Medically Dependent Children Program Provider Manual

MDCP-PM, Section 1000, Introduction

Revision 13-0; Effective August 1, 2013

 

 

The Medically Dependent Children Program Waiver provides a variety of services to support families caring for children who are medically dependent, and to encourage de-institutionalization of children who are currently receiving services in nursing facilities. Specific services include adaptive aids, flexible family support services, minor home modifications, respite, financial management services and transition assistance services. The Consumer Directed Services option is available for respite and flexible family support services.

 

1100 Program Overview

Revision 13-0; August 1, 2013  

 

The Medically Dependent Children Program (MDCP) Provider Manual includes rules and procedures for administering the MDCP Waiver. All providers of MDCP services must follow these rules and procedures in order to comply with the terms of the Department of Aging and Disability Services (DADS) contract. This manual is incorporated by reference as part of the contract with DADS to provide MDCP services.

State rules and federal waiver requirements that apply to MDCP are:

Submit questions or comments to www.mdcp@dads.state.tx.us.

 

1200 Program Definitions

Revision 13-0; August 1, 2013  

 

Rules:

40 Texas Administrative Code (TAC) §51.101, Purpose
40 TAC §51.103, Definitions

Choice List – Defined as a list of licensed providers that have completed licensure, contract and program orientation. The Choice List is maintained in each DADS regional office with the regional case manager.

MDCP-PM, Section 2000, Contracting

Revision 13-0; Effective August 1, 2013

 

 

An applicant must have a Home and Community Support Services Agency license in order to offer respite or flexible family support services under contract in the Medically Dependent Children Program Waiver.

 

2100 License Requirement for a Respite or Flexible Family Support Provider

Revision 13-0; August 1, 2013

 

A provider that plans to offer respite or flexible family support services must hold and maintain a Home and Community Support Services Agency (HCSSA) license in good standing in accordance with 40 TAC Chapter 97. Additional information about the HCSSA license can be found at the Resources for Department of Aging and Disability Services (DADS) Service Providers Web page in the HCSSA section.

The HCSSA license must be maintained in order for the provider to be paid for Medicaid services provided under that contract. If an HCSSA license expires due to failure to comply with license renewal requirements, DADS will terminate the contract since it requires an active license. Furthermore, DADS will immediately begin the process of offering choices of new providers from the Choice List and transferring individuals to their selected new provider to avoid interruption of services.

If DADS chooses not to renew a required license and there is not adequate time to allow DADS individuals to choose a new HCSSA provider prior to contract termination, an HCSSA must notify DADS Community Services Contracts in writing, using one of the following:

 

2110 Licensure Change of Ownership or Control Interest

Revision 13-0; August 1, 2013

 

Resource: Change of Ownership (CHOW) licensure Web page.

A licensed provider under the Home and Community Support Services Agency (HCSSA) 40 Texas Administrative Code, Chapter 97, that intends to sell or transfer the business – known as a change of ownership of the business – will need to inform DADS Community Services Contracts, in addition to the DADS HCSSA licensure unit, if the license holder also has a contract for Medically Dependent Children Program services and intends for the new business owner to continue services under the contract.

A provider operating under a new HCSSA license number and a new contract number, as a result of a CHOW, is not automatically entitled to serve the individuals who received services from the previous provider.

DADS case managers offer individuals choice of a new provider when an HCSSA undergoes a CHOW. The individuals may choose the new provider or any other eligible provider. DADS case managers notify all affected providers of the individual’s choice of a new provider.

 

2200 Contract Requirements

Revision 13-0; August 1, 2013

 

Rules for contracting are located at:

40 TAC Chapter 49, Contracting for Community Care Services
40 TAC Chapter 79, Legal Services

An applicant for a Department of Aging and Disability Services (DADS) contract must comply with all relevant rules and policies to be eligible to establish a contract with DADS.

 

2210 Application for a Contract

Revision 13-0; August 1, 2013

 

The Home and Community Support Services Agency submits Form 2021, License Application, for a contract to the Department of Aging and Disability Services Community Services Contracts unit. The applicant should follow the instructions found on the application Web page.

 

2220 Contract Change

Revision 13-0; August 1, 2013

 

A provider that undergoes a change in business type (e.g., change from a partnership to a corporation) or ownership of the Home and Community Support Services Agency (HCSSA) must notify its DADS Community Services Contracts (CSC) contract manager in writing at least 60 days in advance of the proposed date of the change in business type or ownership.

If the prospective new owner of the HCSSA is not already licensed as an HCSSA, the new owner must download, complete and submit Form 2021, License Application, for an initial license at least 60 days prior to the change of ownership. The new owner should follow the instructions found on the application Web page.

Failure by either the current or prospective owners to provide both DADS Regulatory Services Licensing unit and DADS CSC unit with information about a change in ownership (CHOW) in a timely manner may delay activation of the new HCSSA license or contract linked to the current provider’s HCSSA license. Providers that fail to request the contract change at the same time as the licensure CHOW request may jeopardize the contract. These tasks must be executed simultaneously because HCSSA licensure is required to maintain a Medically Dependent Children Program contract. Providers must comply with all licensure rules related to CHOW.

A provider that undergoes a CHOW or control interest is required to complete a new Form 5871, Disclosure of Ownership and Control Statement, to report the changes. The provider must report changes in ownership, administrators, directors, partners, members, officers, executives, managing employees and trustees of the legal entity and business entities that own the legal entity. See Form 5871 and its instructions for additional guidance.

A provider who wishes to transfer the contract to a different legal entity (an entity with a different Texas Identification Number) must comply with the DADS CSC that was signed by the original provider, which includes that:

“... the Contractor may not transfer or assign this contract without the express prior written approval of the Department.” Providers can view this statement in their copy of the DADS Community Services Contract (Provider Agreement).

DADS CSC unit staff must review and approve the transfer and set the effective date of the new contract.

 

2230 Contract Transfer and Individual Choice

Revision 13-0; August 1, 2013

 

When a contract transfer is requested, the DADS Community Services Contracts unit cancels the previous provider’s contract and issues a new contract with a new contract number to the new provider.

 

2240 Requirement for an Adaptive Aids Provider

Revision 13-0; August 1, 2013

 

An adaptive aids provider must be a durable medical equipment provider with a National Provider Identifier number.

 

2250 Role of the Primary Caregiver in the Contracting Process

Revision 13-0; August 1, 2013

 

The Home and Community Support Services Agency (HCSSA) provides respite and flexible family support services. Every other service, e.g., minor home modifications (MHM), adaptive aids (AA) and transition assistance services (TAS), are services provided by other DADS contracted entities which are chosen by the primary caregiver.The primary caregiver is responsible for negotiating these services.

The DADS case manager offers primary caregivers a choice from a list of providers for MHM. The primary caregiver is responsible for all specifications for procurement and bids according to 40 Texas Administrative Code, Chapter 51, Subchapter C, Division 2. The primary caregiver is responsible for obtaining a minimum of three bids. The primary caregiver submits all the bid information to the DADS case manager who will approve the MHM service. All work must follow Texas Accessibility Standards.

 

2300 Attendant Requirements

Revision 13-0; August 1, 2013

 

Rule: 40 TAC §51.421(c), Requirements for Attendants

Before providing services, the provider must give all unlicensed attendants orientation to the tasks specific to the individual enrolled in the Medically Dependent Children Program in the individual's place of residence. The provider must ensure that a registered nurse determines the attendant’s competency.

 

MDCP-PM, Section 3000, Intake and Case Management

Revision 14-1; Effective September 1, 2014

 

 

Rules:

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

 

3100 Interest Lists

Revision 14-1; September 1, 2014

 

Rules:

40 TAC Chapter 48, Community Care for Aged and Disables, §48.1301, Interest Lists
40 TAC Chapter 51, Division 2, Enrollment, §51.221, Other Responsibilities

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

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

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

The DADS CSIL Unit:

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

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

The enrollment packet sent to the individual contains:

The information packet sent to the case manager contains:

The individual has 30 days from the date of the MDCP interest list release notification letter to complete and return enrollment materials to the case manager. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services, the individual may request to remain on the MDCP interest list, but will be placed at the bottom of the list.

