Contracting to Provide Primary Home Care Services

CPPHCS, Subchapter A, Introduction

Revision 09-1

 

 

§47.1 Purpose

 

(a) This chapter establishes the requirements for a provider contracting to provide community-based services to an individual through the DADS PHC Program. PHC Program services may be provided through a home and community support services agency, the service responsibility option (SRO), or the consumer directed services (CDS) option of service delivery. The SRO is described in Chapter 43 of this title (relating to Service Responsibility Option) and the CDS option is described in Chapter 41 of this title (relating to Consumer Directed Services Option).

(b) The requirements in this chapter apply to PHC services, FC services, and CAS, unless otherwise specified in the text.

 

§47.3 Definitions

 

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

(1) ADL — Activity of daily living. An activity that is essential to daily self care, including bathing, dressing, grooming, routine hair and skin care, meal preparation, feeding, exercising, toileting, transferring, and ambulation. An ADL does not include a service that must be provided or supervised by licensed personnel.

(2) Attendant — A person who provides authorized tasks to an individual.

(3) CAS — Community attendant services. A service under the PHC Program providing in-home attendant services to individuals with an approved medical need for assistance with personal care tasks. CAS (formerly known as §1929(b) or frail elderly) are provided under Title XIX of the federal Social Security Act (relating to Grants to States for Medical Assistance Programs) at 42 U.S.C. §1396t (relating to Home and Community Care for Functionally Disabled Elderly Individuals.

(4)Case manager — A DADS employee who is responsible for case management activities. Activities include eligibility determination, individual registration, assessment and reassessment of an individual's needs, service delivery plan development, and intercession on the individual's behalf.

(5) Contract — The formal, written agreement between DADS and a provider to provide PHC Program services to an individual eligible under this chapter in exchange for reimbursement.

(6) Contract manager — A DADS employee who is responsible for the overall management of the contract with the provider.

(7) Days — Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.

(8) DADS — The Department of Aging and Disability Services.

(9) Expedited referral — An oral request from a case manager to a provider when the case manager determines that an individual's needs require that pre-initiation activities be completed in less than 14 days. The completion date is negotiated between the case manager and provider.

(10) Facsimile notice — Written information sent to a designated number via facsimile.

(11) FC service — Family Care services. A service under the PHC Program providing in-home attendant services to eligible adults. FC services are provided under Title XX of the federal Social Security Act (relating to Block Grants to States for Social Services) at 42 U.S.C. §1397 et seq.

(12) Functional limitation — An individual's requirement for assistance with one or more ADLs caused by a physical limitation or disability.

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

(14) Individual — A person who is enrolled in the PHC Program and, unless the context indicates otherwise, the person's representative.

(15) Medical need — A medical diagnosis that results in a functional limitation.

(16) Non-priority — The eligibility status for service delivery as determined by the case manager for an individual who does not meet the criteria described in §48.2918(d) of this title (relating to Primary Home Care or Community Attendant Services). Services delivered to such an individual may be referred to as non-priority services, and an attendant who serves such an individual may be referred to as a non-priority attendant.

(17) Notice — Includes oral, facsimile, secure e-mail and written notice.

(18) Oral notice — Directly speaking with a person. Oral notice does not include a message left by voice mail.

(19) PHC Program — Primary Home Care Program. A DADS attendant care services program. CAS, PHC, and FC are the three types of services available under the PHC Program.

(20) PHC services — A service under the PHC Program providing in-home attendant services to an individual with an approved medical need for assistance with personal care tasks. PHC services are provided under Title XIX of the federal Social Security Act, at 42 U.S.C. §1396a (relating to State plans for medical assistance).

(21) Practitioner — A person who holds a doctor of medicine or doctor of osteopathy degree and is currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice nurse.

(22) Practitioner's statement — DADS' Practitioner's Statement of Medical Need form.

(23) Priority — The eligibility status for service delivery as determined by the case manager for an individual who meets the criteria described in §48.2918(d) of this title. Services delivered to such an individual may be referred to as priority services, and an attendant who serves such an individual may be referred to as a priority attendant.

(24) Provider — A licensed home and community support services agency that has a contract.

(25) Reckless behavior — Acting with conscious indifference to the consequences.

(26) Regional nurse — A DADS employee who is responsible for authorizing an individual to receive CAS.

(27) Representative — An individual's spouse, other responsible party, designated representative, or legally authorized representative.

(28) Routine referral — A written request from the case manager to a provider to evaluate an individual for service delivery when the case manager determines that the individual's needs do not require an expedited referral.

(29) Secure e-mail notice — Written information sent via electronic mail using sufficient precautions to protect the privacy and security of identifying information in compliance with the requirements of the Health Insurance Portability and Privacy Act of 1996.

(30) Service delivery plan — A single document that is agreed upon and signed by an individual and a provider containing the elements described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities). A single document may be more than one page.

(31) Service schedule — A schedule for delivering attendant services containing the elements described in §47.45(a)(2)(C)(iii) of this chapter.

(32) Signature — A person's name written in longhand or a mark representing his or her name on a document to certify it is correct. Initials are not an acceptable substitute for a signature if the person has the ability to write in longhand.

(33) Supervisor — A provider employee who:

(A) coordinates the delivery of services in an individual's service delivery plan;

(B) supervises attendants; and

(C) meets the requirements for a supervisor in accordance with §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services).

(34) Working day — Any day except a Saturday, Sunday, or state holiday.

(35) Written — Information recorded on paper or other legible document.

(36) Written notice — Written information sent via mail, facsimile, secured email, or hand delivered.

(37) Utilization review — A planned, systematic review of service utilization to evaluate efficiency, quality, and appropriateness of services and service delivery plans. Utilization review may include routinely scheduled review of services or providers, or may be focused on an identified issue.

CPPHCS, Subchapter B, Provider Agency Contracts

Revision 09-1

 

 

§47.11 Contracting Requirements

 

(a) General contracting requirements. A provider must meet all provisions described in this chapter and Chapter 49 of this title (relating to Contracting for Community Care Services), except if a contract is assigned to the provider, the provider is not required to comply with §49.14(c) of this title (relating to Provisional Contracts).

(b) Licensure. The provider in the PHC Program must deliver only personal assistance services, as defined in §97.2 of this title (relating to Definitions) and must provide services in accordance with all licensure requirements pursuant to Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies).

CPPHCS, Subchapter C, Staff Requirements

 

 

§47.21 Supervisor Training Requirements

 

(a) General training. A provider must train a supervisor as described in §97.245 of this title (relating to Staffing Policies).

(b) Program-specific training. The provider must ensure the supervisor understands the applicable rules and procedures of the PHC Program.

