speech/language pathology or support consultation on the proposed IPC in order to assist the employer with development of the CDS budget. The FMSA conducts the CDS orientation while the proposed IPC is under review by HHSC.

The FMSA is required to notify the case manager via HHSC Form 2067, Case Information when the orientation has been completed. The case manager files the form in the individual's record.

Services delivered through the CDS option may not begin until:

HHSC notifies the CMA in writing of whether the proposed IPC is authorized. The case manager must then provide the FMSA with a copy of the HHSC authorized IPC. In the event the number of hours authorized for a CDS service changes as a result of HHSC review, the case manager will notify the FMSA of the change by sending Form 2067 to the FMSA so that adjustments can be made to the individual's CDS budget as necessary.

Financial Management Services (FMS)

For individuals who use the CDS option, the IPC must include FMS. FMS is authorized as a monthly service. For example, for a 12-month period, 12 units of FMS must be included on the IPC.

Support Consultation

If the individual or LAR requests support consultation or the individual's SPT determines support consultation would be beneficial to provide employer coaching, hours for support consultation must also be included on the IPC.

Support consultation is to be used, as needed. On average, an individual may be authorized for six to nine hours of support consultation per year. It is generally not the type of service to be used on a weekly basis.

Note: A CLASS DSA is not responsible for delivering or billing for a service delivered through the CDS option.

If the individual or LAR decides to receive nursing through the CDS option, the DSA is not responsible for supervising or verifying the credentials of the nurse hired by the CDS employer.

 

4300 Monitoring Consumer Directed Services

Revision 17-1; Effective November 1, 2017

 

The case manager monitors CDS services in the same manner as CLASS services delivered through the agency option. A key monitoring role is to determine whether the individual's health and safety is at risk in the environments in which the individual receives CLASS, CFC, and non-CFC/CLASS services and, if necessary, to take action to protect the individual's health and safety. If the case manager learns of a problem with the FMSA, the case manager may report the FMSA to Consumer Rights and Services at HHSC. More detailed information regarding consumer rights and services may be found in Section 1200, Interest List.

The FMSA is required to provide the case manager and CDS employer quarterly reports of expenditures for each CDS. The purpose of these reports is to determine over or under utilization of services. The FMSA will also note any areas of non-compliance with the CDS option on the quarterly report.

 

4400 Corrective Action Plans

Revision 13-2; Effective September 6, 2013

 

Based on review of the quarterly reports or a monitoring visit, the case manager may request a corrective action plan from the employer. It is important to remember it is the CDS employer's responsibility, not the FMSA's, to ensure services are delivered, services are provided in accordance with the service plan, and program rules are being followed.

At the request of the case manager or the FMSA, the CDS employer must develop a corrective action plan using Form 1741, Corrective Action Plan. The person requesting the corrective action plan completes the top part of the form indicating the specific reason a corrective action plan is needed (for example, over expenditure or failure to submit required documentation to the FMSA in a timely manner). The CDS employer completes the corrective action strategies section of the form. The CDS employer must provide a written corrective action plans to the person requiring the plan within 10 calendar days after receiving the request. The CDS employer's plan must be reviewed for feasibility and signed by the SPT. It is the case manager's responsibility to review a CDS employer's corrective action plan to determine whether the resolution proposed in the plan represents a reasonable and viable solution to the identified problem. If the case manager determines the resolution proposed in the plan is not a reasonable and viable solution to the identified problem, the case manager may support the CDS employer as needed to develop a viable plan. The case manager may also suggest the CDS employer consider using support consultation to assist in the development of a corrective action plan.

Corrective action plan information needs to be specific to the identified issue and identify specific strategies and time frames for improvement. The goal of a corrective action plan is to focus on needed supports to ensure the employer succeeds in using the CDS option.

 

4500 Termination from the CDS Option

Revision 13-2; Effective September 6, 2013

 

An individual or LAR may voluntarily request to switch from the CDS option to the provider-managed option. An individual must remain with the provider-managed option for at least 90 days before requesting to transfer back to the CDS option.

The SPT may recommend the individual be involuntarily terminated from the CDS option. For an individual participating in CDS, the case manager must recommend DADS terminate the individual's participation in the CDS option if the case manager determines:

Before an FMSA recommends involuntary termination of participation in the CDS option to an individual's case manager, the FMSA must:

On receipt of a recommendation for involuntary termination from the FMSA or other party, the individual's case manager must:

If the SPT recommends terminating an individual's participation in the CDS option and the individual is receiving other CLASS services from a CLASS DSA, the case manager must:

The case manager will notify the FMSA (using Form 2067, Case Information) a request to terminate the CDS option has been sent to DADS for approval.

 

4600 Transfers from One FMSA to Another

Revision 13-2; Effective September 6, 2013

 

An individual or LAR may transfer to a new FMSA at any time. Upon request, the case manager will provide a list of FMSAs serving the individual's CLASS catchment area to the individual or LAR. The FMSA choice lists are on the DADS website at www.dads.state.tx.us/providers/cds/cdsas/CLASS.cfm.

To locate FMSAs serving the individual's local area, select the county in which the individual resides. The case manager should encourage the individual or LAR to call and interview several FMSAs before selecting one.

 

4610 Transferring FMSA

Revision 17-1; Effective November 1, 2017

 

The transferring FMSA must provide the case manager with the current balance of each service category based on most current IPC authorized and actual delivery up to the transfer effective date (Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet). The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

Within five calendar days of notification by the case manager of the individual's decision to transfer to a different FMSA this information must be delivered to the receiving FMSA.

 

4620 Receiving FMSA

Revision 13-2; Effective September 6, 2013

 

The receiving FMSA's responsibilities start on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the individual after having selected the receiving FMSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Note: FMSAs are not required to be located in the same town in which the individual resides. FMSAs provide FMS. This service does not require ongoing face-to-face contact. While FMSAs are required to make one visit to the individual's home to conduct the CDS orientation before service initiation, the FMSA conducts the remainder of its business via e-mail or fax with the individual or LAR, or the DR if one has been appointed.

 

4630 Services in the CLASS Programs Available Through the CDS Option that may be Received Outside of the State of Texas

Revision 17-1; Effective November 1, 2017

 

An individual in the CLASS Program may receive only the following services through the CDS option while the individual is temporarily staying at a location outside the state of Texas:

Time Limit on Receiving Services Outside of the State of Texas

An individual in the CLASS Program may receive services listed above through the CDS option while the individual is temporarily staying at a location outside of the State of Texas for no more than 30 calendar days within a service plan year.

Notifications to the Case Manager and FMSA from the CDS Employer

If an individual wants to receive a service through the CDS option while the individual is temporarily staying at a location outside the State of Texas, a CDS employer must, at least five working days before the individual leaves the state, send written notification to the individual’s case manager and FMSA stating the individual is temporarily staying at a location outside the state. If circumstances beyond the CDS employer’s control do not permit the notification to be sent within the five-day time frame, the CDS employer must, at least 24 hours before the individual leaves the state, send written notification to the individual’s case manager and FMSA stating the individual is temporarily staying at a location outside the state.

The written notification must include:

Within three working days after the individual's return to the individual’s residence in Texas, the employer must notify the individual's case manager and FMSA, by phone or in writing, of the individual’s return. The FMSA and case manager must keep the notifications required above in the individual’s record.

If a CDS employer does not comply with the notification requirements described above, the CDS employer may be required to develop a corrective action plan in accordance with HHSC rule at Texas Administrative Code (TAC), Title 40, §41.221.

More information on this option is available in Information Letter No. 16-35 – Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

 

4700 CDS Resources

Revision 17-1; Effective November 1, 2017

 

The CDS rules are available on the Secretary of State's website at http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=41.

CDS Frequently Asked Questions is at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/how-cds-works. CDS brochure is at hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/cds/cds-faqs.pdf.

CDS Roles and Responsibilities Chart is at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/implementing-cds.

Additional information regarding CDS may be found at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/cds-training-presentations.

Form Resources

As part of the CDS option, the following forms may need to be completed:

CLASS-PM, Section 5000, Utilization Review (UR)

Revision17-1; Effective November 1, 2017

 

 

5100 Overview

Revision 17-1; Effective November 1, 2017

 

At the Texas Health and Human Services Commission (HHSC)’s discretion, the Community Living Assistance and Support Services (CLASS) staff conducts UR of an Individual Plan of Care (IPC) to determine if:

If requested by HHSC, a CLASS/CFC program provider must submit additional documentation supporting the IPC to HHSC within 10 calendar days after being requested.

If HHSC determines the IPC does not meet the justification for services criterion, HHSC:

If HHSC determines one or more of the CLASS/CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

If HHSC notifies the CMA of the denial or reduction of a CLASS/CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS/CFC service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

The IPC effective period of an enrollment IPC or a renewal IPC modified by HHSC does not change as a result of HHSC' modification.

 

5200 CLASS Cost Limits

Revision 17-1; Effective November 1, 2017

 

This section describes utilization review (UR)  cost limits and service limits employed during review of a proposed IPC. HHSC may, at its discretion, select any proposed IPC for UR, regardless of total cost of services. HHSC selects a proposed IPC for UR at its discretion any time the agency receives a proposed IPC and will verify the IPC does not exceed the CLASS cost ceiling of $114,736.07. CLASS UR also verifies that CLASS services do not exceed a maximum combined cost of $10,000 for adaptive aids and dental treatment and $10,000 for minor home modifications. The IPC must not include more than 30 days of in-home respite and out-of-home respite combined. CFC services, which are subject to utilization review, are not included when verifying the cost ceiling is not surpassed.

As necessary, HHSC will coordinate with the individual's CMA to request additional justification information for proposed services and amounts of services included in an individual's proposed IPC as part of the UR process. The CMA is responsible to respond to HHSC’s UR requests in accordance with the CLASS rule in Title 40 of the Texas Administrative Code (TAC), §45.214. The CMA must submit any requested additional documentation supporting the proposed IPC to HHSC within 10 calendar days after HHSC’s request.

 

 

5300 Dental Utilization Review of Dental Services

Revision 17-1; Effective November 1, 2017

 

HHSC may choose to use a Texas licensed dentist to review a CLASS IPC that includes dental services to obtain needed expert opinion. HHSC staff may consult with a licensed dentist concerning dental services proposals if:

The dentist identified by HHSC to perform dental UR may request additional items (e.g., x-rays, etc.) from the dentist who developed the dental treatment plan, as necessary. The HHSC dentist may contact the treating dentist by telephone, or by using secure e-mail if it is a matter of missing information or clarification. HHSC staff will keep a record of any additional information requested by the HHSC dentist to perform dental UR from the treating dentist, as well as the rationale provided by the HHSC dentist for denying or approving the request.
The HHSC dentist may make cost effectiveness determinations based on the most recently issued version of the Survey of Dental Fees published by the American Dental Association (ADA).

 

CLASS-PM, Section 6000, Contract Monitoring

Revision 17-1; Effective November 1, 2017

 

Federal regulations require the Texas Health and Human Services Commission (HHSC) to assure necessary safeguards are taken to protect the health, safety and welfare of individuals in the Community Living Assistance and Support (CLASS) program. HHSC conducts contract and fiscal compliance monitoring reviews to ensure providers meet all requirements for participation in the CLASS program.

 

6100 Contract Monitoring

Revision 17-1; Effective November 1, 2017

 

A contract and fiscal compliance monitoring review is a systematic review of a contractor's financial, personnel and individual service records to determine compliance with CLASS program and contract requirements.

HHSC randomly selects a sample that includes 5% of the individuals being served by the contracted provider before the review. A minimum of four individuals will be reviewed unless the program provider is serving three or fewer individuals. If the program provider is serving three or fewer individuals, HHSC will review all of the individuals being served HHSC does not provide the sample list before the entrance conference.

HHSC will conduct a contract monitoring review onsite at the physical location identified in the contract. HHSC notifies the program provider of an onsite monitoring review with written notice at least 14 calendar days before the review, which includes:

The program provider must provide:

HHSC staff conducts an entrance conference at the beginning of the monitoring review to discuss:

The provider's documentation is reviewed for program and fiscal compliance. If any financial errors are found, HHSC may require the provider to submit documentation of negative billing to correct these errors.

Upon completion of the monitoring review, HHSC staff conducts an exit conference to:

A provider must attain a minimum compliance level of 90% or above. If a provider attains an overall compliance level of 90% or more, but scores less than 90% on any individual standard, the provider is required to submit a CAP for the standards for which it scored less than 90%. If the overall compliance score is below 90%, HHSC determines the provider to be out of compliance and may submit a referral to the SARC.

HHSC, at its discretion and upon the SARC recommendation, may apply the following sanctions, including:

CLASS-PM, Section 7000, Billing/Record Keeping Requirements

Revision 17-1; Effective November 1, 2017

 

 

7100 Billing and Claims Payment

Revision 17-1; Effective November 1, 2017

 

The following services may be billed under the Community Living Assistance and Support Services (CLASS) Program:

Note: For purposes of this section, the term "provider agency" means a CLASS Case Management Agency (CMA) or Direct Service Agency (DSA), as applicable.

Each DSA must ensure that each CLASS program service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application. The approved service definition for each of the services described in this section are contained within the Texas Administrative Code (TAC). Those service definitions are located in 40 TAC §45.103, Definitions.

Each CLASS service delivered to an individual must be recorded as a distinct event by each service provider. Documentation of services delivered may be provided on Form 3625, CLASS/CFC – Documentation of Services Delivered, by fax or via the electronic visit verification (EVV) system.

Service delivery documentation must be completed according to the Texas Health and Human Services Commission (HHSC) instructions.

Each provider agency must designate a timekeeper to sign Form 3625 to verify its accuracy.

CLASS payment rates are set by the HHSC Rate Analysis. For current rates, see https://rad.hhs.texas.gov/.

 

7110 Case Management Agency (CMA) Services

Revision 17-1; Effective November 1, 2017

 

Case management services provided after the individual has been enrolled in the CLASS program are based on a monthly rate. The number of case management units needed by the individual are determined by the service planning team (SPT) and approved by HHSC on the Individual's Plan of Care (IPC). The monthly case management fee may only be billed during a month when a billable contact has occurred. The case manager must record time spent providing case management services on Form 3625, CLASS/CFC – Documentation of Services Delivered.

If the individual/LAR requests a fair hearing before the effective date of the termination, as specified in the written notice of CLASS Program services and CFC services, the CMA must continue to provide services to the individual.

 

7120 Direct Services Agency (DSA) Services

Revision 17-1; Effective November 1, 2017

 

If the individual/LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must continue to provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

 

7121 Personal Service Agreement or Contract with Another Agency

Revision 17-1; Effective November 1, 2017

 

With the exception of CFC PAS/HAB, transportation-habilitation and in-home respite, the DSA may contract with an individual or agency to provide CLASS services. The DSA is responsible for ensuring all service providers meet required direct service provider qualifications and training requirements.

CLASS services provided through a personal service agreement or contract with the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, or by fax and authenticated by the service provider.

