Texas Home Living (TxHmL) Program Billing Guidelines

TXHMLBG, Section 1000, Introduction

Revision 15-2; Effective October 30, 2015

 

1100 General Information and Statutory Requirements

Revision 12-1; Effective February 10, 2012

 

Department of Aging and Disability Services (DADS) rules at 40 TAC §9.573 set forth requirements for Texas Home Living (TxHmL) Program providers to receive payment for TxHmL Program services. Specifically, 40 TAC §9.573(a)(4) requires a program provider to prepare and submit service claims in accordance with the TxHmL Program Billing Guidelines. Also, Sections II. H. and II. T. of the TxHmL Program Provider Agreement requires program providers to comply with the TxHmL Program Billing Guidelines. In addition, 40 TAC §9.573(a)(11) sets forth circumstances under which a program provider will not be paid or Medicaid payments will be recouped from the program provider.

 

1200 Service Components

Revision 15-2; Effective October 30, 2015

 

The TxHmL Program consists of the following service components:

 

1300 Billing and Payment Reviews

Revision 12-1; Effective February 10, 2012

 

Billing and payment reviews are conducted to determine if a program provider has complied with DADS rules and these billing guidelines. Billing and payment reviews and residential visits are distinct from the reviews described in 40 TAC §9.576, which are performed to determine a program provider's compliance with the program certification principles contained in 40 TAC §9.578-9.579. Appendix I, Billing and Payment Review Protocol, describes how billing and payment reviews are conducted.

TXHMLBG, Section 2000, Definitions

Revision 15-2; Effective October 30, 2015

 

The following words and terms, when used in these billing guidelines, have the following meanings unless the context clearly indicates otherwise:

 

Adult — A person who is 18 years of age or older.

ADLs or activities of daily living — Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring.

Annual vendor — A vendor that provides to a program provider, for a calendar year, one or more adaptive aids costing less than $500.

Behavior support plan — A written plan prescribing the systematic application of behavioral techniques regarding an individual that contains specific objectives to decrease or eliminate targeted behavior.

Billable activity — An activity for which a service claim may be submitted for service components and subcomponents listed in Section 3100, Applicable Service Components.

Calendar Day — Midnight through 11:59 p.m.

Calendar Month — The first day of a month through the last day of that month.

Calendar Week — Sunday through Saturday.

Calendar year — January through December.

CFC PAS/HAB or Community First Choice Personal Assistance Services/Habilitation — A state plan service that consists of:

(A) personal assistance services that provide assistance to an individual in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including:

(I) non-skilled assistance with the performance of the ADLs and IADLs;

(II) household chores necessary to maintain the home in a clean, sanitary and safe environment;

(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and

(IV) assistance with health-related tasks; and

(B) habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:

(I) self-care;

(II) personal hygiene;

(III) household tasks;

(IV) mobility;

(V) money management;

(VI) community integration, including how to get around in the community;

(VII) use of adaptive equipment;

(VIII) personal decision making;

(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and

(X) self-administration of medication.

Clean claim — In accordance with the Code of Federal Regulations, Title 42, §447.45(b), defined as a service claim submitted by a program provider for a service delivered to an individual that can be processed without obtaining additional information from the provider of the service or from a third party.

Competitive employment — Employment in the competitive labor market, performed on a full-time or part-time basis, that pays an individual:

(A) at or above the applicable minimum wage; and

(B) not less than the customary wage and level of benefits paid by an employer to individuals without disabilities performing the same or similar work.

Co-payment — A fixed fee an individual pays for a service at the time the service is provided.

DADS — The Department of Aging and Disability Services.

Deductible — Payment made by an individual in a specified amount for a service received before coverage begins for that service under the insurance policy.

DFPS — The Department of Family and Protective Services.

Extended shift — During a 24-hour period, a combined period of time of more than 16 hours.

Face-to-face — Within the physical presence of another person who is not asleep.

Focused assessment — An appraisal of an individual's current health status by a licensed vocational nurse that:

(A) contributes to a comprehensive assessment conducted by a registered nurse;

(B) collects information regarding the individual's health status; and

(C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided.

Guardian — A guardian of the person or estate appointed for a person in accordance with state law.

Health-related tasks — Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under state law to be performed by a service provider of CFC PAS/HAB. These include tasks delegated by a registered nurse, health maintenance activities as defined in 22 Texas Administrative Code (TAC) §225.4, Definitions, and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist or speech-language pathologist.

IADLs or instrumental activities of daily living — Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing and other essential items; performing essential household chores; communicating by phone or other media; traveling around and participating in the community.

ID/RC Assessment — A form used by DADS for making an LOC determination and LON assignment.

Implementation plan — A written document developed by the program provider for an individual that, for each TxHmL program service on the individual's IPC not provided through the CDS option, includes:

(A) a list of outcomes identified in the PDP that will be addressed using TxHmL Program services;

(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:

(I) observable, measurable, and outcome-oriented; and

(II) derived from assessments of the individual's strengths, personal goals, and needs;

(C) a target date for completion of each objective;

(D) the number of TxHmL Program units of service needed to complete each objective;

(E) the frequency and duration of TxHmL Program services needed to complete each objective; and

(F) the signature and date of the individual, LAR, and the program provider.

Individual — A person enrolled in the Texas Home Living (TxHmL) Program.

Integrated employment — Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers. To the same extent that people without disabilities in comparable positions interact with other people without disabilities, integrated employment does not include:

IPC or individual plan of care — A written plan that:

IPC year — A 12-month period of time starting on the date an authorized initial or renewal IPC begins.

Legally authorized representative — A person authorized by law to act on behalf of an individual and may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.

Licensed vocational nurse — A person licensed to practice vocational nursing in accordance with the Texas Occupations Code, Chapter 301.

Local Authority — An entity to which the Health and Human Services Commission's authority and responsibility, as described in Texas Health and Safety Code, §531.002(11), has been delegated.

LOC or level of care — A determination given to an individual by DADS as part of the eligibility determination process based on data submitted on the ID/RC Assessment.

LON or level of need — An assignment given to an individual by DADS upon which reimbursement for day habilitation, foster/companion care, residential support and supervised living is based. The LON assignment is derived from the service level score obtained from the administration of the Inventory for Client and Agency Planning (ICAP) to the individual and from selected items on the ID/RC Assessment.

Managing conservator — A managing conservator appointed for a minor in accordance with state law.

Minor — An individual under 18 years of age.

Nursing assessment — An appraisal of an individual's current health status that:

(A) contributes to a comprehensive assessment conducted by a registered nurse;

(B) collects information regarding the individual's health status; and

(C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided.

PDP or person-directed plan — A written plan, based on person-directed planning and developed with an applicant or individual in accordance with Form 8665, Person-Directed Plan, that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual (and LAR on the applicant's or individual's behalf) and ensure the applicant's or individual's health and safety.

Program provider — An entity that provides TxHmL Program services under a Medicaid Provider Agreement for the Provision of TxHmL Program Services with DADS.

Registered nurse — A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301.

Residence — A place of bona fide and continuous habitation that is a structure with a common roof and common walls, except if the structure contains more than one dwelling such as an apartment complex or duplex, "residence" means a dwelling within the structure. A person may have only one residence.

RN clinical supervision — The monitoring for changes in health needs of the individual, overseeing the nursing care provided and offering clinical guidance as indicated, to ensure that nursing care is safe and effective and provided in accordance with the nursing service plan for the individual.

RN nursing assessment — An extensive evaluation of an individual's health status completed by a registered nurse that:

(A) addresses anticipated changes in the conditions of the individual as well as emergent changes in the individual's health status;

(B) recognizes changes to previous conditions of the individual;

(C) synthesizes the biological, psychological, spiritual and social aspects of the individual's condition;

(D) collects information regarding the individual's health status;

(E) analyzes information collected about the individual's health status to make nursing diagnoses and independent decisions regarding nursing services provided to the individual;

(F) plans nursing interventions and evaluates the need for different interventions; and

(G) determines the need to communicate and consult with other service providers or other persons who provide supports to the individual.

Self-employment Work in which the individual solely owns, manages and operates a business, is not an employee of another person, entity or business, and actively markets a service or product to potential customers.

Service claim — A request submitted by a program provider to be paid by DADS for a service component or subcomponent.

Service coordination — A service as defined in Chapter 2, Subchapter L, of this title.

Service coordinator — An employee of a Local Authority (see definition of "MRA" in §9.553(20) of this title (relating to Definitions)) who provides service coordination to an individual.

Service planning team — As defined in 40 TAC §9.553(30), a planning team consisting of an applicant or individual, LAR, service coordinator and other persons chosen by the applicant or individual or LAR on behalf of the applicant or individual (for example, a program provider representative, family member, friend or teacher).

Service provider — A staff member or contractor of the program provider who performs billable activity.

Staff member — A full-time or part-time employee of the program provider.

Supervision — The process of directing, guiding and influencing the outcome of an unlicensed staff's performance.

TAC — Texas Administrative Code.

Transportation plan — A written plan, based on person-directed planning and developed with an applicant or individual using Form 3598, Individual Transportation Plan. An individual transportation plan is used to document how transportation will be delivered to support an individual’s desired outcomes and purposes for transportation as identified in the PDP.

Volunteer work — Work performed by an individual without compensation that is for the benefit of an entity or person other than the individual and is performed in a location other than the individual's residence.

TXHMLBG, Section 3000, General Requirements for Service Components Based on Billable Activity

Revision 15-2; Effective October 30, 2015

 

3100 Applicable Service Components

 

Revision 15-2; Effective October 30, 2015

This section applies only to the following service components:

 

3200 Service Claim Requirements

Revision 12-1; Effective February 10, 2012

 

 

3210 General Requirements

Revision 12-1; Effective February 10, 2012

 

Except as provided in Sections 3220 and 3230, a program provider must submit an electronic service claim that meets the following requirements. The claim must:

 

3300 Activity Not Billable

Revision 12-1; Effective February 10, 2012

 

The following activities by a service provider do not constitute billable activity:

 

3400 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

 

3410 General Requirements

Revision 12-1; Effective February 10, 2012

 

To be a qualified service provider, a person must:

 

3420 Service Provider Not Qualified

Revision 12-1; Effective February 10, 2012

 

  1. Service Coordinator Not Qualified as Service Provider
    1. Service Coordinator On Duty
      During the time a service coordinator is on duty as a service coordinator, the service coordinator is not qualified to provide any service component or subcomponent to an individual.
    2. Service Coordinator Off Duty
      During the time a service coordinator is off duty as a service coordinator, the service coordinator is not qualified to provide any service component or subcomponent to an individual if the individual is receiving service coordination from the service coordinator.
  2. Spouse Not Qualified as Service Provider

    A service provider is not qualified to provide a service component or subcomponent to the service provider's spouse.
  3. Relative, Guardian or Managing Conservator Not Qualified as Service Provider for Certain Services

    A service provider is not qualified to provide service coordination, behavioral support services or social work services to an individual if the service provider is:
    • a relative of the individual (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these guidelines);
    • the individual's guardian; or
    • the individual's managing conservator.
  4. Parent, Spouse of Parent or Contractor Not Qualified as Service Provider for Minor

    A service provider is not qualified to provide a service component or subcomponent to a minor if the service provider is:
    • the minor's parent;
    • the spouse of the minor's parent; or
    • a person contracting with DFPS to provide residential child care to the minor, or is an employee or contractor of such a person.
  5. Contractor Not Qualified as Service Provider for an Adult Individual

    A service provider is not qualified to provide to an adult individual a service component or subcomponent if the service provider is a person contracting with DFPS to provide residential child care to the individual, or is an employee or contractor of such a person.