 

§47.23 Attendant Qualifications

 

In addition to the requirements described in §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services), an attendant must:

(1) not be a legal parent, foster parent, or spouse of a parent of a minor who receives the service;

(2) not be the spouse of the individual who receives the service, except for FC services; and

(3) not be designated by a DADS case manager on DADS' authorization for community care services form as "Do not hire."

 

§47.25 Attendant Orientation

 

(a) Orientation. In addition to the requirements described in this section, a provider must ensure each attendant is oriented as described in Chapter 97, Subchapter C, of this title (relating to Minimum Standards for All Home and Community Support Services Agencies) and §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). Orientation is not required for a supervisor when providing personal assistance services.

(b) Method of orientation.

(1) A supervisor must determine the method of attendant orientation, which may be conducted:

(A) in person, with the participation of the individual; or

(B) by telephone or verbally at any location without the participation of the individual at the discretion of the supervisor, if the attendant:

(i) meets the requirements described in §97.701 of this title (relating to Home Health Aides);

(ii) has six continuous months of experience in delivering attendant care;

(iii) has been oriented to the individual and there are service delivery plan changes; or

(iv) has previously provided services to the individual.

(2) The supervisor may use discretion to determine if the attendant needs to be oriented if:

(A) the attendant previously provided services to the individual; and

(B) the service delivery plan has not changed since the attendant provided services to the individual.

(c) Due dates. The supervisor must orient each attendant on or before the time the attendant begins to provide attendant services.

(d) Documentation of attendant orientation.

(1) The supervisor must record the attendant orientation on a single document that includes:

(A) the individual's name and number assigned to the individual by DADS;

(B) the attendant's name;

(C) the date of the attendant orientation;

(D) if the orientation was conducted in person with the individual or without the participation of the individual;

(E) information about how the individual's condition affects the performance of tasks;

(F) the tasks to be performed;

(G) the service schedule;

(H) the number of hours of service the attendant is to provide;

(I) the total number of hours of service the individual is authorized to receive;

(J) safety and emergency procedures, including universal precautions;

(K) specific situations about which the attendant must notify the provider, including:

(i) changes in the individual's needs;

(ii) incidents that affect the individual's condition;

(iii) hospitalization of the individual;

(iv) the individual's absence or relocation from home;

(v) the attendant's inability to work; and

(vi) suspicions or allegations of abuse, neglect, or exploitation of the individual; and

(L) the signature of:

(i) the supervisor who conducts the orientation;

(ii) the attendant who is oriented, if present; and

(iii) the individual, if present.

(2) The provider must maintain documentation of the attendant orientation in the individual's file.

CPPHCS, Subchapter D, Service Plan Development

Revision 09-1

 

 

§47.41 Allowable Tasks

 

The PHC Program includes the following tasks:

(1) personal care tasks related to the care of the individual's physical well being, including:

(A) bathing, which is:

(i) drawing water in sink, basin, or tub;

(ii) hauling or heating water;

(iii) laying out supplies;

(iv) assisting in or out of tub or shower;

(v) sponge bathing and drying;

(vi) bed bathing and drying;

(vii) tub bathing and drying; and

(viii) providing standby assistance for safety;

(B) dressing, which is:

(i) dressing the individual;

(ii) undressing the individual; and

(iii) laying out clothes;

(C) meal preparation, which is:

(i) cooking a full meal;

(ii) warming up prepared food;

(iii) planning meals;

(iv) helping prepare meals; and

(v) cutting client's food for eating;

(D) feeding/eating, which is:

(i) spoon-feeding;

(ii) bottle-feeding;

(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and

(iv) providing standby assistance or encouragement;

(E) exercise, which is walking with the individual;

(F) grooming, shaving, or oral care, which is:

(i) shaving;

(ii) brushing teeth;

(iii) shaving underarms and legs, when requested;

(iv) caring for nails; and

(v) laying out supplies;

(G) routine hair or skin care, which is:

(i) washing hair;

(ii) drying hair;

(iii) assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair;

(iv) combing or brushing hair;

(v) applying nonprescription lotion to skin;

(vi) washing hands and face;

(vii) applying makeup; and

(viii) laying out supplies;

(H) assistance with self-administered medications, which is assistance with medication as defined in §97.2(11) of this title (relating to Definitions);

(I) toileting, which is:

(i) changing diapers;

(ii) changing colostomy bag or emptying catheter bag;

(iii) assisting on or off bedpan;

(iv) assisting with the use of a urinal;

(v) assisting with feminine hygiene needs;

(vi) assisting with clothing during toileting;

(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;

(viii) changing external catheter;

(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and

(x) providing standby assistance; and

(J) transfer, which is:

(i) non-ambulatory movement from one stationary position to another, not including carrying;

(ii) adjusting or changing the individual's position in a bed or chair (positioning);

(iii) assisting in rising from a sitting to a standing position;

(K) ambulation, which is:

(i) assisting in positioning for use of a walking apparatus;

(ii) assisting with putting on and removing leg braces and prostheses for ambulation;

(iii) assisting with ambulation or using steps;

(iv) assisting with wheelchair ambulation; and

(v) providing standby assistance;

(2) home management tasks that support the individual's health and safety, including:

(A) cleaning, which is:

(i) cleaning up after the individual's personal care tasks;

(ii) emptying and cleaning the individual's bedside commode;

(iii) cleaning the individual's bathroom;

(iv) changing the individual's bed linens and making the individual's bed;

(v) cleaning floor of living areas used by the individual;

(vi) dusting areas used by the individual;

(vii) carrying out the trash and setting out garbage for pick up;

(viii) cleaning stovetop and counters;

(ix) washing the individual's dishes; and

(x) cleaning refrigerator and stove;

(B) laundry, which is:

(i) doing hand wash;

(ii) gathering and sorting;

(iii) loading and unloading machines in residence;

(iv) using laundromat machines;

(v) hanging clothes to dry;

(vi) folding and putting away clothes; and

(C) shopping, which is:

(i) preparing a shopping list;

(ii) going to the store and purchasing or picking up items;

(iii) picking up medication; and

(iv) storing the individual's purchased items; and

(3) escorting, including:

(A) accompanying the individual outside the home to support the individual in living in the community;

(B) arranging for transportation, not including direct individual transportation;

(C) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and

(D) waiting in the doctor's office or clinic with an individual if necessary due to client's condition or distance from home.

 

§47.43 Referrals

 

(a) A provider must:

(1) accept all DADS referrals for services under the PHC Program; and

(2) conduct the pre-initiation activities as described in §47.45 of this chapter (relating to Pre-Initiation Activities).

(b) There are two methods of referral:

(1) For expedited referrals, the case manager makes the referral by oral notice and on DADS' authorization for community care services form.

(2) For routine referrals, the case manager makes the referral on DADS' authorization for community care services form.