 

7122 Minor Home Modifications and Adaptive Aids

Revision 17-1; Effective November 1, 2017

 

The DSA will only be reimbursed for adaptive aids and minor home modifications included in Appendix I, Adaptive Aids, and Appendix II, Minor Home Modification Services, and authorized by HHSC on the individual's IPC. Minor home modifications and adaptive aids purchased by the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, and signed by the appropriate representative of the DSA. The DSA representative must be a:

The DSA must have a signed and dated invoice from the vendor indicating work performed and/or services delivered and the date of completion. The DSA must keep required documentation related to procurement and cost.

 

7200 Billable Activities

Revision 11-1; Effective June 13, 2011

 

 

 

7210 Case Management

Revision 17-1; Effective November 1, 2017

 

The following activities are billable and must include a face-to-face or telephone contact with the individual/LAR:

Note: A face-to-face or telephone contact with the paid caregiver (e.g., CFC PAS/HAB, transportation-habilitation staff, respite care provider, nurse, etc.) does not establish a billable activity.

Effective March 20, 2016, each case manager must have at least one face-to-face or telephone contact with the individual or LAR or other persons acting on behalf of the individual, such as an advocate or family member, per month to provide case management. Case management in the CLASS program is paid a monthly rate based on at least one billable contact. The CMA must ensure the service date billed for this contact agrees with the date of the actual billable contact.

Case management billing must be documented on Form 3625, CLASS/CFC – Documentation of Services Delivered, and supported by documented contact notes that include:

 

7220 Nursing

Revision 11-1; Effective June 13, 2011

 

The following activities may be billed under the CLASS program if included in the individual's approved IPC:

 

7221 Specialized Nursing

Revision 11-1; Effective June 13, 2011

 

Nursing services provided to an individual who requires tracheostomy care or is ventilator dependent must be billed to the CLASS program if included in the individual's authorized IPC.

 

 

7230 Therapies

Revision 11-1; Effective June 13, 2011

 

 

 

7231 Behavioral Support Services

Revision 17-1; Effective November 1, 2017

 

Behavioral support services are specialized interventions that assist an individual in increasing adaptive behaviors and replacing or modifying challenging or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in the community.

A program provider must ensure the behavioral support services provider is a:

The behavioral support services provider must have received training in behavioral support or have experience in providing behavioral support. The DSA may document a behavioral support provider’s compliance with this requirement by listing any training related to behavioral support the provider states has been completed. The DSA program director or RN may also document observation of positive outcomes for any individual receiving behavioral support services. The DSA may also document observation of the behavioral support provider by successfully completing the billable tasks listed below.

The following activities may be billed under the CLASS program if included in the individual's authorized IPC:

The behavioral support provider must provide justification for time required to develop an individualized behavior support plan. The justification should include time necessary to conduct the functional assessment, any review of individual records, and time spent developing an individualized behavior support plan.

Seclusion

CLASS rules prohibit use of seclusion during the provision of CLASS services. Seclusion is defined as the involuntary separation of an individual away from other individuals and the placement of the individual alone in an area from which the individual is prevented from leaving. Seclusion offers no beneficial purpose and presents a significant health and safety risk to the individual.

 

7232 Occupational Therapy, Physical Therapy, and Speech and Language Pathology

Revision 17-1; Effective November 1, 2017

 

A current physician's order for each therapy is required before the delivery of occupational therapy, physical therapy and speech and language pathology. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized Individual Plan of Care:

The therapist must provide justification for time required to develop an assessment of the individual’s need for an adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the individual’s needs.

 

7233 Specialized Therapies

Revision 17-1; Effective November 1, 2017

 

Specialized therapy services must be related to the individual's disability. Specific therapeutic goals must be in place for each specialized therapy provided under the CLASS program to address the individual's disability. A current physician's order for each therapy is required before the delivery of specialized therapy services. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the individual's authorized IPC:

The therapist must provide justification for time required to develop an assessment of the individual’s need for and adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the individual’s needs.

The following services are available under specialized therapies and may be billed under the CLASS program if included in the individual's authorized IPC.

Reimbursement Rates

The current specialized therapies unit rate ceiling per hour is located on the HHSC Rates Analysis website. For services with a unit rate ceiling, the rate negotiated with the provider agency must be at or below the approved ceiling rate; the negotiated rate then becomes the unit rate for that particular service.

Requisition Fees

Requisition fees are 10% of the expenditure for the specialized therapy.

 

7234 Cognitive Rehabilitation Therapy

Revision 15-2; Effective November 20, 2015

 

Cognitive Rehabilitation Therapy (CRT) assists an individual in learning or relearning cognitive skills that have been lost or altered, as a result of damage to brain cells or brain chemistry, in order to enable the individual to compensate for lost cognitive functions. CRT includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

If an individual might need CRT, the assigned case manager must assist the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-CLASS program service.

A program provider must ensure a CRT service provider provides and monitors the provision of CRT to the individual in accordance with the plan of care and is a:

The plan of care for CRT is developed based on a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional.

An acquired brain injury (ABI) is an injury to the brain that occurs after birth, is non-congenital and non-degenerative, and that disrupts the normal function of the brain. The definition of ABI also includes traumatic brain injury (TBI) and other brain injuries resulting from any anoxic condition. Additional information on acquired brain injuries is located on the website for the Texas Health and Human Services Commission office on Acquired Brain Injuries at https://hhs.texas.gov/services/disability/office-acquired-brain-injury.

 

7235 Dietary Services (Nutritional Services)

Revision 15-2; Effective November 20, 2015

 

The provision of nutrition services is defined in Texas Occupations Code, Chapter 701. A program provider must ensure dietary services are provided by a licensed dietician.

The following activities may be billed under the CLASS program. if included in the individual's authorized Individual Plan of Care:

 

7236 Auditory Integration/Auditory Enhancement Training

Revision 15-2; Effective November 20, 2015

 

Auditory integration/auditory enhancement is specialized training that assists an individual to cope with hearing dysfunction or over-sensitivity to certain frequency ranges of sound by facilitating auditory processing skills and exercising the middle ear and auditory nervous system.

A program provider must ensure the service is provided by a licensed audiologist or a licensed assistant in audiology. An individual must have an audiogram performed by a licensed audiologist as a pre-requisite for auditory integration/auditory enhancement training.

 

7240 Supported Employment, Prevocational Services and Employment Assistance

Revision 17-1; Effective November 1, 2017

 

Additional information regarding provision of supported employment, prevocational services, and employment assistance can be located in a guide available at hhs.texas.gov/services/disability/employment/employment-first/employment-guide-people-disabilities.

 

7241 Supported Employment

Revision 17-1; Effective November 1, 2017

 

Supported employment is a service that provides assistance to sustain competitive employment to an individual who requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.

Competitive employment is employment that pays an individual at or above the greater of the applicable minimum wage or the prevailing wage paid to individuals without disabilities for performing the same or similar work.

A program provider must ensure a supported employment service provider:

A service provider of supported employment may not be the:

Before including supported employment on an individual's IPC, a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.). If an individual is already employed and in need of assistance maintaining a job, a CMA should not refer the individual to HHSC. Instead, the provider should seek approval through the individual’s service plan to provide supported employment or other services needed to maintain an individual’s employment.

HHSC does not authorize payment for training that is not directly related to an individual's supported employment program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

 

7242 Prevocational Services

Revision 17-1; Effective November 1, 2017

 

Prevocational services are services that are not job-task oriented and are provided to an individual to prepare the individual for employment and who the SPT does not expect to be employed, without receiving supported employment, within one year after prevocational services begin.

Before including prevocational services on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Act (20 USC 1401 et seq). HHSC does not provide any services similar to CLASS prevocational services; therefore, a Case Management Agency (CMA) is not required to obtain a denial from HHSC before including prevocational services on an individual’s IPC.

A program provider must ensure a provider of prevocational services:

A service provider of prevocational services may not be the:

The following activities may be billed as prevocational services under the CLASS program if included in the individual's authorized IPC:

 

7243 Employment Assistance

Revision 17-1; Effective November 1, 2017

 

Employment assistance is provided to an individual to help the individual locate competitive employment in the community.

A program provider must ensure an employment assistance service provider:

A service provider of employment assistance may not be the:

Before including employment assistance on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.).

An individual seeking employment assistance must apply for those services through HHSC before receiving employment assistance services through CLASS services. CLASS may provide employment assistance to individuals who have applied for services through HHSC until HHSC completes development of the individual plan for employment (IPE).

HHSC does not authorize payment for training that is not directly related to an individual's employment assistance program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

 

7250 Transition Assistance Services (TAS)

Revision 15-2; Effective November 20, 2015

 

TAS assists an individual in setting up a household in the community before being discharged from a nursing facility or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) and enrolling in the CLASS program. There is a cost limit of $2,500 for TAS and an individual may receive TAS only once in the individual's lifetime. TAS is not available if an individual's enrollment IPC includes support family services or continued family services in the CLASS program.

Available services include:

 

7260 Support Family Services (SFS) and Continued Family Services (CFS)

Revision 11-1; Effective June 13, 2011

 

 

 

7261 SFS

Revision 17-1; Effective November 1, 2017

 

SFS consist of services required for an individual under age 18 in the CLASS program to reside within the home of a family other than the home of the natural or adopted parent(s). The support family agency will recruit, train and certify the SFS provider. The SPT, including the support family agency, will coordinate placement into an SFS provider.

The support family agency must be licensed by the Department of Family and Protective Services (DFPS) as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide SFS.

SFS is reimbursed at a daily rate to provide 24-hour services that include:

 

7262 CFS

Revision 17-1; Effective November 1, 2017

 

CFS is for people who are unable to continue with SFS. CFS provides a 24-hour family living arrangement in a home using the same criteria for SFS and meeting the requirements of a support family home. The continued family agency will recruit, train and certify the CFS provider. The case manager, the continued family agency, the natural family and the DSA will coordinate placements into a CFS provider.

A continued family agency must be licensed by DFPS as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide CFS.

CFS is reimbursed at a daily rate to provide 24-hour services that include:

 

7270 Adaptive Aids, Minor Home Modifications and Dental Treatment

Revision 17-1; Effective November 1, 2017

 

 

7271 Adaptive Aids

Revision 12-2; Effective October 17, 2012

 

An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform ADL or perceive, control or communicate with the environment in which the individual lives.

The maximum allowable for adaptive aids and dental treatment combined is $10,000 per IPC period for an adaptive aid listed in Appendix I, Adaptive Aids.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

 

7272 Minor Home Modifications

Revision 12-1; Effective January 13, 2012

 

A minor home modification is a physical adaptation to an individual's residence is necessary to address the individual's specific needs and enables the individual to function with greater independence in the individual's residence or to control his or her environment.

The maximum allowable for minor home modifications is $10,000 for the lifetime of the individual and up to $300 per IPC period for repair and maintenance of minor home modifications purchased through the CLASS program after the lifetime cost limit has been met.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

If the minor home modification has several components, these may be billed separately as they are completed (e.g., bathroom modification that involves widening a doorway, adding grab bars to the tub and installing a special toilet adaptation). Materials may be billed separately from the labor necessary to complete the task.

 

7273 Dental Treatment

Revision 17-1; Effective November 1, 2017

 

The following routine preventive, therapeutic, orthodontic and emergency dental treatment may be billed under the CLASS program if included in the individual's authorized IPC:

Cosmetic orthodontia is excluded from CLASS program services.

 

7280 Transportation-Habilitation, CFC PAS/HAB and Respite Care

Revision 17-1; Effective November 1, 2017

 

 

 

7281 Transportation - Habilitation

Revision 17-1; Effective November 1, 2017

 

A program provider must ensure a transportation-habilitation service provider who is hired on or after July 1, 2015, has:

The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

 

7281.1 Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB)

Revision 17-1; Effective November 1, 2017

 

Effective June 1, 2015, the majority of activities previously included as part of the CLASS habilitation services are now available through the non-waiver Medicaid state plan CFC PAS/HAB service.

A program provider must ensure a CFC PAS/HAB service provider has:

The following activities may be billed to CFC PAS/HAB if included in the individual's authorized IPC:

 

7281.2 Community First Choice (CFC) Support Management

Revision 17-1; Effective November 1, 2017

 

CFC support management offers training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. There is no reimbursement rate for CFC Support Management. CFC Support Management is available to all individuals and is different from CDS Support Consultation as described in Section 4100. A Financial Management Services Agency (FMSA) are required to offer support management.

 

7282 Respite Care

Revision 17-1; Effective November 1, 2017

 

An individual is eligible for respite if:

Because respite includes personal care, the provider may not bill for habilitation when the individual is in the respite setting. The provider may bill for other CLASS program services the individual requires while in the respite setting. The provider may not bill for minor home modifications made to an out-of-home respite setting.

 

7290 Pre-Enrollment Assessments

Revision 17-1; Effective November 1, 2017

 

The CMA is reimbursed a pre-enrollment assessment fee for providing case management services necessary to enroll an applicant into the CLASS program. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

For a full assessment fee, the case manager must submit a completed Form 3621, CLASS/CFC – Individual Plan of Care, along with a completed Form 3625, CLASS/CFC – Documentation of Services Delivered.

A partial assessment fee may be requested in the event the applicant declines CLASS program services or does not meet eligibility requirements. For a partial assessment fee, the case manager must submit a completed Form 3657, Pre-Enrollment Assessment, which should be submitted with completed Form 3625 to HHSC.

The DSA is reimbursed a pre-enrollment assessment fee for providing pre-enrollment activities necessary to enroll an applicant into the CLASS program as outlined in Section 3310, Enrollment. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

 

7300 Non-Billable Time and Activities

Revision 17-1; Effective November 1, 2017

 

The following are examples of non-billable time and activities:

 

7400 Duplicate Services

Revision 17-1; Effective November 1, 2017

 

A direct service provider may bill for only one service at a time. Examples include:

 

7500 Billable Units

Revision 17-1; Effective November 1, 2017

 

A billable unit of service is the method for calculating the amount the provider agency may bill HHSC. Units are measured by increments of time or by the cost of the item provided.

 

7510 Services Unit Measurements

Revision 17-1; Effective November 1, 2017

 

The following services use time as the measure. One unit of service is defined as:

Case Management monthly rate
Transportation-Habilitation one hour
CFC PAS/HAB one hour
Nursing one hour
Occupational Therapy one hour
Physical Therapy one hour
Speech and Language Pathology one hour
Cognitive Rehabilitation Therapy one hour
Behavioral Support Services one hour
Dietary Services one hour
Respite one 24-hour period
Specialized Therapies one hour
Supported Employment one hour
Employment Assistance one hour
Prevocational Services one hour
Support Family Services daily rate
Continued family services daily rate

The following services are measured by the cost of the item provided:

All services measured by the hour use the following formula to calculate the billable unit, unless the service is respite.

Number of providers × time spent delivering services ÷ number of individuals served = billable unit of services
Examples:
1 provider × 1 hour of service ÷ 1 individual = 1 billable hour
1 provider × 1 hour of service ÷ 2 individuals = 1/2 hour billable per individual
1 provider × 1 hour of service ÷ 3 individuals = 1/3 hour billable per individual
2 providers × 1 hour of service ÷ 3 individuals = 2/3 hour billable per individual

 

7520 Respite Care

Revision 11-1; Effective June 13, 2011

 

The unit of service for respite care is defined as a 24-hour period. The respite rate is billed for each individual in a respite setting.