 

3430 Relative, Guardian or Managing Conservator Qualified as Service Provider

Revision 15-2; Effective October 30, 2015

 

If a relative, guardian or managing conservator is not otherwise disqualified to be a service provider as described in Section 3420 of this section or in Section 4000, Specific Requirements for Service Components Based on Billable Activity, the relative, guardian or managing conservator may provide audiology services, dietary services, occupational therapy, physical therapy, speech and language pathology services, day habilitation, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, transportation as a community support activity, employment assistance, respite or supported employment if the relative, guardian or managing conservator is a qualified service provider for the particular service component or subcomponent being provided.

 

3500 Unit of Service

Revision 12-1; Effective February 10, 2012

 

 

3510 15-Minute Unit of Service

 

Revision 15-2; Effective October 30, 2015

The following service components and subcomponents have a unit of service of 15 minutes:

 

3520 Daily Unit of Service

Revision 12-1; Effective February 10, 2012

 

The day habilitation component has a unit of service of one day.

 

3600 Calculating Units of Service for Service Claim

Revision 12-1; Effective February 10, 2012

 

 

3610 15-Minute Unit of Service

Revision 15-2; Effective October 30, 2015

 

  1. Service Event
    For service components and subcomponents that have a unit of service of 15 minutes, a service event:
    • is a discrete period of continuous time during which billable activity for one service component is performed by one service provider;
    • consists of one or more billable activities; and
    • ends when the service provider stops performing billable activity or performs billable activity for a different service component.

    Example:
    If a service provider performs billable activity for registered nursing from 12:00-12:30, performs activity that is not billable from 12:30-12:36, then performs additional billable activity from 12:36-12:48, two service events have occurred, one for 30 minutes (12:00-12:30), and another for 12 minutes (12:36-12:48).
  2. Service Time
    1. Professional Therapies, Nursing Service Components, Supported Employment and Employment Assistance

      A program provider must use the following formula for calculating the service time for professional therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, supported employment and employment assistance:

      Number of service providers x length of service event divided by the number of persons served = service time.

      In this formula, "person" means a person who receives a service funded by DADS, including an individual and a person enrolled in the intermediate care facility for persons with intellectual disability (ICF/ID) program or a waiver program other than TxHmL.

      Examples
      No. of Service Providers X Length of Service Event ÷ No. of Persons = Service Time per Individual
      1 X 20 min. ÷ 3 = 6.66 min.
      1 X 30 min. ÷ 2 = 15 min.
      2 X 30 min. ÷ 2 = 30 min.
      2 X 30 min. ÷ 1 = 60 min.
      1 X 45 min. ÷ 4 = 11.25 min.
      1 X 60 min. ÷ 1 = 60 min.
      1 X 60 min. ÷ 2 = 30 min.
      1 X 60 min. ÷ 3 = 20 min.
      2 X 120 min. ÷ 6 = 40 min.
    2. Transportation as a Community Support Activity

      A program provider must determine service time for the transportation as a community support activity in accordance with No. 6 in Section 4520, Community Support Billing Requirements.
    3. Respite

      A program provider must use the length of the service event as the service time for respite.
  3. Units of Service for Service Claim

    A program provider must convert a service time to a unit(s) of service for a service claim in accordance with Appendix III, Conversion Table.

 

3620 Daily Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. Day Habilitation
    A program provider may include one-quarter (.25), one-half (.5), three-quarters (.75) or one unit of service per calendar day on a service claim for day habilitation.

 

3700 Billing Service Components Provided at the Same Time and Billing Day Habilitation Provided at the Same Time as Service Coordination

Revision 12-1; Effective February 10, 2012

 

 

3710 One Service Provider

Revision 12-1; Effective February 10, 2012

 

One service provider may not provide different service components or subcomponents at the same time to the same individual.

3720 Multiple Service Providers

Revision 15-2; Effective October 30, 2015

 

  1. Providing Different Service Components or Subcomponents
    1. Compliance with this Paragraph
      Multiple service providers may provide different service components or subcomponents at the same time to the same individual only as provided in this paragraph.
    2. Service Provider of Professional Therapies
      A service provider of professional therapies may provide a service to an individual at the same time a service provider of any other service component or subcomponent is providing a service to the same individual if:
      • the professional therapies activity is an assessment or observation of the individual; and
      • the assessment or observation is actually occurring at the same time the other service component or subcomponent is being provided.

      Example:
      An occupational therapist observes and assesses an individual's fine motor skills while the individual receives day habilitation services. A program provider may submit a service claim for both occupational therapy and day habilitation for the overlapping time period because billable activity for both day habilitation and occupational therapy was occurring at the same time.

      Example:
      An individual receives day habilitation from 8:00 a.m.-9:00 a.m. A speech therapist provides speech therapy to an individual at the day habilitation site from 9:00 a.m.-10:00 a.m., but the individual is unable to participate in the day habilitation activities while the therapy is provided. The individual receives day habilitation again from 10:00 a.m.-11:00 a.m. A program provider may submit a service claim for four units of speech therapy for this time period, but may not submit a service claim for day habilitation because the program provider provided only two non-consecutive hours of day habilitation.
    3. Service Provider of Respite

      A service provider of respite may provide a service to an individual at the same time a service provider of specialized therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing or supported employment provides a service to the same individual.
    4. Service Provider of Transportation as a Community Support Activity

      A service provider of transportation as a community support activity may perform a face-to-face service for an individual at the same time a service provider of professional therapies, registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, and Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) provides a service to the same individual.
  2. Multiple Service Providers of the Same Service Component or Subcomponent with a 15-Minute Unit of Service

    Multiple service providers of the same service component or subcomponent with a 15-minute unit of service, as listed in Section 3510, 15-Minute Unit of Service, may perform an activity at the same time for the same individual if multiple service providers are needed to perform the activity.

 

3730 Service Coordination and Day Habilitation Provided at the Same Time

Revision 12-1; Effective February 10, 2012

 

A service provider of day habilitation may provide day habilitation to an individual at the same time a service coordinator is providing service coordination to the individual at the day habilitation setting.

3800 Written Documentation

Revision 12-1; Effective February 10, 2012

 

 

3810 General Requirements

Revision 15-2; Effective October 30, 2015

 

  1. Legible

    A program provider must have written, legible documentation to support a service claim.
  2. Required Content
    1. All Service Components or Subcomponents (Except for Nursing Service Components, and Some Professional Therapies and Transportation as a Community Support Activity and Supported Employment Activity of Transporting an Individual)

      Except as provided in subparagraphs (b), (c) and (d) of this paragraph, the written documentation to support a service claim for a service component or subcomponent must include:
      • the name of the individual who was provided the service component or subcomponent;
      • the day, month and year the service component or subcomponent was provided;
      • the service component or subcomponent that was provided; and
      • a written service log, as described in Section 3820, Written Service Log and Written Summary Log, for each individual in accordance with the following:
        • for professional therapies, respite, employment assistance and supported employment, a written service log written by a service provider who delivered the service component or subcomponent; and
        • for day habilitation, a written service log or a written summary log by a service provider who delivered the service component or subcomponent.
    2. Nursing Service Components
      • The written documentation to support a service claim for the nursing service components of registered nursing, licensed vocational nursing, specialized registered nursing and specialized licensed vocation nursing must:
        • be written after the service is provided; and
        • include:
          • the name of the individual who was provided the nursing service component;
          • the day, month and year the nursing service component was provided;
          • the nursing service component that was provided;
          • a detailed description of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular nursing service component being claimed;
          • a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business;
          • the exact time the service event began and the exact time the service event ended documented by the nurse making the written documentation;
          • a description of the medical need for the activity performed during the service event;
          • a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the registered nurse or licensed vocational nurse in response to the incident; and
          • for any activity simultaneously performed by more than one registered nurse or more than one licensed vocational nurse, a written justification in the individual's implementation plan for the use of more than one registered nurse or licensed vocational nurse; and
        • be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the documentation or implementation plan of why a billable activity took more time than typically required to complete.
      • The following are unacceptable as a description of the activities in written documentation to support a service claim for a nursing service component:
        • ditto marks;
        • words or symbols referencing:
          • other written documentation that supports a claim for nursing services; or
          • written service logs or written summary logs;
        • non-specific statements such as "had a good day," "did ok," or "no problem today;"
        • a statement or other information that is photocopied from:
          • other written documentation that supports a claim for nursing services; or
          • written service logs or written summary logs; and
        • a medication log.
    3. Reimbursement of Co-payment or Deductible for a Professional Therapies Subcomponent

      Co-payment
      A program provider must have written documentation to support a service claim to obtain reimbursement for a co-payment for a professional therapies subcomponent that meets the requirements of Section 4270, Insurance Co-Payment and Deductible (see No. 1, Item c.).

      Deductible
      A program provider must have written documentation to support a service claim to obtain reimbursement for payments made toward a deductible for a professional therapies subcomponent that meets the requirements of Section 4270 (see No. 2, Item c.).
    4. Transportation as a Community Support Activity

      A program provider must have written documentation to support a service claim for transportation as a community support activity that meets the requirements of Section 4520, Community Support Billing Requirements (see No. 7, Item b.).

 

3820 Written Service Log and Written Summary Log

Revision 12-1; Effective February 10, 2012

 

  1. Required Content and Timeliness
    1. Written Service Log

      A written service log must:
      • be written after the service is provided;
      • for service components or subcomponents with a 15-minute unit of service, as listed in Section 3510, 15-Minute Unit of Service, include:
        • a description or list of activities performed by the service provider and the individual that evidences the performance of one or more of the billable activities described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular service component or subcomponent being claimed; and
        • a brief description of the location of the service event, as described in Section 3610, 15-Minute Unit of Service (see No. 1), such as the address or name of business;
      • be supported by information that justifies the length of the service event, as described in Section 3610 (see No. 1), such as an explanation in the written service log or implementation plan of why a billable activity took more time than typically required to complete;
      • for service components or subcomponents with a daily unit of service, as listed in Section 3520, Daily Unit of Service, include:
        • a description or list of activities performed by the service provider and the individual that evidences the performance of the billable activities described in Section 4000 for the particular service component or subcomponent being claimed;
      • be made within reasonable time after the activity being documented is provided; and
      • include the signature and title of the service provider making the written service log.
    2. Written Summary Log

      A written summary log must:
      • be written after services have been provided;
      • include information that identifies the individual for whom the written summary log is made;
      • include a general description or list of activities performed during the calendar week in which the service component or subcomponent was provided;
      • be made within a reasonable time after the week being documented; and
      • include the signature and title of the service provider making the written summary log.
  2. Unusual Incidents or Progress Toward Objectives

    The description of the activities in a written service log or written summary log must include a description of any unusual incident that occurs such as a seizure, illness or behavioral outburst, and any action taken by the service provider in response to the incident.
  3. Unacceptable Content

    The following are unacceptable as a description of the activities in a written service log or written summary log:
    • ditto marks;
    • references to other written service logs or written summary logs using words or symbols;
    • non-specific statements such as "had a good day," "did ok," or "no problem today;"
    • a statement or other information that is photocopied from other completed or partially completed written service logs or written summary logs; and
    • a medication log.
  4. Separate Written Service Log or Written Summary Log for Service Component, Subcomponent or Service Event

    A program provider must have a separate written service log or separate written summary log for each service component or subcomponent, as described in Section 3810, General Requirements (see No. 2(a), fourth bullet), and for each service event as described in Section 3610 (see No. 1).

