Appendices

Appendix I, Transferring Individuals Due to Provider Contract Terminations or Contract Assignments

Revision 17-2; Effective March 31, 2017

 

Terminology

A contract termination occurs when a provider (business entity) will no longer have a contract with the Texas Health and Human Services Commission (HHSC). A contract termination requires that the individual receiving services from HHSC be transferred to a different provider before the effective date of the contract termination. For Community Care for Aged and Disabled (CCAD), the term contract termination replaces contract cancellation.

A contract assignment occurs when a contract is transferred from one business entity to another business entity. In this situation, there is an exchange between two business entities and the receiving business entity is assigned a new provider number. When a contract assignment occurs, the affected individual’s service authorization record is transferred to the new provider through an automated mass transfer process in the Service Authorization System (SAS).

Not all changes in the provider’s operation will require a provider change action. A contracted provider may have a change in ownership in which part of the business ownership changes, a complete change in ownership or a name change in the provider’s license. Not all of these provider operations result in the change in provider number. For CCAD, the term contract assignment replaces contract conversion.

 

Contract Termination Transfer Determination Procedures

When a contracted provider decides to terminate its contract with HHSC or when a contract assignment is needed, the contractor must notify HHSC contract staff. Notification of a contract termination may be received by contract or regional management staff. The contract termination end date negotiated with the provider must be 60 calendar days or less after the date the written notice of contract termination is received. If contract termination is due to license revocation, the end date is 30 calendar days or less. Expedited transfer procedures must be used if the contract termination or assignment occurs with less than 10 calendar days notification to HHSC.

Upon notification of a contract termination or contract assignment, the regional director will determine whether transfers will be handled as either routine or expedited transfers. The regional director must immediately report to the Community Care Services Eligibility (CCSE) director when a decision to apply expedited transfer procedures is made. A decision to apply routine procedures does not require notification to state office staff. The regional director will advise the case worker whether the transfer will be accomplished using routine or expedited transfer procedures.

The case worker must not initiate transfer procedures due to a contract termination until contract or regional management staff issues an official written notice to the provider.
If there is adequate time to refer the individual to a new provider without disrupting services or adversely impacting the individual, the regional director will advise the case worker to use routine transfer procedures.

If there is not adequate time to refer the individual to a new provider without disrupting services or if implementing routine procedures may adversely impact the individual, the regional director will advise the case worker to use expedited transfer procedures. An adverse impact is likely to occur when the individual:

  • requires total care;
  • is unable to transfer from a bed to a chair without help;
  • is unable to manage toileting tasks without help;
  • is in danger of not receiving daily nourishment because he is unable to prepare or eat his meals without help;
  • requires nursing services; or
  • has no caregiver available to provide the tasks necessary to maintain the individual’s health or welfare.

In some instances, services may be disrupted for a short time; however, if there is no adverse impact to the individual, the regional director may advise the case worker to use routine transfer procedures.

 

CCAD Routine Transfer Procedures for Contract Terminations

If the regional director directs staff to apply routine transfer procedures, the CCAD case worker completes the following activities:

  • Contacts the individual to advise of the contract termination and to request the individual’s choice of a new provider. If the individual does not select a provider agency from the list of contracted agencies in the service area, an agency may be selected for the individual as a last resort. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date. The regional director may designate a time frame for provider selection depending on the contract termination date.
  • Reviews the individual’s service plan for accuracy and if any changes are needed, revises the service plan. If the CCAD case worker is unable to determine the individual’s needs by telephone, or if an annual assessment is due within 30 days, the CCAD case worker makes a home visit to complete a reassessment of the individual. If there are changes in the service plan, the CCAD case worker sends Form 2101, Authorization for Community Care Services, to the current provider agency. The required time frame for conducting an annual reassessment is no longer three months.
  • Negotiates the transfer date with both provider agencies avoiding any service disruption to the individual whenever possible.
  • Sends an initial referral packet to the new provider agency within five calendar days of the contact and sends the losing provider a copy of Form 2101.

For a routine transfer referral, the receiving provider follows procedures and requirements for initial referrals except for Primary Home Care (PHC) and Community Attendant Services (CAS). For PHC and CAS, a new practitioner’s statement is not required for the transfer.

 

Expedited Transfer Procedures for CCAD Contract Terminations

An expedited transfer must be used when there is not adequate time to use the routine referral process to refer the individual to a new provider without disrupting services. In an expedited transfer, special procedures are used to quickly transfer the individual to a provider that can promptly begin service delivery. The regional director determines when an expedited transfer should be used. Generally, an expedited transfer is used when the contract termination occurs with less than 10 calendar days notification to HHSC, a large number of individuals are involved in the transfer, or both.