Examples
One individual in a respite setting for 24 hours = 1 billable unit
Two individuals in a respite setting for 24 hours = 1 billable unit per individual
Three individuals in a respite setting for 24 hours = 1 billable unit per individual

 

7600 Billing Partial Units

Revision 11-1; Effective June 13, 2011

 

To arrive at a monthly total for services that have one hour as the unit of service, add all units of a single type of service provided by all service providers of that service during the month. If the monthly total is not a whole number, or 1/4 unit increments, round the total up to the nearest 1/4 unit. Convert the partial unit to the decimal equivalent when billing:

1-15 minutes of service = unit (.25)
15.1 minutes to 30 minutes = unit (.5)
30.1 minutes to 45 minutes = unit (.75)
45.1 minutes to 60 minutes = 1 unit (1.0)

Example

Habilitation service provider A

= 12 hours and 12 minutes

Habilitation service provider B

= 5 hours

Habilitation service provider C

= 4 hours and 15 minutes

Total time for May

= 21 hours and 27 minutes

Billable habilitation units for May

= 21.5 (twenty-one and one-half)

 

 

 

7610 Billing Units of Respite Service

Revision 11-1; Effective June 13, 2011

 

Partial units of respite are calculated as follows:

1 hour of service
2 hours of service
3 hours of service
4 hours of service
5 hours of service
6 hours of service
7 hours of service
8 hours of service
9 hours of service
10 hours of service
11 hours of service
12 hours of service
13 hours of service
14 hours of service
15 hours of service
16 hours of service
17 hours of service
18 hours of service
19 hours of service
20 hours of service
21 hours of service
22 hours of service
23 hours of service
24 hours of service

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

1/24 unit (.04)
2/24 unit (.08)
3/24 unit (.12)
4/24 unit (.17)
5/24 unit (.21)
6/24 unit (.25)
7/24 unit (.29)
8/24 unit (.33)
9/24 unit (.37)
10/24 unit (.42)
11/24 unit (.46)
12/24 unit (.50)
13/24 unit (.54)
14/24 unit (.58)
15/24 unit (.62)
16/24 unit (.67)
17/24 unit (.71)
18/24 unit (.75)
19/24 unit (.79)
20/24 unit (.83)
21/24 unit (.87)
22/24 unit (.92)
23/24 unit (.96)
24/24 unit (1.0)

 

7620 Billing Units of Out-of-Home Respite Service

Revision 11-1; Effective June 13, 2011

 

The DSA must use the following procedure to bill as closely as possible to the actual cost for out-of-home respite services delivered. To calculate the units of respite that the DSA would bill for, the provider needs to calculate to the nearest partial unit the amount that allows adequate reimbursement to cover the actual cost of the service based on the current out-of-home respite rate per 24-hour period. This is done by dividing the total actual cost for respite by the current daily rate.

Administrative costs to the DSA related to arranging for respite services cannot be included in this billing calculation but should be reported on the DSA's cost report.

 

7700 Record Keeping Requirements

Revision 11-1; Effective June 13, 2011

 

The provider agency must maintain financial and supporting documents, statistical records and any other records pertinent to the services for which a claim or cost report was submitted to the department or its agent. If a provider agreement or contract has no specific termination date in effect, the records and documents must be kept for a minimum of three years and 90 days after the end of the federal fiscal year in which services were provided. If any litigation, claim or audit involving these records begins before the three-year period expires, the provider agency must keep the records and documents for at least three years and 90 days or until all litigation, claims or audit findings are resolved. The case is considered resolved when a final order is issued in litigation or the department and provider agency enter into a written agreement. The provider agency must keep records of non-expendable property acquired under the contract for three years after the final disposition of the property. In this section, contract period means the begin date through the end date specified in the original contract; extensions are considered separate contract periods.

The provider agency must maintain medical records for five years from the date the last services were delivered to the individual by the provider agency.

Medical records include:

 

7800 Service Delivery Records

Revision 17-1; Effective November 1, 2017

 

The CMA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

The DSA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

Evidence that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act, must include documentation of the individual having applied for HHSC. Individuals receiving educational services through a school system must seek to have employment assistance or supported employment services included in the Individual Education Plan, when appropriate.

The requirement to document the service provided in an individual’s record does not apply if the service/activity performed is a non-delegated task provided by an unlicensed service provider that is documented on the IPP.

CLASS-PM, Appendices

CLASS-PM, Appendix I, Adaptive Aids

Revision 17-1; Effective November 1, 2017

 

Adaptive aids are items or services necessary to assist an individual to maintain function or to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function. Adaptive aids enable individuals with functional impairments to perform activities of daily living or to control the environment in which they live. Adaptive aids purchased through the Community Living Assistance and Support Services (CLASS) program are essential items or services provided to enhance the individual's independence in the community. For some individuals, adaptive aids are basic to making the environment usable so activities such as preparing food, eating, dispensing medications, dressing and grooming, maintaining the home, and moving within the community, can be performed as independently as possible. Adaptive aids are devices, controls, appliances or services that enable individuals with related conditions to:

  • increase their abilities to perform activities of daily living and decrease the need for paid staff;
  • prevent the risk of institutionalization;
  • control the environment in which they live;
  • modify or improve the individual's ability to live successfully in the community;
  • increase the individual's safety, security and accessibility; and
  • improve service accessibility and delivery.

Adaptive aids may be provided to meet the needs identified in an assessment conducted by an appropriate, licensed professional, as outlined in this appendix. The long-range cost effectiveness of adaptive aids will be considered since these items often provide several years of service.

Limits on the amount, frequency, or duration of this service:

Nutritional supplements and enteral feeding formulas and supplies available through the CLASS program are limited to those listed on the website maintained by Noridian Healthcare Solutions at: https://www.dmepdac.com/dmecsapp/

To determine if the requested nutritional supplement might be available through the CLASS program, navigate to the Noridian Healthcare Solutions website. On that Web page, in the section labeled “Search DMEPOS Product Classification List,” enter the product name in the text box labeled “Product Name,” and click the “GO” button. If the product is displayed on the resulting page, the nutritional supplements may be reimbursed by the CLASS program, based on the justification provided.

The same website can also provide a list of all nutritional supplements. Navigate to the same website listed above and in the section labeled “Search DMEPOS Product Classification List,” locate the text at box labeled “Classification.” Highlight the category “Enteral Nutrition” and click the “GO” button. This will provide a list of all nutritional products that may be reimbursable through the CLASS program.

Adaptive Aids are provided under this waiver when no other financial resource is available or when other available resources have been exhausted.

Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is required for all requested adaptive aids. Requests for adaptive aids that require additional information to be provided by the appropriate licensed professional (as listed below) or require bids must accompany Form 3660, as applicable.

If the requested adaptive aid is related to transportation services, the case manager must complete Form 3598, Individual Transportation Plan, based on the deliberations of the service planning team (SPT). This form must be submitted to the Texas Health and Human Services Commission (HHSC) in conjunction with applicable forms as outlined below.

All assessments for adaptive aids requested through the CLASS program must:

  • be based on a face-to-face evaluation of the individual by the appropriate licensed professional, practicing within the scope of his/her licensure, conducted not more than one year before the date of purchase of the adaptive aid;
  • include a description of and a recommendation for a specific adaptive aid listed in this appendix and any associated items or modifications necessary to make the adaptive aid functional;
  • include the individual's diagnosis of a related condition(s) and identify how this adaptive aid will meet the needs of the individual and must include consideration of alternatives known to the appropriate licensed professional to meet the individual’s need(s) based on this diagnosis (for example, cerebral palsy, quadriplegia or deafness);
  • include a description of the symptom(s) related to the diagnosis (for example, unable to ambulate without assistance); and
  • include a description of the specific needs of the individual and how the adaptive aid will meet those needs (for example, the individual needs to ambulate safely and independently from room to room and the use of a walker will allow him to do so).

Adaptive aids needed on an ongoing basis will require documentation to justify the need for the adaptive aid(s) once per Individual Plan of Care (IPC) period. Repair and maintenance of items purchased through the CLASS program do not require justification unless the cost of the repair is expected to exceed $300.

However, the repair does require justification from a licensed professional if the cost exceeds $300 or the repair is to an adaptive aid not purchased through CLASS.

The maximum amount HHSC will authorize as payment to a direct services agency (DSA) for all adaptive aids and dental treatment combined for an individual is $10,000 per IPC period, which includes the cost of repair and maintenance of an adaptive aid. A maximum of $300 per IPC period may be authorized for repair and maintenance of an adaptive aid(s) so the SPT is not required to complete Form 3660 for repair and maintenance funds requests that do not exceed $300. The SPT must include the amount requested on an individual's IPC in the adaptive aids service category.

The SPT must:

  • consider a written assessment from the appropriate licensed professional recommending an adaptive aid;
  • document any discussion about the recommended adaptive aid; and
  • agree that the recommended adaptive aid is necessary and should be purchased.

For purchases of an adaptive aid or medical supply costing over $500, the case management agency (CMA), DSA and individual/legally authorized representative (LAR) must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

All individuals must attempt to obtain needed adaptive aids or durable medical equipment through all possible non-waiver resources available to that individual. Medicare and Medicaid are two common resources available to many individuals in the CLASS program that must be accessed prior to requesting an adaptive aid through CLASS.

The CMA must obtain one of the following as proof of non-coverage by Medicaid:

  • a letter from Texas Medicaid Healthcare Partnership (TMHP) that includes:
    • a statement that the requested adaptive aid is denied under the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
    • the reason for the denial, which must not be one of the following:
      • Medicare is the primary source of coverage;
      • information submitted to TMHP was incomplete, missing, insufficient or incorrect;
      • the request was not made in a timely manner; or
      • the adaptive aid must be leased; or
  • a provision from the current Texas Medicaid Providers Procedure Manual stating the requested adaptive aid is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs.

In addition to the documentation required above for an individual eligible for Medicare, a CMA must obtain one of the following documents that specifies denial of an adaptive aid:

  • a letter from Cigna Government Services that includes:
    • a statement that the requested adaptive aid is denied under Medicare; and
    • the reason for the denial, which must not be one of the following:
      • information submitted to Cigna Government Services to make payment was incomplete, missing, insufficient or incorrect;
      • the request was not made in a timely manner; or
      • the adaptive aid must be leased;
  • a letter from Cigna Government Services stating that the adaptive aid is approved and the amount to be paid, which must be less than the cost of the requested adaptive aid; or
  • a provision from the current Region C DMERC (Durable Medical Equipment Region C) DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies) Supplier Manual stating that the requested adaptive aid is not covered by Medicare.

The following are examples of documentation that are not acceptable as proof of non-coverage:

  • a statement from a Medicaid enrolled durable medical equipment (DME) provider that the adaptive aid requested is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
  • a statement from a Medicare DME provider that the adaptive aid requested is not covered by Medicare.

The CMA is responsible for assisting the individual or legally authorized representative (LAR), as necessary, to pursue all non-CLASS resource options for an adaptive aid prior to requesting an adaptive aid through CLASS. Some examples may include private insurance coverage or other state or local program resources for which the individual may be eligible.

Within five business days of receipt of this record, the CMA must provide copies of all documentation to the DSA verifying that non-CLASS resources were exhausted.

As specified in the instructions for Form 3660, the case manager provides Form 3660 to the individual/LAR when an adaptive aid, medical supply, minor home modification, dental service or dental sedation is requested. Form instructions for Part A specify this section must be completed by the case manager or individual/LAR. Additionally, the case manager completes Part B before the form is then provided to the DSA. DSAs must arrange for the appropriate professional, practicing within the scope of licensure, and as identified adjacent to each adaptive aid listed below to complete Part C of Form 3660. The DSA representative completes Part D. The DSA then submits Form 3660 to the case manager along with written documentation as outlined in Section 3500, Service Initiation.

For adaptive aids with a cost of $500 or higher, a DSA must obtain comparable bids for the requested adaptive aid from three vendors. Comparable bids describe the adaptive aid and any associated items or modifications identified in an assessment for an adaptive aid. A bid must:

  • state the total cost of the requested adaptive aid;
  • include the name, address and telephone number of the vendor;
  • include a complete description of the adaptive aid and any associated items, modifications or specifications, which may include pictures or other descriptive information from a catalog, website or brochure;
  • include the number of hours of direct service to be provided and the hourly rate of the service (only for those adaptive aids that are services); and
  • be obtained within one year after the written assessment is obtained.

A DSA may obtain only one bid for the following adaptive aids:

  • eyeglasses;
  • hearing aids, batteries and repairs; and
  • orthotic devices, orthopedic shoes and braces.

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests authorization for payment for an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid.

The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The only items and services purchasable by the DSA as adaptive aids are listed in this appendix. The maximum amount HHSC authorizes as payment to the DSA for all adaptive aids purchased for an individual receiving CLASS program services is $10,000 per IPC period.

With the exception of a vehicle modification, all adaptive aids purchased for an individual through the CLASS program are the exclusive property of that individual.

The CLASS program does not purchase adaptive aids or medical supplies offered as pre-owned, used or refurbished.

Adaptive aids identified on the IPC must include documentation describing how the item or service:

  • is necessary to protect the individual's health and welfare in the community;
  • addresses the individual's related condition;
  • is not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
  • enhances an individual's integration in the community and prevents admission to an institution while maintaining and improving independent functioning;
  • is the most appropriate type and amount of CLASS program services to meet the individual's needs; and
  • is cost effective.

Individuals must be assessed by the most qualified, licensed professional who can justify the need and appropriateness of a requested adaptive aid.

Following are licensed professionals who may assess the need for an adaptive aid in the CLASS program.

  • Audiologist (AU) — A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Psychological Associate (PSA) — A person licensed in accordance with Texas Occupations Code, Chapter 501.
  • Licensed Professional Counselor (LPC) — A person licensed in accordance with Texas Occupations Code, Chapter 503.
  • Licensed Dental Practitioner (DDS) — A person licensed in accordance with Texas Occupations Code, Chapter 251.
  • Dietitian (DI) — A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
  • Registered Nurse (RN) — A person licensed to practice professional nursing by the Texas Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
  • Physician (MD)(DO) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155. This includes professionals practicing as a medical doctor or as a doctor of osteopathic medicine.
  • Occupational Therapist (OT) — A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
  • Ophthalmology (OPH) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
  • Optometrist (OPT) — A person licensed as an optometrist or therapeutic optometrist in accordance with the Texas Occupations Code, Chapter 351.
  • Physical Therapist (PT) — A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
  • Psychologist (PS) — A person licensed as a psychologist, provisionally licensed psychologist or psychological associate in accordance with Chapter 501 of the Texas Occupations Code.
  • Speech-Language Pathologist (SP) — A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Clinical Social Worker (SW) — A person licensed as a clinical social worker in accordance with the Texas Occupations Code, Chapter 505.