 

3830 Proof of Service Provider Qualifications

Revision 12-1; Effective February 10, 2012

 

A program provider must have the following documentation as proof that a service provider is qualified:

 

3840 Proof of Location of Residence of Service Provider

Revision 15-2; Effective October 30, 2015

 

  1. Photo ID, Voter's Registration Card, Lease or Utility Bill

    Except as provided in No. 2 below, a program provider must have two documents from the following categories to prove the location of the residence of a service provider of transportation as a community support activity or respite services:
    • a driver's license or other government issued photo identification of the service provider;
    • a voter's registration card of the service provider;
    • a lease agreement for the time period in question with the name of the service provider as the lessee or an occupant; or
    • a utility bill for the time period in question in the name of the service provider.
  2. Other Proof

    At its discretion, DADS may accept other written documentation as proof of the location of the residence of a service provider of respite or transportation as a community support activity.

 

3850 Example Forms

Revision 15-2; Effective October 30, 2015

 

Form 4118, Respite Service Delivery Log, may be used to document a service component or subcomponent (except for day habilitation for an individual receiving supported employment, employment assistance and for transportation as a community support activity) in accordance with this section. These documents are only examples. A program provider may document a service component or subcomponent in any way that meets the requirements of this section and the written documentation requirements described in Section 4000, Specific Requirements for Service Components Based on Billable Activity, for the particular service component or subcomponent being claimed.

TXHMLBG, Section 4000, Specific Requirements for Service Components Based on Billable Activity

Revision 15-3; Effective December 11, 2015

 

 

4100 Reserved for Future Use

Revision 12-1; Effective February 10, 2012

 

 

4200 Professional Therapies

Revision 14-1; Effective April 10, 2014

 

 

 

4210 General Description of Service Component

Revision 14-1; Effective April 10, 2014

 

The professional therapies service component consists of the following subcomponents:

 

4220 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the professional therapies service component are:

 

4230 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the professional therapies service component.
  2. Activities Not Listed in Section 4220
    Any activity not described in Section 4220, Billable Activity, is not billable for the professional therapies service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the professional therapies service component:
    • providing services outside the scope of the service provider's practice;
    • providing services that are performed by a service coordinator or were performed by a former case manager;
    • scheduling an appointment;
    • transporting an individual;
    • traveling or waiting to provide a professional therapies subcomponent;
    • training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment;
    • creating written documentation as described in Section 4260, Written Documentation;
    • reviewing a written narrative or written summary of a service component as described in Section 3820, Written Service Log and Written Summary Log; and
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

 

4240 Qualified Service Provider

Revision 14-2; Effective September 1, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the professional therapies subcomponents must be as follows:

 

4250 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the professional therapies service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for professional therapies may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4260 Written Documentation

Revision 14-1; Effective April 10, 2014

 

Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for professional therapies that:

 

4270 Insurance Co-payment and Deductible

Revision 14-1; Effective April 10, 2014

 

  1. Co-payment
    1. Number of Units on Service Claim
      If a program provider is aware that an individual is covered by an insurance policy that requires a co-payment for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the co-payment and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the lesser of the maximum number of units of service for which payment by the TxHmL Program will not exceed the amount of the co-payment paid by the policyholder.

      Example:
      An individual receives four units of service (one hour) of physical therapy and the insurance policy covering the individual requires a $20 co-payment, for which the policyholder requests to be reimbursed. If the TxHmL Program pays $19.35 per unit of service of physical therapy, the program provider must submit a service claim for one unit of service of physical therapy (the maximum number of units of service for which payment will not exceed the amount of the co-payment).
    2. Program Provider Must Pay Policyholder Amount of Service Claim
      A program provider that submits a service claim to obtain reimbursement for a co-payment must pay the policyholder the amount the program provider receives as payment for the service claim.

      Example:
      Using the facts given in the example above, the program provider must pay the policyholder $19.35.
    3. Written Documentation
      A program provider must have written documentation to support a service claim submitted to obtain reimbursement for a co-payment made for a professional therapies subcomponent. The written documentation must include:
      • a copy of the insurance policy specifying the amount that must be paid by the policyholder as a co-payment;
      • a receipt that verifies payment of the co-payment by the policyholder;
      • an explanation of benefits (EOB) regarding the professional therapies subcomponent provided to the individual from the insurance company that issued the policy, showing that co-payments were required of the policyholder; and
      • proof that the policyholder was paid the service claim amount by the program provider.
  2. Deductible
    1. Number of Units on Service Claim
      If a program provider is aware that an individual is covered by an insurance policy that requires a deductible for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the deductible and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the maximum number of units of service for which payment by the TxHmL Program will not exceed the amount of the deductible paid by the policyholder for the professional therapies subcomponent.

      Example:
      An individual receives four units of service (one hour) of physical therapy services. The policyholder pays $100 for the services, which is applied toward a deductible, and requests to be reimbursed. If the TxHmL Program pays $19.35 per unit of service of physical therapy, the program provider must submit a service claim for the number of units of service the individual received, or four units of service of physical therapy.
    2. Program Provider Must Pay Policyholder Amount of Service Claim
      A program provider that submits a service claim to obtain reimbursement for payment made toward a deductible for a professional therapies subcomponent must pay the policyholder the amount the program provider receives as payment for the service claim.

      Example:
      Using the facts given in the example above, the program provider must pay the policyholder $77.43 ($19.35 x 4 units of service).
    3. Written Documentation
      A program provider must have written documentation to support a service claim to obtain reimbursement for a payment made toward a deductible for a professional therapies subcomponent. The written documentation must include:
      • a copy of the insurance policy specifying the amount that must be paid by the policyholder as a deductible;
      • an EOB regarding the professional therapies subcomponent provided to the individual from the insurance company that issued the policy, showing payments toward the deductible were required of the policyholder; and
      • proof of payment that verifies the policyholder was paid the service claim amount by the program provider.

 

4300 Day Habilitation

Revision 12-1; Effective February 10, 2012

 

 

4310 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The day habilitation service component is the provision of assistance to an individual that is necessary for the individual to acquire skills to reside, integrate and participate successfully in the community.

 

4320 Requirements of Setting

Revision 12-1; Effective February 10, 2012

 

Day habilitation may be provided to an individual only in a setting that is not the residence of the individual, unless the provision of day habilitation in a residence is justified because of the individual's medical condition or behavioral issues or because the individual is of retirement age, and such justification is documented in the individual's record.

 

4330 Billable Activity

Revision 14-2; Effective September 1, 2014

 

The only billable activities for the day habilitation service component are:

 

4340 Activity Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the day habilitation service component.
  2. Activities Not Listed in Section 4330
    Any activity not described in Section 4330, Billable Activity, is not billable for the day habilitation service component.
  3. Meeting Vocational Production Goal Not Billable Activity
    Assisting an individual for the sole purpose of meeting a vocational production goal is an example of an activity that is not billable for the day habilitation service component.

 

4350 Restrictions Regarding Submission of Claims for Day Habilitation

Revision 14-2; Effective September 1, 2014

 

A program provider may not submit a service claim for:

 

4360 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the day habilitation service component must have one of the following:

 

4370 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. One Day
    A unit of service for the day habilitation service component is one day.
  2. Service Claim for Unit of Service
    1. One-quarter Unit of Service
      A program provider may submit a service claim for day habilitation for one-quarter (0.25) unit of service if the program provider provides at least one and one-quarter hours of consecutive day habilitation on a calendar day.
    2. One-half Unit of Service
      A program provider may submit a service claim for day habilitation for one-half (0.5) unit of service if the program provider provides at least two and one-half hours of day habilitation on a calendar day. Two of the two and one-half hours must be consecutive.
    3. Three-quarters Unit of Service
      A program provider may submit a service claim for day habilitation for three-quarters (.75) unit of service if the program provider provides at least three and three-quarter hours of day habilitation on a calendar day. Two of the three and three-quarter hours must be consecutive.
    4. One Unit of Service
      A program provider may submit a service claim for day habilitation for one unit of service if the program provider provides at least five hours of day habilitation on a calendar day. Two of the five hours must be consecutive.

 

4380 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for day habilitation that:

 

4400 Registered Nursing

Revision 12-1; Effective February 10, 2012

 

4410 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301, provided to an individual with a medical need.

 

4420 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the registered nursing service component are:

 

4430 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the registered nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the registered nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the registered nursing service component, regardless of whether they constitute the practice of registered nursing:
    • performing or supervising an activity that does not constitute the practice of registered nursing, including:
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4420;
    • creating written documentation as described in Section 4470, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing unless supervising the licensed vocational nurse, specialized registered nursing or specialized licensed vocational nursing unless supervising the licensed vocational nurse) or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4440 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the registered nursing service component must be a registered nurse.

 

4450 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the registered nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for registered nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4460 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for registered nursing provided to one individual on a single calendar month. The service times of more than one registered nurse may be accumulated on the last day of the month. The service time of more than one registered nurse may be accumulated on the last day of the month.

Example:

A registered nurse provides registered nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 25, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for registered nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for registered nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of registered nursing to an individual. During the same month, Nurse B provides 7 minutes of licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4470 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4471 Licensed Vocational Nursing

Revision 12-1; Effective February 10, 2012

 

 

4471.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The licensed vocational nursing service component is the provision of licensed vocational nursing to an individual, as defined in Texas Occupations Code, Chapter 301.

 

4471.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the licensed vocational nursing service component are:

 

4471.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the licensed vocational nursing service component.
  2. Activities Not Listed in Section 4471.2
    Any activity not described in Section 4471.2, Billable Activity, is not billable for the licensed vocational nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:

 

4471.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the licensed vocational nursing service component must be a licensed vocational nurse.

 

4471.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the licensed vocational nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for licensed vocational nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4471.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one licensed vocational nurse may be accumulated on the last day of the month.

Example:

A nurse provides licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for licensed vocational nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month July 31, 2012, three units of service for licensed vocational nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of licensed vocational nursing to an individual. During the same month, Nurse B provides 7 minutes of registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4471.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4472 Specialized Registered Nursing

Revision 12-1; Effective February 10, 2012

 

 

4472.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The specialized registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301, to an individual who has a tracheostomy or is dependent on a ventilator.

 

4472.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the specialized registered nursing service component are:

 

4472.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized professional nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized registered nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the specialized registered nursing service component, regardless of whether they constitute the practice of registered nursing:
    • performing or supervising an activity that does not constitute the practice of registered nursing, including:
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4472.2, Billable Activity;
    • creating written documentation as described in Section 4472.7, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing unless supervising the licensed vocational nurse, specialized registered nursing, or specialized licensed vocational nursing unless supervising the licensed vocational nurse), or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4472.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized registered nursing service component must be a registered nurse.

 

4472.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the specialized registered nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for specialized registered nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4472.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized registered nursing provided to one individual during a single calendar month. The service times of more than one specialized registered nurse may be accumulated on the last day of the month.

Example:

A nurse provides specialized registered nursing services to one individual three times in a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for specialized registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized registered nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized registered nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of specialized registered nursing to an individual. On the same calendar day, Nurse B provides 7 minutes of specialized licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4472.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for specialized registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4473 Specialized Licensed Vocational Nursing

Revision 12-1; Effective February 10, 2012

 

 

4473.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The specialized licensed vocational nursing service component is the provision of licensed vocational nursing, as defined in Texas Occupations Code, Chapter 301, to an individual who has a tracheostomy or is dependent on a ventilator.

 

4473.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the specialized licensed vocational nursing service component are:

 

4473.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized licensed vocational nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized licensed vocational nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the specialized licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:
    • performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:
      • performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse;
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4473.2, Billable Activity;
    • creating written documentation as described in Section 4473.7, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4473.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized licensed vocational nursing service component must be a licensed vocational nurse.