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

DADS send a letter with attached enrollment materials to the individual’s parent or guardian which must be completed and promptly returned to DADS. If the application packet is not returned to DADS by 30 days from the date of the MDCP interest list release notification letter, DADS will remove the individual’s name from the interest list.

 

3200 Limited Stay Nursing Facility for Medically Fragile Individuals

Revision 14-1; September 1, 2014

 

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

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

Individuals determined medically fragile by the DADS state office physician and approved for a limited NF stay must stay at least part of two days in the NF. Admission and discharge from the facility must occur on different days.

 

3210 MFP Procedures for Requesting a Limited Nursing Facility Stay

Revision 14-1; September 1, 2014

 

Individuals who wish to request MDCP services through the Money Follows the Person (MFP) option must contact the Community Services Interest List (CSIL) Unit at 877-438-5658. The CSIL Unit will forward the name of the individual, or the individual's parent or guardian, interested in the MFP option to the appropriate regional MDCP supervisor or regionally-designated representative.

The regional MDCP case manager must contact the individual, or the individual's parent or guardian, by phone to explain the individual must:

If the individual's physician recommends a limited stay, the DADS regional nurse and DADS state office physician will review the documentation and approve the limited stay request if the physician documentation clearly supports that the individual meets two or more of the criteria on Form 2406.

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

 

3300 Case Management Process

Revision 14-1; September 1, 2014

 

The provider, DADS case manager and individual work together to develop the Individual Plan of Care (IPC), as required by 40 Texas Administrative Code (TAC) §51.217, Individual Plan of Care. Refer to the Case Manager Medically Dependent Children Program Handbook for information about these activities. The DADS case manager then sets up the IPC and submits it to the Home and Community Support Services Agency (HCSSA) or Financial Management Services Agency (FMSA) of choice.

  1. The DADS case manager and DADS regional nurse work with the individual during a home visit to set up the draft IPC.
  2. The DADS case manager shares (by either email or fax) the draft IPC with the HCSSA or FMSA provider that the individual previously chose.
  3. The provider reviews and decides whether to accept the individual for services. The provider may choose to conduct a home visit prior to accepting the individual for services. If the provider decides to accept the individual for services, the provider must follow the steps in TAC §51.413, Response to Service Authorization.
  4. Within 14 calendar days of receiving the service authorization, the provider must follow the rules at TAC §51.415, Notification to the Individual.
  5. Once the provider decides to accept the individual, the provider contacts the DADS case manager by phone or using Form 2067, Case Information.
  6. The provider then begins home visits to deliver services according to the IPC.

The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion between the DADS case manager and the provider must occur in time to meet the 30-day time frame for authorizing services from the initial home visit. After all parties (the case manager, individual, provider and primary caregiver) agree with the draft IPC, the service initiation date is negotiated according to §51.217(b).

 

3310 Initiating the Individual Plan of Care (IPC)

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.217, Individual Plan of Care

The service initiation date is negotiated during the development of the IPC and prior to the provider receiving a service authorization form. The provider must ensure the service delivery record contains a copy of the IPC and appropriate documentation supporting the claim for the services delivered. The provider must maintain an in-home record and notify the DADS case manager if a significant change in the individual’s health occurs during the IPC period.

 

3311 Service Initiation Date

Revision 14-1; September 1, 2014

 

Rules:

40 TAC §51.217(b), Individual Plan of Care
40 TAC §51.413, Response to Service Authorization
40 TAC §51.417, Notification to the Case Manager

During the development of the Individual Plan of Care (IPC), the service initiation date is negotiated prior to the provider receiving a service authorization form.

After the initial service initiation date has been agreed upon by all parties, the DADS case manager sends the provider the appropriate service authorization form, any or all of the following:

The provider must sign the service authorization form and send the original and a signed copy of the practitioner’s orders back either by U.S. mail or fax transmission to the DADS case manager within 14 days of receipt of the service authorization form. (See §51.413.)

If the provider is unable to provide services as indicated on the service authorization form, the provider must contact the DADS case manager by telephone and fax or mail Form 2067, Case Information, and notify the individual or primary caregiver within one work day of awareness prior to the service initiation date. (See §51.417.)

 

3312 Documentation of the IPC

Revision 14-1; September 1, 2014

 

Rule: 40 TAC, §51.509, Claims and Service Delivery Records

The provider must ensure the service delivery record contains a copy of the Individual Plan of Care (IPC) and documentation supporting the claim for the services delivered. This includes the following forms, as applicable:

The DADS case manager will send copies of the IPC, which could include Form 2410, Form 2411, Form 2412, Form 2414, Form 2415 and/or Form 2430, to the provider at the time of the initial assessment, annual reassessment or whenever an interim IPC is completed. The provider must ensure these documents are included in the service delivery record.

 

3320 Changes to the IPC

Revision 14-1; September 1, 2014

 

The provider must notify the DADS case manager if an individual has a significant change in health during the Individual Plan of Care (IPC) period and requests to make a change to the IPC. The individual or primary caregiver may also request to change providers (typically the Home and Community Support Services Agency) at any time during the IPC year.

 

3321 Interim IPC

Revision 14-1; September 1, 2014

 

Rules:

40 TAC §51.415, Notification to the Individual
40 TAC §51.417, Notification to the Case Manager

The provider must notify the DADS case manager upon awareness if an individual has a significant change in health during the Individual Plan of Care (IPC) period and requests to make a change to the IPC. The change can be requested by the Home and Community Support Services Agency (HCSSA), individual or primary caregiver. If the DADS case manager determines that an IPC change is needed, the DADS case manager sends the provider Form 2065-B, Notification of Waiver Services, along with all applicable service authorization forms. The effective date of the IPC change is the date the DADS case manager entered the request into the Service Authorization System (SAS), or the date negotiated with:

The date negotiated cannot be a date prior to the date the request was processed. The DADS case manager sends a copy of the service authorization to the HCSSA.

The provider must immediately, upon awareness, notify the DADS case manager by telephone and send Form 2067, Case Information, if it is determined that the provider cannot deliver the services as authorized on the revised IPC. See §51.417 for further detail. In addition, the provider must notify the individual or primary caregiver and give both parties the reason why services cannot be delivered. See §51.415 for further details and the time frame for notification to the individual or primary caregiver.

 

3322 Provider Transfers During the IPC Period

Revision 14-1; September 1, 2014

 

The individual or primary caregiver may request to change providers, typically the Home and Community Support Services Agency (HCSSA), at any time during the Individual Plan of Care (IPC) year. The provider must notify the DADS case manager verbally and in writing, using Form 2067, Case Information, within five working days if the individual notifies the provider that he wishes to be transferred to another provider. The DADS case manager negotiates the effective date of the change with the individual/primary caregiver and the providers. The DADS case manager completes the transfer within 14 days of when the case manager received the request from the individual or primary caregiver to change providers.

The DADS case manager sends the gaining provider Form 2065-B, Notification of Waiver Services, authorizing the transfer to the gaining provider. The losing provider will receive an authorization termination notice from the DADS case manager on one of the following forms:

The DADS case manager terminates the service authorization and adds the end date, which must be the day before services begin with the gaining provider. The DADS case manager sends this form to the losing provider and the individual. The losing provider's authorization will be terminated within the same 14-day time frame to complete the provider transfer.

When an individual transfers from one provider to another, the DADS case manager will send the losing provider Form 2067, requesting the:

The losing provider must respond to the DADS case manager before the 14th day after the date written on Form 2067.