Other Abbreviations and Numbers

(1) — The item must meet Medicaid standards/specifications.
(2) — Equipment rental is highly recommended by HHSC prior to purchase

Adaptive aids that may be covered in the CLASS program must be included on the following list and include the installation, maintenance and repair of approved items not covered by warranty:

  1. Lifts
    1. wheelchair lifts (OT, PT)
    2. porch or stair lifts (OT, PT)
    3. stairway lifts (only in residences owned by the individual/family) (OT, PT)
    4. bathtub seat lifts (OT, PT)
    5. ceiling lifts that transport the individual around the home via tracks (only in residences owned by the individual and/or family) (OT, PT)
    6. other hydraulic, manual or other electronic lifts (OT, PT)
  2. Mobility Aids (including batteries and chargers) — wheelchairs and scooters for facilitating participation in recreational activities and sports are not covered
    1. manual/electric wheelchairs and necessary accessories (OT, PT, MD, DO)
    2. adult stroller/travel chair (OT, PT)
    3. mobility bases for customized chairs (OT, PT)
    4. braces, crutches, walkers, canes (including white canes) and necessary accessories (OT, PT, MD, DO)
    5. prescribed prosthetic devices (OT, PT, MD, DO)
    6. orthopedic
    7. bus passes, metro transit services, taxi services for non-medical transportation only (for specific purposes related to individual's habilitation goals; not to be used in lieu of medical transportation) (any listed licensed professional)
    8. portable ramps that do not require installation (OT, PT)
    9. automatic door openers (OT, PT)
    10. gait trainer (OT, PT)
    11. mobility aids for individuals with a diagnosed visual impairment listed on the Approved Diagnostic Codes for Persons with Related Conditions, such as:
      • materials to construct adaptive mobility aids (for example, PVC pipes to construct an adapted cane or pre-cane device); (OT, PT, MD, DO, OPH, OPT)
      • color contrast or reflective tape (to mark paths, drop-offs, etc); (OT, PT, MD, DO, OPH, OPT)
      • global positioning systems (GPS) and appropriate accessories to allow independent travel within the community; (OT, PT, MD, DO, OPH, OPT)
      • tinted glasses, visors and sunshields to regulate glare; (OT, PT, MD, DO, OPH, OPT)
      • flashlights; (OT, PT, MD, DO, OPH, OPT) and
      • magnifying devices. (OT, PT, MD, DO, OPH, OPT)
  3. Position Devices
    1. standing frames/boards (OT, PT)
    2. removable bathtub rails (OT, PT)
    3. toilet chair (OT, PT)
    4. orthotic devices (OT, PT, MD, DO)
    5. hospital beds and necessary accessories (must meet Medicaid standards/specifications) (OT, PT)
    6. egg crate mattresses, sheepskin and other medically related padding (OT, PT, MD, DO)
    7. lift recliners (OT, PT)
    8. trapeze bars (OT, PT)
  4. Communication Aids
    1. communicators
      1. direct selection communicators (SP)
      2. alphanumeric communicators (SP)
      3. scanning communicators (SP)
      4. adapted telephones for an individual diagnosed with visual and/or hearing impairments listed on the Approved Diagnostic Codes for Persons with Related Conditions (for example, amplified telephones, phones with enlarged keypads, phones with Braille displays, captioned telephones and speaker phones for people who cannot use conventional telephones) (SP, OT)
      5. Telecommunication Device for the Deaf (TDD) or telephone typewriter/ teletypewriter (TTY) machines with Braille displays (SP)
      6. Video relay phone and equipment for video relay service (the monthly service fee is not included or covered) (SP)
      7. telebraille and teletype machines (SP)
      8. materials to construct communication aids (SP, PS, PSA, LPC, OT)
      9. communication books, communication symbols, experience books and calendar systems (to include calendar boxes, shelves and charts) (PS, PSA, LPC, LCSW)
      10. speech amplifiers and assistive listening devices (SP, OT)
    2. hearing aids beyond the Medicaid limit (SP, AU)
    3. hearing aid supplies beyond the Medicaid limit (SP, AU, MD, DO, RN)
    4. sign language interpreter service for non-routine communications, such as SPT meetings or medical/professional appointments (SP, PS, PSA, LPC, AU, MD, DO)
  5. Computers and Appropriate Accessories

    The following items may be purchased under the adaptive aids category for communication needs not met by an augmentative communication device, to operate adaptive software, for assistance with money management or for environmental control purposes.
    1. computers and appropriate accessories (OT, PT, SP)
    2. appropriate software to address the needs listed above (limited to three per year) (OT, PT, SP)
    3. adapted workstations/chairs (OT, PT, SP)
    4. Braille displays (OT, PT, SP)
    5. Braille printers/embossers (OT, PT, SP)
    6. electronic Braille note takers (OT, PT, SP)
  6. Environmental Controls
    1. electronic environmental control devices (OT)
    2. voice activated, light activated and motion activated devices (to include amplified features) (OT)
    3. control switches/pneumatic switches and devices (OT)
      1. sip and puff controls (OT)
      2. adaptive switches/devices (OT)
      3. sensory adaptations (OT)
  7. Adaptive Equipment for Activities of Daily Living
    The following are based on the needs of the individual as authorized on the Individual Program Plan.
    1. assistive devices
      1. reachers (OT, PT, MD, DO, RN)
      2. stabilizing devices (OT, PT, MD, DO)
      3. weighted equipment (OT, PT, PS, PSA, LPC)
      4. holders (for example, book stands, page turners, cup holder) (OT, PT, MD, DO, RN)
      5. signature stamp or signature guide (OT, PT, MD, DO, RN, OPT, OPH)
      6. electric self-feeders (OT, PT) (2)
      7. microwave ovens (only for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional ovens) (OT, PT)
      8. food processors and blenders (only for individuals with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances or for individuals with visual impairment that would be necessary for the individuals' safety) (OT, PT, DI)
      9. Electric toothbrush or waterpik device (only for individuals with muscular weakness in upper body or who lack manual dexterity) (DDS, OT, PT)
      10. variations of everyday equipment
        1. shaped, bent, built-up utensils (OT, PT, DI)
        2. long-handed equipment (OT, PT, DI)
        3. addition of friction coverings (OT, PT, DI)
        4. coated feeding equipment (OT, PT, DI)
        5. count-a-medication dose systems/manual medication reminder systems (OT, PT, MD, DO, RN)
        6. pill crushers/splitter (OT, PT, MD, DO, RN)
        7. specially adapted kitchen appliances (OT, PT, DI)
        8. toilet seat reducer rings (OT, PT, MD, DO, RN)
        9. food preparation utensils (OT, PT, DI)
        10. specially adapted clocks/wristwatches for individuals with visual or hearing impairment (OT, PT, AU, OPH, OPT)
        11. adapted scale (OP, PT, MD, DO, RN, DI)
        12. prescribed therapy aids (to be used with therapist oversight) (OT, PT, OPT, OPH, SP, PS, PSA, LPS, DI)
        13. service animals and required maintenance (cost effectiveness of medical intervention to be determined on an individual basis) (OT, MD, DO, OPH)
        14. quad gloves (OT, PT, MD, DO, RN)
    2. safety devices
      1. bed rails (OT, PT, MD, DO, RN, PS, PSA, LPC)
      2. safety padding (OT, PT, MD, DO, RN, PS, PSA, LPC)
      3. helmets (OT, PT, MD, DO, RN, PS, PSA, LPC)
      4. walking belts/gait belts (OT, PT, MD, DO, RN)
      5. flutter boards (OT, PT, MD, DO)
      6. personal floatation devices (in context with therapeutic purposes) (OT, PT, MD, DO)
      7. elbow and knee pads (OT, PT, MD, DO, RN, PS, PSA, LPC)
      8. emergency response service; (backup systems and supports used to ensure continuity of services and supports to include electronic devices and an array of available technology, personal emergency response systems and other mobile communication devices). (OT, PT, MD, DO, RN)
      9. water walkers (OT, PT, MD, DO)
      10. adapted fire extinguishers (OT, PT, MD, DO, RN)
      11. adapted smoke and CO² extinguishers (OT, PT, MD, DO, RN)
      12. visual alert systems (OT,PT, OPT, OPH)
      13. vibrating alert systems (OT, PT)
      14. auditory alert system (OT, PT, MD, DO RN)
    3. shower chairs/transfer benches (OT, PT, MD, DO)
    4. electric razors (for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional hygiene tools) (OT, PT, MD, DO, RN)
    5. flexible, disposable drinking straws for individuals with muscular weakness or who cannot drink from a regular drinking glass or cup (OT, PT, MD, DO, RN)
    6. hand-held shower attachments that are portable and do not require installation (OT, PT, MD, DO, RN)
  8. Medically Necessary Supplies
    1. tracheostomy care (MD, DO, RN)
    2. decubitus care (MD, DO, RN)
    3. ostomy care (MD, DO, RN)
    4. respirator/ventilator care (MD, DO, RN)
    5. catheterization (MD, DO, RN)
    6. diapers, linens and other incontinence supplies not covered by the Medicaid state plan (MD, DO, RN)
    7. nutritional supplements (MD, DO, RN, DI)
    8. internal feeding formulas and supplies (MD, DO, RN, DI)
    9. transcutaneous electrical nerve stimulation (TENS) units/supplies/repairs (OT, PT, MD, DO, RN)
    10. specialized thermometers (OT, PT, MD, DO, RN)
    11. diabetic supplies (OT, PT, MD, DO, RN, DI)
    12. glucose monitors (OT, PT, MD, DO, RN, DI)
    13. medical supply cabinets (OT, PT, MD, DO, RN)
    14. humidifiers (OT, PT, MD, DO, RN)
    15. suctioning devices (MD, DO, RN)
    16. prescription eyeglasses/accessories beyond Medicaid limit (OPT, OPH)
    17. muscle stimulators (OT, PT, MD, DO, RN)
    18. medically necessary heating and cooling units prescribed by a physician for individuals with respiratory or cardiac problems or people who cannot regulate their body temperature (MD, DO)
    19. urinary incontinence devices and supplies (MD, DO, RN)
    20. blood pressure monitors (MD, DO, RN)
    21. vitamins with a prescription not covered by Medicaid and identified as available previously in this Appendix (MD, DO)
    22. gloves (beyond Medicaid limit) excluding non-sterile gloves per the Occupational Safety and Health Standards included in Code of Federal Regulations 1910 §1910.138(a)-(b) when they are for the protection of the employee (MD, DO, RN)
    23. medication cups (beyond Medicaid limit) (MD, DO, RN)
  9. Specialized Training and Instructions
    1. computer literacy training to educate individuals in use of adaptive software necessary to perform activities of daily living and prevent institutionalization (limited to 10 sessions per software unit) (OT, PT, SLP)
    2. driving lessons for vehicles fitted with adaptive equipment (OT, PT, MD, DO)
  10. Modification/Additions to Primary Transportation Vehicles

    A vehicle lift adaptation may be approved for a vehicle owned by an individual or an individual's family member if it is the primary mode of transportation for the individual, but it cannot exceed one lift/ramp modification every five years. Repairs and maintenance not covered by warranty are not limited to the five-year requirement.

    A vehicle that is expected to be modified or adapted with any of the items/services listed in A. through K. below must meet one of the following criteria:
    • vehicle is less than 5 years old and mileage is less than 50,000 miles; or
    • vehicle passed an independent inspection performed by a certified automotive technician using the Form XXXX CLASS Used Vehicle Evaluation.
      1. vehicle lifts (OT, PT, MD, DO)
      2. vehicle ramps (OT, PT, MD, DO)
      3. wheelchair/scooter lifts and carriers (OT, PT, MD, DO)
      4. turning/transfer seats (OT, PT, MD, DO)
      5. driving controls
        1. brake/accelerator hand controls (OT, PT, MD, DO)
        2. dimmer relays/switches (OT, PT, MD, DO)
        3. horn buttons (OT, PT, MD, DO)
        4. wrist supports (OT, PT, MD, DO)
        5. hand extensions (OT, PT, MD, DO)
        6. left foot gas pedals (OT, PT, MD, DO)
        7. right turn levers (OT, PT, MD, DO)
        8. gear shift levers (OT, PT, MD, DO)
        9. steering spinners (OT, PT, MD, DO)
      6. medically necessary air conditioning unit prescribed by a physician
        for individuals with respiratory or cardiac problems or people who can't
        regulate their body temperature (MD, DO)
      7. removal or placement of seats to accommodate a wheelchair (OT, PT, MD, DO)
      8. installation, adjustment or placement of mirrors to overcome visual obstructions of wheelchair in vehicle (OT, PT, MD, DO)
      9. raising of the roof/lowering of the floor/modifying the suspension
        of the vehicle to accommodate an individual riding in a wheelchair (OT, PT, MD, DO)
      10. manual wheelchair tie-downs/electronic wheelchair restraints (OT, PT, MD, DO)
      11. seat belt covers (OT, PT, MD, PS, PSA, LPC)
      12. automatic door openers (OT, PT, MD, DO)
  11. Repair and maintenance of items on the authorized list above as allowable by rule.
  12. Temporary lease/rental of DME to allow for repair, purchase or replacement of an essential support system or while non-CLASS resources reviews the necessity of an adaptive aid for an individual. Lease/rental shall not exceed 90 days.

Exception

This section does not include all adaptive aids that are excluded from funding by the CLASS program. Funding of insurance copayments for therapeutic services is limited to those therapeutic services available in the CLASS program. Funding of insurance copayments for prescription medication is unavailable through the CLASS Program. Unlimited prescribed medications beyond the three per month limit available under the Texas Medicaid State Plan are provided to individuals enrolled in the waiver through the managed care organization providing acute care services. An individual who is eligible for both Medicaid and Medicare (dually eligible) must obtain prescribed medications through the Medicare Prescription Drug Plan or, for certain medications excluded from Medicare, through the Texas Medicaid State Plan.

Form Resources

The following forms may need to be completed as part of the request process for adaptive aids:

  • Form 3598, Individual Transportation Plan
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
  • Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
  • Form 8605, Documentation of Completion of Purchase
  • Form 8606, Individual Program Plan (IPP)
  • Form 2432, CLASS Vehicle Evaluation

CLASS-PM, Appendix II, Minor Home Modification Services

Revision 17-1; Effective November 1, 2017

 

Home modifications are those services that assess the need to arrange for and provide modifications and/or improvements to the individual's living quarters to allow for community living and ensure safety, security and accessibility. Minor home modifications (MHM) do not include major home renovation, remodeling or construction of additional rooms. By rule, the Community Living Assistance and Support Services (CLASS) program assures that minor home modifications are:

  • cost-effective;
  • associated with the related condition;
  • necessary to avoid institutionalization;
  • provide safe access to the home and community; and
  • improve self-reliance and independence.

Approval of all MHMs identified on the Individual Plan of Care (IPC) must include documentation describing why each item is necessary and how it relates to the individual's disability. Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is required for all requested MHMs. Requests for MHMs that require additional information to be provided by the appropriate licensed professional (as listed below) or require bids must accompany Form 3660, as applicable.