 

4473.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the specialized licensed vocational nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for specialized licensed vocational nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4473.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one specialized licensed vocational nurse may be accumulated.

Example:

A nurse provides specialized licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for specialized licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized licensed vocational nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized licensed vocational nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of specialized licensed vocational nursing to an individual. During the same month, Nurse B provides 7 minutes of registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4473.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for specialized licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4500 Community Support (Transportation)

Revision 15-2; Effective October 30, 2015

 

4510 General Description of Service Component

Revision 15-2; Effective October 30, 2015

 

The community support service component is transportation provided to an individual.

 

4520 Community Support Billing Requirements

Revision 15-2; Effective October 30, 2015

 

  1. Billable Activity
    The only billable activity for the community support subcomponent is transporting the individual, except from one day habilitation, employment assistance or supported employment site to another.
  2. Activity Not Billable
    1. Activities in Section 3300
      The activities listed in Section 3300, Activity Not Billable, are not billable for transportation as a community support activity.
    2. Activities Not Listed in No. 1 Above
      Any activity not described in No. 1 above is not billable for transportation as a community support activity.
  3. Restrictions Regarding Submission of Claims for Transportation as a Community Support Activity
    A program provider may not submit a service claim for transporting an individual from one habilitation or supported employment site to another.
  4. Qualified Service Provider
    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of transportation as a community support activity:
    • may not have the same residence as the individual; and
    • must have one of the following:
      • a high school diploma;
      • a high school equivalency certificate issued in accordance with the law of the issuing state; or
      • both of the following:
        • a successfully completed written competency-based assessment demonstrating the ability to provide transportation as a community support activity and the ability to document the provision of transportation as a community support activity in accordance with Section 3800, Written Documentation, and No. 8 below; and
        • written personal references which evidence the service provider's ability to provide a safe and healthy environment for the individual from at least three persons who are not relatives of the service provider (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these billing guidelines).
  5. Unit of Service
    1. 15 Minutes
      A unit of service for transportation as a community support activity is 15 minutes.
    2. Fraction of a Unit of Service
      A service claim for transportation as a community support activity may not include a fraction of a unit of service.
    3. Service Time
      Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.
  6. Written Documentation

    Transportation as a Community Support Activity Specific Information
    A program provider must have written documentation to support a service claim for transportation as a community support activity. The written documentation must include:
    • the name of the individual who was being transported;
    • the day, month and year the transportation was provided;
    • the place of departure and destination for the individual being transported;
    • a notation of whether the program provider is using Method A or Method B to calculate transportation time, as required by (7)(b)(II);
    • a begin and end time for each transportation time, as described in (7)(b);
    • the total minutes of each transportation time;
    • for each "trip" if using Method A (see (7)(a)(III) and (IV)) or, for each "segment" if using Method B (see (7)(a)(V)):
      • the number of passengers;
      • the number of service providers;
      • the resulting service time; and
      • the signature of the service provider transporting the individual;
    • the unit of service for a service claim resulting from each service time; and
    • any service times accumulated to make a unit of service for a service claim.

    Example Form
    Form 2124, Community Support Transportation Log, may be used to document transportation as a community support activity. This log is only an example, however. A program provider may document such activity in any way that meets requirements.

  7. Determining Unit of Service for Transportation as a Community Support Activity

    General Process
    The unit of service for a service claim for transportation as a community support activity is determined by:
    • calculating transportation time, number of passengers and number of service providers using Method A or Method B, as described in Item b. below;
    • determining service time using the formula set forth in Item c below; and
    • converting service time to units of service for a service claim using Appendix III, Conversion Table, as described in Item d. below.
    1. Calculating Transportation Time, Passengers, Service Providers
      1. How to Calculate
        Transportation time, number of passengers and number of service providers must be calculated using Method A or Method B as described below.
      2. Use of Only One Method on a Single Calendar Day
        A program provider may not use Method A and Method B on the same calendar day.
      3. Definitions Applicable for Method A and Method B
        The following definitions apply to Method A and Method B:
        • A "passenger" is a person who receives a service funded by DADS, including a person enrolled in the intermediate care facilities for persons with intellectual disability (ICF/ID) program or a waiver program other than HCS.
        • A "trip" is a discrete period of continuous time during which one or more individuals are being transported in the same vehicle.
      4. Method A
        Using Method A, the transportation time, number of passengers and number of service providers are the same for all individuals transported in a single trip:
        • Transportation time begins when the first individual gets on the vehicle and ends when the last individual gets off the vehicle.
        • The number of passengers is the total number of passengers transported during the trip.
        • The number of service providers is the total number of service providers who provide services during the trip, including the driver of the vehicle.
      5. Method B
        Using Method B, the transportation time, number of passengers and number of service providers are determined separately for each individual transported in a single trip in segments that begin and end when the number of passengers or the number of service providers changes during the trip.
    2. Determining Service Time
      1. How to Determine
        Service time must be determined using the transportation time, number of passengers and number of service providers for an entire trip (if using Method A) or for each segment of a trip (if using Method B).
      2. Formula
        The formula for calculating the service time is:
        Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers
    3. Converting Service Time to Units of Service
      Service time must be converted to units of service for a service claim as set forth in Appendix III.
    4. Examples of Determining Unit of Service for Transportation as a Community Support Activity
      See Appendix II, Determining Units of Service for the Community Support Activity of Transporting an Individual, for examples of determining the units of service for a service claim for transportation as a community support activity.
    5. Accumulation of Service Times
      1. For Single Calendar Day
        A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for transporting one individual on a single calendar day. The service times of more than one service provider may be accumulated.
      2. Example of Accumulating Service Time
        See Appendix II for an example of accumulating service time for transportation as a community support activity.

 

4600 Respite

Revision 12-1; Effective February 10, 2012

 

 

4610 General Description of Service Component

Revision 15-2; Effective October 30, 2015

 

  1. Temporary Provision of Assistance
    The respite service component:
    • is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills; and
    • provides relief for a caregiver of the individual who:
        • is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills;
        • provides relief for a caregiver of the individual who:
          • has the same residence as the individual;
          • routinely provides assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills;
          • is temporarily unavailable to provide such assistance and support; and
          • is not a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) unless:
            • the service provider of CFC PAS/HAB routinely provides unpaid assistance and support to the individual; and
            • is used to provide temporary support to the primary caregiver.
  2. Room and Board
    If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge.

 

4620 Billable Activity

Revision 14-2; Effective September 1, 2014

 

The only billable activities for the respite service component are:

 

4630 Respite in Residence or During Overnight Stay in Non-residence

Revision 12-1; Effective February 10, 2012

 

  1. Residence
    If an individual receives respite in a residence, the residence must be:
    • the individual's residence;
    • a three-person residence;
    • a four-person residence; or
    • the residence of another person (other than a three-person residence or a four-person residence) in which no more than three persons are receiving TxHmL or HCS Program services or a non-TxHmL/HCS program service similar to TxHmL or HCS Program services.
  2. Non-residence
    If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving TxHmL or HCS Program services or a non-TxHmL/HCS Program service similar to TxHmL or HCS Program services may be in the setting.

 

4631 Residential Location

Revision 12-1; Effective February 10, 2012

 

A program provider may provide respite to an individual only if the program provider has documented a residential location of "own/family home" on the individual's IPC.

 

4640 Activity Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the respite service component.
  2. Activities Not Listed in Section 4620
    Any activity not described in Section 4620, Billable Activity, is not billable for the respite service component.

 

4650 Submitting a Service Claim for Respite

Revision 12-1; Effective February 10, 2012

 

  1. Respite Provided in an Individual's Residence
    If a program provider provides respite in an individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day.
  2. Respite Provided in Location Other Than the Individual's Residence
    If a program provider provides 10 hours or more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.

 

4651 Restrictions Regarding Submission of Claims for Respite

Revision 15-2; Effective October 30, 2015

 

A program provider may not submit a service claim for:

 

4660 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the respite service component:

 

4670 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the respite service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for respite may not include a fraction of a unit of service.

 

4680 Payment Limit

Revision 12-1; Effective February 10, 2012

 

The maximum amount DADS will pay a program provider for respite provided to an individual is based on the dollar cap for services per IPC year.

 

4690 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for respite. The written documentation must:

 

4700 Supported Employment

Revision 12-1; Effective February 10, 2012

 

 

4710 General Description of Service Component

 

Revision 14-2; Effective September 1, 2014

Supported employment means assistance provided in order to sustain competitive employment or self-employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed. Supported employment includes employment adaptations, supervision, training related to an individual’s assessed needs, and earning at least a minimum wage (if not self-employed).

4720 Billable Activity

 

Revision 15-3; Effective December 11, 2015

The only billable activities for the supported employment service component are:

 

4730 Activity Not Billable

Revision 15-2; Effective October 30, 2015

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the supported employment service component.
  2. Activities Not Listed in Section 4720
    Any activity not described in Section 4720, Billable Activity, is not billable for the supported employment service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the supported employment service component:
    • interacting with an individual prior to the individual's employment;
    • face-to-face contact with an individual to provide Supported Employment services simultaneously with Day Habilitation services, Employment Assistance, Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) or Respite;
    • habilitation activities provided and billed as part of the Day Habilitation or CFC PAS/HAB service component;
    • time spent waiting to provide a service;
    • any activity taking place in a sheltered work environment 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;
    • any activity that occurs before or after employment which is gained as a result of paying an employer to encourage the employer to hire an individual;
    • any activity that occurs before or after employment which is gained as a result of paying an employer for supervision, training, support and adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business;
    • paying the individual as an incentive to participate in Supported Employment activities; and
    • paying the individual for expenses associated with the start-up costs or operating expenses of an individual’s business.

 

4740 Qualified Service Provider

Revision 14-1; Effective April 10, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the supported employment service component:

 

4750 Restrictions Regarding Submission of Claims for Supported Employment

Revision 14-1; Effective April 10, 2014

 

A program provider may not submit a service claim for supported employment provided to an individual if supported employment is available to the individual through the public school system.

 

4760 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the supported employment service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for supported employment may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4770 Written Documentation

Revision 14-1; Effective April 10, 2014

 

A program provider must have written documentation to support a service claim for supported employment. The written documentation must:

 

4800 Employment Assistance

Revision 14-1; Effective April 10, 2014

 

 

4810 General Description of Service Component

Revision 14-1; Effective April 10, 2014

 

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

 

4820 Employment Assistance Billable Time/Activities

Revision 15-2; Effective October 30, 2015

 

Employment Assistance 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:

 

4830 Employment Assistance Non-Billable Time/Activities

Revision 15-2; Effective October 30, 2015

 

Unit of Service: 15 minutes

 

4840 Employment Assistance Qualified Service Provider

Revision 14-1; Effective April 10, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the employment services component:

 

4850 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the supported employment service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for supported employment may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4860 Employment Assistance Documentation Requirements

Revision 14-1; Effective April 10, 2014

 

Documentation will be maintained in the file of each participant receiving employment assistance verifying that such assistance is not otherwise available to the participant under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142. See the DADS/DARS MOA for more detail on coordination and documentation processes: Standards for Manual Consumer Services Contract Providers.

A service log for each service event that describes the service and, when appropriate, includes information pertaining to the individual's progress toward goals and objectives.