The regional director designates a coordinator to work with contract staff and providers to establish transfer dates. The coordinator or case worker identifies individuals whose annual reassessments are due or in process and negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for individuals with the new provider.

Using the expedited transfer process, the individual is offered a choice of providers. If the individual does not select a provider agency from the list of contracted agencies in the service area at the point of contact, the case worker assigns a provider from the regional agency rotation log. The rotation log must be maintained and kept up to date.

 

CCAD Expedited Transfer Procedures for Contract Terminations

If the regional director determines to apply expedited transfer procedures, the CCAD case worker completes the following activities:

  • Contacts the individual to advise of the contract termination and to request the individual’s choice of a new provider. If the individual does not select a provider agency from the list of contracted agencies in the service area within the designated time frame, the individual will be assigned to a provider agency by rotation. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date.
  • Reviews the individual’s service plan for accuracy and if any changes are needed, revises the service plan. If the CCAD case worker is unable to determine the individual’s needs by telephone or if an annual assessment is due within 30 days, the CCAD case worker makes a home visit to complete a reassessment of the individual. If there are changes in the service plan, the CCAD case worker sends Form 2101 to the current provider agency. The required time frame for conducting an annual reassessment is no longer three months.
  • Negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for each individual with the new provider and documents on Form 2065-A, Notification of Community Care Services, the negotiated effective date is due to expedited contract termination.
  • Sends a referral packet to the new provider agency and notes “Expedited Transfer” on Form 2101 within five calendar days of the provider agency selection and sends the losing provider a copy of Form 2101.

For an expedited transfer referral, the receiving provider follows procedures and requirements for initial referrals except for PHC and CAS. For PHC and CAS, a new practitioner’s statement is not required for the transfer.

 

Contract Termination – Residential Living Arrangements

 

The transfer process for an individual residing in an adult foster care (AFC) home, assisted living (AL) facility, host family setting or residential care (RC) facility is complicated by the necessity to find a new living arrangement for the individual. Use the following steps when handling a contract termination affecting an individual residing in an AFC, AL, host family or RC setting.

Step

Responsibility

Action

1

Regional Director

  • works with contract staff, the case worker and providers to negotiate the date the transfer must be completed; and
  • identifies resources available to regional staff in facilitating transfer activities (for example, HHSC ombudsman).

2

Contract Staff

  • surveys regional facilities to identify available residential settings; and
  • provides a list of available residential settings to the case worker and the individual.

3

Case Worker

  • meets with residents (individually or as a group) to present available options that may include:
    • remaining in the current residential setting as a private pay resident;
    • transferring to a residential setting contracted with HHSC;
    • receiving services in the individual’s own home; or
    • moving to a nursing facility;
  • negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for each individual with the new residential setting contracted provider, if that option is selected;
  • documents on Form 2065-A or Form 2065-B the negotiated effective date is due to expedited contract termination; and
  • completes the same procedures noted for routine or expedited transfers, except for time frames provided by the regional director or coordinator based on the contract termination end date.

Depending on the option selected by the individual when a residential setting contract is terminated, the case worker completes the appropriate procedures to complete the action. For example, if an individual in a residential setting chooses to go to his daughter’s home in the community, the case worker follows normal procedures for authorizing services in the community. If an individual chooses to move or return to a nursing facility permanently, the case worker follows normal procedures to terminate program eligibility and services.


Contract Terminations When No Other Provider is Available

In some situations, a provider may request to terminate its contract and there is no other provider available in the service area to provide that service. For example, if a Home-Delivered Meals provider terminates its contract, there may not be another provider in the service area to deliver meals. In that case, the HHSC case worker must contact the individual and offer any other available resources to meet that need. In this example, the individual may elect to receive services by an attendant to prepare meals or locate a congregate meal location.

When a service is terminated rather than transferred to a new provider, the HHSC case worker must send Form 2065-A or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual noting the service is terminated due to the contract termination.


Contract Assignment

Residential and Non-Residential Settings

After HHSC contract staff have negotiated the contract assignment effective date, contract staff will notify the regional director that the provider plans to assign its contract, as well as the contract assignment effective date. A transfer due to a contract assignment must not occur before the contract assignment effective date.

On or within two working days after the contract assignment effective date, regional staff must send Form 2097, Provider Contract Assignment Notification Letter, to the individual informing him of the change in provider. The letter informs the individual of the change in contract and offers the option to change to a provider selected by the individual or remain with the new provider. The letter informs the individual of the change in contract and offers the option to change to a provider selected by the individual or remain with the new provider.