All assessments for MHMs requested through the CLASS program must:

  • be based on a face-to-face evaluation of the individual by the licensed professional, conducted not more than one year before the date of purchase of the MHM;
  • include a description of and a recommendation for a specific MHM listed in this appendix and any associated items or modifications necessary to make the MHM functional;
  • include a diagnosis that is related to the individual's need for the MHM (for example, cerebral palsy, quadriplegia or deafness);
  • include a description of the condition related to the diagnosis (for example, unable to ambulate without assistance); and
  • include a description of the specific needs of the individual and how the MHM will meet those needs (for example, an individual who uses a wheelchair for mobility in his home and the community needs to be able to enter the shower area of his residence safely. In order to achieve this goal, barriers in the bathroom need to be removed and a roll-in shower needs to be created).

Repair and maintenance of items purchased through the CLASS program do not require justification from a medical professional.

The service planning team must:

  • consider a written assessment recommending an MHM;
  • document any discussion about the recommended MHM; and
  • agree that the recommended MHM is necessary and should be purchased.

The case management agency (CMA), direct services agency (DSA) and individual/legally authorized representative (LAR) must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications. Form 3660 is not required to accompany an IPC revision that adds only the cost of obtaining specifications to the IPC.

The DSA must submit Form 3660, along with specifications and bids for any MHM with a cost of $1,000 or higher, to the CMA. The case manager must issue an IPC revision or IPC renewal to obtain a service authorization from the Texas Health and Human Services Commission (HHSC) for the proposed MHM.

For MHMs with a cost of $1,000 or higher, a DSA must obtain comparable bids for the requested MHM from three vendors. Comparable bids describe the MHM and any associated items or modifications identified in an assessment for an MHM. A bid must:

  • state the total cost of the requested MHM;
  • include the name, address and telephone number of the vendor;
  • include a complete description of the MHM and any associated items or modifications as identified in a written assessment, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • be obtained within one year after the written assessment.

A DSA may obtain only one bid or two comparable bids for an MHM if the DSA has written justification for obtaining fewer than three bids because the MHM is available from a limited number of vendors.

If a DSA will request authorization for payment for an MHM that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid.

The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the MHM; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The only MHMs purchasable by the DSA are listed in this appendix. The maximum amount HHSC authorizes as payment to the DSA for all MHMs purchased for an individual receiving CLASS program services is $10,000. This is a lifetime limit for an individual who receives CLASS program services. After reaching the lifetime maximum cost of $10,000, an individual may receive, during an IPC period, a maximum of $300 for repair and maintenance of an MHM purchased through the CLASS program, needed after one year has elapsed from the date the MHM is complete.

MHMs are provided under this waiver when no other financial resource is available or when other available resources have been exhausted. MHMs will not be used to modify homes that are owned or leased by providers of waiver services. Modifications must be for existing structures and must not increase the square footage of the dwelling. Excluded are those adaptations or improvements to the home that are of general utility and are not a direct medical or remedial benefit to the individual, such as carpeting (except to allow independent mobility for persons using crutches, wheelchairs, three-wheel scooters, and other aids which offer increased personal mobility), roof repair, central air conditioning, etc. If alternative solutions exist, modifications will be approved by staff from HHSC based on considerations of cost and comparable functionality.

MHMs have to be assessed by the most qualified licensed professionals who can justify the need and appropriateness of a requested MHM.

The following licensed professionals may assess the need for an MHM in the CLASS program.

  • Audiologist (AU) — A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Psychological Associate (PSA) — A person licensed as a psychological associate in accordance with the Texas Occupations Code, Chapter 501.
  • Licensed Professional Counselor (LPC) — A person licensed as a professional counselor in accordance with the Texas Occupations Code, Chapter 503.
  • Dietitian (DI) — A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
  • Registered Nurse (RN) — A person licensed to practice professional nursing by the Texas Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
  • Physician (MD) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155.
  • Occupational Therapist (OT) — A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
  • Ophthalmology (OPH) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
  • Optometrist (OPT) — A person licensed as an optometrist or therapeutic optometrist in accordance with the Texas Occupations Code, Chapter 351.
  • Physical Therapist (PT) — A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
  • Psychologist (PS) — A person licensed as a psychologist, provisionally licensed psychologist or psychological associate in accordance with Chapter 501 of the Texas Occupations Code.
  • Speech-Language Pathologist (SP) — A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.

Home modifications that may be covered in the CLASS program must be included on the following list and include the installation, maintenance and repair of approved items not covered by warranty.

  1. Home Modifications
    1. floor leveling (only in residences owned by the individual and/or family and only when the installation of a ramp is not possible) (OT, PT)
    2. vinyl flooring or industrial grade carpet necessary to ensure the safety of the individual, prevent falling, improve mobility and adapt a living space occupied by a beneficiary who is unable to safely use existing floor surface (OT, PT)
    3. medically necessary steam cleaning of walls, carpet, support equipment and upholstery (MD)
    4. roll-in showers (OT, PT)
    5. sink modifications (OT, PT)
    6. sink cut-outs (OT, PT)
    7. bathtub modifications (OT, PT)
    8. water faucet controls (OT, PT)
    9. toilet modifications (OT, PT)
    10. floor urinal and bidet adaptations (OT, PT)
    11. plumbing modifications (OT, PT)
    12. turnaround space modifications (OT, PT)
    13. worktable/work surface adjustments (OT, PT)
    14. cabinet development/adjustments (OT, PT)
  2. Specialized Accessibility/Safety Adaptations/Additions (including repair and maintenance)
    1. ramps (constructed to provide access into and within the home) (OT, PT)
    2. protective awnings over ramps (OT, PT, MD)
    3. door widening (OT, PT, MD)
    4. widening/enlargement of garage and/or carport to accommodate primary transportation vehicle and to allow people using wheelchairs to enter and exit their adapted vehicles safely (OT, PT)
    5. installation of sidewalk for access from non-connected garage and/or driveway to residence when existing surface condition is a safety hazard for the person with a disability (OT, PT)
    6. porch/patio leveling (only when the installation of a ramp is not possible) (OT, PT)
    7. grab bars and handrails (OT, PT, MD)
    8. door bells, door scopes and adaptive wall switches (OT, PT)
    9. safety glass, safety alarms (does not include home security systems), security door locks, fire safety approved window locks, security window screens and visual alert systems (for example, for individuals with behavioral problems) (OT, PT, MD, PSA, LPC)
    10. medically necessary air filtering devices (MD)
    11. protective padding and corner guards for walls (OT, PT, MD, PSA, LPC)
    12. recessed lighting with mesh covering and metal dome light covers for individuals with behavior problems (OT, PT, MD, PSA, LPC)
    13. emergency back-up gas-powered generators (limited to critical medical equipment) (OT, PT, MD)
    14. medically necessary noise abatement renovations to provide increased sound proofing for people with sensory impairments (OT, PT, MD, PSA, LPC)
    15. lever door handles (OT, PT, MD, RN)
    16. door replacement only when required for accessibility (OT, PT, MD)
    17. intercom systems for people with limited mobility or visual impairment (OT, PT, OPT, OPH)
    18. Video monitoring for individuals with limited mobility and to ensure health and safety (OT, PT, PSA, LPC, MD)
  3. Repair and maintenance of items on the authorized list above as allowable by rule.

CLASS-PM, Appendix III, Mutually Exclusive Services

CLASS-PM, Appendix IV, Dental Treatment

Revision 11-1; Effective June 13, 2011

 

Dental treatment consists of dental services and dental sedation.

Dental services within the Community Living Assistance and Support Services (CLASS) program include the following.

  • Emergency Dental Treatment — Includes procedures necessary to control bleeding, relieve pain and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures.
  • Routine Preventative Dental Treatment — includes examinations, X-rays, cleanings, sealants, oral prophylaxes and topical fluoride applications.
  • Therapeutic Dental Treatment — Includes fillings; scaling; extractions; crowns; pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development.
  • Orthodontic Dental Treatment — Includes treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index.

Note: Dental treatment in CLASS does not include cosmetic orthodontia.

Dental sedation in CLASS includes sedation that is necessary to perform dental treatment, including non-routine anesthesia, (for example, intravenous sedation, general anesthesia or sedative therapy prior to routine procedures).

Note: Dental sedation does not include administration of routine local anesthesia.

The maximum amount the Department of Aging and Disability Services (DADS) authorizes as payment for all adaptive aids and dental treatment combined is $10,000 per Individual Plan of Care (IPC) year.

Individuals must exhaust all non-CLASS resources before requesting dental treatment through CLASS.

Note: Individuals under age 21 have access to Texas Health Steps for their dental treatment and as such do not qualify to receive dental treatment in CLASS.

Procurement Process for Dental Services/Dental Sedation

The case management agency (CMA) must:

  • provide general information about the availability of dental services/dental sedation to the individual or legally authorized representative (LAR) during service planning and at any other time upon request by the individual or LAR.
  • inform the individual or LAR about the limitations of dental services/dental sedation as it applies in CLASS.
  • aid the individual or LAR to access non-CLASS resources for needed dental care.
  • complete, with input from the individual or LAR, Part A of Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation.
  • complete Part B of Form 3660.
  • submit Form 3660 to the direct service agency (DSA) selected by the individual or LAR no later than 14 business days from completion of Form 3660, Part A. Note: This form must be signed by the individual or LAR.
  • receive and review the dental treatment plan for the individual.
  • initiate an IPC revision within five business days of receipt of Form 3660 and the treatment plan.
  • transmit an IPC revision signed by all applicable service planning team (SPT) members to DADS at least 30 calendar days before the effective date proposed by the SPT.
  • provide a record of the DADS-approved IPC to all SPT members.
  • monitor service delivery in accordance with the IPC and Individual Program Plan (IPP) and applicable CLASS standards.

The DSA must:

  • complete Form 3660, Part C, within five business days of receipt from the CMA.
  • obtain a written treatment plan from a qualified service provider for dental treatment (a person licensed to practice dentistry, dental surgery or dental hygiene in accordance with Texas Occupations Code, Chapter 256) within 14 business days of receipt of the request (Form 3660). The individuals' preferences in the selection of the service provider for dental treatment should be considered when obtaining the treatment plan.
  • ensure the treatment plan includes a complete description of the proposed dental services, dental sedation service and a breakdown of the cost for each element of the proposed service.
  • provide a copy of the proposed treatment plan to the CMA.

Once the DSA has determined the cost of the requested dental treatment and/or dental sedation, the DSA must request in writing that the case manager initiate an IPC revision. The DSA must inform the individual's case manager of the cost of the requested dental treatment and/or dental sedation.

After reviewing submitted documentation, if DADS determines the requested dental treatment and/or dental sedation meets the standards outlined in this appendix, DADS authorizes the IPC.

The DSA must initiate delivery of the requested dental treatment and/or dental sedation within14 calendar days after the date DADS authorizes the proposed IPC or the effective date of the individual's IPC, as determined by the SPT (whichever is later).

If the DSA cannot provide the dental treatment and/or dental sedation within the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing before the 14-day time frame expires, that the dental treatment and/or dental sedation will not be provided within the 14-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the dental treatment and/or dental sedation.

Immediate Jeopardy

When an individual requires emergency dental treatment and/or dental sedation, the DSA will provide the services in accordance with Section 3330, Revision, and Section 3510, Immediate Jeopardy. Following provision of emergency dental treatment, the CMA must complete an IPC revision in accordance with Section 2331, Immediate Jeopardy.

CLASS-PM, Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs

Revision 18-1; Effective February 14, 2018

 

General Guidelines for Direct Service Agencies (DSAs)

The DSA is responsible for complying with these guidelines and instructions when completing functional assessments and reassessments for all individuals served by the DSA, according to the Community Living Assistance and Support Services (CLASS) program requirements:

Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, and Instructions

List of ICD-10 Approved Diagnostic Codes for Persons with Related Conditions (use for assessments with effective dates on or after Oct. 1, 2017):
https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf

Guidelines for completing the Inventory for Client and Agency Planning (ICAP)/Scales of Independent Behavior – Revised (SIB-R):
ICAPguidelines.pdf

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI), and Instructions

All of these resources can be found on the HHS website: https://hhs.texas.gov/

The ID/RC Assessment is the document that contains all of the information required to determine an individual’s initial and continuing eligibility for the CLASS program. The ID/RC summarizes demographic, diagnostic and functional information about the individual.

The tools used to determine functional ability are the RCESI and the Adaptive Behavior Level (ABL) assessment tool. The DSA may select from among four ABL tools for use in the CLASS program: the ICAP, the SIB-R, the Vineland Adaptive Behavior Scales and the American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales. The ICAP and SIB-R must be administered by the DSA registered nurse (RN) according to the guidelines noted above. The other two assessments are done by the appropriate professional, usually a licensed psychologist, as identified in the guidelines for the use of these tools. It is up to the DSA to choose the tool used to complete the functional assessments of individuals served by the DSA. The ICAP and the SIB-R must be purchased and licensed through Riverside Publishing (https://www.hmhco.com/classroom-solutions/assessment (link is external)).

The ID/RC, the RCESI, the ABL assessment tool, and the nursing assessment using the CLASS/DBMD Nursing Assessment form must be completed at the time of enrollment (the CLASS/DBMD Nursing Assessment form is not a required part of the ID/RC packet). The DSA RN must conduct these assessments (with the exception of the Vineland or the AAIDD, as stated above). At the time of the annual re-enrollment, these assessments are repeated, with the exception of the ABL assessment tool, which is required only every five years, or if a situation changes. These documents are completed by an RN because the RN has the professional ability to assess the clinical status of the individual and is required to comply with the contractual obligations of the provider, in addition to following the rules of conduct outlined by the Texas Board of Nurses. All corrections to the above referenced documents must also be made by an RN.

All ID/RC packets must include, at a minimum, Form 8578, Form 8662 and the summary (scoring program) of the ABL assessment results.

Initial Eligibility

ID/RC Purpose Code 2 – Initial application; denote this in field 13 on Form 8578.

The DSA must provide the individual’s physician with a list of the Approved Diagnostic Codes for Persons with Related Conditions (see the link above). From this list, the physician will be asked to identify the diagnosis and associated diagnostic code that is primarily responsible for the individual’s disability. If the individual does not have a diagnosis of a related condition, as identified in the Approved Diagnostic Codes for Persons with Related Conditions, the physician must still indicate a diagnosis for the individual and International Classification of Diseases (ICD) code. The physician must complete the section on Page 3 of the ID/RC to testify to the validity of the information in fields 19 – 27 of the form. The physician must be a licensed MD or DO. The DSA is not required to obtain the physician’s signature in handwritten format; the DSA must comply with applicable Home and Community Support Services Agency (HCSSA) requirements related to the receipt of physician orders, as outlined in 40 Texas Administrative Code, Chapter 97, Subchapter C.

The DSA RN must administer the RCESI and the ABL assessment tool, if an ICAP or SIB-R.

An initial application will not have Individual Plan of Care (IPC) begin or end dates identified on the ID/RC. When the ID/RC is authorized by DADS, a begin date will be assigned, based on the date the packet was received by DADS. After all assessments are completed, the RN completes the ID/RC form, signs and dates the form, and forwards it to the physician for his review and sign-off. When returned by the physician, the ID/RC packet is then mailed to DADS for review.

Instructions for the ID/RC form require the program provider that transmits Form 8578 to maintain the original Form 8578 and all other original forms in the individual’s record.