The service log must include:

TXHMLBG, Section 5000, General Requirements for Service Components Not Based on Billable Activity

Revision 14-1; Effective April 10, 2014

 

5100 Applicable Service Components

Revision 12-1; Effective February 10, 2012

 

Section 5000 applies only to the following service components:

 

5200 Service Claim Requirements

Revision 12-1; Effective February 10, 2012

 

A program provider must submit an electronic service claim that meets the following requirements:

 

5300 Written Documentation

Revision 12-1; Effective February 10, 2012

 

  1. Legible
    A program provider must have written, legible documentation as described by this section and Section 6000, Adaptive Aids, Minor Home Modifications and Dental Treatment, to support a service claim.
  2. Proof of Licensed Professional Qualifications
    A program provider must have a written document from the appropriate state licensing agency or board to prove that a licensed professional, as required by Section 6160, Required Documentation for an Adaptive Aid (see No. 1, Item a), and a provider of dental treatment, as described in Section 6350, Provider of Dental Treatment, is properly licensed.

TXHMLBG, Section 6000, Adaptive Aids, Minor Home Modifications and Dental Treatment

Revision 15-1; Effective March 26, 2015

 

6100 Adaptive Aids

Revision 12-1; Effective February 10, 2012

 

 

6110 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform activities of daily living or to control the individual's environment.

 

6120 Billable Adaptive Aids

Revision 12-1; Effective February 10, 2012

 

The only billable items and services for the adaptive aids service component are listed in Appendix IV, Billable Adaptive Aids. The repair and maintenance of a billable item not covered by warranty is also billable for the adaptive aids service component.

 

6130 Items and Services Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Items and Services Not Listed in Appendix IV
    Any item or service not listed in Appendix IV, Billable Adaptive Aids, is not billable under the adaptive aids service component.
  2. Examples of Non-Billable Items and Services
    The following are examples of items and services that are not billable for the adaptive aids service component:
    • an appliance (for example, washer, dryer, stove, dishwasher or vacuum cleaner);
    • swimming pool;
    • hot tub;
    • eye exam;
    • shoes not specifically designed for the individual;
    • automobile;
    • lift for a vehicle other than one owned or leased by the individual's care provider, the individual or the individual's relative (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these guidelines);
    • toy, game or puzzle;
    • recreational equipment (for example, swing set or slide);
    • personal computer or software for purposes other than to augment expressive and receptive communication (for example, educational purposes);
    • medication, including a co-payment for a medication;
    • daily hygiene products (for example, deodorant, lotions, soap, toothbrush, toothpaste, feminine products, adhesive bandages or cotton swabs);
    • rent;
    • utilities (for example, gas, electric, cable or water);
    • food;
    • ordinary bedding supplies (for example, bedspread, pillow or sheet);
    • exercise equipment;
    • pager, including a monthly service fee;
    • conventional telephone, including a cellular phone or a monthly service fee;
    • home security system, including a monthly service fee;
    • non-sterile gloves for use by paid service providers;
    • iPads, iPods or tablets; and
    • iPad, iPod or tablet accessories or applications.

 

6140 Property of Individual

Revision 12-1; Effective February 10, 2012

 

Except for a vehicle lift, a billable item must be the exclusive property of the individual to whom it is provided.

 

6150 Payment Limit

Revision 15-1; Effective March 26, 2015

 

The maximum amount DADS pays a program provider for all adaptive aids provided to an individual is $10,000 per IPC year.

 

6160 Required Documentation for an Adaptive Aid

Revision 13-1; Effective January 1, 2014

 

  1. Adaptive Aid Costing $500 or More

For an adaptive aid costing $500 or more, a program provider must obtain the documentation described below before purchasing the adaptive aid.

  1. Written Assessment

A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific adaptive aid, as shown in Appendix IV, Billable Adaptive Aids. The written assessment must:

  1. Individual and Program Provider Agreement

An individual or legally authorized representative and program provider must:

  1. Proof of Non-coverage by Medicaid and Medicare
    1. Adaptive Aids Noted with a (1) or (2) on Appendix IV, Billable Adaptive Aids
      1. Documentation Required

Except as provided in II, Nutritional Supplements, below, for an adaptive aid noted on Appendix IV, Billable Adaptive Aids, with a (1) or, for an adaptive aid noted with a (2) for an individual who is under 21 years of age, the program provider must obtain one of the following as proof of non-coverage by Medicaid:

  1. Additional Documentation Required for Individuals Who are Eligible for Medicare

In addition to the documentation required by Item i above, for an individual eligible for Medicare, a program provider must obtain one of the following for an adaptive aid noted with a (1) or (2) on Appendix IV:

  1. Unacceptable Documentation

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

  1. Nutritional Supplements

For a nutritional supplement (service code 121), the program provider must obtain one of the following as proof of non-coverage by Medicaid:

  1. Bids

 

  1. Required Number of Bids

A program provider must obtain comparable bids for the requested adaptive aid from three vendors, except as provided in Item III. below. Comparable bids describe the adaptive aid and any associated items or modifications identified in the assessment required by Item a. above.

  1. Required Content and Time Frame

A bid must:

  1. Program Provider Not Required to Obtain Three Bids
    1. One Bid

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

  1. One or Two Bids

A program provider may obtain only one bid or two comparable bids for an adaptive aid, other than one listed in Item i. above, if the program provider has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

  1. Request for Payment of Higher Bid
    1. Documentation Required

If a program provider will request authorization for payment, as described by Section 6170, Authorization for Payment, that is not based on the lowest bid, the program provider must have written justification for payment of a higher bid.

  1. Examples of Justification That May Be Acceptable

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

  1. Proof of Ownership

If applicable, a program provider must obtain proof that the individual, individual's family member or care provider owns the vehicle for which a vehicle lift (service code 101) is requested.

  1. Adaptive Aids Costing Less Than $500

For an adaptive aid costing less than $500, a program provider must obtain the documentation described in this paragraph before purchasing the adaptive aid.

  1. Individual and Program Provider Agreement, Proof of Non-Coverage, Bids and Proof of Ownership

For an adaptive aid costing less than $500, a program provider must obtain:

  1. Approval of Annual Vendor

In lieu of obtaining bids in accordance with (1)(d) above for an adaptive aid costing less than $500 monthly, a program provider must, in accordance with this subparagraph, obtain DADS approval of an annual vendor.

  1. Documentation Required

To obtain approval of an annual vendor, a program provider must submit the following written documentation to DADS:

  1. Approval Period and Time Frame for Submission
    1. Approval Period

An approval of an annual vendor by DADS is only valid for a calendar year.

  1. Time Frame for Submission

To obtain approval of an annual vendor, a program provider must submit documentation required by No. I above:

  1. Approval of Multiple Vendors

DADS may approve more than one annual vendor for a program provider per calendar year.

  1. Vendor Used for All Individuals

If DADS approves an annual vendor to provide an adaptive aid, a program provider must use the vendor to supply the adaptive aid to all individuals of the program provider who need the adaptive aid.

 

6170 Authorization for Payment

 

Revision 12-1; Effective February 10, 2012

  1. Requesting Authorization for Payment
    1. Adaptive Aids Costing $500 or More
      To obtain authorization for payment for an adaptive aid costing $500 or more, a program provider must:
      • submit a completed Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, to DADS in accordance with the form instructions; and
      • keep in the individual's record the documentation required by Section 6160, Required Documentation for an Adaptive Aid (see No. 1).
    2. Adaptive Aid Costing Less than $500
      To obtain authorization for payment for an adaptive aid costing less than $500, a program provider must:
      • submit a completed Form 4116-MHM-AA to DADS in accordance with the form instructions; and
      • keep in the individual's record the documentation required by Section 6160 (see No. 2).
    3. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for an adaptive aid in accordance with the instructions on Appendix VII, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet.

  2. Time Frame for the Request for Authorization for Payment
    A program provider must request authorization for payment for an adaptive aid no later than 12 months after the last day of the month in which the individual received the adaptive aid.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount which DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Requests
      If a request for authorization for payment is denied, a program provider must submit a corrected request no more than 12 months after the last day of the month in which the individual received the adaptive aid.

 

6200 Minor Home Modifications

Revision 12-1; Effective February 10, 2012

 

 

6210 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

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

 

6220 Billable Minor Home Modifications

Revision 12-1; Effective February 10, 2012

 

The only billable adaptations for the minor home modification service component are listed in Appendix V, Billable Minor Home Modifications. The repair and maintenance of a billable adaptation not covered by warranty is also billable for the minor home modifications service component.

 

6230 Adaptations Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Adaptations Not Listed in Appendix V
    Any adaptation not listed in Appendix V, Billable Minor Home Modifications, is not billable under the minor home modification service component.
  2. Examples of Non-Billable Adaptations
    The following are examples of adaptations that are not billable for the minor home modification service component:
    • general repair of a residence (for example, repairing a leaking roof or rotten porch, controlling termite damage or leveling a floor);
    • general remodeling of a residence that does not address an individual's specific needs;
    • an adaptation that adds square footage to a residence;
    • construction of new room, including installation of plumbing and electricity;
    • a septic tank;
    • general plumbing or electrical work;
    • hot water heater;
    • central heating or cooling system;
    • heater;
    • fire sprinkler system;
    • fire alarm system;
    • appliance (for example, washer, dryer, stove, dishwasher or refrigerator);
    • fence;
    • carport;
    • driveway;
    • deck; and
    • hot tub.

 

6240 Payment Limit

Revision 12-1; Effective February 10, 2012

 

Payment by DADS to a program provider for minor home modifications is subject to the following limitations:

 

6250 Required Documentation for a Minor Home Modification

Revision 12-4; Effective November 19, 2012

 

  1. Minor Home Modification Costing $1,000 or More
    For a minor home modification costing $1,000 or more, a program provider must obtain the documentation described in this paragraph before purchasing the minor home modification.
    1. Written Assessment
      A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific minor home modification on Appendix V, Billable Minor Home Modifications. The written assessment must:
      • be based on a face-to-face evaluation of the individual by the licensed professional conducted in the individual's residence not more than one year before the date of purchase of the minor home modification;
      • include a description of and a recommendation for a specific minor home modification listed Appendix V and any associated installation specifications necessary to make the minor home modification functional;
      • include a diagnosis that is related to the individual's need for the minor home modification (for example, cerebral palsy, quadriplegia or deafness);
      • include a description of the condition related to the diagnosis (for example, unable to ambulate without assistance); and
      • include a description of the specific needs of the individual and how the minor home modification will meet those needs (for example, the individual needs to enter and exit the home safely and the addition of a wheelchair ramp will allow him to do so).
    2. Individual and Program Provider Agreement
      An individual or legally authorized representative and program provider must:
      • meet and consider the written assessment required by Item a.;
      • document any discussion about the recommended minor home modification;
      • agree that the recommended minor home modification is necessary and should be purchased; and
      • document their agreement in writing and sign the agreement.
    3. Bids
      1. Required Number of Bids
        A program provider must obtain comparable bids for the requested minor home modification from three vendors, except as provided in No. III below. Comparable bids describe the minor home modification and any associated installation specifications identified in the written assessment required by Item a. above.
      2. Required Content and Time Frame
        A bid must:
        • be cost effective according to current market prices for the adaptive aid and be the lowest cost based on availability unless contraindicated by specific written justification for using a higher bid;
        • state the total cost of the requested minor home modification and, if it includes more than one modification, state the cost of each modification by service code;
        • include the name, address and telephone number of the vendor;
        • include a complete description of the minor home modification and any associated installation specifications, as identified in the written assessment required by Item a.;
        • include a drawing or picture of both the existing and proposed floor plans;
        • include a statement that the minor home modification will be made in accordance with all applicable state and local building codes; and
        • be obtained within one year after the written assessment required by Item a. above is obtained.
      3. Program Provider Not Required to Obtain Three Bids
        A program provider may obtain only two comparable bids for the requested minor home modification if the program provider has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.
      4. Request for Payment of Higher Bid
        1. Documentation RequiredIf a program provider will request authorization for payment that is not based on the lowest bid, as described by Section 6260, Authorization for Payment, the program provider must have written justification for the payment of a higher bid.
        2. Examples of Justification That May be Acceptable
          An example of justification that supports payment of a higher bid is the inclusion of a longer warranty for the minor home modification.
  2. Minor Home Modification Costing Less Than $1,000
    For a minor home modification costing less than $1,000, a program provider must obtain the following documentation before purchasing the minor home modification:
    • an individual and program provider agreement, as described in No. 1., Item b. above (except that there may be no written assessment to consider), made not more than one year before the date of purchase of the minor home modification; and
    • bids, as described in Item c. above; and
    • if applicable, written justification for less than three bids or payment of a higher bid as described in No. 1, Item c., (III) and (IV) above.