Individual Chooses to Remain With the New Provider

After receiving confirmation of the automated mass transfer, the case worker reviews the Texas Medicaid and Healthcare Partnership error page in the Service Authorization System (SAS) to identify an individual whose service authorization record transfer was not processed. It should not be necessary to check each service authorization record. However, for CCAD, the SAS wizard will not replicate the provider change until the case worker runs the wizard, selecting "Provider Transfer." To prevent billing problems, the CCAD case worker must complete a provider transfer in the SAS wizard immediately for an individual whose service authorization records were not automatically converted. For assistance with an individual whose service authorization records were not automatically converted, contact the coordinator or the regional Claims Management Services (CMS) coordinator.

The losing provider should provide the new provider with all applicable forms. If the losing provider does not provide the forms to the new provider, the case worker must provide copies of the current forms to the new provider. For CCAD, refer to Appendix XIII, Contents of Referral Packets, for the list of forms to be sent for provider transfers.

It is not necessary to obtain acceptance by the new provider or send Form 2065-A to the individual or new provider. The case worker must document in the case record the transfer was due to a contract assignment from the losing provider to the new provider. In a mass transfer completed through the automated transfer process, only the SAS service authorization records are automatically changed to end the losing provider and authorize all services to the gaining provider.

For CCAD, the SAS wizard does not automatically update all data. The provider transfer must be processed in the wizard so the history and Form 2101 data will match changes to the service authorization records.


Individual Chooses to Change to a Different Provider

If the individual chooses to change from the new provider that received the contract assignment to a provider selected by the individual, the case worker must complete two provider change actions. The CCAD case worker uses the SAS wizard to complete the provider change actions. The first provider change action is to change service authorizations from the losing provider to the new provider for services delivered after the contract assignment effective date. The second provider change action is to change service authorizations from the new provider to the provider selected by the individual for services.

Both CCAD provider change actions must be completed within the time frame in Section 4676, Change of Providers.

For all programs, the individual may change providers at any time, as described in current procedures regardless of any changes in the provider’s operation.

Questions may be directed to the Policy Development and Oversight mailbox at: pdo@hhsc.state.tx.us.

 

Appendix II, Cost Limit for Purchased Services

Revision 17-1; Effective March 15, 2017

 

 

Under state law, the Texas Health and Human Services Commission may not purchase alternate care for an individual when the cost per day of the care exceeds the cost per day in a nursing facility. Few combinations of Community Care for Aged and Disabled (CCAD) services even approach this cost. However, case managers must be careful when authorizing maximum levels of personal attendant services along with another CCAD service.

To determine rates for services that vary by region or contract (for instance, Family Care, Emergency Response Services or Home-Delivered Meals), the highest allowable rate is used. To ensure the correct amount of services are purchased, contact the regional contract manager to obtain the actual unit rate in a specific region.

When an individual receives multiple services, contact the regional contract manager to:

  • obtain current unit rates that apply to the services authorized; and
  • determine the total cost of services to ensure that the nursing facility average is not exceeded.

 

Appendix III, Contracting to Provide Special Services to Persons with Disabilities

Revision 17-1; Effective March 15, 2017

 

http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=40&pt=1&ch=58&sch=A&rl=Y

Appendix III-A Appropriate/Inappropriate  Individual Characteristics Special Services to Persons with Disabilities — Attendant Services Program

 

 

Appendix III-A, Appropriate/Inappropriate Individual Characteristics Special Services to Persons with Disabilities - (ASP)

Revision 17-1; Effective March 15, 2017

 

Attendant services are inappropriate for an applicant or current individual whose needs exceed the scope of the contract. The case worker uses the following examples of appropriate and inappropriate individual characteristics to decide if an applicant or individual's needs can be adequately met through the program.

APPROPRIATE INAPPROPRIATE
  • Requires assistance with personal care or health-related tasks. Has other reliable resources to meet health, safety, and independent living needs not authorized or provided through the service/contract.
  • Will be dependent upon the contractor for medical care or health-related tasks that are not within the scope of the service/contract.
  • Manages his emotional or mental disorder with prescribed drug regimen.
  • Threatens the safety of himself or others and/or does not maintain his medication regimen.
  • May have occasional periods of forgetfulness, confusion, or disorientation, or lack social and/or communication skills.
  • Is totally disoriented, confused, incoherent, or incapable of following or giving instructions.
  • Requires medication for rest or sleep.
  • Requires attendant visits during the night to control disruptive behavior.
  • Occasionally uses alcohol or non-prescribed drugs that do not result in disruptive behavior.
  • Is addicted to alcohol or non-prescribed drugs and is not in an active treatment plan.
  • Is realistic about responsibilities for semi-independent living and limitations of services provided through this contract.
  • Requires a highly structured living arrangement or does not demonstrate semi-independent living skills.