Continuing Eligibility

ID/RC Purpose Code 3 – Reassessments

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an ID/RC, an RCESI (this must be completed every year) and an ABL assessment (ICAP/SIB-R) if the current one is greater than five years old, or is no longer valid. If the ABL tool is the Vineland or the AAIDD, the DSA will arrange to have this done. If the individual’s situation has not changed since the last submission, a copy of the summary of results (the scoring program) of the current ABL assessment is included in the packet.

The RN will record the IPC begin and end dates. For a reassessment, the ID/RC packet must not be submitted more than 120 calendar days prior to the individual’s IPC begin date. The packet must be submitted no less than 60 calendar days prior to the expiration of the current IPC.

If an ID/RC is reviewed by DADS and is authorized before the IPC begin date, the ID/RC will be approved with the IPC begin date.

If the ID/RC is not received by DADS with complete and accurate information in order to be authorized before the individual’s IPC begin date, the ID/RC will be authorized with the DADS receipt date.

When an ID/RC is approved after the IPC begin date, a Purpose Code E will be required to cover the gap between the individual’s original IPC begin date and the authorized, later date on the Purpose Code 3.

ID/RC Purpose Code E – Required to cover a lapse in eligibility

A Purpose Code E must be completed by the DSA RN to cover the period from the individual’s IPC begin date to the day before the Purpose Code 3 was authorized by DADS. A Purpose Code E is required to document the individual’s continuous program eligibility.

The DSA must:

  • prepare a Purpose Code E if the ID/RC packet with the Purpose Code 3 is not submitted in sufficient time to arrive at DADS by the individual’s IPC begin date;
  • date the completion of the Purpose Code E as the date that it is actually prepared;
  • ensure the Purpose Code E is a separate document (it cannot be a copy of the Purpose Code 3 and it must match the Purpose Code 3 exactly, except for the completion dates);
  • ensure that if a Purpose Code E is submitted separately from the Purpose Code 3, to include a copy of the authorized Purpose Code 3 in the packet and indicate on the Purpose Code E the exact end date for the Purpose Code E (copies of the RCESI and ABL assessment tool are not required with submission of a Purpose Code E to DADS as long as these documents are submitted with a DADS authorized Purpose Code 3); and
  • ensure the IPC begin date for a Purpose Code E is the same as the original IPC begin date.

A Purpose Code E does not require a physician’s signature, even if one is requested for the Purpose Code 3.

Note: In situations that require submission of a Purpose Code E, there can be no break in service provision to the individual.

Form 8578, Intellectual Disability/Related Condition Assessment

Form fields that do not apply – The following fields should always be blank for CLASS:

  • 6 — Component Code;
  • 7 — Case No;
  • 73 — CARE ID;
  • 18 — LON;
  • 29 — IQ;
  • 68 — IQ Instrument; and
  • Page 2 of the ID/RC.

DADS does not issue remands for these fields. Staff are not required to insert "NA" in these fields as NA is understood.

Dates on Form 8578

  • Completion dates for the ID/RC must be on or after the RCESI dates and the date of completion of the ABL assessment, unless it was necessary to conduct a new assessment;
  • Date in field 12 on or before the date in field 58;
  • Date in field 58 on or before the physician’s date on Page 3;
  • If preparing a Purpose Code E, document the date that the form was completed; and
  • If re-typing a form in response to a remand from DADS, document the date that the form was re-typed in field 58, or explain that the form was re-typed in the provider comments section.

Alignment Between Diagnosis and ICD Code

For assessments with effective dates prior to Oct. 1, 2015, the list of ICD-9 approved diagnostic codes for persons with related conditions can be found here.

For assessments with effective dates on or after Oct. 1, 2017, the list of ICD-10 approved diagnostic codes for persons with related conditions can be found at:
https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf (link is external).

Diagnoses for eligibility consideration by DADS must be a diagnosis included in the approved list. The individual’s diagnosis must be a valid code documented exactly as the diagnosis is denoted in the list. On or after Oct. 1, 2015, ICD-9 codes will no longer be accepted. ICD-10-CM is composed of codes with three, four, five, six or seven characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of four, five, six or seven characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided.

An example is H91.9, Unspecified Hearing Loss, which by itself is not a valid code. Examples of valid codes within category H91.9 contain five characters, such as:

H91.90, Unspecified Hearing Loss, Unspecified Ear;
H91.91, Unspecified Hearing Loss, Right Ear;
H91.92, Unspecified Hearing Loss, Left Ear; and
H91.93, Unspecified Hearing Loss, Bilateral.

Notes:

  • Additional digits are needed for most 800 codes (850 is the exception).
  • The diagnosis has to record what is in the list, through the final digit. Example: 854.01
    854. = intracranial injury of other and unspecified nature; .0 = no mention of open intracranial wound; 1 = (from Page 5 of the list) no loss of consciousness; 854.01 = intracranial injury of other and unspecified nature, no intracranial wound, no loss of consciousness.

List the diagnosis associated with the code in the approved list:

  • Text up to the parentheses or semicolon; a specific condition can always be included in parentheses.
  • The text in parentheses usually clarifies a diagnosis or contains other diagnoses that are included in the broader diagnosis; it is not necessary to record these unless the text in parentheses applies. Example: 299.0 Autistic disorder; does the individual have just childhood autism, or does he have infantile psychosis or Kanner’s syndrome?
  • It is acceptable to abbreviate (PDD, CP; "NOS" for unspecified; "no" for without).

The primary diagnosis is the only diagnosis field that is required in CLASS.

  • If secondary or tertiary diagnoses are recorded, they must be documented fully and accurately. Even if the primary diagnosis is an eligible related condition with the correct ICD-9 code, the ID/RC will not be authorized if the additional diagnoses and ICD-9 codes are not accurate.
  • If a secondary or tertiary diagnosis is recorded that is not on the list of Approved Diagnostic Codes, the provider must go to the global ICD-9 to obtain the correct code.

The physician attests to the accuracy of these diagnoses and codes. In the event any changes or modifications are required to these fields, the DSA must obtain the physician’s agreement, as indicated by the signature and date on Page 3.

Problematic Fields on Form 8578

Mistakes in documentation in these fields are common:

  • Previous Residence (16) – This refers to the individual's previous residence, location or program before being enrolled in the CLASS program. Staff may have to ask the family to help determine this value.
  • Recommended LOC (17) – This is usually an ‘8’; put a zero here to indicate that the individual is not eligible for the program; ‘1’ does not apply to the CLASS program.
  • Version Code (21, 25, 28) – This is always ‘9’; may change in 2013.
  • Score Identified by ABL Instrument (74) – For ICAPs, this will contain the same value as in field 33; for SIB-Rs, this is the score represented by X/90; this does not apply to the other ABL tools.
  • Functional Assessment (75) – This is the score from the RCESI and should match what is reported on the assessment. The value will always be between 1 and 6 for those over age 10, and 1 to 4 for those under age 10.

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI)

This assessment measures the functional limitations in the six major areas of life activities. To qualify for CLASS, the individual must have impairments in at least three of the six areas for persons age 10 and over, or three of the four areas for those under age 10 (42 Code of Federal Regulations 45.1010).

Right of the individual to sign:

  • If the individual is an adult with no guardian and is able to respond to the assessment, he may answer for himself and must sign for himself.
  • If the individual has a guardian, the guardian must sign Form 8662. In addition to the guardian’s signature, the individual may sign for himself.
  • No other person can sign for the individual, even if a guardian. The guardian will usually be represented as the informant. If the individual is his own guardian, but is unable to sign or stamp his name, he should make some kind of mark (using hand-over-hand assistance, if necessary). The nurse can note "John’s mark" and her signature on the form is testimony to his signing. If the individual is unable to make a mark even with hand-over-hand, note the reason on the form in the comment section – this is reserved only for rare circumstances.

Use of Informant — If an informant is needed to assist the individual, regardless of legal status, that informant must always sign the form as the informant. If the individual is his own guardian, he must sign the form in addition to the informant.

Note: If the form is altered after the assessment, for instance to remove the name of an informant, the form must be re-signed and dated by the appropriate person(s) to indicate agreement with the change(s).

Consistency Between Activities, the Summary and the ID/RC

  • The Summary in Section 4 (B) 1 must match what is recorded in the individual activities on Pages 1 and 2. The score must match what is on the ID/RC (field 75).
  • Note the age of the individual – Activities E and F are not applicable to children under age 10.
  • Score between 1 and 6:
    • For an individual age 10 and older, the maximum score is 6
    • For a child under age 10, the maximum score is 4.

Adaptive Behavior Level (ABL) Assessment Tool

ICAP, SIB-R, Vineland, AAIDD:

  • Only ICAPs and SIB-Rs are done by DSA RNs.
  • ICAP and SIB-R are very similar and guidelines are the same for both.
  • The DSA RN does face-to-face with the individual, regardless of age.
  • The RN must engage the individual during the time of assessment, even if a minor and even when the RN will make use of an informant to assist in completion of the assessment:
    • RN is the independent, objective observer and assessor of the individual;
    • RN must take into account the information provided by the individual or family (can sometimes be under- or over-estimate of actual abilities);
    • RN observes, may use props, can ask the individual to demonstrate tasks or can generalize from other tasks;
    • RN compiles information from individual/family/attendants/etc., and from the RN’s own observations and knowledge of the individual, to arrive at an independent assessment.
  • Booklet – the supporting clinical documentation for the ABL assessment:
    • must be complete, accurate, and done in permanent pen;
    • must match the scoring program; and
    • the original must be kept in the individual’s file.
  • The transferring DSA must forward all originals in the individual’s case record; if no originals are available, a receiving DSA may want to conduct a new assessment.

Problem Behaviors

  • Not every behavior is a problem; not every problem is serious (per assessment guidelines, that can be found at the following link: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/lidda/icapguidelines.pdf).
  • Definition of a problem (from the guidelines):
    • Many behaviors, even if listed as examples, may not be problems if they are mild, infrequent or age appropriate.
    • For the purpose of the CLASS assessment, a behavior is not a problem if it does not require the attention or intervention of staff, or if it is not discussed as an issue during the service planning team.
    • Does not include behaviors that are a part of the diagnosis, that are medical problems or for which a behavior plan would not be effective.
  • Criteria for severity (from the guidelines):
    • From least (mild) to most severe (critical).
    • Guidelines help the RN to determine the severity of the problem.
    • This section is to assess what behavior is going to present a problem for the service provider; it does not necessarily matter how serious a behavior may be to a parent or other family member if the behavior is not a factor with regard to direct service provision.
  • Staff record only one problem behavior in a category and do not record the same behavior in more than one category.
  • Staff can record more than one problem in the individual’s record, but must choose only one to report in the assessment document.

The ICAP or SIB-R is an assessment of the individual’s activity in the month directly prior to the time the assessment is conducted:

  • If a behavior occurs less than once a month and did not occur during the previous month, it does not have to be listed.
  • If a behavior is not a problem/not serious, the frequency should be "never."
  • This section is for recording serious problem behavior; if a behavior is not a problem or is not serious, the individual should not be penalized for it.

The ABL is assessed at least every five years, or as necessary if the individual’s situation changes. The ABL assessment must be reviewed at the time of every reassessment to verify continuing accuracy.

  • Children may need to be assessed more frequently.
  • Necessary whenever a situation or needs change.
  • Maintain an original record for the files.

Perform Quality Control Before Submitting ID/RC Packets to DADS

Only the most recent ID/RC packet submission is relevant as this information renews at least annually.

All required forms must be complete and accurate:

  • No blank fields (other than those identified in the instructions).
  • Check consistency – birth dates, onset dates.
  • Check previous Level of Care forms (Form 8578 or Form 3650) – diagnosis, code, birth date, onset date.
  • Ensure that remands have been thoroughly checked and that all remand reasons have been fully addressed.
  • The submission must be within the appropriate time frame.
  • The submission for reassessments must be within the 120- to 60-day time frame.
  • Compare the diagnosis and code against the current DADS List of Approved Diagnostic Codes for Persons with Related Conditions.

Remands

Return all material, including the material that was originally submitted plus all new material and all remand forms, with each re-submission to DADS. DADS must be able to track the history of the packet with each re-submission, including:

  • what has been requested and corrected;
  • who worked the packet before; and
  • all dates must be clearly defined.

Corrections/Additions – Mark through the incorrect value, insert the correct value, initial, and date each correction or addition of missing information. For RCESI or the ABL assessment, provide clear indication of the correct response.

Consistency Within and With Other Information Provided

  • Birth dates; completion dates on other forms;
  • Legal status (field 15), RCESI, ICAP, etc.;
  • ABL Assessment, and ABL (field 30);
  • Field 74 (Score identified by ABL Instrument – same as field 33 for the ICAP); and
  • Behavior Program (field 34), Nursing (39), Day Services (41), Employment Services (44):
    • If a service is indicated, the related fields must be populated, and vice versa.
    • Nursing is a required service and these fields should always be completed for a Purpose Code 3; at the very least this represents the nursing that is allotted on the IPC.
    • Behavior Program (field 34) and fields 35 – 38; if no behavior program, these fields must be 0 and vice versa.

ID/RC Processing Timeline

DADS requires 15 working days to process ID/RC packets. Working days do not include weekend days or state or federal holidays. In addition, the provider must allow four days of mail time from the date the provider mailed the packet, and four days following the DADS processing timeline for the mail to be received back by the provider.

Contact Information

For ID/RC inquiries, staff:

  • Fax a name or a list of individuals to DADS Administrative Assistant at 512-438-5135.
  • Include the name, Medicaid number (or Social Security number), and date the packet is mailed.
  • If not within the processing timeline outlined, wait to inquire until the processing timeline has lapsed.

For questions related to an assessment or status, contact the IDD Waivers Program Enrollment/Utilization Review Unit in Access and Intake at DADS at 512-438-3609.

  • Voice message – Speak slowly and distinctly.
  • Leave name, number and a brief message.

Mail – All ID/RC packets are mailed to DADS unless other arrangements are made.

Regular Mail

Department of Aging and Disability Services
P.O. Box 149030, Mail Code W-521
Austin TX 78714-9030

Priority or Overnight Mail – Physical Address

Department of Aging and Disability Services
701 W. 51st St., Mail Code W-521
Austin, TX 78751

Note: Always include Mail Code W-521 for accurate routing.