 

6260 Authorization for Payment

Revision 12-1; Effective February 10, 2012

 

  1. Requesting Authorization for Payment
    1. Minor Home Modification Costing $1,000 or More
      To obtain authorization for payment for a minor home modification costing $1,000 or more, a program provider must:
      • submit a completed Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, to DADS in accordance with the form instructions.
      • keep in the individual's record the documentation required by Section 6250, Required Documentation for a Minor Home Modification (see No. 1).
    2. Minor Home Modification Costing Less than $1,000
      To obtain authorization of payment for a minor home modification costing less than $1,000, a program provider must:
      • submit a completed Form 4116-MHM-AA to DADS in accordance with the form instructions.
      • keep in the individual's record the documentation required by Section 6250 (see No. 2).
    3. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for a minor home modification in accordance with the instructions in Appendix V.
  2. Time Frame for the Request for Authorization for Payment
    A program provider must request authorization for payment for a minor home modification no later than 12 months after the last day of the month in which the minor home modification was completed.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount which DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Requests
      If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the minor home modification was completed.

 

6300 Dental Treatment

Revision 12-1; Effective February 10, 2012

 

 

6310 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The dental treatment service component includes emergency dental treatment, preventive dental treatment, therapeutic dental treatment and orthodontic dental treatment.

 

6320 Age Requirement

Revision 12-1; Effective February 10, 2012

 

Dental treatment may be provided only to an individual 21 years of age or older.

 

6330 Billable Dental Treatment

Revision 12-1; Effective February 10, 2012

 

The only billable services for the dental treatment service component are:

 

6340 Services Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Items and Services Not Listed in Subsection (C)
    Any service not listed in Section 6330, Billable Dental Treatment, is not billable under the dental treatment service component.
  2. Examples of Non-Billable Services
    The following are examples of services that are not billable for the dental treatment service component:
    • cosmetic orthodontia; and
    • teeth whitening.

 

6350 Provider of Dental Treatment

Revision 12-1; Effective February 10, 2012

 

A provider of the dental treatment service component must be a person licensed to practice dentistry in accordance with Texas Occupations Code, Chapter 256.

 

6360 Payment Limit

Revision 12-1; Effective February 10, 2012

 

The maximum amount DADS pays a program provider for all dental treatment provided to an individual is $1,000 per IPC year.

 

6370 Authorization for Payment

Revision 12-4; Effective November 19, 2012

 

  1. Requesting Authorization for Payment
    1. Dental Treatment
      To obtain authorization for payment for dental treatment, a program provider must:
      • submit a completed Form 4116-Dental, Dental Summary Sheet, to DADS in accordance with the form instructions; and
      • keep in the individual's record:
        • a statement from the provider of dental treatment that includes:
          • the individual's name; and
          • a description of each dental service provided to the individual, itemized by cost;
        • proof that the program provider purchased the dental treatment, and the date of purchase; and
        • a completed Form 4116-Dental to DADS in accordance with the form instructions.
    2. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for dental treatment in accordance with the instructions in Appendix IX. The requisition fee is not counted toward the payment limit that DADS pays a program provider for dental treatment, as described in Section 6360, Payment Limit.
  2. Time Frame for Request for Authorization for Payment
    A program provider must request authorization for payment for dental treatment no later than 12 months after the last day of the month in which the individual received the dental treatment.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Request
      If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the individual received the dental treatment.

Appendices, TXHMLBG

TXHMLBG, Appendix I, Billing and Payment Review Protocol

Revision 12-1; Effective February 10, 2012

  1. Introduction

This protocol is used to conduct a billing and payment review of a Texas Home Living (TxHmL) Program provider. A billing and payment review is a review conducted by DADS staff of written documentation maintained by a program provider and submitted to DADS upon request. The purpose of a review is to determine whether the program provider is in compliance with the TxHmL Program Billing Guidelines. DADS recoups from a program provider for a service claim that DADS cannot verify is supported by written documentation in accordance with the Billing Guidelines and may require corrective action by the program provider.

 

  1. Types of Reviews
    1. Routine reviews
      A routine review is a billing and payment review conducted by DADS for an TxHmL program provider at least once every two years per program provider. During a routine review, DADS reviews documentation required by the Billing Guidelines for:
      • services provided during a three-month period of time; and
      • the following number of individuals:
        • for a TxHmL provider for which a routine review resulted in a recoupment amount that is 10% or less of the total amount of the claims reviewed, five individuals plus 5% of the total number of individuals provided services during the review period;
        • for a TxHmL provider for which a routine review has not been conducted:
          • if the program provider provided TxHmL Program services to 10 or fewer individuals during the review period, the number of individuals provided services during the review period, but in no case more than five individuals; or
          • if the program provider provided TxHmL Program services to more than 10 individuals during the review period, five individuals plus 10% of the total number of individuals provided services during the review period; or
          • for a TxHmL provider for which a routine review resulted in a recoupment amount that is more than 10% of the total amount of the claims reviewed:
            • if the program provider provided TxHmL Program services to 10 or fewer individuals during the review period, all of the individuals; or
            • if the program provider provided TxHmL Program services to more than 10 individuals during the review period, 10 individuals plus 10 % of the total number of individuals provided services during the review period.
    2. Special reviews
      A special review is a billing and payment review conducted by DADS for one or more TxHmL provider agreements as a result of a billing anomaly identified by DADS staff or as a result of information related to billing issues received from a source other than DADS staff. During a special review, DADS reviews documentation for:
      • any length of time as determined by DADS;
      • any number of individuals as determined by DADS; and
      • any type of service as determined by DADS.
  2. Methods of Review
    1. On-site review
      An on-site review is a billing and payment review conducted at a program provider's place of business.
    2. Desk review
      A desk review is a billing and payment review conducted at a DADS office.
  3. Routine Review Process
    1. On-site review
      1. DADS notifies a program provider of an on-site review by telephone at least 14 days before and by facsimile at least one day before the date the on-site review is scheduled to begin. The telephonic and written notices include a statement that all written documentation required by the Billing Guidelines related to a specified program provider agreement must be made available to the DADS review team at a specified time and place.
      2. At least two business days before the on-site review, DADS faxes to the program provider a list of individuals for whom records will be reviewed and who receive services outside the waiver contract area of the on-site review location.
      3. Upon arrival at the program provider's place of business, the DADS review team informs the program provider of the individuals receiving services in the waiver contract area in which the review is being conducted and time period for which written documentation will be reviewed. During the review, the review team may expand the time period under review and may request documentation related to individuals who were not initially included in the review.
      4. The review team reviews the documentation submitted by the program provider. The review team does not accept any documentation created by the program provider during the review.
      5. When the review team completes the initial review of the documentation submitted by the program provider, the review team gives the program provider a list of all unverified claims and explains why the claims are unverified. The review team allows the program provider to provide additional documentation and refute the unverified claims.
      6. The review team conducts an exit conference with the program provider. During the exit conference the review team summarizes the findings of the review, provides technical assistance to improve documentation practices, and answers questions from the program provider. The review team also gives an estimate of the amount of claims to be recouped. DADS does not allow the program provider to submit additional documentation or refute any unverified claims after the exit conference.
      7. DADS sends a letter by certified mail to the program provider. Generally, DADS sends this letter within 30 days after the exit conference. If DADS did not identify any unverified claims, the letter notifies the program provider of such. If DADS identified unverified claims, the letter includes a detailed report of the unverified claims, the reason the claims were not verified, the amount to be recouped by DADS, any required corrective action and notice of the right to request an administrative hearing. Examples of corrective actions that DADS may require a program provider to take are submitting a plan to improve the program provider's billing practices and reviewing documentation beyond the scope of the billing and payment review.
      8. If DADS requires a program provider to take a corrective action and the program provider does not request an administrative hearing for the recoupment, DADS includes in the letter described in paragraph (f) above a date by which the program provider must take the corrective action. If the program provider does not take the required corrective action by the date required by DADS, DADS may:
        • impose a vendor hold on payments due to the program provider under the TxHmL provider agreement until the program provider takes the corrective action; and
        • terminate the provider agreement.
    2. Desk review
      DADS notifies a program provider of a desk review by telephone and certified mail. The written notice specifies the individuals and time period to be reviewed, as well as the documentation the program provider must submit to DADS for the desk review. The notice states that the documentation must be received by DADS within 14 calendar days after the program provider receives the notice. The date the notice is received by the program provider is the date of the signature appearing on the "green card" — Postal Service form 1138. If the signature is not dated, the received date will be the date the "green card" is postmarked.
      1. DADS will accept one of the following as proof of its receipt of the documentation submitted by the program provider:
        • the dated signature of a DADS employee on a "green card" — Postal Service form 1138;
        • a dated signature of an agent of DADS evidencing receipt of the documentation; or
        • a dated, traceable receipt from a commercial courier service or the U.S. Postal Service.
      2. DADS does not accept documentation submitted via facsimile or documentation received by DADS after the 14-day time period described in the notice.
      3. The review team reviews the documentation submitted by the program provider. During the review, the review team may expand the time period under review and may request documentation related to individuals who were not initially included in the review.
      4. DADS sends a letter by certified mail to the program provider. If DADS did not identify any unverified claims, the letter notifies the program provider of such. If DADS identified unverified claims, the letter includes a detailed report of the unverified claims, the reason the claims were not verified and the amount to be recouped by DADS. The letter also gives the program provider an opportunity to submit additional documentation for certain unverified claims and a written argument to refute any unverified claim. Further, the letter states that the additional documentation and written argument must be received by DADS within 14 calendar days after the program provider receives the letter. The date the letter is received by the program provider is the date of the signature appearing on the "green card" – Postal Service form 1138. If the signature is not dated, the received date will be the date the "green card" is postmarked.
      5. Proof of receipt by DADS of any additional documentation and written argument submitted by the program provider is the same as the proof of receipt of documentation described in paragraph (b) directly above.
      6. DADS does not accept additional documentation or a written argument submitted via facsimile or received by DADS after the 14-day time period described in the letter.
      7. The review team reviews any additional documentation and argument submitted by the program provider. DADS sends a letter by certified mail to the program provider that either upholds the unverified claims listed in the previous letter or revises the unverified claims and adjusts the amount to be recouped by DADS. The letter also gives the program provider notice of the right to request an administrative hearing.
  4. Special Review Process
    A special review is generally conducted in accordance with the process for a routine review except:
    • DADS may not always give a program provider prior notice of an on-site review;
    • during an on-site review, DADS may interview an individual or program provider staff and may visit an individual's residence or any other location where an individual receives TxHmL Program services; and
    • in addition to documentation required by the Billing Guidelines, DADS may request the program provider to submit documentation required by state or federal law, rule or regulation for DADS review.
  5. Payment of Unverified Claims
    Payment to DADS by a program provider of an unverified claim is accomplished by DADS recouping the program provider's TxHmL Medicaid payments for the amount of the unverified claim. Such recoupment is done electronically through the automated billing system. A program provider may determine the unverified claim upon which recoupment was based by referring to the applicable electronic billing report.