 

 

Appendix IV, Workflow and Time Frames

Revision 17-3; Effective May 15, 2017

 

Workflow and Time Frames for a Routine Primary Home Care (PHC) Referral
Time Frames Action
  Intake is received.
Within 14 Calendar Days The case worker schedules a visit and assesses the applicant for services. The case worker has 30 calendar days from this date to complete the application.
Within 5 Business Days of the Home Visit

The case worker enters the assessment information in the Service Authorization System (SAS) and sends the provider a referral packet including:

  • Form 2059, Summary of Client's Need for Service;
  • Auto Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (generated by SAS); and
  • Referral Form 2101, Authorization for Community Care Services, to begin Pre-Initiation Activities.
The date of the home visit is day "0."
Within 14 Calendar Days The provider completes the pre-initiation activities and obtains Form 3052, Practitioner's Statement of Medical Need, and sends to the case worker.
Within 5 Business Days of Receipt of Form 3052 The case worker reviews Form 3052 for completeness and if complete, sends the Authorization Form 2101, to the provider. The "Mail Date" (Item 1) and the "Begin Date" (Item 4) are the same

The date of receipt of Form 3052 is day "0."

Within 2 Business Days of the Begin Date on Form 2101 The case worker completes and sends Form 2065-A, Notification of Community Care Services, to the individual.
Within 30 Calendar Days of the Home Visit Date The application must be completed by sending the Authorization Form 2101, to the provider.
Within 7 Calendar Days of Receipt of the Authorization Form 2101 The provider initiates services.
Intake Received and Determined to be Expedited or Immediate The case worker schedules the visit and assesses the applicant within the time frames for an immediate referral (24 hours) or an expedited referral (5 calendar days).
By the Next Business Day from the Home Visit Date The case worker makes an oral request to the provider to begin pre-initiation activities and negotiates a date for the completion of pre-initiation activities (which is less than 14 days). The case worker sends the referral packet including Form 2059, Auto Form 2060, and Referral Form 2101 with the negotiation information in the comments.
By the Negotiated Date The provider calls the case worker and provides the information from the completed Form 3052. The case worker and the provider negotiate a start date.
Within 5 Business Days of the Negotiation Contact from the Provider The case worker sends the Authorization Form 2101 to the provider, entering the negotiated start date in Item 4 and sends Form 2065-A to the individual.
Within 7 Business Days from the Negotiation Contact The provider sends the case worker Form 3052.

 

Workflow and Time Frames for an Initial Referral for Community Attendant Services (CAS)
Time Frames Action
  Intake is received.
Within 14 Calendar Days The case worker schedules a visit and assesses the applicant for services.
Note: If the intake is immediate or expedited, the case worker schedules according to the appropriate time frame. Unless new intakes are being placed on the interest list by the region, a referral to Family Care is mandatory for immediate or expedited intakes.
Within 2 Business Days of Receipt of the Application Form The case worker hand delivers or faxes Form H1200-EZ, Application for Assistance – Aged and Disabled, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Date of receipt is day "0."
Within 7 Business Days of Receipt of the Eligibility Notification from MEPD The case worker sends the provider a referral packet including Form 2059, Auto Form 2060 (generated by SAS) and Referral Form 2101.
Within 14 Calendar Days of Receipt of the Referral Packet The provider sends Form 3052 to the HHSC nurse. The provider may send a courtesy copy of Form 2101.
Within 5 Business Days of Receipt of Form 3052 The HHSC nurse enters the information in SAS and sends the provider Authorization Form 2101 with a copy to the case worker.

 

The date of receipt of Form 3052 is day "0."

Within 2 Business Days of Receipt of Form 2101 from the HHSC nurse The case worker sends the individual Form 2065-A.

 

The date of receipt is day "0."

Within 7 Calendar Days of Receipt of Authorization Form 2101 The provider initiates services.

 

Workflow and Time Frames for a CAS Reassessment
Time Frames Action
Within 12 Months of the Previous Assessment The case worker makes the home visit for the annual reassessment.
Within 5 Business Days of the Home Visit The case worker sends Referral Form 2101 to the provider and to the HHSC nurse. If there are no changes in the service plan, the case worker leaves the "Begin Date" blank. If there are changes in the service plan, the case worker enters the "Begin Date" according to the action:

 

  • The effective date for an increase is 7 calendar days from the "Mail Date" on Form 2101.
  • The effective date for a decrease is 13 days from the "Mail Date" on Form 2101. This date must match the date on Form 2065-A.