 

§47.45 Pre-Initiation Activities

 

(a) Pre-initiation activities. A supervisor must complete the following activities for each referral.

(1) The supervisor must conduct an evaluation.

(A) The evaluation must be a single document that includes the individual's self-report of:

(i) the dates and reasons for any hospitalization within the last three months; and

(ii) the assistance needed for the individual to perform ADLs, including any assistive devices or medical equipment used by the person.

(B) If the provider determines during the evaluation that the individual exhibits reckless behavior that results in imminent danger to the health and safety of the individual or provider staff, the provider must convene an Interdisciplinary Team meeting as described in §47.49 of this chapter (relating to Interdisciplinary Team) to discuss the barriers to service delivery.

(2) The supervisor must develop a service delivery plan on a single document that:

(A) is agreed upon and signed by the individual and the provider;

(B) indicates the location of service delivery;

(C) records the following:

(i) the tasks which the individual is authorized to receive;

(ii) the total weekly hours of service DADS authorizes the individual to receive;

(iii) the service schedule, which must include as necessary, based on an individual’s needs, certain time periods for the delivery of specified tasks;

(iv) frequency of supervisory visits; and

(v) a statement that:

(I) the PHC Program only provides the tasks allowable in the program as described in §47.41 of this chapter (relating to Allowable Tasks) and agreed to on the service delivery plan; and

(II) the provider is not responsible for meeting the applicant's needs other than tasks allowed under the PHC Program.

(3) The provider must obtain a complete practitioner's statement and submit for DADS' review as described in §47.47 of this chapter (relating to Medical Need Determination). This paragraph does not apply to FC services.

(A) For routine referrals:

(i) send a copy of the practitioner’s statement to DADS by facsimile or secured email; or

(ii) mail a copy of the practitioner’s statement to DADS.

(B) For expedited referrals:

(i) DADS may send the authorization for community services form pending receipt of the practitioner’s statement if the provider notifies DADS that the provider has received a complete practitioner’s statement that documents the individual’s medical condition is the cause of the individual’s functional impairment.

(ii) Upon notification of a completed practitioner’s statement, DADS and the provider will negotiate a start-of-care date.

(iii) The provider must send the complete practitioner’s statement to DADS within 7 working days after service initiation.

(iv) If a complete practitioner’s statement is not sent to DADS within 7 working days after service initiation the provider is not entitled to payment from DADS until the date DADS receives the completed practitioner’s statement. In this circumstance, DADS will change the service initiation date to the date DADS receives the completed practitioner’s statement.

(v) The signature date of the practitioner must be on or before the negotiated start-of-care date.

(b) Service delivery plan variances.

(1) The provider must notify the case manager of a variance in the service delivery plan when the initial service delivery plan developed by the provider:

(A) has more hours than authorized on DADS' authorization for community care services form;

(B) has no personal care services, except for FC services; or

(C) is temporarily changed as described in paragraph (3) of this subsection.

(2) The provider must provide services according to the existing service delivery plan, until the provider receives a new DADS' authorization for community care services form, except the provider may temporarily change the service delivery plan if:

(A) the individual requests and requires temporary assistance with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and

(B) the change in tasks does not increase the total approved hours of service or continue for more than 60 days.

(3) The provider must request and obtain a new DADS authorization for community services form when a temporary variance in tasks on the service delivery plan is to continue for more than 60 days or would result in more hours of service provided than have been approved.

(4) The provider must request a new DADS authorization for community care services form before a temporary variance from the service delivery plan continues for more than 60 days.

(5) The provider must maintain the following documentation regarding the temporary service delivery plan variance in the individual's file:

(A) the specific variance in the service delivery plan;

(B) the duration of the temporary variance; and

(c) the reason for the temporary variance as described in paragraph (3) of this subsection.

(c) Pre-initiation activities due date. The provider must complete the pre-initiation activities as follows:

(1) for routine referrals, within 14 days after one of the following dates, whichever is later:

(A) the referral date on DADS' authorization for community care services form; or

(B) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness; and

(2) for expedited referrals, by the date negotiated between the case manager and provider, which must be less than 14 days after the oral request.

(d) Delay in pre-initiation activities.

(1) A provider may delay meeting the due dates in subsection (c) of this section only for reasons beyond its control such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.

(2) The provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:

(A) the reason for the delay, which must be beyond the provider’s control;

(B) either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and

(C) a description of the provider's ongoing efforts to complete pre-initiation activities.

(3) The provider must notify the case manager of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case manager may refer the individual to another provider.

(e) Documentation of pre-initiation activities.

(1) The provider may combine the evaluation and service delivery plan into a single document, but each item must be clearly identifiable.

(2) The provider must maintain documentation of the pre-initiation activities in the individual's file.

 

§47.47 Medical Need Determination

 

(a) Applicability. This section does not apply to FC services or transfers of individuals in the PHC Program.

(b) Determining medical need. A provider must obtain and submit a complete practitioner's statement to DADS for review by the applicable due date, as described in §47.45(c) of this chapter, (relating to Pre-Initiation Activities) for:

(1) an individual whom DADS refers to the provider (unless the individual requests and is to receive FC services);

(2) an individual currently receiving FC services whom DADS refers to the provider for PHC services or CAS; and

(3) an individual currently receiving services whom DADS refers to the provider to have medical need reassessed, as requested by the case manager, such as when the initial medical need was established for a limited time.

(c) Submitting a practitioner's statement. A provider must submit a complete practitioner's statement to:

(1) the DADS case manager for PHC services; and

(2) the DADS regional nurse for CAS.

(d) Reinstatement of services after termination. If DADS notifies the provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

(e) Mental illness and mental retardation. Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnoses, but may establish medical need through a related diagnosis that results in a functional limitation.

 

§47.49 Interdisciplinary Team

 

(a) Interdisciplinary Team (IDT). The IDT is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:

(1) the individual or the individual's representative, or both;

(2) a provider representative; and

(3) a DADS representative, who may be:

(A) the case manager (or designee);

(B) the case manager's supervisor (or designee);

(C) the contract manager (or designee); or

(C) the regional nurse (or designee).

(b) Convening an IDT meeting.

(1) The provider must convene an IDT meeting:

(A) within three working days of the date the provider suspends services to an individual under §47.71(a)(7) or (b) of this chapter (relating to Suspensions); or

(B) within seven working days of the date the provider identifies an issue that prevents the provider from carrying out a requirement of the PHC Program.

(2) A provider must make and document a good faith effort to include all members of the IDT described in subsection (a) of this section.

(3) If the provider is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the provider must convene the IDT meeting with the available members and send the documentation of the IDT meeting described in subsection (e) of this section to the Regional Director for the DADS region in which the individual resides. The documentation must be sent within five working days after the date of the IDT meeting.