 

3400 Reporting Issues to the DADS Case Manager

Revision 14-1; September 1, 2014

 

A provider reports verbally to the DADS case manager by the next working day that it will no longer serve the individual due to health and safety concerns. The provider must follow up the verbal report within five working days with Form 2067, Case Information, which must include the reasons why the provider cannot serve the individual.

If the individual has chosen and is assigned a new provider, the case manager provides the new provider with sufficient information to avoid putting the provider at risk. With this information, the provider can adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise.

 

3410 Service Delivery Issues Reported to the DADS Case Manager

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.417, Notification to the Case Manager

The provider is required to report service delivery issues to the DADS case manager, as described in §51.417. DADS requires a provider to notify the DADS case manager of issues that impact service delivery. The provider may notify the DADS case manager of any issues either verbally or by fax using Form 2067, Case Information, within one working day. If the provider notifies the DADS case manager orally, the provider must follow up with written documentation on Form 2067 within five working days of the verbal notification unless otherwise stated in the rule.

 

3411 Primary Caregiver Refuses to Comply with IPC

Revision 14-1; September 1, 2014

 

The provider must notify the DADS case manager verbally and must send the DADS case manager Form 2067, Case Information, if the primary caregiver does not follow the Individual Plan of Care (IPC). The DADS case manager will contact the primary caregiver to discuss the situation within 14 days of receiving a report of service delivery issues from the provider. If the issue continues after the initial contact, the DADS case manager convenes a service planning team meeting to address the issue.

 

3412 Provider Unable to Verify Medicaid Status

Revision 14-1; September 1, 2014

 

The provider is required to verify the individual’s Medicaid eligibility each month. The provider may verify the individual's eligibility status by using the Medicaid Eligibility Service Authorization Verification (MESAV) system available through the Texas Medicaid & Healthcare Partnership (TMHP) login website. If the provider is unable to verify the individual's Medicaid eligibility status after checking MESAV, the provider may contact the DADS case manager by phone or by faxing a copy of Form 2067, Case Information, to verify the individual's Medicaid eligibility status via the Texas Integrated Eligibility Redesign System (TIERS). The DADS case manager will verify the individual’s Medicaid eligibility status and notify the provider.

 

3413 Provider Unable to Begin on Service Initiation Date

Revision 14-1; September 1, 2014

 

If the provider determines that service will not begin on the authorized service initiation date, the provider must notify the DADS case manager verbally and follow up by faxing Form 2067, Case Information, to the DADS case manager with the reason for the delay and the new service initiation date. This action must occur within five working days of oral notification.

 

3414 Provider Initiated Changes to Delivery of Services

Revision 14-1; September 1, 2014

 

The provider may notify the DADS case manager verbally, but must fax the DADS case manager Form 2067, Case Information, of any changes in service delivery within one working day of becoming aware of the need for a change. The DADS case manager determines if the change in service delivery requires a change to the individual's Individual Plan of Care (IPC). The DADS case manager contacts the individual by phone or home visit if the change in service delivery requires a change to the IPC. If the individual agrees with the change, the DADS case manager will complete the change to the IPC following DADS case management procedures. If the individual does not agree with the change, the DADS case manager must contact the provider and resolve the provider's change in service delivery. The provider may not exceed the amount of services already authorized on the IPC.

 

3500 Loss of Medicaid Eligibility

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.405(b), Monitoring Medicaid Eligibility

If the provider becomes aware the individual has lost Medicaid eligibility, the provider must immediately inform the DADS case manager verbally and must send the case manager Form 2067, Case Information, within one working day of awareness. If Medicaid eligibility is no longer in effect, the provider stops providing services immediately and the DADS case manager will follow this action with a formal notice to the individual and provider that services were suspended. The provider must notify the individual or primary caregiver by phone or home visit regarding the need to suspend services and the reason why.

MDCP services cannot continue past the last date of Medicaid eligibility. The provider will receive Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, from the DADS case manager cancelling the authorization. DADS will not reimburse providers for services delivered when the individual does not have Medicaid eligibility, even if the individual files a timely appeal.

The DADS case manager will notify the provider of the loss of Medicaid via Form 2067.

 

3510 Service Reduction, Service Denial or Case Termination

Revision 14-1; September 1, 2014

 

In most situations, the DADS case manager must provide 30 days notification to the individual for any case action that is a service reduction, service termination or case termination. The intent of the 30-day notification time frame is to allow the individual and primary caregiver sufficient time to adjust to DADS decision.

The DADS case manager does not have to give 30 days notice for service or case denials as the individual has not yet received services.

In some instances, delaying termination or reduction of services for 30 days may have an adverse effect on the individual. In these instances, DADS may provide less than 30 days notification for any case action. These instances may include:

If the individual or primary caregiver requests the case action occur before the 30-day notification time frame, the DADS case manager must inform the individual and primary caregiver that the individual:

Within two working days of receiving a request to waive the 30-day notification for any case action, the DADS case manager must send the individual or primary caregiver Form 1574. The form must be completed and returned to the DADS case manager before the date of the required 30-day notification of any case action.

If Form 1574 is not returned to the DADS case manager before the date of the required 30-day notification of any case action, the DADS case manager sends the notification to the individual, primary caregiver and provider for the case action 30 days in advance of the effective date. The effective date for the case action will be negotiated between the DADS case manager, the individual or primary caregiver, and the provider.

 

3511 Service Reduction Notification

Revision 14-1; September 1, 2014

 

Approved

The DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and the following service authorization forms, as applicable, to the individual and the provider within two working days of completing the IPC.

Denial

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to:

 

3512 Case Termination Notification

Revision 14-1; September 1, 2014

 

In a case termination due to voluntary withdrawal from the program, the termination date is the last date the individual or primary caregiver requests MDCP services.

The DADS case manager must contact the provider at least two working days before the case termination effective date to prevent the provider from delivering services to the individual after the case termination date. The contact may be by telephone or on Form 2067, Case Information, sent by the DADS case manager using fax, email or U.S. mail.

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for case terminations. The effective date of Form 2065-C is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver program or the last day of MDCP services requested by the individual or primary caregiver. The DADS case manager completes and sends Form 2065-C and applicable service authorization forms to the individual and the provider within two working days of determining program ineligibility.

 

3513 Service Reduction Information

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.243, Denials, Terminations and Service Reductions

 

3514 Provider Information for Completing Service Reductions

Revision 14-1; September 1, 2014

 

When the DADS case manager plans a change to the Individual Plan of Care (IPC) for a service reduction, it may be necessary to obtain service delivery information from the provider to complete the change. When this occurs, the DADS case manager verifies with the provider the number of units or the cost of services delivered from the authorized start date through the day before the IPC change is effective.

The provider will receive from the DADS case manager Form 2067, Case Information, which will request the:

After the DADS case manager receives the completed Form 2067 from the provider, the DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and applicable service authorization forms to the individual and the provider within two working days of completing the service reduction to the IPC. The effective date of Form 2065-B and applicable service authorization forms for a service reduction is 30 days after the date on the individual's notification letter.

 

3520 Service Suspensions

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.241, Service Suspensions by DADS

The DADS case manager or a provider may suspend an individual's MDCP services during the Individual Plan of Care (IPC) period. The DADS case manager or the provider must suspend MDCP services when:

If an individual or caregiver or someone else in the residence exhibits behavior that constitutes imminent danger or a threat to the health or safety of the individual or another person, the provider must take action. Examples include, but are not limited to:

If the individual's safety may be at risk, the provider must contact the Department of Family and Protective Services (DFPS) at 1-800-252-5400 and the police, if appropriate, the same day the provider is aware of the suspension. The provider must also notify the DADS case manager of the risk to an individual’s health and safety the same day the provider is reporting that information to DFPS and the police.

An individual who threatens his own health or safety or that of others should be considered for referral to the Local Authority and the police, if appropriate.