CLASS Fax Number – 512-438-5135

CLASS-PM, Appendix VI, DADS Contract Management

CLASS-PM, Appendix VII, HIV/AIDS in the Workplace

CLASS-PM, Appendix VIII, Medicaid for the Elderly and People with Disabilities

CLASS-PM, Appendix IX, List of Excluded Individuals and Entities (LEIE)

CLASS-PM, Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart

Revision 17-1; Effective November 1, 2017

 

IPP Service Summary/IPP Service Review Due Dates Chart

IPC Renewal Date

 

First DSA/FMSA Summary Due Date First CMA Review Due Date Second DSA/ FMSA Summary Due Date Second CMA Review Due Date Third DSA/ FMSA Summary Due Date Third CMA Review Due Date Earliest Renewal Meeting Date Latest Date to Submit IPC to HHSC
Jan 1 Feb 28 Mar 31 May 31 June 30 Aug 31 Sept 30 Oct 3 Dec 2
Feb 1 Mar 31 April 30 June 30 July 31 Sept 30 Oct 31 Nov 3 Jan 2
Mar 1 April 30 May 31 July 31 Aug 31 Oct 31 Nov 30 Dec 1 Jan 30
April 1 May 31 June 30 Aug 31 Sept 30 Nov 30 Dec 31 Jan 1 Mar 2
May 1 June 30 July 31 Sept 30 Oct 31 Dec 31 Jan 31 Jan 31 April 1
June 1 July 31 Aug 31 Oct 31 Nov 30 Jan 31 Feb 28 Mar 3 May 2
July 1 Aug 31 Sept 30 Nov 30 Dec 31 Feb 28 Mar 31 April 2 June 1
Aug 1 Sept 30 Oct 31 Dec 31 Jan 31 Mar 31 April 30 May 3 July 2
Sept 1 Oct 31 Nov 30 Jan 31 Feb 28 April 30 May 31 June 3 Aug 2
Oct 1 Nov 30 Dec 31 Feb 28 Mar 31 May 31 June 30 July 3 Sept 1
Nov 1 Dec 31 Jan 31 Mar 31 April 30 June 30 July 31 Aug 3 Oct 2
Dec 1 Jan 31 Feb 28 April 30 May 31 July 31 Aug 31 Sept 2 Nov 1

CLASS-PM, Appendix XI, Retired Information Letters

Revision 13-5; Effective November 19, 2013

 

The Department of Aging and Disability Services (DADS) deployed the revised Community Living Assistance and Support Services (CLASS) Provider Manual in June 2011. This manual contains contract guidelines that were formerly found in Information Letters (ILs).

Content in this manual and the Texas Administrative Code (TAC) supersedes any previous ILs or similar guidance published by DADS. The ILs retired as a result are listed below. DADS recommends that providers remove the ILs from their records to ensure they reference the most current information. Any letters or program guidance issued prior to Internet accessibility is null and void, including policy previously sent by U.S. mail.

Number Title Date Posted Date Removed
IL 2010-59 Policy Clarification Regarding Utilization Review in the Community Living Assistance Services and Supports Waiver Program 4/26/2010 6/13/2011
IL 2010-22 Information Letter Clarifying Behavioral Support Services 2/17/2010 6/13/2011
IL 2010-02 Enhancements to the CLASS Program Notification Processes [Note: this letter was withdrawn on 6/3/2010] 5/13/2010 6/3/2010
IL 2009-158 Personal Care Services and CLASS Habilitation 12/11/2009 6/13/2011
IL 2009-127 Rate Increase and IPC Adjustments for CDS 9/09/2009 6/13/2011
IL 2009-120 Expansion of Services Available Through the Consumer Directed Services (CDS) Option in the CLASS Program 9/02/2009 6/13/2011
IL 2009-110 Renewal of CLASS Waiver 8/31/2009 6/13/2011
IL 2008-97 New Service Codes for CDS Respite for the CLASS Program 7/01/2008 6/13/2011
IL 2008-75 Billing Procedures for CMA Vendor Number Transfers 5/23/2008 6/13/2011
IL 2008-64 Revisions to Forms 3621 and 3621-T 5/23/2008 6/13/2011
IL 2008-34 Nursing Services Billing 3/05/2008 6/13/2011
IL 2008-19 Correction to Form 3621 2/12/2008 6/13/2011
IL 2008-127 Utilization Review of Individual Service Plans (ISPs) 9/04/2008 6/13/2011
IL 2008-123 Behavioral Support Services 8/22/2008 6/13/2011
IL 2008-11 CLASS Utilization Review and Cost Ceiling 1/24/2008 6/13/2011
IL 2007-59 CLASS Transfer Process (Clarifies transfer process) 6/20/2007 6/13/2011
IL 2007-57 Billing Procedures for CMA and DSA Pre-Assessments 6/29/2007 6/13/2011
IL 2007-46 CLASS Individual Service Plan and Billing Processes (Billing Info) 6/20/2007 6/13/2011
IL 2007-16 Discontinuation of Payment for Monthly Service Fees for Communication Devices (No monthly bills) 4/04/2007 6/13/2011
IL 2007-120 Additional Information for Coordinating CLASS Enrollments when Applicants Are Currently Receiving Assistance from Personal Care Services (PCS) (This letter was rescinded 11/21/2008) 11/15/2007 11/21/2008
IL 2007-116 Addition of Specialized Nursing 12/07/2007 6/13/2011
IL 2007-104 Addition of Specialized Therapies Requisition Fee 10/19/2007 6/13/2011
IL 2006-95 New CLASS Form 1351 -- Decline of Offer for CLASS Program Enrollment (New form) 11/15/2006 6/13/2011
PL 2004-22 /
IL 2004-36
Documents from the Texas Department of Human Services after September 1, 2004 8/10/2004 6/13/2011
IL 2004-34 New Medicaid Waiver Service of Support Family Services 7/14/2004 6/13/2011
IL 2001-17 Electronic Access to Program Rules and Handbooks (All letters, manuals and TAC on web) 9/14/2001 6/13/2011
CMS 2001-07 Claims Information (Claims and end of FY) 7/13/2001 6/13/2011
CMS 2001-02 Miscellaneous Claims (Claims paid after end of fiscal year) 3/30/2001 6/13/2011
CMS 2001-01 Loss of Medicaid Eligibility Report (How providers learn of ME loss) 12/28/2000 6/13/2011
CMS 2000-10 Procedures for Overlapping Services in the Service Authorization System (SAS) / Claims Management System (CMS) (Info for SO staff) 1/31/2001 6/13/2011
CMS 2000-08 Most Common NHIC Errors and SAS Causes 11/22/2000 6/13/2011
CMS 2000-06 New R&S Report (Enhancements made to R&S Report take effect on 8/14/00.) 8/04/2000 6/13/2011
CLASS2002-05 Program Terminology and Staff Orientation (Remove 24 hour training requirement) 09/23/2002 6/13/2011
CLASS2002-04 Adaptive Aids, Minor Home Modifications, and Medical Supplies 04/19/2002 6/13/2011
CLASS2002-02 Cost Ceilings in the CLASS Program 02/08/2002 6/13/2011
CLASS2002-01 Level-of-Care determination for CLASS participants 01/17/2002 6/13/2011
CLASS2001-04 Respite Care 11/09/2001 6/13/2011
CLASS2001-03 Calculating Requisition Fees and Participant-Requested for Upgrades 11/15/2001 6/13/2011
CLASS2001-02 Appropriation Riders, 77th Legislative Session 09/19/2001 6/13/2011
CLASS2001-01 Updated Procedures for Processing Form 3621, Page 1, Individual Service Plan 06/15/2001 6/13/2011
CLASS2000-05 Documentation of Services Delivered, Form 3625 09/01/2000 6/13/2011
CLASS2000-04 Individual Service Plan, Form 3621-1 08/24/2000 6/13/2011
CLASS2000-03 Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions 07/27/2000 6/13/2011
CLASS2000-01 Procedures for completing and submitting the Level-of-Care and attachment(s) 07/15/2000 6/13/2011
CLASS1999-16 Changes to the instructions on Form 3625, Documentation of Services Delivered 01/20/2000 6/13/2011
CLASS1999-08 Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions 08/19/1999 6/13/2011
CLASS1999-04 CLASS Policy Clarification No. 99004 (Updated list of ICD-9-CM & Form 3650-A/B Instructions) 04/15/1999 6/13/2011
CLASS1999-02 Documentation requirements for purchase of computers and accessories through the CLASS Program 03/19/1999 6/13/2011
CLASS 2004-03 Request for Hearings 11/05/2004 6/13/2011
CLASS 2004-02 Implementation Procedures for Rider 7(b)(2) in the CLASS Program 10/22/2004 6/13/2011
CLASS 2004-01 Implementation of Support Family Services (SFS Introduced. NF residents, under 18, discharged into the CLASS offered SFS as an alternative to residing with their natural family.) 8/25/2004 6/13/2011
CLASS 2003-04 Revised List of Approved Service and Billing Codes for CLASS (HHSC approved rates for CLASS CDSA providers for SFY 2004 and 2005.) 8/29/2003 6/13/2011
CLASS 2003-03 Class Rate Changes, Effective September 1, 2003 (HHSC approved rates for CLASS providers for SFY 2004 and 2005) 8/29/2003 6/13/2011
CLASS 2003-02 Revised List of Approved Service and Billing Codes for CLASS (CLASS providers must use approved service codes and billing codes on or after September 1, 2003. If not used, the claim will be rejected.) 8/26/2003 6/13/2011
CLASS 2003-01 Follow-Up to CLASS Info letter No. 02-02 Rate Changes (CDSA requirements for monitoring usage) 2/10/2003 6/13/2011
CLASS 2002-03 Follow-Up to CLASS Info letter No. 02-02 - Rate Changes (CDS rate changes) 10/04/2002 6/13/2011
CLASS 2002-02 Rate Changes 7/26/2002 6/13/2011
CLASS 2001-02 CLASS Rate Changes 8/28/2001 6/13/2011
CLASS 2001-01 Frequently Asked Questions (FAQ's) (Supervisory Visits, IPC Change, CMA billing w/Transfer, Sleeping during respite) 6/26/2001 6/13/2011
CLASS 2000-01 Correction to Info letter #2000-01 CLASS Rate Changes and New Service Cap 9/29/2000 6/13/2011
CLASS 1999-30 Re-issuance of Info letter #1999-30 - New/Amended Client Eligibility Rules 7/01/2000 6/13/2011
CLASS 1999-12 Revised CLASS Forms 7/09/1999 6/13/2011
CLASS 1999-06 New Rules for CLASS Provider Agencies (New TAC introduced) 3/31/1999 11/19/2013

If there are questions about the CLASS provider manual or any of the letters that were retired, send an email message to class@hhsc.state.tx.us.

CLASS-PM, Appendix XII, Advance Directives

CLASS-PM, Forms

Form Title
1290 Long Term Care Claim  
1351 Request to Withdraw from the CLASS Application Process ES
1581 Consumer Directed Services Option Overview ES
1582 Consumer Directed Services Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1720 Appointment of a Designated Representative  
1735 Employer and  Employer and Financial Management Services Agency Service Agreement  
1739 Service Provider Agreement  
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
2067 Case Information  
2076 Authorization to Release Medical Information ES
2124 Community Support Transportation Log  
2432 Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) Vehicle Evaluation  
3591 CLASS IPC/IDRC Cover Sheet  
3595 IPP Service Review  
3596 PAS/Habilitation Plan - CLASS/DBMD/CFC  
3598 Individual Transportation Plan  
3599 Habilitation Service Provider Orientation/Supervisory Visits  
3621 CLASS/CFC - Individual Plan of Care  
3621-T CLASS/CFC - IPC Service Delivery Transfer Worksheet  
3622 Denial of Application for CLASS  
3623 Approval of Application for CLASS  
3624 Termination, Reduction or Denial of CLASS  
3625 CLASS/CFC - Documentation of Services Delivered ES
3627 Specialized Nursing Certification  
3628 Provider Agency Model Service Backup Plan  
3629 Individual Program Plan Addendum  
3657 Pre-Enrollment Assessment  
3660 Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation  
3849-A Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications  
4800-D Fair Hearing Request Summary  
4800-DA 4800-D Addendum  
6509 CLASS/DBMD Coordination of Care  
6515 CLASS/DBMD Nursing Assessment  
8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
8507 Understanding Program Eligibility - CLASS/DBMD  
8578 Intellectual Disability/Related Condition Assessment  
8598 Non-Waiver Services  
8601 Verification of Freedom of Choice ES
8604 Transition Assistance Services (TAS) Assessment and Authorization  
8605 Documentation of Completion of Purchase  
8606 Individual Program Plan (IPP)  
8606-A Therapy Justifications - Attachment to IPP  
8662 Related Conditions Eligibility Screening Instrument  
H1200 Application for Assistance - Your Texas Benefits  
H1350 Opportunity to Register to Vote  
H1746-A MEPD Referral Cover Sheet  
H1826 Case Information Release ES
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES

ES  = form also available in Spanish.

CLASS-PM, Revisions

CLASSPM, 18-1, Appendix V Revised

Revision Notice 18-1; Effective February 14, 2018

 

The following change(s) were made:

Revised

Title

Change

Appendix V

ID/RC Processing, for additional information and detailed instructions for DSAs

Provides a website link to the Approved Diagnostic Codes for Persons with Related Conditions List Effective October 2017.

CLASS-PM, 17-1, Miscellaneous Changes

Revision Notice 17-1; Effective November 1, 2017

 

The following change(s) were made:

Revised Title Change
Entire Manual Miscellaneous
  • Changes all DADS and DARS references to HHSC throughout the entire manual.
  • Adds Form 3629, Individual Program Plan Addendum, Form 1720, Appointment of a Designated Representative, Form 1735, CLASS, Service Provision Requirements Addendum, Form 8507, Understanding Program Eligibility - CLASS/DBMD and Form 8601, Verification of Freedom of Choice throughout manual.
  • Deletes Forms 3597, CLASS Habilitation Training Plan and 1517, Level of Care Redetermination Cover Sheet.
  • Clarifies and updates eligibility, enrollment and cancellation processes and procedures as well as updates to services and safety procedures throughout manual.
Additional Changes to Manual
Revised Title Change
1000 Initial Training for Habilitation and Respite Service Providers Adds the exact title of TAC where CLASS rules are found.
2121 Initial Training for Staff with Direct Contact Defines direct contact and the type of training needed for those whose job involves direct contact.
2123 CMA Staff Training for Person-Centered Planning Adds Section 2123 and includes who must receive person-centered training.
2200 Eligibility Updates information case manager is responsible for when verifying eligibility.
2300 Service Planning Clarifies how the case manager facilitates SPT meetings to develop a plan for the individuals functioning.
2500 Provision of Direct Services by CMA Adds Section 2500 and includes TAC rules and specifics from Title 42 of the Code of Federal Regulations.
3100 DSA Responsibilities Clarifies tasks the DSA is required to perform.
3120 Service Planning Team (SPT) Meetings/DSA Staff Training Requirement. Deletes this chapter and changes Chapter 3130, DSA Staff Training Requirement to Chapter 3120.
3121 Initial Training for Direct Contact Staff Changes Section 3131, Initial Training for Direct Contact Staff, to Section 3121 keeping the same title. Clearly defines direct contact.
3121.1 Initial Training for CFC PAS/HAB or CLASS Transportation-Habilitation and Respite Service Providers Renumbers from 3131.1 to Section 3132.1 and changes name adding CFC PAS/HAB or CLASS Transportation.
3122

Initial and Annual Training for All DSA Staff

Renumbers 3132 to Section 3122. Adds information about Form 8606, Individual Program Plan (IPP) and Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC.
3123 Types of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers Renumbers 3133 to Section 3123.  Updates title with reference to CFC PAS/HAB or CLASS Transportation.
3124 Required Training for CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers Renumbers 3134 to Section 3124.  Updates title with reference to CFC PAS/HAB or CLASS Transportation.
3125 Required Training for Certain Special CFC PAS/HAB or Special Transportation-Habilitation Service Providers Renumbers 3135 to Section 3125. Updates with reference to CFC PAS/HAB or CLASS Transportation.
3126 Documentation of Required Experience for Special Service Provider Exception Renumbers 3136 to Section 3126.  Updates with reference to CFC PAS/HAB.
3300 Service Planning Updates DSA roll in planning IPPs.
3310 Enrollment Updates CLASS program vacancy process.
3320 DSA Renewal of Level of Care Updates the DSA role in revising the IPC.
3331 Immediate Jeopardy of CLASS Individual Updates section title adding “of Class Individual”.
3350 IPP Service Summaries Updates references, links and terminology.
3510 Immediate Jeopardy of CLASS and CFC Providers Updates section title.
3600 CFC PAS/HAB or CLASS Transportation-Habilitation Services Documentation Changes section title from old Habilitation Services Documentation title.
4630 Services in the CLASS Programs Available Through the CDS Option that may be Received Outside of the State of Texas Adds Section 4630 to manual.
5200 CLASS Cost Limits Changes title from UR Threshold to CLASS Cost Limits and updates cost ceiling and allowable maximum combined costs.
5300 Dental Utilization Review of Dental Services Add Section 5300 to manual.
6100

Contract Monitoring

Deletes Readiness Review and changes Section 6200 to 6100 Contracting Monitoring.
7120 Direct Services Agency (DSA) Services Updates section name to Direct Services Agency (DSA) Services from Direct Service Agency (DSA) Services.
7210 Case Management Updates billable activities.
7233 Specialized Therapies Updates billable activities.
7280 Transportation-Habilitation, CFC PAS/HAB and Respite Care Changes title from Habilitation and Respite Care to Transportation-Habilitation, CFC PAS/HAB and Respite Care.
7281.1 Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) Adds Section 7281.1.
7281.2 Community First Choice (CFC) Support Management Adds Section 7281.2.
Appendix I Adaptive Aids Adds doctor of osteopathic medicine (DO) to list of approved licensed professionals.
Form 3595 IPP Service Review Revise form by removing service category 10V.