(c) IDT meeting.

(1) The IDT meeting may be conducted by telephone or in person.

(2) The IDT must:

(A) evaluate the issue;

(B) identify any solutions to resolve the issue; and

(C) make recommendations to the provider.

(d) IDT meeting outcome. The provider must do one of the following within two working days after the IDT meeting:

(1) implement the recommendations of the IDT; or

(2) discharge the individual from the provider and refer the individual to the case manager for referral to another provider.

(e) Documentation of the IDT meeting. The provider must document the IDT meeting in the individual's file, including the:

(1) specific reasons for calling the IDT meeting;

(2) participants in the IDT meeting;

(3) recommendations of the IDT;

(4) action as a result of the IDT recommendations; and

(5) reasons for the provider's actions.

CPPHCS, Subchapter E, Service Requirements

Revision 09-1

 

 

§47.57 Service Delivery Options

 

An individual receiving PHC Program services has a choice of one of the following three service delivery options.

(1) Agency option. In the agency option:

(A) the provider is responsible for personnel decisions, such as selecting, supervising, and dismissing the attendant who provides services to the individual, with input from the individual;

(B) the provider is responsible for:

(i) recruitment of attendants and substitute attendants (a responsibility the individual may share);

(ii) payroll for attendants and substitute attendants; and

(iii) filing tax-related reports of attendants and substitute attendants;

(C) the provider is the employer of record of attendants and substitute attendants; and

(D) the provider is responsible for providing substitute attendants.

(2) Consumer directed services (CDS) option. In the CDS option, as described in Chapter 41 of this title (relating to Consumer Directed Services Option):

(A) the individual recruits, hires, manages, and fires attendants;

(B) the individual is the employer of record of his or her attendant and substitute attendant;

(C) the individual is responsible for providing substitute attendants; and

(D) the consumer directed services agency (CDSA) is responsible for financial management services, including:

(i) registering as the individual's employer-agent with the Internal Revenue Service and the Texas Workforce Commission;

(ii) managing payroll for attendants and substitute attendants, including filing tax-related reports;

(iii) tracking expenditures; and

(iv) submitting quarterly expenditure reports to the employer and case manager; and

(E) the CDSA is not required to be licensed under Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies) when performing the functions described in subparagraph (D) of this paragraph.

(3) Service responsibility option (SRO). In the SRO, as described in Chapter 43 of this title (relating to Service Responsibility Option):

(A) the individual selects, manages, supervises, and dismisses attendants;

(B) the provider is the employer of record for the attendant and substitute attendant;

(C) the provider is responsible for:

(i) providing substitute attendants if necessary;

(ii) managing payroll for attendants and substitute attendants; and

(iii) filing tax-related reports of attendants and substitute attendants;

(D) the individual and supervisor must negotiate the frequency of supervisory visits;

(E) the individual is responsible for the new attendant orientation; and

(F) the provider is required to be licensed under Chapter 97 of this title if performing the functions described in subparagraph (C) of this paragraph.

 

§47.59 Support Consultation

 

(a) Support consultation is an optional service available when the consumer directed services (CDS) option or service responsibility option (SRO) is chosen by an individual.

(b) Support consultation in CDS:

(1) is provided by a DADS-certified support advisor and provides a level of assistance and training beyond that provided by the consumer directed services agency (CDSA) through financial management services; and

(2) helps an employer to meet the required employer responsibilities of the CDS option to successfully deliver program services.

(c) Support consultation in the SRO provides the required SRO orientation and additional support when needed by an individual to effectively carry out individual responsibilities under the SRO.

 

§47.61 Service Initiation

 

(a) Service initiation. The provider must initiate services:

(1) for routine referrals described in §47.43 of this chapter (relating to Referrals):

(A) for FC services, within 14 days after the following, whichever is later:

(i) the referral date on DADS' authorization for community care services form; or

(ii) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date is used to determine timeliness; or

(B) for PHC and CAS, within seven days after provider receipt of DADS' authorization for community care services form; and

(2) for expedited referrals described in §47.43 of this chapter, on the date negotiated between the case manager and provider.

(b) Notification of service initiation. Within 14 days after initiating services, the provider must send service initiation to the case manager.

(c) Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond its control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider’s control;

(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and

(3) a description of the provider's ongoing efforts to initiate services.

(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

 

§47.63 Service Delivery

 

(a) Service interruptions. A service interruption occurs when, on a particular day or time when services are scheduled:

(1) the client requests that:

(A) no hours of service be provided; or

(B) fewer hours of service than reflected in the service schedule be provided; or

(C) a specific attendant not provide services to the client;

(2) the client is not at home when services are scheduled;

(3) services are suspended as described in §47.71 of this chapter (relating to Suspensions); or

(4) services are not delivered for other reasons beyond the control of the provider agency, such as acts of nature and other disasters.

(b) Delivery of services.

(1) The provider agency must ensure:

(A) services are delivered according to the service plan described in §47.45 of this chapter (relating to Pre-Initiation Activities);

(B) all authorized and scheduled services are provided to a client, except in the case of a service interruption, as defined in subsection (a) of this section; and

(C) a client does not receive, during a calendar month, more than five times the weekly authorized hours on the Texas Department of Human Services' (DHS's) Authorization for Community Care Services form.

(2) The provider agency must not exceed the weekly authorized hours except in the case of a temporary increase:

(A) due to unusual circumstances and client need; and

(B) requested by the client.

(C) This paragraph does not apply to the circumstances described in subsection (d) of this section.

(c) Service interruption documentation.

(1) In the case of a priority client, the provider agency must document all service interruptions by the 30th day after the beginning of the service interruption.

(2) In the case of a non-priority client, the provider agency must document all service interruptions that exceed 14 consecutive days by the 30th day after the day service interruption exceeds 14 consecutive days.

(A) For a fixed service schedule, the service interruption begins on the first day services are scheduled but not delivered.

(B) For a variable service schedule, the service interruption begins the Sunday following the week the client did not receive all the weekly hours on a service plan approved by the client.

(3) The reason documented must be a reason listed in subsection (a) of this section.

(4) If the provider agency learns of a service interruption after the deadlines listed in paragraphs (1) and (2) of this subsection, the provider agency must document the following as soon as the provider agency learns of the service interruption:

(A) the reason for the service interruption. The reason documented must be a reason listed in subsection (a) of this section;

(B) the reason for the delay in documenting the service interruption; and

(C) the date the provider agency learned of the service interruption.

(d) Service delivery outside the client's home.

(1) The provider agency may develop a service plan that includes services regularly delivered at a location other than the client's home. The service plan must not exceed the weekly hours authorized on DHS's Authorization for Community Care Services form.