 

3521 Notification of Service Suspensions

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419, Service Suspensions by Program Provider

The provider is required to notify the DADS case manager verbally or by fax no later than one working day after services are suspended giving the reason for the suspension, the effective date of the suspension and the duration, if known, for service suspensions initiated by the provider. The provider must include an explanation of the attempts to resolve the issues that initiated the suspension. If the program provider's notification is verbal, the program provider must send written notification using Form 2067, Case Information, to the DADS case manager within five working days after the verbal notification.

The DADS case manager contacts the individual and tries to resolve the problem within 12 days from the date on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. If the problem cannot be resolved, the provider may report to DADS that it will no longer serve the individual due to health and safety concerns.

For any situation requiring waiver service suspension, the DADS case manager notifies the individual and provider by completing Form 2065-C. If the individual or provider has informed the DADS case manager of the return date from an institution, the DADS case manager notes the duration of the suspension on the comments section of Form 2065-C.

 

3522 Extension of Suspension

Revision 14-1; September 1, 2014

 

DADS may extend a suspension for an additional 30 days if the reason for the individual's suspension will exceed 180 days.

If the individual or primary caregiver notifies DADS with a request for MDCP services to resume, the DADS case manager reviews the reasons for the request to determine if an exception will be permitted. Examples of reasons for extending the suspension period for individuals:

 

3523 Resuming Services

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419(d), Service Suspensions by Program Provider, Resuming Services After a Suspension

The duration of the suspension may depend on the reason for the suspension, such as the individual requiring an extended stay in a hospital or nursing facility (NF). The DADS case manager will communicate with the provider or individual to obtain a date to resume services.

DADS requires providers resume services after a suspension:

The DADS case manager completes Form 2065-B, Notification of Waiver Services, to notify the individual and provider to resume services. The DADS case manager completes and sends Form 2065-B to the individual and provider within two working days:

 

3524 Temporary Nursing Facility Admissions

Revision 14-1; September 1, 2014

 

The first date of service after the temporary admission to the nursing facility (NF) is the date of the NF discharge and the service end date is the same as the Individual Plan of Care period. The DADS case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan.

 

3525 Service Denials and Case Closure

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.243, Denials, Terminations, and Service Reductions

 

3600 Appeals and Hearings

Revision 14-1; September 1, 2014

 

Rule: 1 TAC, Chapter 357, Subchapter A, Uniform Fair Hearing Rules

An individual may appeal a DADS action. A DADS action means a service suspension, service reduction, denial or termination. To appeal a DADS action, an individual must make a request for a fair hearing verbally or in writing to the case manager within 90 days from the date on the notice of the DADS action.

If an individual who is currently receiving services requests a fair hearing before the effective date of the DADS action on the notice, the program provider will be notified by the DADS case manager to continue services; however, if a suspension occurs because of reckless behavior, then services will not continue during the appeal process.

If an individual who is currently receiving services does not submit a request for a fair hearing before the effective date of DADS action on the notice, the program provider must, unless otherwise directed by the DADS case manager, discontinue services on the effective date of the DADS action on the notice.

MDCP-PM, Section 4000, Provider Responsibilities

Revision 14-1; Effective September 1, 2014

 

 

4100 Provider Requirements

Revision 14-1; September 1, 2014

 

Rule: 40 Texas Administrative Code (TAC), Chapter 51, Subchapter D, Provider Requirements

All providers must follow all rules in Divisions 1 and 2 of Subchapter D. In addition, providers follow the rules that are relevant to them in Divisions 3 through 8, which require compliance based on the service each Medically Dependent Children Program (MDCP) provider has contracted with the Texas Department of Aging and Disability Services (DADS) to provide.

 

4200 Individuals with Qualified Income Trusts

Revision 14-1; September 1, 2014

 

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

MDCP providers are responsible for collecting co-payment amounts from individuals who have a QIT and are receiving respite or flexible family support services through MDCP. 42 Code of Federal Regulations (CFR), §435.726 (a) and (b) states:

  1. “The agency must reduce its payment for home and community-based services provided to an individual specified in paragraph (b) of this section, by the amount that remains after deducting the amounts specified in paragraph (c) of this section from the individual's income.
  2. This section applies to individuals who are eligible for Medicaid under CFR §435.217 and are receiving home and community-based services furnished under a waiver of Medicaid requirements specified in part 441, subpart G or H of this subchapter.”

For individuals receiving MDCP services who have income from a QIT, the Medicaid for the Elderly and People with Disabilities (MEPD) staff determine if the individual must pay a co-payment amount prior to receiving MDCP services. When this occurs, the DADS case manager enters this amount on Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement, or Form 2065-B, Notification of Waiver Services. The provider must collect this co-payment amount monthly, prior to billing for MDCP services through the Texas Medicaid & Healthcare Partnership (TMHP). The trustee must pay the co-payment directly to the provider by the 10th of the month, or no later than 10 days after MDCP services have started in situations when services did not start on the first of the month. The provider must also notify the DADS case manager within one working day of the ten-day time frame if the co-payment amount has not been collected by submitting Form 2067, Case Information, to the DADS case manager.

 

4300 Electronic Verification Visit (EVV)

Revision 14-1; September 1, 2014

 

40 TAC Chapter 68, Electronic Visit Verification (EVV) System, §68.101(5), Application, applies to in-home respite and flexible family support services as they relate to MDCP. Providers can access and view all EVV requirements and a list of areas in which MDCP providers are required to utilize EVV at the DADS EVV website.

 

4400 Attendant Orientation

Revision 14-1; September 1, 2014

 

All unlicensed attendants must receive orientation to tasks specific to the individual participating in the MDCP program at the individual's place of residence prior to providing services. This requirement is found in 40 TAC, Chapter 51, §51.421, Requirements for Attendants Providing Respite and Flexible Family Support Services.

 

4500 Service Backup Plan

Revision 14-1; September 1, 2014

 

Rule: 40 TAC Chapter 51, Subchapter D, Division 2, §51.411(c), General Service Delivery

A provider must have a backup plan in case the provider is unable to deliver respite or flexible family support services, as specified on the service schedule.

Within 14 days after a provider receives an initial assessment or annual reassessment service authorization form or the backup plan changes, a provider must send the DADS case manager a copy of the provider's backup plan for service delivery.

Within 14 days after a provider receives an initial assessment or annual reassessment service authorization form, or the backup plan changes, a provider must give an individual a written copy of the provider's backup plan for service delivery, if the provider is unable to provide services as scheduled, and information on the individual's right to change providers.

MDCP-PM, Section 5000, Utilization Review Program

Revision 14-1; Effective September 1, 2014    

 

 

The Texas Legislature, through the General Appropriations Act, mandates the use of utilization management and review practices, as necessary, to ensure the appropriate scope and level of services are provided to individuals and to ensure compliance with federal cost-effectiveness requirements.

 

5100 Utilization Review (UR) Program Description

Revision 14-1; September 1, 2014

 

Every two years, the Texas Legislature, through the General Appropriations Act, mandates the use of utilization management and UR practices, as necessary, to ensure the:

The focus of DADS UR is based on the direction provided in the General Appropriations Act.

 

5110 Case Selection Processes

Revision 14-1; September 1, 2014

 

Each fiscal year, DADS selects a statistically valid statewide random sample of individual cases, based on the program total enrollment and proportionate to the number of people serviced in a region. The unit of sample is the individual who is actively enrolled in the program.

Based on this selection process, DADS performs a review of selected individuals based on the current Individual Plan of Care.

 

5111 Review Processes

Revision 14-1; September 1, 2014

 

Utilization Review (UR) procedures may include review of DADS case files and contracted provider documents, a face-to-face assessment of the individual and his living environment, and interviews with staff from DADS, the Home and Community Support Services Agency (HCSSA), agency caregivers and other MDCP contracted providers. The UR nurse may request files or documents from the HCSSA or other MDCP contracted provider to include service-related documentation, such as plans of care, service records, training records, time sheets, minor home modification or adaptive aid documentation. The UR nurse will provide the time frame by which the HCSSA and other contracted providers need to submit the information.