TXHMLBG, Appendix II, Determining Units of Service for the Community Supports Activity of Transporting an Individual

Revision 12-1; Effective February 10, 2012

 

Determining Units of Service for a Single Trip (Examples 1 and 2)

Example 1

Example 1 Facts

  • A program provider transports Individuals A, B and C, who are individuals receiving HCS supported home living, and Passenger D, a person enrolled in the program provider's ICF/ID program, in the same vehicle, using one service provider.
  • Individual A departs at 8:15 a.m., Individual B departs at 8:25 a.m., and Individual C and Passenger D depart at 9:00 a.m.
  • Individuals A and B arrive at 9:15 a.m. Individual C and Passenger D arrive at 10:00 a.m.
Individual Departure Time Arrival Time
A 8:15 9:15
B 8:25 9:15
C 9:00 10:00
D 9:00 10:00

Example 1: Method A

Transportation time for Individuals A, B, and C is 105 minutes, with four passengers (A, B, C and D) and one service provider: The first individual (A) departed at 8:15 a.m. and the last individual (C) arrived at 10:00 a.m. The time between 8:15 and 10:00 is 105 minutes.

Passenger D does not need units of service determined because he is not enrolled in the HCS program. However, he is counted when determining the number of passengers.

The service time for individuals A, B, and C is 26.25 minutes:

Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

Service Time = (1 x 105) ÷ 4
Service Time = 105 ÷ 4
Service Time = 26.25 minutes

Using Appendix III, Conversion Table, the service time of 26.25 minutes is converted to 2 units of service.

Using Method A, Individuals A, B and C all have 2 units of service.

Example 1: Method B

Individual A's transportation time has three segments:

  • transportation time of 10 minutes (8:15-8:25) with one passenger (A only) and one service provider;
  • transportation time of 35 minutes (8:25-9:00) with two passengers (A and B) and one service provider; and
  • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider.

Individual B's transportation time has two segments:

  • transportation time of 35 minutes (8:25-9:00) with two passengers (A and B) and one service provider; and
  • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider.

Individual C's transportation time has two segments:

  • transportation time of 15 minutes (9:00-9:15) with four passengers (A, B, C and D) and one service provider; and
  • transportation time of 45 minutes (9:15-10:00) with two passengers (C and D) and one service provider.

Passenger D does not need units of service determined because he is not enrolled in the HCS program. However, he is counted when determining the number of passengers.

Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

Individual A's service time for each segment:

  • Service Time = (1 x 10) ÷ 1
    Service Time = 10 ÷ 1
    Service Time = 10 minutes
  • Service Time = (1 x 35) ÷ 2
    Service Time = 35 ÷ 2
    Service Time = 17.5 minutes
  • Service Time = (1 x 15) ÷ 4
    Service Time = 15 ÷ 4
    Service Time = 3.75 minutes

Individual B's service time for each segment:

  • Service Time = (1 x 35) ÷ 2
    Service Time = 35 ÷ 2
    Service Time = 17.5 minutes
  • Service Time = (1 x 15) ÷ 4
    Service Time = 15 ÷ 4
    Service Time = 3.75 minutes

Individual C's service time for each segment:

  • Service Time = (1 x 15) ÷ 4
    Service Time = 15 ÷ 4
    Service Time = 3.75 minutes
  • Service Time = (1 x 45) ÷ 2
    Service Time = 45 ÷ 2
    Service Time = 22.5 minutes

Total service time for each individual is determined by adding the service time of each segment:

  • Individual A: 10 minutes + 17.5 minutes + 3.75 minutes = 31.25 minutes
  • Individual B: 17.5 minutes + 3.75 minutes = 21.25 minutes
  • Individual C: 3.75 minutes + 22.5 minutes = 26.25 minutes

Using Appendix III, Conversion Table, service time is converted to units of service:

  • Individual A: 31.25 minutes = 2 units of service
  • Individual B: 21.25 minutes = 1 unit of service
  • Individual C: 26.25 minutes = 2 units of service

Using Method B, Individual B has 1 unit of service, and Individuals A and C each have 2 units of service.

Example 2

Example 2 Facts

  • A program provider transports two individuals, Individuals E and F, in the same vehicle using two service providers.
  • Individual E departs with a service provider at 2:00 p.m. Individual F departs with another service provider at 2:10 p.m.
  • Individuals E and F arrive at 2:40 p.m.
Individual Departure Time Arrival Time
E 2:00 2:40
F 2:10 2:40

Example 2: Method A

The transportation time for Individuals E and F is 40 minutes, with two passengers (E and F) and two service providers. The first individual (E) departed at 2:00 and the last individuals (E and F) arrived at 2:40. The time between 2:00 and 2:40 is 40 minutes.

The service time for individuals E and F is 40 minutes:

Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

  • Service Time = (2 x 40) ÷ 2
    Service Time = 80 ÷ 2
    Service Time = 40 minutes

Using Appendix III, Conversion Table, the service time of 40 minutes is converted to 3 units of service.

Using Method A, Individuals E and F each have 3 units of service of supported home living for the transportation provided.

Example 2: Method B

Individual E's transportation time has two segments:

  • transportation time of 10 minutes (2:00-2:10) with one passengers (E only) and one service provider; and
  • transportation time is 30 minutes (2:10-2:40) with two passengers (E and F) and two service providers.

Individual F's transportation time has one segment:

  • Transportation time is 30 minutes (2:10-2:40) with two passengers (E and F) and two service providers.

Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers

Individual E's service time for each segment:

  • Service Time = (1 X 10) ÷ 1
    Service Time = 10 ÷ 1
    Service time = 10 minutes
  • Service Time = (2 X 30) ÷ 2
    Service Time = 60 ÷ 2
    Service Time = 30 minutes

Individual F's service time:

  • Service Time = (2 X 30) ÷ 2
    Service Time = 60 ÷ 2
    Service Time = 30 minutes

Total service time for Individual E is determined by adding the service time of each segment:

  • Individual E: 10 minutes + 30 minutes = 40 minutes

Using Appendix III, Conversion Table, service time is converted to units of service:

  • Individual E: 40 minutes = 3 units of service
  • Individual F: 30 minutes = 2 units of service

Using Method B, Individual E has 3 units of service and Individual F has 2 units of service.

Determining Units of Service for Multiple Trips (Example 3)

Example 3

Example 3 Facts

  • A program provider transports Individuals A, B and C and Passenger D, as described in Example 1 (this will be referred to as the "outgoing trip").
  • The program provider transports Individuals A, B and C and Passenger D back to their original locations later the same day (the "return trip").
  • Service times for the return trip for Individuals A, B and C are the same as the service times for the outgoing trip.

Example 3: Method A Service Times (see Example 1: Method A)

Individual Outgoing Trip
Service Time
Return Trip
Service Time
A 26.25 26.25
B 26.25 26.25
C 26.25 26.25

Example 3: Method A – Without Accumulation of Service Times

Service times for the outgoing and return trips for Individuals A, B and C are not accumulated; units of service from the outgoing trip (see Example 1: Method A) are combined with the units of service of the return trip: 2 units of service + 2 units of service = 4 units of service.

Using Method A without accumulating service times for the outgoing and return trips, Individuals A, B and C each have 4 units of service.

Example 3: Method A – With Accumulation of Service Times

Service times of the outgoing and the return trips for Individuals A, B and C are accumulated for a total service time of 52.5 minutes: 26.25 minutes + 26.25 minutes = 52.5 minutes.

Using Appendix III, Conversion Table, the total service time of 52.5 minutes is converted to 3 units of service.

Using Method A and accumulating service times for the outgoing and return trips, Individuals A, B and C each have 3 units of service.

Example 3: Method B Service Times (see Example 1: Method B)

Individual Outgoing Trip
Service Time
Return Trip
Service Time
A 31.25 31.25
B 21.25 21.25
C 26.25 26.25

Example 3: Method B – Without Accumulation of Service Times

Service times for the two trips are not accumulated; units of service from the outgoing trip (see Example 1: Method B) are combined with the units of service of the return trip:

  • Individual A: 2 units of service + 2 units of service = 4 units of service
  • Individual B: 1 unit of service + 1 unit of service = 2 units of service
  • Individual C: 2 units of service + 2 units of service = 4 units of service

Using Method B without accumulating service times for the outgoing and return trips, Individuals A and C each have 4 units of service; Individual B has 2 units of service.

Example 3: Method B – With Accumulation of Service Times

Service times of the outgoing and the return trips for Individuals A, B and C are accumulated for a total service time:

  • Individual A: 31.25 minutes + 31.25 minutes = 1 hour, 2.5 minutes
  • Individual B: 21.25 minutes + 21.25 minutes = 42.5 minutes
  • Individual C: 26.25 minutes + 26.25 minutes = 52.5 minutes

Using Appendix III, Conversion Table, the total service time is converted to units of service:

  • Individual A: 1 hour, 2.5 minutes = 4 units of service
  • Individual B: 42.5 minutes = 3 units of service
  • Individual C: 52.5 minutes = 3 units of service

Using Method B and accumulating service times for the outgoing and return trips, Individual A has 4 units of service, and Individuals B and C each have 3 units of service.

TXHMLBG, Appendix III, Conversion Table

TXHMLBG, Appendix IV, Billable Adaptive Aids

Revision 13-1; Effective January 1, 2014

 