(2) The provider agency may deliver services outside the client's home when the service plan does not include the regular delivery of such services.

(3) The provider agency:

(A) may deliver services outside the client's home only if the client requests such services.

(B) is not required to pay for expenses incurred by attendants delivering services outside the client's home.

(C) must:

(i) make a reasonable effort to deliver services at a location other than the client's home when requested by the client;

(ii) maintain written justification if the client's request was not granted; and

(iii) document in the client's file:

(I) each instance when a client requested services at a location other than the home;

(II) whether the client's request was granted;

(III) what services were provided; and

(IV) where the services were delivered.

(e) Service delivery documentation.

(1) The provider agency must document the delivery of services, including:

(A) the provider agency name;

(B) the provider agency vendor number;

(C) the attendant name;

(D) the client name;

(E) the DHS client number;

(F) the specific service delivery period, including month, day, and year, as applicable;

(G) the tasks assigned;

(H) the units of service delivered;

(I) the dates services were delivered;

(J) certification that the attendant delivered the documented tasks.

(i) For electronic service delivery documentation systems, each person delivering services inputs a unique identifier to certify the services delivered.

(ii) For paper service delivery documentation systems, each person delivering services signs the timesheet to certify the services delivered.

(I) The attendant must sign his or her name or a mark representing his or her name on the timesheet to certify that it is correct. Initials are not an acceptable substitute for a signature.

(II) An attendant who is unable to sign the timesheet may designate another person to sign the timesheet. The provider agency must maintain written documentation of the:

(-a-) reason the attendant is unable to sign the timesheet; and

(-b-) identity of the person authorized to sign the timesheet on behalf of the attendant.

(2) Paper service delivery documentation must be a single document with a specific service delivery period not exceeding one calendar month.

(f) Documentation of service delivery. The provider agency must maintain documentation of service delivery in the client file. The provider agency must be able to identify all attendants delivering tasks to the client.

 

§47.65 Supervisory Visits

 

(a) Supervisory visits. A supervisor must conduct in-person supervisory visits to assess and document on a single form whether:

(1) the service delivery plan is adequate;

(2) the individual continues to need the services;

(3) the individual needs a service delivery plan change;

(4) the attendant continues to be competent to provide the authorized tasks; and

(5) the attendant is delivering the authorized tasks.

(b) Frequency. A supervisor must establish the frequency of in-person supervisory visits, based on the specific needs of the individual, the attendant, or both. The frequency of in-person supervisory visits must be at least annually.

(c) Documentation of supervisory visits. The provider must maintain documentation of each supervisory visit in the individual's file.

(d) Combining a supervisory visit and a new attendant orientation. A supervisor may conduct a scheduled supervisory visit and a new attendant orientation at the same time.

 

§47.67 Service Delivery Plan Changes

 

(a) Increase in hours or terminations.

(1) A provider must submit written notification to the case manager within seven days after learning of any change that may:

(A) require an increase in hours in the individual's service delivery plan; or

(B) result in the termination of services due to the individual receiving no personal care tasks, except for FC services.

(2) The notification must include the:

(A) date the provider learned of the need for the change;

(B) reason for the change;

(C) type of change (including the number of hours of service); and

(D) signature and date of the provider representative.

(b) Decrease in hours. The provider must develop a new service delivery plan, as described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities), within 21 days of the provider identifying the need for an ongoing decrease in hours from the service delivery plan currently approved by the individual.

(c) Immediate increase in hours of service.

(1) The provider must notify the case manager, or designee, of the reason an individual requires an immediate increase in hours of service, and must obtain approval from DADS of both the number of additional hours of service to be provided the individual and the effective date of the change.

(2) The provider must implement the immediate increase in hours of service on the negotiated effective date of the change.

(3) The provider must document the immediate increase in hours of service. Documentation must include:

(A) the date the provider received approval for the change;

(B) the name of the DADS staff who approved the change;

(C) the effective date of the change; and

(D) the number of hours of service authorized.

(4) The provider must maintain documentation of service delivery plan changes:

(A) in the individual's file; and

(B) according to the terms of the contract.

(d) Implementation of service delivery plan changes. The provider must implement the service delivery plan change on the following date, whichever is later:

(1) the authorization begin date on DADS' authorization for community care services form; or

(2) five days after the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the authorization begin date on the form will be used to determine timeliness.

(e) Delay in implementation of service delivery plan changes. If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document by the next working day any failure to implement a service delivery plan change on the effective date of the change. The documentation must include:

(1) the reason for the failure to timely implement the service delivery plan change; and

(2) the new implementation date.

 

§47.69 Transfers

 

(a) Negotiation of an individual's transfer from one provider to another. The providers involved in an individual's transfer must coordinate with the case manager to negotiate the transfer date.

(b) Initiation of services. The receiving provider must initiate services on the negotiated date. The negotiated date is the begin date on DADS' authorization for community care services form.

(c) Evaluation and service delivery plan. On or before the begin date, the receiving providerm must:

(1) conduct an evaluation, as described in §47.45 of this chapter (relating to Pre-Initiation Activities); and

(2) develop a service delivery plan, as described in §47.45 of this chapter.

 

§47.71 Suspensions

 

(a) Required suspensions. A provider must suspend services if:

(1) an individual temporarily or permanently leaves the contracted service delivery area;

(2) the individual moves to a location where services cannot be provided under the PHC Program;

(3) the individual dies;

(4) the individual is admitted to an institution, which is a:

(A) hospital;

(B) nursing facility;

(C) state school;

(D) state hospital;

(E) intermediate care facility serving persons with mental retardation or a related condition; or

(F) correctional facility.

(5) the individual requests that services end;

(6) the Health and Human Services Commission denies the individual's Medicaid eligibility (not applicable to FC services); or

(7) the individual or someone in the individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person, in which case the provider must make an immediate referral to:

(A) the Texas Department of Family and Protective Services or other appropriate protective services agency;

(B) local law enforcement, if appropriate; and

(C) the individual's case manager.

(b) Optional suspensions. The provider may suspend services if:

(1) the individual or someone in the individual's home engages in discrimination against a provider or DADS employee in violation of applicable law; or

(2) the individual refuses services for more than 30 consecutive days.

(c) Notification of service suspension. The provider must notify the case manager of any suspension by the first working day after the provider suspends services. The notice must include:

(1) the date of service suspension;

(2) the reason(s) for the suspension;

(3) the duration of the suspension, if known; and

(4) for a suspension under subsection (a)(7) or (b) of this section, a written explanation of the circumstances surrounding the suspension.

(d) Interdisciplinary Team (IDT) meeting. The provider must convene an IDT meeting, as described in §47.49 of this chapter (relating to Interdisciplinary Team), if services are suspended under subsection (a)(7) or (b) of this section.