 

5112 Communication of UR Findings

Revision 14-1; September 1, 2014

 

The Utilization Review (UR) findings may be in agreement with the Individual Plan of Care (IPC), as written, or the UR staff findings may indicate a need for a reduction, denial, termination, increase or addition of a service or services. The UR nurse discusses the preliminary findings and rationale for the findings with the DADS case manager and Home and Community Support Services Agency (HCSSA), as applicable, to ensure all relevant information is considered. During this discussion, the UR nurse identifies the required time frames for submitting additional input and documentation. After reviewing the additional information, the UR nurse and UR nurse manager finalize the findings.

The UR regional manager submits findings indicating a need to reduce, deny, terminate, increase services or add new services to the Access and Intake, Community Services regional director for processing. Regional UR staff evaluate the findings and, if no formal exception is filed, send the new IPC to the DADS case manager for implementation. The DADS case manager mails the individual a notice of adverse action with a right to appeal for IPC changes resulting in a reduction, denial or termination of services. DADS case managers use existing time frames for reporting IPC changes to the HCSSA. UR findings in agreement with the IPC are tracked by UR for routine reporting, but no further action is taken.

 

5113 Other UR Reporting Requirements

Revision 14-1; September 1, 2014

 

The Utilization Review nurse immediately notifies the Community Services regional director, Consumer Rights and Services, and the Home and Community Support Services Agency if either of the following situations is identified during a review:

MDCP-PM, Section 6000, Billing, Claims and Records

Revision 14-1; Effective September 1, 2014    

A provider must have a Texas Department of Aging and Disability Services (DADS) Medicaid contract to receive Medicaid payment for the Medically Dependent Children Program (MDCP). The provider is paid at periodic intervals, depending on when the provider submits bills for approved services.

6100 TMHP Remittance and Status (R&S) Report

Revision 14-1; September 1, 2014

The R&S Report contains information on pending, paid, denied and adjusted claims. The Texas Medicaid & Healthcare Partnership (TMHP) provides weekly R&S Reports to give providers detailed information about the status of the claims submitted to TMHP.

6110 R&S Report Resources

Revision 14-1; September 1, 2014

6200 Reimbursement Rates

Revision 14-1; September 1, 2014

The Rate Analysis Department (RAD) of the Texas Health and Human Services Commission develops reimbursement methodology rules for determining payment rates or rate ceilings for MDCP.

6210 Reimbursement Methodology

Revision 14-1; September 1, 2014

Rule: 1 TAC Chapter 355, §355.507, Reimbursement Methodology for the Medically Dependent Children Program

6220 Rate Analysis and Posted Rates

Revision 14-1; September 1, 2014

The Texas Health and Human Services Commission (HHSC) approves rate changes, either increases or decreases, for the MDCP program. Rates are posted on the HHSC Rate Analysis website.

6300 Authorization of OHR Services in an Accredited Camp Setting

Revision 14-1; September 1, 2014

MDCP providers cannot request additional payment for Out-of-Home Respite (OHR) services in an accredited camp setting, including administrative fees, from MDCP individuals or their families when participating in camp activities.

6310 Rate in an Accredited Camp Setting

Revision 14-1; September 1, 2014

The maximum allowable rate for Out-of-Home Respite (OHR) services in an accredited camp setting for individuals enrolled in MDCP is based upon the rates approved by the Texas Health and Human Services Commission (HHSC) at this link.

As indicated on the website, HHSC has approved one rate (Service Code 11G) for MDCP OHR services in an accredited camp setting when services are provided by an agency holding a Provider Agreement for MDCP with DADS.

The service unit is one hour. DADS case managers authorize the number of service units according to the number of hours the individual is expected to use during the service plan year.

DADS requires providers to bill the actual hourly cost to provide the service or the maximum allowable rate.

6311 Administrative Fees for OHR Services in an Accredited Camp Setting

Revision 14-1; September 1, 2014

The Provider Agreement states the provider must accept reimbursement rates that are in effect, or as amended, as payment in full for the services delivered. The provider must not make any additional charge to the individual, any member of his or her family, or to any other source for any supplementation for services, unless specifically allowed by DADS rules. The provider cannot charge the individual when the waiver (i.e., Medicaid) is paying.

The Provider Agreement also requires services to be provided in the same manner and to the same degree that those services are provided to the general public. Therefore, MDCP providers of accredited camp settings cannot request payment from individuals or their families for additional charges related to membership in a “Respite Club” or any similar designation.

DADS will not authorize any additional payments or administrative fees requested by the service provider in the authorization request for this service. Providers of an accredited camp setting must reimburse individuals or their family members for any administrative fees collected that relate to the provision of Out-of-Home Respite services in an accredited camp setting.

6400 Reimbursement for OHR Services Provided by Nursing Facilities

Revision 14-1; September 1, 2014

The billing codes for these rates and other necessary information needed for billing is located in the Long-Term Care Billing Code crosswalk.

Any changes requested to current authorizations will be completed as a revision to the Individual Plan of Care (IPC) according to current policy and in the same manner as any other IPC change. Providers must contact the DADS case manager to request changes to the IPC. Providers must maintain documentation to support the need for these services.

Before billing for these services, providers should check the Medicaid Eligibility Service Authorization Verification (MESAV) system to ensure that the authorization has been entered into the Service Authorization System (SAS).

Providers may contact the Texas Health and Human Services Commission Rates Analysis mailbox at RateAnalysisDept@hhsc.state.tx.us for additional information pertaining to MDCP rates.

6500 Rounding When Billing

Revision 14-1; September 1, 2014

All MDCP Home and Community Support Services Agencies (HCSSAs) must bill DADS for MDCP respite and flexible family support services in quarter-hour (15 minutes) increments. For a given billing cycle, HCSSAs must total all respite units and flexible family support units provided to an individual by any staff. If the billing cycle total is not a whole number or unit increment, the HCSSA must round up or down prior to billing. Within each quarter-hour increment, HCSSAs must round up to the next quarter-hour when the actual time worked is eight minutes or more, and round down to the previous quarter hour when the actual time worked is seven minutes or less.

A provider should bill respite and flexible family support services according to the following schedule: 1 hour = 1 unit, 45 minutes = .75 unit, 30 minutes = .50 unit, and 15 minutes = .25 unit. These services may be provided by an attendant, an attendant with delegation, a licensed vocational nurse or a registered nurse.

The following are offered as examples:

Rounding may affect the total amount of service delivery time available when compared to the amount authorized on the individual plan of care and the amount saved for use in a subsequent month.

MDCP-PM, Section 7000, Service Delivery

Revision 14-1; Effective September 1, 2014

 

 

This section provides additional detail on services available under special circumstances or to certain targeted populations.

 

7100 Program Services

Revision 14-1; September 1, 2014

 

Program service descriptions are provided in the manual as a convenience to readers. Full program information is contained in the MDCP waiver.

 

7110 Respite Services Description

Revision 14-1; September 1, 2014

 

Rules:

40 Texas Administrative Code (TAC) Chapter 51, §51.103(40), Definitions
40 TAC Chapter 51, Division 3, Service Delivery Requirements for Respite and Flexible Family Support Services
40 TAC Chapter 51, Subchapter E, Claims Payment and Documentation

Respite services occur in two forms:

 

7111 In-Home Respite

Revision 14-1; September 1, 2014

 

In-home respite is a service which provides temporary relief for the primary caregiver from caregiving activities when the primary caregiver would usually perform such activities. Respite is typically provided in the residence of the individual, but may be provided in other community settings except for limitations documented in 40 TAC Chapter 51, §51.231, Service Limitations.