  1. Abbreviations and Numbers
    The following abbreviations and numbers, as used in this attachment, have the following meanings:
    1. Licensed Professionals
      • (AU) — A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
      • (DI) — A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
      • (NU) — A person licensed to practice professional or vocational nursing by the Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
      • (MD) — A person licensed as a physician in accordance with Texas Occupations Code, Chapter 155.
      • (OT) — A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
      • (OPH) — A person licensed as a physician in accordance with Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
      • (OPT) — A person licensed as an optometrist or therapeutic optometrist in accordance with Texas Occupations Code, Chapter 351.
      • (PT) — A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
      • (PS/BS) — A person licensed as a psychologist, provisional license holder or psychological associate in accordance with Chapter 501 of the Texas Occupations Code; a person certified by DADS as described in 40 TAC §5.161; or a behavior analyst certified by the Behavior Analyst Certification Board, Inc.
      • (SP) — A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.
    2. Other Abbreviations and Numbers
      • (1) — The item is available through Texas Medicaid Home Health Services and Medicare for all individuals.
      • (2) — The item is available through Texas Health Steps for all individuals under the age of 21.
  2. List of Billable Adaptive Aids
    The following items and services, listed by category, including repair and maintenance not covered by warranty, are billable adaptive aids:
    • Lifts
    101 a vehicle lift adaptation for a vehicle owned by an individual, an individual's family member or foster/companion care provider if it is the primary mode of transportation for the individual, but not to exceed one lift every five years. Repairs and maintenance not covered by warranty are not limited to the five-year requirement. (OT, PT, MD)
    A vehicle that is excepted to be modified or adapted must meet one of the following criteria:
    • Vehicle is less than 5 years old and mileage is less than 50,000 miles; or
    • Vehicle passed an independent inspection performed by a certified automotive technician.
    104 a hydraulic, manual or electronic lift (1, 2) (OT, PT, MD), replacement sling (1) (OT, PT, MD), a barrier-free (ceiling or wall mounted) lift system, a porch lift or stair lift
    128 a transfer bench (1, 2) (OT, PT, MD)
    • Mobility Aids
    106 a crutch, walker or cane (1, 2) (OT, PT, MD)
    107 an orthotic device, orthopedic shoes or a brace which is custom fabricated specifically for an individual (2) (OT, PT, MD)
    157 a manual or electric wheelchair or a necessary accessory (1, 2) (OT, PT, MD)
    158 a forearm platform attachment for a walker (1, 2) (OT, PT, MD)
    159 a portable wheelchair ramp (1, 2) (OT, PT, MD)
    160 a battery or charger for an electric wheelchair (1, 2) (OT, PT, MD, NU)
    161 a gait trainer or gait belt (1, 2) (OT, PT, MD, NU)
    163 a stroller, push-chair or travel seat (OT, PT, MD)
    • Positioning Devices
    151 a hospital bed (1) or crib (2) (OT, PT, MD)
    154 a standing board or frame, positioning chair, or wedge (1, 2) (OT, PT, MD)
    155 a trapeze bar (1, 2) (OT, PT, MD)
    156 a lift chair, but not the lift mechanism if it is reimbursable through Medicare (OT, PT, MD)
    162 a bath or shower chair (1, 2) (OT, PT, MD, NU)
    164 a toileting chair (1, 2) (OT, PT, MD, NU)
    165 a portable bathtub rail (1, 2) (OT, PT, MD)
    • Controls and Switches
    109 a sip and puff control (1, 2) (OT, PT)
    110 an adaptive switch used to operate items necessary for daily functioning (OT, PT)
    • Environmental Control Units
    111 an adaptive lock (OT, PT)
    112 an electronic control unit or automatic door opener (OT, PT)
    114 a voice, light, smoke or motion activated device (OT, PT,AU)
    • Medical Supplies
    120 diapers, briefs, pull-ons, liners, diaper wipes, disposable underpads, reusable underpads (1, 2) (MD, NU)
    121 a multivitamin product with a prescription, a nutritional supplement listed in the Texas Medicaid Provider Procedures Manual (for example, Ensure, Boost, Glucerna) or Thick-It (2) (MD)
    122 an enteral feeding formula and supplies (1, 2) (MD)
    201 medically necessary supplies for tracheotomy care, decubitus care, ostomy care, respirator/ventilator care or catheterization (1, 2) (MD)
    206 a glucose monitor or other supplies for an individual's use in self-monitoring (1, 2) (MD, NU)
    207 an adapted medication dispenser or pill crusher (MD, NU)
    208 an air humidifier, purifier or specialized air filter, or a medically necessary portable heating and/or cooling device to manage the symptoms of a seizure disorder, respiratory or cardiac condition, or inability to regulate body temperature (MD)
    209 a muscle stimulator (OT, PT, MD)
    210 temporary rental of a billable adaptive aid to allow for the repair, purchase or replacement of the adaptive aid (1, 2) (OT, PT, MD, NU)
    211 a urinal (1, 2) (MD, NU)
    212 a specialized thermometer (MD, NU)
    213 a specialized scale (MD, NU, DI)
    214 medical support hose (1) (MD, NU)
    215 specialized clothing (for example, a weighted vest), a dressing aid or bib (OT, PT, MD, NU)
    216 a specialized or treated mattress or mattress cover) (2) (MD, NU)
    217 an egg-crate, sheepskin or other medically necessary mattress pad (1, 2) (MD, NU)
    218 a cleft palate feeder (1, 2) (MD, OT, PT, DI)
    219 a blood pressure or pulse monitor for an individual's use in self-monitoring (1) (MD, NU)
    220 Prescription eyeglasses beyond Medicaid limit (2) (OPH, OPT)
    221 non-sterile disposable gloves for individuals who require catheterization, have skin breakdown or require wound care, or have a documented disease that may be transmitted through urine or stool and the care of the individual is provided by a non-paid caregiver (1,2) (MD,NU)
    • Communication Aids (including batteries)
    124 a direct selection, alphanumeric, scanning or encoding communicator (2) (SP)
    125 a speech amplifier or augmentative communication device) (1, 2) (SP)
    126 sign language interpreter service for non-routine communications, such as Ip meetings, or medical/professional appointments (SP, AU, MD)
    251 an emergency response system or service, monitoring device (MD, NU) or medical alert bracelet (MD, NU
    254 a communication board or book (2) (SP)
    255 a closed-captioning device for an individual with a hearing impairment (AU)
    256 a signature stamp for an individual with a visual or physical impairment, muscular weakness or limited range of motion (OPH, OT, PT)
    257 a signature guide for an individual with a visual or physical impairment, muscular weakness or limited range of motion (OPH, OT, PT)
    258 a personal computer or accessory necessary for the individual to communicate independently (SP)
    259 specialized training for augmentative communication software, not to exceed $1,000 per individual, per IPC year (2) (SP)
    260 a hearing aid (2) (AU) or battery (2) (AU, MD, NU)
    • Adapted Equipment for Activities of Daily Living
    401 a device or item used to enable an individual to independently pick up or grasp an object (for example, a reacher) (OT, PT)
    402 a device or item used to enable an object to be firmly positioned and secure (for example, a dycem mat) (OT, PT)
    403 a device or item used to enable an individual to independently hold and sustain control of an object (for example, a hand strap) (OT, PT)
    404 adapted dinnerware, an eating utensil or meal preparation device (OT, PT)
    405 a specialized clock or wristwatch for an individual with a visual or hearing impairment (OT, PT)
    406 an electric razor or electric toothbrush for an individual with a muscular weakness or limited range of motion who shaves self or brushes own teeth (OT, PT)
    407 a speaker, large button or braille telephone for an individual who is verbal but cannot use a conventional telephone (OT, PT)
    408 a microwave oven, if use of a conventional oven presents a safety hazard to the individual (OT, PT)
    409 a hand-held shower device (1, 2) (OT, PT)
    • Safety Restraints and Safety Devices
    113 a safety restraint (2) (PS, MD) or wheelchair tie down (OT, PT, MD, NU)
    450 a bed rail (1, 2) (OT, PT, MD, NU)
    451 safety padding (1, 2) (PS/BS, OT, PT, MD)
    452 a helmet used due to a seizure disorder or other medical condition (2) (PS/BS, MD, NU)
    453 an adaptation to furniture (PS/BS) (OT, PT)

TXHMLBG, Appendix V, Billable Minor Home Modifications

TXHMLBG, Appendix VI, Degree of Consanguinity or Affinity

TXHMLBG, Appendix VII, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet

TXHMLBG, Forms

Form Title
2122 Service Delivery Log with Written Narrative/Written Summary
2123 Adaptive Aid/Minor Home Modification Request for Prior Approval
2124 Community Support Transportation Log
4116-MHM-AA Minor Home Modification/Adaptive Aids Summary Sheet
4117 Supported Employment/Employment Assistance Service Delivery Log
4118 Respite Service Delivery Log
4120 Day Habilitation Service Delivery Log
4123 Nurse Services Delivery Log - Billable Activities

Informacion in espanol = form also available in Spanish.

TXHMLBG, Revisions

TXHMLBG, Revision 15-3, Billable Activity

Revision Notice 15-3; Effective December 11, 2015

 

The following change(s) were made:

Revised Title Change
4720 Billable Activity Adds securing transportation for or transporting an individual, as necessary, to assist self-employment, work from home or perform in a work setting. Deletes obsolete bullets.

TXHMLBG, Revision 15-2, Miscellaneous Changes

Revision Notice 15-2; Effective October 30, 2015
 

The following change(s) were made:

Revised Title Change
1200 Service Components Adds community support (transportation).
2000 Definitions Adds ADLs or activities of daily living, CFC PAS/HAB
or Community First Choice Personal Assistance Services/Habilitation,
health-related tasks, IADLs or instrumental activities of daily living,
and transportation plan.
3100 Applicable Service Components Adds community support (transportation).
3430 Relative, Guardian or Managing Conservator Qualified as Service Provider Adds transportation as a community support activity.
3510 15-Minute Unit of Service Adds transportation as a community support activity.
3610 15-Minute Unit of Service Changes terminology to supported employment and employment assistance. Adds transportation as a community support activity.
3720 Multiple Service Providers Adds transportation as a community support activity and adds CFC PAS/HAB. Deletes obsolete information.
3810 General Requirements Adds transportation as a community support activity.
3840 Proof of Location of Residence of Service Provider Adds transportation as a community support activity.
3850 Example Forms Adds transportation as a community support activity.
4220 Billable Activity Adds CFC PAS/HAB and transportation as a community support activity.
4420 Billable Activity Adds CFC PAS/HAB and transportation as a community support activity.
4471.2 Billable Activity Adds CFC PAS/HAB and transportation as a community support activity.
4472.2 Billable Activity Adds CFC PAS/HAB and transportation as a community support activity.
4473.2 Billable Activity Adds CFC PAS/HAB and transportation as a community support activity.
4500 Community Support (Transportation) Changes the title.
4510 General Description of Service Component Updates the community support service component is transportation provided to an individual.
4520 Community Support Billing Requirements Changes the title and updates the first paragraph to
the only billable activity for the community support subcomponent is
transporting the individual, except from one day habilitation,
employment assistance or supported employment site to another. Adds
transportation as a community support activity.
4610 General Description of Service Component Adds the respite service component is not a service
provider of CFC PAS/HAB unless the service provider of CFC PAS/HAB
routinely provides unpaid assistance and support to the individual and
is used to provide temporary support to the primary caregiver.
4651 Restrictions Regarding Submission of Claims for Respite Deletes obsolete information.
4720 Billable Activity Adds determining how the individual will travel to and from a job.
4730 Activity Not Billable Adds CFC PAS/HAB.
4820 Employment Assistance Billable Time/Activities Adds determining how the individual will travel to and from a job.
4830 Employment Assistance Non-Billable Time/Activities Adds CFC PAS/HAB.

TXHMLBG, Revision 15-1, Section 6150 Change

Revision Notice 15-1; Effective March 26, 2015

 

The following change(s) were made:

Revised Title Change
6150 Payment Limit Changes $6,000 to $10,000.

 

TXHMLBG, Revision 14-2, Miscellaneous Changes

Revision Notice 14-2; Effective September 1, 2014

 

The following change(s) were made:

Revised Title Change
2000 Definitions Revises the definitions for competitive employment and integrated employment, and adds self-employment.
4240 Qualified Service Provider Adds a licensed clinical social worker and a licensed professional counselor.
4330 Billable Activity Removes to develop opportunities for employment in the community.
4350 Restrictions Regarding Submission of Claims for Day Habilitation Adds day habilitation that is being provided by one service provider who is also the same service provider of a different component or subcomponent to the same individual at the same time, and adds day habilitation in the individual’s residence without prior justification.
4420 Billable Activity Moves the placement of information about checking medications.
4471.2 Billable Activity Moves the placement of information about checking medications.
4472.2 Billable Activity Moves the placement of information about checking medications.
4473.2 Billable Activity Moves the placement of information about checking medications.
4610 General Description of Service Component Adds the respite service component is used to provide temporary support to the primary caregiver in non-routine circumstances.
4620 Billable Activity Adds any billable activity referenced in this section that occurs at a camp that is accredited by the American Camp Association.
4651 Restrictions Regarding Submission of Claims for Respite Adds respite provided to an individual on a routine basis.
4710 General Description of Service Component Adds self-employment to the first sentence.
4720 Billable Activity Adds several billable activities for the supported employment service component.
4730 Activity Not Billable Adds several activities that re not billable for the supported employment service component.
4820 Employment Assistance Billable Time/Activities Describes Employment Assistance services and adds several individualized, person-directed services.
4830 Employment Assistance Non-billable Time/Activities Adds using Medicaid funds paid by the Department of Aging and Disability Services.

TXHMLBG, Contact Us,

For questions about the Texas Home Living Program Billing Guidelines, email: txhmlpolicy@hhsc.state.tx.us

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