(e) Resuming services after suspension. This subsection does not apply to paragraphs (a)(7) or (b)(1) of this section.

(1) A provider must resume services after suspension on the earliest of the following:

(A) upon the individual's return home, or the date the provider becomes aware of the individual's return home, if applicable;

(B) on the date specified in writing by the case manager;

(C) as a result of a recommendation by the IDT; or

(D) upon the provider's receipt of notification from the case manager that the provider must resume services pending the outcome of an appeal.

(2) The provider must notify the case manager of the date services resume within seven days after that date.

 

§47.72 Compliance with Program Requirements

 

(a) Termination of services. DADS may terminate services to an individual who has had services suspended on more than three occasions as described in §47.71(a)(7) or (b)(1) of this subchapter (relating to Suspensions).

(b) Right of appeal. An individual for whom services have been terminated may appeal this decision by requesting a fair hearing as described at 1 TAC Chapter 357 (relating to Hearings).

 

§47.73 Annual Reauthorization for Community Attendant Services (CAS)

 

(a) Reauthorization request.

(1) Upon receipt of the annual DADS authorization for community care services form, a provider must request annual reauthorization for all CAS.

(2) The provider must send the following to the regional nurse to obtain annual reauthorization:

(A) DADS' authorization for community care services form received from the case manager; and

(B) a signed statement indicating whether the supervisor agrees or disagrees with the tasks and hours indicated on DADS' authorization for community care services form, and if the supervisor disagrees, the statement must provide the specific reasons for disagreeing with the hours and tasks on this form.

(b) Reauthorization request due date. The provider must submit the information described in subsection (a)(2) of this section to the regional nurse within 14 days after one of the following dates, whichever is later:

(1) the referral date on DADS' authorization for community care services form; or

(2) the date the provider receives DADS' authorization for community care services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness.

(c) Authorization determination. DADS makes the authorization determination and notifies the provider before the annual reauthorization is due.

(d) Documentation of annual reauthorization. The provider must maintain documentation of the written request for reauthorization for CAS in the individual's file.

 

§47.75 Complaints

 

A provider must comply with the complaint procedures described in:

(1) §49.17 of this title (relating to Complaint Procedures);

(2) §49.18 of this title (relating to Client Rights and Responsibilities);

(3) §97.249 of this title (relating to Reportable Conduct); and

(4) §97.250 of this title (relating to Investigations).

CPPHCS, Subchapter F, Claims Payment and Documentation

Revision 09-1

 

 

§47.81 Monitoring Medicaid Eligibility

 

 

(a) Applicability. This section does not apply to individuals who are receiving FC services.

(b) Verification of Medicaid eligibility. A provider must verify each month that an individual remains Medicaid eligible. The provider may verify the individual's current Medicaid eligibility by:

(1) viewing the individual's Health and Human Services Commission Medicaid Identification form; or

(2) using the current systems available to verify individual registration.

(c) Reimbursement. The provider is not entitled to payment from DADS for services delivered if the provider fails to verify the individual has current Medicaid eligibility.

 

§47.83 Monitoring Reviews

 

(a) Monitoring reviews. DADS conducts monitoring reviews in the PHC Program as described in Chapter 49 of this title (relating to Contracting for Community Care Services) and in this chapter.

(b) Fiscal monitoring. Fiscal monitoring in the PHC Program includes monitoring financial errors, which are applied to the entire unit of service. Financial errors include the following instances:

(1) DADS reimburses a provider for services, but the service delivery documentation is missing for the period for which services are reimbursed. DADS applies the error to the total number of units reimbursed for the pay period.

(2) DADS reimburses the provider for services, but the attendant fails to complete the units of service delivered portion of the service delivery documentation. DADS applies the error to the total number of units reimbursed for the pay period.

(3) DADS reimburses the provider for hours that exceed the total number of hours recorded on the service delivery documentation. DADS applies the error to the total number of units reimbursed in excess of the units recorded on the service delivery documentation. The lowest of the three totals in subparagraphs (A)-(C) of this paragraph is used to calculate the total number of hours recorded on the service delivery documentation:

(A) the sum of time in and time out;

(B) the sum of daily totals of time; or

(C) the total time recorded.

(4) DADS reimburses the provider for units of service for days on which the individual did not receive services. DADS applies the error to the total number of units reimbursed for the day on which the individual did not receive services.

(5) DADS reimburses the provider for units of service for days on which the individual was Medicaid ineligible. DADS applies the error to the total number of units reimbursed for the days on which the individual was Medicaid ineligible. This paragraph does not apply to FC services.

 

§47.85 Retroactive Payment Procedures

 

(a) Applicability.

(1) This section does not apply to family care services.

(2) A provider agency that chooses to request retroactive payment must comply with the requirements of this section.

(b) Definition of retroactive payment. A retroactive payment is payment by the Texas Department of Human Services (DHS) to a provider agency for services under the Primary Home Care Program that are provided before the date the case manager determines the person's eligibility for the services.

(c) Reimbursement.

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

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

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

(2) DHS only reimburses the provider agency for the:

(A) services described in §47.41 of this chapter (relating to Allowable Tasks);

(B) number of hours of services allowed to be provided the person, calculated as described in §48.2918(c) of this title (relating to Eligibility for Primary Home Care); and

(C) allowable costs of the Primary Home Care Program, as described in 1 TAC, Chapter 355 (relating to Medicaid Reimbursement Rates).

(3) DHS will not reimburse the provider agency for the retroactive period if:

(A) the provider agency fails to submit the required documentation within the required time frames; or

(B) the person provided services does not meet the requirements described in subsection (d) of this section.

(d) Requirements before requesting retroactive payment. The provider agency may not request retroactive payment unless:

(1) the person appears to be Medicaid eligible as defined in §48.1201 of this title (relating to Definition of Program Terms);

(2) the provider agency obtains a practitioner's written statement as described in §47.47 of this chapter (relating to Medical Need Determination);

(3) the person requires at least one personal care task as described in §47.41 of this chapter; and

(4) the provider agency has verified and documented that the person is not already receiving services under the Primary Home Care Program from another provider agency.

(e) Pre-initiation activities. The provider agency must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).

(f) Intake referral. On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local DHS office by telephone and make an intake referral by providing DHS information on the person to start the eligibility process.

(g) Service initiation. The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

(h) Requesting retroactive payment.

(1) A provider agency's written request for retroactive payment must include:

(A) a copy of the service plan required by subsection (e) of this section;

(B) a copy of DHS's Practitioner's Statement of Medical Need form; and

(C) the retroactive payment information, including the:

(i) "name of the provider agency;

(ii) contact information for the person;

(iii) date services were started;

(iv) tasks provided to the person. This includes both tasks allowed and not allowed by the Primary Home Care Program;

(v) weekly hours of service provided to the person. This includes hours allotted to tasks allowed and not allowed by the Primary Home Care Program; and

(vi) cost per hour of service charged to the person.