Other community settings may include a:

All respite settings must be located within the state of Texas.

 

7112 Out-of-Home Respite

Revision 14-1; September 1, 2014

 

Respite provided in in-home settings should not be confused with out-of-home respite, which is provided in the following contracted settings:

 

7120 Flexible Family Support Services

Revision 14-1; September 1, 2014

 

Flexible family support services provide temporary relief for the primary caregiver from caregiving activities during the time when the primary caregiver is working, attending job training or attending school.

 

7130 Adaptive Aids

Revision 14-1; September 1, 2014

 

Rules:

40 TAC Chapter 51, Subchapter B, Division 3, §51.231(c), Service Limitations
40 TAC Chapter 51, Subchapter C, Division 1, Adaptive Aids
40 TAC Chapter 51, Subchapter D, Division 7, Service Delivery Requirements for Adaptive Aids
40 TAC Chapter 51, Subchapter E, Claims Payment and Documentation

Adaptive aids (AAs) are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function. AAs enable an individual to perform activities of daily living or control the environment in which the individual lives.

AAs are approved on a case-by-case basis. Examples of AAs that DADS may approve are:

 

7140 Minor Home Modifications

Revision 14-1; September 1, 2014

 

Rule: 40 TAC Chapter 51, §51.323, List of Minor Home Modifications

A minor home modification (MHM) must be a modification to the individual’s home that is necessary to ensure the health, welfare and safety of the individual, or to enable the individual to function with greater independence in the individual’s home.

 

7141 AA and MHM Bid Forms

Revision 14-1; September 1, 2014

 

MDCP requires specific information from providers during the bidding process for adaptive aids (AAs) and minor home modifications (MHMs). To help providers with these bids, DADS provides forms that contain all of the necessary information. The use of these forms is optional; however, the required information is not optional and must be submitted before a bid will be reviewed.

DADS will return all bids which do not include the required information to the provider. Incomplete bids that need to be returned and resubmitted may lead to a delay in an MDCP participant getting an AA or MHM completed. Once the forms are re-submitted with all required information, the forms will be reviewed by DADS staff.

 

7150 Transition Assistance Services

Revision 14-1; September 1, 2014

 

40 TAC Chapter 62, Contracting To Provide Transition Assistance Services

The Transition Assistance Services (TAS) benefit makes a one-time only payment for non-recurring, set-up expenses for individuals transitioning to the community.

Providers may find additional information on the TAS website.

 

7160 Employment Services

Revision 14-1; September 1, 2014

Employment services are intended to assist individuals to find employment and maintain employment in the community. Senate Bill 45, passed by the 83rd Legislature, required that all Medicaid waivers offer Employment Assistance (EA) and Supported Employment (SE). Both EA and SE are offered under the Consumer Directed Services option.

 

7161 Employment Assistance (EA)

Revision 14-1; September 1, 2014

 

The Home and Community Support Services Agency (HCSSA) will provide EA to an individual to help the individual locate paid competitive employment or self-employment in an integrated setting in the community.

Competitive employment is work:

An integrated setting is a setting typically found in the community in which applicants or eligible individuals interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

Self-employment is work in which the individual:

EA services include, but are not limited to, the following:

EA may be provided through the waiver if documentation is maintained in the individual’s record that the service is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973, or for individuals under age 22, under a program funded under the Individuals with Disabilities Education Act (IDEA). (20 United States Code (U.S.C.) §1401 et seq.)

The provider must ensure provision of EA, as identified through use of Form 2429, Job Interest Assessment, to individuals if the services are not available through DARS, or for individuals under age 22, the local school district for individuals.

 

7162 EA Services

Revision 14-1; September 1, 2014

 

Employment Assistance (EA) services consist of developing and implementing strategies for achieving the individual’s desired employment outcome, including more suitable employment for individuals who are employed. Services are individualized, person-directed and may include:

For self-employment, services may additionally include:

EA does not include using Medicaid funds paid by DADS to the provider for incentive payments, subsidies or unrelated vocational training expenses, such as:

The case manager will notify the provider of the inclusion of employment assistance services on the individual’s Individual Plan of Care (IPC) by sending Form 2411, Interim Plan of Care, or Form 2412, Budget Revision, along with Form 2430, Employment Assistance and Supported Employment Service Authorization, to the provider or, for Consumer Directed Services delivered services, to the financial management services agency. The provider must begin providing or subcontracting for the EA services described and approved in the individual’s IPC.

 

7163 Documentation Requirements for EA

Revision 14-1; September 1, 2014

 

For the period of time employment assistance (EA) is included in the individual’s Individual Plan of Care (IPC), the service provider must develop and update quarterly a plan for delivering EA, including documentation of the following information:

 

7164 Supported Employment (SE)

Revision 14-1; September 1, 2014

 

Supported Employment (SE) services help an individual sustain competitive employment or self-employment.

Competitive employment is work:

An integrated setting is a setting typically found in the community in which applicants or eligible individuals interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

Self-employment is work in which the individual:

SE services include:

SE may be provided through the waiver if documentation is maintained in the individual’s record, for an individual under age 22, that the service is not available to the individual under a program funded under the Individuals with Disabilities Education Act (IDEA). (20 U.S.C. §1401 et seq.)

The provider must ensure provision of SE, as needed, for an individual to sustain competitive employment or self-employment, if the services are not available through the local school district for an individual under age 22.

 

7165 Supported Employment Activities

Revision 14-1; September 1, 2014

 

Supported Employment (SE) services consist of developing and implementing strategies for helping the individual sustain competitive employment or self-employment. Services are individualized, person-directed and include:

For self-employment, services may additionally include:

SE does not include sheltered work or other similar types of vocational services furnished in specialized facilities, or using Medicaid funds paid by DADS to the provider for incentive payments, subsidies or unrelated vocational training expenses, such as:

The case manager will notify the provider of the inclusion of SE services on the individual’s Individual Plan of Care prior to the Department of Assistive and Rehabilitative Services (DARS) closing out the individual's services, if applicable, or for initial SE services by sending Form 2411, Interim Plan of Care, or Form 2412, Budget Revision, along with Form 2430, Employment Assistance and Supported Employment Service Authorization, to the provider, or for Consumer Directed Services delivered services to the financial management services agency. The provider must begin providing or subcontracting for the SE services described and approved in the individual’s service plan without a gap between the provision of DARS services and the waiver services.

 

7166 Documentation Requirements for SE

Revision 14-1; September 1, 2014

For the period of time supported employment (SE) is included in the individual’s Individual Plan of Care (IPC), the service provider must develop and update quarterly a plan for delivering SE, including documentation of the following information:

 

7170 Role of the Case Manager

Revision 14-1; September 1, 2014

 

The DADS case manager coordinates with other agencies, including the Texas Health and Human Services Commission, regarding an individual’s continued Medicaid eligibility once he or she begins working. The DADS case manager also coordinates with the Department of Assistive and Rehabilitative Services (DARS) and the local school districts, seeking third party resources before using employment assistance and supported employment (in the case of school districts).

Activity includes:

 

7180 Department of Assistive and Rehabilitative Services (DARS)

Revision 14-1; September 1, 2014

 

Before using employment assistance, the individual must first seek services from DARS. Also known as the Vocational Rehabilitation (VR) agency, DARS is the state agency whose primary focus is assisting individuals with disabilities to obtain integrated, competitive employment.

Note: The individual does not have to, and should not be referred to, DARS for supported employment.