CLASS-PM, 16-2, Form Added

Revision Notice 16-2; Effective May 16, 2016

 

The following change(s) were made:

Revised Title Change
2310 Enrollment Adds Form 2124, Community Support Transportation Log.
3320 DSA Renewal Adds Form 2124.

CLASS-PM, 16-1, Form Change

Revision Notice 16-1; Effective January 28, 2016

 

The following change(s) were made:

Revised Title Change
2310 Enrollment Replaces obsolete Form 3590, CLASS — Nursing Assessment, with Form 6515, CLASS/DBMD Nursing Assessment
2320 Renewal Replaces Form 3590 with Form 6515.
2330 Revision Replaces Form 3590 with Form 6515.
3310 Enrollment Replaces Form 3590 with Form 6515.
Forms Forms Table of Contents Deletes Form 3590.

CLASS-PM, Acronyms

Revision 13-2; Effective September 6, 2013

 

AAIDD — American Association of Intellectual and Developmental Disabilities

ABL — Adaptive Behavior Level

ABS — Adaptive Behavior Scales

ADL — Activities of Daily Living

ARD — Admission, Review and Dismissal

CAP — Corrective Action Plan

CAS — Community Attendant Services

CBA — Community Based Alternatives

CDS — Consumer Directed Services

CDSA — Consumer Directed Service Agency

CFS — Continued Family Services

CLASS — Community Living Assistance and Support Services

CMA — Case Management Agency

CMPAS — Consumer Managed Personal Attendant Services

CRS — Consumer Rights and Services

DADS — Department of Aging and Disability Services

DARS — Department of Assistive and Rehabilitative Services

DBMD — Deaf Blind with Multiple Disabilities

DFPS — Department of Family and Protective Services

DR — Designated Representative

DSA — Direct Service Agency

DSHS — Department of State Health Services

ERS — Emergency Response Services

EVV — Electronic Visit Verification

FC — Family Care

FMS — Financial Management Services

FMSA — Financial Management Services Agency

HCS — Home and Community-based Services

HDM — Home-Delivered Meals

HHSC — Health and Human Services Commission

ICAP — Inventory for Client and Agency Planning

ICF/IID — Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions

IEP — Individual Education Plan

IHFSP — In-Home and Family Support Program

IPC — Individual Plan of Care

IPP — Individual Program Plan

LA — Local Authority

LAR — Legally Authorized Representative

LOC — Level of Care

MDCP — Medically Dependent Children Program

OT — Occupational Therapy

PDP — Person Directed Planning

PHC — Primary Home Care

PT — Physical Therapy

RC — Residential Care

SARC — Sanction Action Review Committee

SFS — Support Family Services

SIB-R — Scales of Independent Behavior – Revised

SPT — Service Planning Team

SSI — Social Security Income

SSPD — Special Services for Persons with Disabilities (24-Hour)

TAS — Transition Assistance Services

TMHP — Texas Medicaid & Healthcare Partnership

TxHmL — Texas Home Living

UR — Utilization Review

Vineland-II — Vineland Adaptive Behavior Scales, Second Edition

CLASS-PM, Glossary

Revision 13-2; Effective September 6, 2013

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

# A C D E F H I L M N P R S T U

§1915(c) Medicaid Waiver — The provision of the Social Security Act that authorizes the secretary of Health and Human Services to grant waivers of certain Medicaid statutory requirements so that a state may furnish home and community-based services to Medicaid beneficiaries who need a level of institutional care that is provided in a hospital, nursing facility or intermediate care facility for persons with intellectual disability (ICF/ID).

# A C D E F H I L M N P R S T U

Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of an individual. Types of abuse include:

  • physical abuse (a physical act by an individual that may cause physical injury to another individual).
  • psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual).
  • sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of an individual by another).
  • verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate an individual).

Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.

Agency Option — A service delivery option in which the provider agency is the employer of record of the direct service provider of a specific CLASS program service.

Applicant — A person who has requested CLASS program services for whom eligibility for CLASS is in the process of being determined.

Appeal — The formal process by which an applicant, individual, or the applicant or individual's parent, guardian or legally authorized representative (LAR) requests a review of an adverse action.

 

# A C D E F H I L M N P R S T U

 

Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based" id="Community">Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based services and supports to people with developmental disabilities other than intellectual disability as an alternative to residing in an intermediate care facility.

Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.

Case Manager — An employee of the Case Management Agency (CMA) who serves as the focal point for service planning and delivery. Responsibilities include needs assessment and reassessment, development of the service plan, identifying appropriate community resources, monitoring the appropriateness and quality of services, providing crisis intervention and advocacy, safeguarding individual rights, and keeping records.

 

Case Management Services — Services that assist the individual in:

 

  • assessing the individual's needs;
  • enrolling into the CLASS program;
  • developing the Individual's Plan of Care (IPC);
  • coordinating the provision of CLASS program services;
  • monitoring the effectiveness of the CLASS program services and the individual's progress toward achieving the outcomes identified;
  • revising the IPC, as appropriate;
  • accessing non-CLASS program services;
  • crisis resolution; and
  • advocating for the individual's needs.

Case Management Agency (CMA) — Contracted agency that provides case management services to the individual.

Catchment Area — A geographic area composed of multiple Texas counties.

Consumer Directed Services (CDS) Option — A service delivery option in which an individual/LAR employs and retains service providers and directs the delivery of program services.

Consumer Directed Service Agency (CDSA) — The name of the entity that provided financial management services to the individual/LAR who serve as the employer of their service providers. The entity is now called Financial Management Services Agency (FMSA).

Continued Family Service (CFS) Agency — Agency that provides services to an individual age 18 or older who resides with a support family, which allows the individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADL. The individual must be receiving support family services immediately before receiving continued family services. A CFS agency must maintain licensure as a Child-Placing Agency through the Texas Department of Family and Protective Services (DFPS).

Consumer Rights and Services (CRS) — A division within the Department of Aging and Disability Services (DADS) that receives and processes complaints from individuals, family members, providers and the general public about the care, treatment or services provided to an individual.

 

# A C D E F H I L M N P R S T U

 

Denial — An action taken by DADS that:

  • denies an individual's request for enrollment into the CLASS program;
  • disallows a CLASS program service requested on an IPC that was not authorized on the prior IPC; or
  • disallows a portion of the amount or level of a CLASS program service requested on an IPC that was not authorized on the prior IPC.

Department of Aging and Disability Services (DADS) — Texas state agency that provides long-term services and supports to older people and individuals with physical, intellectual and developmental disabilities. DADS also regulates providers of long-term services and supports, and administers the state's guardianship program.

Department of Assistive and Rehabilitative Services (DARS) — Texas state agency that administers programs that ensure Texas is a state where people with disabilities, and children who have developmental delays, enjoy the same opportunities as other Texans to live independent and productive lives.

Department of Family and Protective Services (DFPS) — Texas state agency that protects children, the elderly and people with disabilities from abuse, neglect and exploitation by involving clients, families and communities.

Department of State Health Services (DSHS) — Texas state agency that promotes optimal health for individuals and communities while providing effective health, mental health and substance abuse services to Texans.

Direct Services — CLASS program services other than case management, financial management services, support consultation or transition assistance services.

Direct Service Agency (DSA) — A program provider that is a licensed Home and Community Supports Service Agency (HCSSA) that contracts with DADS to provide direct services to the individual.

Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.

 

# A C D E F H I L M N P R S T U

 

Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of an individual by taking advantage of an individual's disability or impairment.

 

# A C D E F H I L M N P R S T U

 

Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by DADS.

Financial Management Services Agency (FMSA) — An entity that provides financial management services to the individual/LAR who serve as the employer of their service providers.

 

# A C D E F H I L M N P R S T U

 

Habilitation Attendant — A direct service provider who can be an employee of a DSA or a CDS employer who assists an individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADLs.

Health and Human Services Commission (HHSC) — Texas state agency that provides leadership and direction, and fosters the spirit of innovation needed to achieve an efficient and effective health and human services system for Texans. HHSC oversees the operations of the health and human services system, provides administrative oversight of Texas health and human services programs, and provides direct administration of some programs, which is composed of five agencies:

  • Health and Human Services Commission (HHSC)
  • Department of Aging and Disability Services (DADS)
  • Department of State Health Services (DSHS)
  • Department of Assistive and Rehabilitative Services (DARS)
  • Department of Family and Protective Services (DFPS)

 

# A C D E F H I L M N P R S T U

 

Individual — A person who is determined by DADS to be eligible for or who receives CLASS program services.

 

Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.

Individual Plan of Care (IPC) — A written plan developed by an individual's service planning team that describes the type and amount of each CLASS program service to be provided to the individual, and services and supports to be provided to the individual through non-CLASS program resources including natural supports, medical services and educational services.

IPC Period — The effective period of an enrollment IPC and a renewal IPC as follows:

  • for an enrollment IPC, the period of time from the effective date of an enrollment IPC, until the first calendar day of the same month of the effective date in the following year; and
  • for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC.

Individual Program Plan (IPP) — A written plan that describes the goals and objectives to be met by the provision of each CLASS program service on an individual's IPC that are supported by justifications, are measurable and have timelines.

Institutional Services — Medicaid-funded services provided in a nursing facility licensed in accordance with Texas Health and Safety Code, Chapter 242, or in an ICF/ID certified by DADS for a capacity of more than six people.

Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID) — A public or private facility that provides health and habilitation services to individuals with intellectual disabilities or related conditions.

Interest List (IL) — A list of people who have contacted DADS and expressed an interest in receiving waiver services, but who have not applied for or been determined eligible for services.

 

# A C D E F H I L M N P R S T U

 

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

 

# A C D E F H I L M N P R S T U

 

Medicaid — A program administered by the federal Centers for Medicare and Medicaid Services (CMS), and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.

Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.

Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease.

Medicaid Eligibility Services Authorization Verification (MESAV) — The automated system used by DADS to notify providers of Medicaid eligibility and service authorizations.

Money Follows the Person (MFP) — A policy that allows residents of nursing facilities to enroll into certain Medicaid waiver programs without having to wait on a program interest list upon determination of program eligibility.

Mutually Exclusive — DADS waiver or Community Care for the Aged and Disabled (CCAD) services that an individual may not receive while enrolled in the CLASS program because services may be duplicative in addressing the individual's needs.

 

# A C D E F H I L M N P R S T U

 

Neglect — The failure to provide an individual the reasonable care required, including but not limited to:

  • food,
  • clothing,
  • shelter,
  • medical care,
  • personal hygiene, and
  • protection from harm.

Non-CLASS Services — Services that are not provided under CLASS waiver provisions of §1915(c) of the Social Security Act.

Notice — A written statement describing the intent of action the state will bring against an individual or the individual's LAR at least 10 days before the date of action.

Nursing Facility — A residential institution that primarily provides:

  • skilled nursing care and related services for residents who require medical or nursing care;
  • rehabilitation services for the rehabilitation of injured, disabled or sick people; or
  • health-related care and services, on a regular basis, to individuals who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through institutional facilities.

 

# A C D E F H I L M N P R S T U

 

Provider Agency — An entity that has a contract with DADS to deliver CLASS services. See DSA and CMA.

 

# A C D E F H I L M N P R S T U

 

Related Condition (RC) — A severe chronic disability attributed to a condition other than mental illness but found to be closely related to intellectual disability. The condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities and requires treatment or services similar to those required for people with intellectual disabilities. It is manifested before the person reaches age 22, is likely to continue indefinitely, and results in substantial functional limitations in at least three of the following areas of major life activity:

  • self care,
  • understanding and use of language,
  • learning,
  • mobility,
  • self-direction, and
  • capacity for independent living.

 

# A C D E F H I L M N P R S T U

 

Service Planning Team (SPT) — A planning team convened and facilitated by a CLASS program case manager consisting of:

  • individual/LAR,
  • case manager, and
  • DSA representative.

An SPT may also include:

  • other people as requested by the individual/LAR; and
  • a person selected by the DSA, with the approval of the individual or LAR, who is professionally qualified by certification or licensure and has special training and experience in the diagnosis and habilitation of people with the individual's related condition, or directly involved in the delivery of services and supports to the individual.

Support Family Service (SFS) Agency — Agency providing services to an individual under age 18 who resides with a support family that allows the individual to reside successfully in a community setting by supporting the individual to acquire, maintain and improve self-help, socialization and daily living skills or assisting the individual with ADLs. An SFS agency must maintain licensure as a Child-Placing Agency through DFPS.

Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.

 

# A C D E F H I L M N P R S T U

 

Transition Assistance Services (TAS) Agency — Agency that provides a one-time service 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.

Termination — A term used when an individual no longer meets the program’s eligibility criteria and services are ended.

Texas Health Steps-Comprehensive Care Program — Texas Health Steps is also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. Texas Health Steps is dedicated to:

  • expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts, and;
  • recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.

Texas Medicaid & Healthcare Partnership (TMHP) — A coalition of contractors headed by ACS State Healthcare LLC, which administers claims processing for Texas Medicaid and other state health-care programs for the state of Texas, under contract with HHSC.

 

# A C D E F H I L M N P R S T U

 

Utilization Review — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.

 

CLASS-PM, Contact Us

For questions about the Community Living Assistance and Support Services Provider Manual, email: classpolicy@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us