(2) The provider agency must submit the written request for retroactive payment:

(A) to the case manager or, if no case manager has been assigned, to DHS intake staff; and

(B) within seven days after the date the provider agency processes the intake referral.

(i) Charges to persons who receive services.

(1) The provider agency may charge a person for services for which the provider agency intends to request retroactive payment, unless the person is Medicaid eligible.

(2) The provider agency must reimburse the entire amount of all payments made by the person to the provider agency for eligible services, even if those payments exceed the amount DHS will reimburse for the services, if DHS determines that the person is eligible for the Primary Home Care Program.

(j) Documentation of retroactive payment requests. The provider agency must maintain documentation of retroactive payment requests in the person's file.

 

§47.87 Record Keeping

 

(a) General record keeping requirements. A provider must maintain records according to:

(1) Chapter 49 of this title (relating to Contracting for Community Care Services);

(2) Chapter 69 of this title (relating to Contract Administration);

(3) the terms of the contract;

(4) this chapter; and

(5) the provider's company policies.

(b) Program specific records. A provider must maintain records of compliance with the requirements of this chapter.

(c) Financial records. A provider must maintain financial records:

(1) to support its billings to DADS for payment under §47.89 of this chapter (relating to Reimbursement);

(2) to document reimbursements made by DADS, including:

(A) amount of reimbursement;

(B) voucher number;

(C) the warrant number;

(D) the date of receipt of the reimbursement; and

(E) any other information necessary to trace deposits of reimbursements and payments made from the reimbursements in the provider's accounting system; and

(3) in accordance with generally accepted accounting principles (GAAP) and DADS procedures, including:

(A) deposit slips, bank statements, cancelled checks, and receipts;

(B) purchase orders;

(C) invoices;

(D) journals and ledgers;

(E) payroll and tax records;

(F) service delivery documentation;

(G) Internal Revenue Service, Department of Labor, and other government records and forms;

(H) records of insurance coverage, claims, and payments (for example, medical, liability, fire and casualty, and workers' compensation);

(I) equipment inventory records;

(J) records of the provider's internal accounting procedures; and

(K) a chart of accounts, as defined by GAAP.

(d) Subcontractor records. If a provider utilizes a subcontractor, the provider must maintain records of the subcontractor's activities. Maintaining all records to support subcontractor claims is the responsibility of the provider.

(e) Failure to maintain records. Failure to maintain records as specified in this section may result in:

(1) corrective action plans;

(2) monetary exceptions; or

(3) other actions deemed necessary or appropriate by DADS.

 

§47.89 Reimbursement

 

(a) Billing requirements.

(1) A provider must bill for services provided as described in §49.41 of this title (relating to Billings and Claims Payment).

(2) The provider must not bill DADS for:

(A) more hours than an individual's weekly authorization, except when services are delivered as described in §47.63(a) of this chapter (relating to Service Delivery);

(B) services delivered in a licensed facility, if the facility is required by the license to provide those services; and

(C) services or tasks that duplicate any services or tasks provided to the individual by another source.

(b) Hourly rate. The provider must agree to accept the hourly rate authorized by DADS

(c) Documentation. The provider must maintain the documentation described in this chapter to be eligible for reimbursement.

(d) Rounding. The provider must bill DADS for services in quarter-hour increments, rounding up to the next quarter-hour if the actual time worked is eight minutes or more, and rounding down to the previous quarter hour if the actual time worked is seven minutes or less.

(e) Allowable tasks. The provider must bill DADS only for the tasks described in §47.41 of this chapter (relating to Allowable Tasks).

CPPHS, Subchapter G, Utilization Review

Revision 09-1

 

 

§47.91 Utilization Review

(a) DADS conducts utilization review of a service delivery plan and supporting documentation at any time to:

(1) determine the appropriateness of services;

(2) validate a service provision; or

(3) evaluate the quality of services.

(b) A provider, consumer directed services employer, and consumer directed services agency must submit documentation supporting the service delivery plan to DADS as requested by DADS.

(c) If DADS determines that one or more of the tasks specified in a service delivery plan do not meet the requirements described in Subchapter D of this chapter (relating to Service Delivery Plan Requirements) and Subchapter E of this chapter (relating to Service Requirements), DADS denies or reduces the hours or tasks, modifies the service delivery plan effective from the date of the utilization review, and sends written notification of the denial or reduction to the individual and provider.

(d) In addition to the utilization review conducted in accordance with subsection (a) of this section, DADS may conduct utilization reviews of providers and services based on utilization patterns and trends.

CPPHCS, Appendices

CPPHCS, Appendix I, Chapter 49, Contracting for Community Care Services

Revision 04-1; Effective June 1, 2004

 

This appendix is available online only at the following website:
http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=40&pt=1&ch=49&rl=Y

CPPHCS, Appendix II, DADS Contract Management

CPPHCS, Appendix III, Expedited Payment System

Revision 04-1; Effective June 1, 2004

 

Purpose

  • To request expedited payment.
  • To liquidate expedited payment.

Requesting Expedited Payment

Follow procedures below to request expedited payment through the paper claims process.

Note: Expedited payment is available only to community-based alternative services, family care, and primary home care agencies that offer personal assistance services.

Complete Form 1290 in the usual manner but enter 80% of the pervious month's reimbursement as the expedited payment amount.

Claim Requirements

Mail the expedited payment claim (Form 1290) by the 20th of the service month. (Example: The service month is September; mail the expedited payment claim by September 20th).

Liquidating (Reconciliating) Expedited Payment

After the first of the month after the service month, submit a regular detailed claim, using Form 1290 for each client for the previous month. On Form 1290, indicate the amount of the claim, including the expedited payment. CMS deducts the expedited payment from the claim and pays you the difference. If the claim submitted does not completely reconcile, then CMS takes 100% of the claim. CMS waits until another claim comes in to reduce the difference.

You must reconcile the expedited payment by the 25th of the month. Example: The service month is September; expedited payment claim is submitted September 20th; reconciliation must be done by the 25th of October. If you do not reconcile by the date the ceiling is posted for the next expedited payment (usually after the 25th of the month), you will not receive the next expedited payment.

If your expedited payment is not liquidated by the date the ceiling is posted for the next payment, you WILL NOT receive the next expedited payment.

If your expedited payment claim is rejected, Form 1290 is returned to you. Complete a new Form 1290.

The liquidation of the expedited payment does not begin until the receipt of the regular detailed claim for the month covered by the expedited payment.

Sanctions

Providers who do not comply with the reconciliation requirements will not receive an expedited payment for at least one month. For providers who have continuous problems billing for expedited payment, DHS retains the right to cancel participation in the expedited billing system.