 

7181 Role of DARS in Employment Assistance

Revision 14-1; September 1, 2014

 

The individual and any other support persons, as desired, should meet with the Department of Assistive and Rehabilitative Services (DARS) Vocational Rehabilitation (VR) counselor to apply for DARS services as soon as possible after the individual identifies an employment goal. To locate the nearest DARS office, visit the Office Locator Web page. In addition to the information listed on Page 2 of the DARS Applicant Guide, the individual should bring or submit to the DARS office before his initial appointment:

 

7182 Coordination of DADS and DARS Services

Revision 14-1; September 1, 2014

 

If the Vocational Rehabilitation (VR) counselor determines that the Department of Assistive and Rehabilitative Services (DARS) is not the appropriate resource to meet the individual's needs and does not take an application for services, documentation of this decision in the individual's record serves as sufficient evidence that DARS services are not available and the individual is eligible to receive employment assistance (EA).

An individual who has applied for services from DARS is eligible to receive EA until DARS has developed the individual’s plan for employment (IPE). The individual’s service planning team must ensure that communication is maintained with the DARS VR counselor regarding waiver-funded services provided between the DARS VR application and the "start date" of services from DARS, as defined in the individual's DARS VR IPE.

Note: If an individual refuses to contact DARS, he or she may not receive EA.

With permission of the individual, the service planning team members supporting an individual determined eligible for DARS services, along with the individual, must:

DADS and DARS have a memorandum of agreement in place that further describes the coordination policies and processes for individuals seeking employment.

 

7190 Roles of the HCSSA or CDS Employer

Revision 14-1; September 1, 2014

 

The Home and Community Support Services Agency (HCSSA) and Consumer Directed Services (CDS) employer have two main roles in supporting the employment services.

  1. Help to Locate Services

The HCSSA and financial management services agency (FMSA) assist individuals in locating employment related services, such as transportation. They encourage individuals and their families to choose an employment services provider as early in the service planning process as possible. They also provide the individual with a list of employment services providers from which to choose.

A Supplemental Security Income (SSI) or Social Security Disability Income (SSDI) eligible individual has the option to receive employment services from an Employment Network (EN) through the Ticket to Work program. A list of ENs in Texas can be found on the DARS Ticket to Work website.

  1. Ensure Provision of Services

The HCSSA and FMSA identify individuals who are interested in pursuing employment and assist them in identifying and obtaining their desired employment outcome. They provide or contract for Employment Assistance Services when DARS funding is not available. They provide or contract for Supported Employment Services. They also engage with qualified staff to greatly enhance the effectiveness of employment services.

There are many training opportunities available, including those through the:

 

7200 Consumer Directed Services (CDS) Option

Revision 14-1; September 1, 2014

 

40 TAC Chapter 41, Consumer Directed Services Option

The CDS option is available for respite, flexible family support services, employment assistance and supported employment provided by an attendant or by a nurse.

The CDS option allows individuals or their legally authorized representatives the opportunity to hire, train, supervise and fire, if necessary, their service providers. CDS employers are required to select a financial management services agency (FMSA), formerly called Consumer Directed Services Agency, to pay the employees and file employer taxes on behalf of the CDS employer. The FMSA also provides an in-person CDS employer orientation when an individual starts the CDS option.

CDS employers can find additional information about the CDS option in the:

In addition to following the CDS option rules for employer responsibilities, the CDS rules point out which MDCP rules apply to CDS employers, including:

The CDS rules require FMSAs at the initial CDS employer orientation to explain the specific program rule requirements that CDS employers must follow. Each employer must sign Form 1735, Employer and Financial Management Services Agency Service Agreement, Form 1735-MDCP.pdf, to acknowledge understanding of MDCP rules.

 

7300 Personal Care Services (PCS)

Revision 14-1; September 1, 2014

 

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

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

An individual receiving MDCP services may apply to receive services through the PCS program, in addition to receiving services from MDCP. Since PCS addresses different needs than those met by MDCP services, the individual's decision to access PCS does not affect the MDCP services authorized by DADS case managers.

For individuals receiving services from both PCS and MDCP, close coordination between DADS and PCS case managers is necessary to ensure the MDCP Individual Plan of Care accurately reflects all services being delivered.

 

7310 MDCP Applicant Who Receives PCS

Revision 14-1; September 1, 2014

 

If an individual receives services from Personal Care Services (PCS) and wants to apply for MDCP services, the DADS case manager informs the individual about the coordination of services that must occur between the DADS and PCS case managers.

 

7320 CDS Option and Personal Care Services

Revision 14-1; September 1, 2014

 

If the individual is using the Consumer Directed Services (CDS) option for MDCP services and Personal Care Services, the CDS employer must use the same financial management services agency (FMSA) for both programs. Using a single FMSA reduces any tax risk to the employer by avoiding duplication of employer tax identification numbers and fiscal/employer agents.

 

7400 Targeted Case Management (TCM)

Revision 14-1; September 1, 2014

 

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

DADS waiver services, including MDCP and TCM, are mutually exclusive. An individual receiving MDCP services cannot receive TCM at the same time.

MDCP-PM, Section 8000, Denial, Termination and Suspension

Revision 14-1; Effective September 1, 2014

 

 

8100 Termination of Medicaid

Revision 14-1; September 1, 2014

 

In most situations, the DADS case manager must provide a 30-day notification to the individual for any case action that is a service reduction, service termination or case termination. The intent of the 30-day notification time frame is to allow the individual and primary caregiver sufficient time to adjust to DADS decision.

In some instances, delaying termination or reduction of services for 30 days may have an adverse effect on the individual. In these instances, DADS may provide less than 30 days notification for any case action.

If the individual or primary caregiver requests the case action occur before the 30-day notification time frame, the DADS case manager must inform the individual and primary caregiver that the individual:

Within two working days of receiving a request to waive the 30-day notification for any case action, the DADS case manager must send the individual or primary caregiver Form 1574. The form must be completed and returned to the DADS case manager before the date of the required 30-day notification of any case action.

If Form 1574 is not returned to the DADS case manager before the date of the required 30-day notification of any case action, the DADS case manager sends the notification to the individual, primary caregiver and provider for the case action 30 days in advance of the effective date. The effective date for the case action will be negotiated between the DADS case manager, the individual or primary caregiver, and the provider.

 

8200 Service Reduction

Revision 14-1; September 1, 2014

 

Rule: 40 Texas Administrative Code (TAC) §51.243, Denials, Terminations and Service Reductions

 

8210 Service Reduction Notification

Revision 14-1; September 1, 2014

 

The DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and all of the following applicable service authorization forms to the individual and the provider within two working days of completing the Individual Plan of Care:

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to:

 

8220 Provider Information for Completing Service Reductions

Revision 14-1; September 1, 2014

 

When the DADS case manager plans a change to the Individual Plan of Care (IPC) for a service reduction, it may be necessary to obtain service delivery information from the provider to complete the change. When this occurs, the DADS case manager verifies with the provider the number of units or the cost of services delivered from the authorized start date through the day before the IPC change is effective.

The provider will receive from the DADS case manager Form 2067, Case Information, which will request the:

After the DADS case manager receives the completed Form 2067 from the provider, the DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and applicable service authorization forms to the individual and the provider within two working days of completing the service reduction to the IPC. The effective date of Form 2065-B and applicable service authorization forms for a service reduction is 30 days after the date on the individual's notification letter.

 

8300 Self-Reported Incidents

Revision 14-1; September 1, 2014

 

Rule: 40 TAC Chapter 97, §97.249, Self-Reported Incidents of Abuse, Neglect and Exploitation

This rule includes definitions of reportable incidents. A provider must report incidents to Consumer Rights and Services (CRS) at 800-458-9858. Additional information can be found on the CRS website.