CPPHCS, Appendix IV-A, Reimbursement Methodology for Primary Home Care Services and Family Care Services

Revision 05-1; Effective February 1, 2005

 

§355.5902 Reimbursement Methodology for Primary Home Care

This rule is available on the Secretary of State's Texas Administrative Code website at
http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

To access Texas Health and Human Services Commission rules, click on Title 1, Administration, then Part 15. Click on Chapter 355, Reimbursement Rates, then Subchapter G, Telemedicine Services and Other Community-Based Services, to access this rule.

CPPHCS, Appendix IV-B, Cost Determination Process

CPPHCS, Appendix IV-C, Consumer Directed Services Payment Option

CPPHCS, Appendix V, Medicaid for the Elderly and People with Disabilities

CPPHCS, Appendix VI, Reserved for Future Use

CPPHCS, Appendix VII, Advance Directives

CPPHCS, Appendix VIII, Criminal History Check of Employees in Certain Agencies Serving the Elderly or Persons with Disabilitie

CPPHCS, Appendix IX, HIV/AIDS in the Workplace

CPPHCS, Appendix X Information Letters

Revision 04-1; Effective June 1, 2004

 

Information letters regarding Primary Home Care Services are located at:
https://www.dads.state.tx.us/providers/communications/letters.cfm

CPPHCS, Appendix XI, Mutually Exclusive Services

CPPHCS, Appendix XII, List of Excluded Individuals and Entities (LEIE)

CPPHCS, Forms

Form Title
2307-A Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities
3054 Primary Home Care Service Delivery Record
H1002 Provider Electronic Visit Verification Vendor System Selection

Informacion in espanol = form also available in Spanish.

 

CPPHCS, Revisions

CPPHCS, Revision 15-1, Mutually Exclusive Services

Revision Notice 15-1; Effective January 16, 2015

 

The following changes were made:

Section Title Change
Appendix XI Mutually Exclusive Services Removes Community Based Alternatives, Emergency Care, STAR MRSA and MC Dental. Changes STAR+PLUS to STAR+PLUS Program and updates the information.

CPPHCS, Revision 13-1, Forms Added

Revision Notice 13-1; Effective September 30, 2013

 

The following forms and instructions were added to the Forms Table of Contents:

Forms Title
2307-A Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities
3054 Primary Home Care Service Delivery Record
3056 Primary Home Care Program Utilization Review Report
3059 Primary Home Care Program Fiscal Monitoring Guide

CPPHCS, Revision 09-1, Program access, service initiation and service utilization

Revision Notice 09-1; Effective June 1, 2009

 

This revision implements rule changes to improve controls for program access, service initiation and service utilization in the Primary Home Care (PHC) Program. The revision also describes the process for expedited referrals and amends contracting requirements for providers with a contract assignment. Additionally, the amendments update rule language and terms and correct agency names and cross-references.

The following changes were made:

§47.1 states that PHC Program services may be provided through the agency, service responsibility option (SRO), or consumer directed services (CDS) option for service delivery.

§47.3 updates definitions for community attendant services (CAS), medical need, non-priority, practitioner, practitioner's statement, primary home care (PHC) services, priority, representative, routine referral, signature, supervisor, working day and written; adds definitions for ADL, DADS, expedited referral, functional limitation, individual, oral notice, service delivery plan and utilization review; and deletes the definitions of client, negotiated referral and practitioner's statement date.

The repeal of §47.5 deletes rule language that provides an overview of provider requirements.

§47.11 allows a provider to provide services under any category of licensure in Chapter 97, rather than limiting the provider to the personal assistance services license category, and, in the case of contract assignment, does not require the provider to first obtain a provisional contract.

§47.23 updates attendant qualification requirements.

§47.25 revises the requirements for attendant orientation, including the method and documentation of an orientation.

§47.41 updates the requirements concerning allowable tasks.

§47.43 updates requirements concerning methods of referral.

§47.45 revises the requirements for pre-initiation activities, including service delivery plan documentation and delivery requirements, and amends service delivery plan variance requirements and pre-initiation activity time frames.

§47.47 updates the requirements for determination of medical need, requires a provider to submit an original, complete DADS practitioner's statement to the DADS case manager for PHC services and the DADS regional nurse for CAS, and states that if services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

§47.49 states that a DADS representative may be a case manager's supervisor, requires a provider to make and document a good faith effort to include all members of an interdisciplinary team (IDT) in an IDT meeting, and updates the documentation requirements of an IDT meeting.

New §47.57 contains an explanation of the three service delivery options (agency option, CDS option and SRO) available to an individual receiving PHC Program services.

New §47.59 explains that support consultation is an optional service available when an individual receiving PHC Program services chooses CDS or SRO.

§47.61 updates service initiation requirements and requires a provider to receive a DADS authorization for community care services form instead of establishing an individual's medical need to initiate services. The amendment also updates expedited referral requirements, updates when a service initiation notice must be sent, and states that a provider may delay service initiation only for reasons beyond its control, such as natural or other disasters, that are not directly caused by the provider.

§47.65 requires a supervisor to conduct a supervisory visit in-person and states that a supervisor may conduct a scheduled supervisory visit and a new attendant orientation jointly.

§47.67 updates the requirements a provider must follow when increasing the hours or terminating services and states that if the provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date.

New §47.72 introduces requirements related to termination of services and the right of an individual to appeal the action.

§47.73 requires a provider to request reauthorization for all CAS upon receipt of an annual DADS authorization for community care services form and states that DADS makes the authorization determination and notifies the provider before the end of the current authorization.

New §47.75 references the complaint procedure rules with which a provider must comply.

§47.83 amends the list describing what constitutes a financial error on the part of a provider.

§47.87 updates general record keeping requirements for providers and deletes the requirement that a provider maintain a record of company policies.

New §47.91 adds the requirements governing utilization reviews.

CPPHCS, Revision 05-1, Revised Appendices

Revision Notice 05-1; Effective February 1, 2005

 

The following changes were made:

Deleted:

  • Appendix IV, Reimbursement Methodology for Primary Home Care

Revised:

  • Appendix IV-A, Reimbursement Methodology
  • Appendix IV-B, Cost Determination Process
  • Appendix IV-C, Consumer Directed Services Payment Option

This revision updates appendices with rules relating to cost determination process, reimbursement methodologies, and the establishment and adjustment of reimbursement rates by the Texas Health and Human Services Commission. The noted rules now link directly to the applicable Texas Administrative Code sections on the Texas Secretary of State's web page.

CPPHCS, Contact Us

For questions about the Contracting to Provide Primary Home Care Services Handbook, email: ccadpolicy@hhsc.state.tx.us

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