 

8400 Service Suspensions

Revision 14-1; September 1, 2014

 

Rules:
40 TAC, Chapter 51, Subchapter B, Division 3, §51.419, Service Suspensions by Program Provider
40 TAC, Chapter 51, Subchapter D, Division 2, §51.241, Service Suspensions by DADS

The DADS case manager or a provider may suspend an individual's MDCP services during the Individual Plan of Care (IPC) period. The DADS case manager or the provider must suspend MDCP services when:

If an individual or caregiver or someone else in the residence exhibits behavior that constitutes imminent danger or a threat to the health or safety of the individual or another person, the provider must take action. Examples include, but are not limited to:

If the individual's safety may be at risk, the provider must contact the Department of Family and Protective Services (DFPS) at 1-800-252-5400, and the police, if appropriate, the same day the provider is aware of the suspension. The provider must also notify the DADS case manager of the risk to an individual’s health and safety the same day the provider is reporting to DFPS and the police.

An individual who threatens his own health or safety or that of others should be considered for referral to the Local Authority and the police, if appropriate.

 

8410 Notification of Service Suspensions

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419, Service Suspensions by Program Provider

The provider is required to notify the DADS case manager no later than one working day after services are suspended giving the reason for the suspension, the effective date of the suspension and the duration, if known, for service suspensions initiated by the provider. The provider must include an explanation of the attempts to resolve the issues that initiated the suspension.

The DADS case manager contacts the individual and tries to resolve the problem within 12 days from the date on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. If the problem cannot be resolved, the provider may report to DADS that it will no longer serve the individual due to health and safety concerns.

For any situation requiring waiver service suspension, the DADS case manager notifies the individual and provider by completing Form 2065-C. If the individual or provider has informed the DADS case manager of the return date from an institution, the DADS case manager notes the duration of the suspension on the comments section of Form 2065-C.

 

8411 Extension of Suspension

Revision 14-1; September 1, 2014

 

DADS may extend a suspension for an additional 30 days if the reason for the individual's suspension will exceed 180 days.

If the individual or primary caregiver notifies DADS of the wish for MDCP services to resume, the DADS case manager reviews the reasons for the request to determine if an exception will be permitted. Examples of reasons for extending the suspension period for individuals include:

 

8412 Resuming Services

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419(d), Service Suspensions by Program Provider, Resuming Services After a Suspension

The duration of the suspension may depend on the reason for the suspension, such as the individual requiring an extended stay in a hospital or nursing facility. The DADS case manager will communicate with the provider or individual to obtain a date to resume services.

DADS requires providers resume services after a suspension:

The DADS case manager completes Form 2065-B, Notification of Waiver Services, to notify the individual and provider to resume services. The DADS case manager completes and sends Form 2065-B to the individual and provider within two working days:

 

8500 Temporary Nursing Facility Admissions

Revision 14-1; September 1, 2014

 

The first date of service after the temporary admission to the nursing facility is the date of the nursing facility discharge and the service end date is the same as the Individual Plan of Care period. The DADS case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan.

 

8600 Service Denials and Case Termination

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.243, Denials, Terminations, and Service Reductions

 

8610 Case Termination Notification

Revision 14-1; September 1, 2014

 

In a case termination due to voluntary withdrawal from the program, the termination date is the last date the individual or primary caregiver requests MDCP services.

The DADS case manager must contact the provider at least two working days before the case termination effective date to prevent the provider from delivering services to the individual after the case termination date. The contact may be by telephone or on Form 2067, Case Information, sent by the DADS case manager using fax, email or U.S. mail.

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for case terminations. The effective date of Form 2065-C is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver program or the last day of MDCP services requested by the individual or primary caregiver. The DADS case manager completes and sends Form 2065-C and applicable service authorization forms to the individual and the provider within two working days of determining program ineligibility.

MDCP-PM, Appendices

MDCP-PM, Appendix I, Advance Directives

MDCP-PM, Appendix II, HIV/AIDS in the Workplace

MDCP-PM, Appendix IV, Reserved for Future Use

Reserved for Future Use

MDCP-PM, Appendix VI, Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits, Provider Types and Service Rates

MDCP-PM, Appendix VII, Consumer Directed Services Payment Option

MDCP-PM, Appendix VIII, Additional Non-Waiver Services

Appendix IX, DADS Contract Management

MDCP-PM, Appendix X, List of Excluded Individuals and Entities (LEIE)

Appendix V, Services Available from Other State Agencies

Appendix V-A, Department of State Health Services (DSHS)

Appendix V-B, Department of Assistive and Rehabilitative Services (DARS)

Appendix V-C, Texas Veterans Commission (TVC)

Appendix V-E, Department of Family and Protective Services (DFPS)

Appendix V-F, Rehabilitation Technology Resource Center

MDCP-PM, Forms

 

Form Title
0003 Authorization to Furnish Information
1574 Exception to the 30-Day Notification
1584 Consumer Participation Choice
1735 Employer and Financial Management Services Agency Service Agreement
1737 Employer and Employee Service Agreement
1739 Service Provider Agreement
1740 Service Backup Plan
1745 Service Delivery Log with Written Narrative/Written Summary
2021 License Application
2065-B Notification of Waiver Services
2065-C Notification of Ineligibility or Suspension of Waiver Services
2067 Case Information
2401 Qualified Income Trust (QIT) Co-Payment Agreement
2402 Consumer Directed Services Option ? Services Authorization
2406 Physician Recommendation for Length of Stay in a Nursing Facility
2410 Medical-Social Assessment and Individual Plan of Care
2411 Interim Plan of Care
2412 Budget Revision
2414 Flexible Family Support Services Authorization
2415 Respite Service Authorization
2416 Minor Home Modifications and Adaptive Aids Service Authorization
2429 Job Interest Assessment
2430 Employment Assistance and Supported Employment Authorization
2432 Vehicle Evaluation
2434 Adaptive Aids - Van Lift Provider Bid
2435 Adaptive Aids Bid
2436 Minor Home Modification Bid
2439 Selection Acknowledgement
5871 Disclosure of Ownership and Control Statement
5871-S Disclosure of Ownership and Control Statement - Short Form
8604 Transition Assistance Services (TAS) Assessment and Authorization
H1002 Provider Electronic Visit Verification Vendor System Selection
H1200 Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement

Informacion in espanol = form also available in Spanish.

MDCP-PM, Revisions

MDCP-PM, 15-1, January 16, 2015, Mutually Exclusive Services

Revision Notice 15-1; Effective January 16, 2015

 

 

The following change(s) were made:

 

Section Title Change
Appendix III 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.

14-1, September 1, 2014, Sections Added

Revision Notice 14-1; Effective September 1, 2014

 

 

The following change(s) were effective September 1, 2014, and added to the Provider Manual September 30, 2014:

 

Section Title Change
3000 Intake and Case Management Adds Sections 3100 through 3600.
4000 Provider Responsibilities Adds Sections 4100 through 4500.
5000 Utilization Review Program Adds Sections 5100 through 5113.
6000 Billing, Claims and Records Adds Sections 6100 through 6500.
7000 Service Delivery Adds Sections 7100 through 7400.
8000 Denial, Termination and Suspension Adds Sections 8100 through 8610.
Appendix VI Resource Utilization Groups (RUG) Individual Plan of Care (IPC) Cost Limits, Provider Types and Service Rates Updates the limits for September 2014.

MDCP-PM, 13-1, October 15, 2013, Appendix Removed

Revision Notice 13-1; Effective October 15, 2013

 

 

Revised Title Change
Appendix IV Reserved for Future Use Removes the Acute Medicaid List of Adaptive Aids and Medical Supplies appendix as it does not apply to the Medically Dependent Children Program.

MDCP-PM, 13-0, August 1, 2013, New Handbook

Revision Notice 13-0; Effective August 1, 2013

 

 

The Medically Dependent Children Program (MDCP) Provider Manual includes rules and procedures for administering the MDCP Waiver. All providers of MDCP services must follow these rules and procedures in order to comply with the terms of the Department of Aging and Disability Services (DADS) contract. This manual is incorporated by reference as part of the contract with DADS to provide MDCP services.

MDCP-PM, Contact Us

For questions about the Medically Dependent Children Program Provider Manual, email: mdcppolicy@hhsc.state.tx.us

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