The case worker sends Form 2065-A to the individual to notify him of the change in the service plan.

Within 14 Calendar Days of Receipt of Form 2101 from the Case Worker The provider sends Form 2101 and the agreement or disagreement* with the plan to the HHSC regional nurse.
Within 5 Business Days of Receipt of Form 2101 from the Provider The HHSC nurse reviews the service plan and completes the authorization in the Authorization Wizard. The nurse sends Authorization Form 2101 to the provider and the case worker.

 

* If the provider disagrees with the service plan, the HHSC nurse negotiates with the provider and the case worker to arrive at an agreement.

If Form 2101 is not received from the provider within 21 calendar days, the HHSC nurse contacts the provider to request the form.

 

Workflow and Time Frames for a Day Activity and Health Services (DAHS) Referral
Time Frames Action
  Intake is received.
Within 14 Calendar Days The case worker schedules a visit or contacts the applicant by telephone and assesses the applicant for services.
Within 5 Business Days of the Assessment The case worker sends the provider a referral packet including Form 2059 and Referral Form 2101.
Within 14 Calendar Days of Receipt of the Referral Packet The provider sends the prior approval request packet to the HHSC regional nurse, which includes:
  • Referral Form 2101;
  • Form 3050, Day Activity and Health Services Health Assessment/Individual Service Plan; and
  • Form 3055, Physician's Orders (DAHS).
Within 5 Business Days of Receipt of the Packet The HHSC regional nurse determines if the applicant meets the medical criteria for DAHS and if so, enters the information in SAS. The nurse sends the provider Authorization Form 2101 with a copy to the case worker.

 

The date of receipt of the packet is day "0."

Within 2 Business Days of Receipt of Form 2101 from the HHSC Regional Nurse The case worker sends the individual Form 2065-A.

 

The date of receipt is day "0."

Within 7 Calendar Days of the Begin Date on Form 2101 The provider initiates services, unless the individual has been attending the facility under a facility-initiated referral.
Within 14 Calendar Days of the Begin Date on Form 2101  

Appendix V, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

Appendix VI, Minimum Standards for Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

 

http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=40&pt=1&ch=48&sch=K&rl=Y

 

Appendix VII, Casework Procedures

Revision 17-1; Effective March 15, 2017

 

Casework Procedures

 

Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics

Appendix IX, Notification/Effective Date of Decision

Revision 18-1; Effective June 15, 2018

 

 

Case Action Date Form Is Mailed/Given to Individual Effective Date to be Entered on Form 2065-A, Notification of Community Care Services
If application is denied, includes denied one service that was requested but granted another service: Within two workdays of denial. Not applicable for denials.
If application is certified: Within two workdays of certification. The effective date is the date on Form 2064, Eligibility Worksheet, or the negotiated date.

The effective date for Primary Home Care (PHC), Community Attendant Services (CAS) and Title XIX Day Activity and Health Services (DAHS) cases is not applicable. Check the "pending" box to indicate eligibility is contingent on medical approval. For Residential Care (RC) cases in which the individual is determined eligible for Emergency Care, enter the date the individual was determined eligible.
If a verbal referral is necessary: Within two workdays of certification. The date is negotiated with the provider for PHC and Family Care (FC) or the provider and regional nurse for CAS.
If there is:
 
  • denial of priority status at the individual's request,
  • a change to priority status,
  • a decrease in copayment, or addition of a service;
Within two workdays of the decision. The date the action is completed is the date the change goes into effect.
If there is an increase in units or priority level: Within two workdays of the decision. The date must be within seven days after the date on Form 2101, Authorization for Community Care Services.

If the individual loses PHC eligibility and is transferred to FC, whether or not there is a change in units or if priority status is terminated due to the:

  • loss of a personal care task needed for PHC, CAS or DAHS;
  • addition of a resource or caregiver which performs all of the previously purchased tasks;
  • individual becoming financially ineligible;
  • loss of unmet need; or
  • individual requesting that service(s) be terminated;
12 full days before the date services are reduced, terminated or transferred, unless the individual loses Medicaid. 12 full days following the date Form 2065-A is mailed. If Day 12 falls on a weekend or holiday, the effective date is the following workday.
If services are reduced/terminated because:
  • an individual loses CAS eligibility for financial reasons and is not transferred to FC;
Within two workdays of the date the case worker learns of the denial. The last day of the final month of CAS eligibility as determined by the Medicaid for the Elderly and People with Disabilities (MEPD) case specialist.
  • an interest list individual withdraws;
Not applicable. No notice is sent in this situation.
  • a DAHS facility-initiated individual does not want to have the initial paperwork processed for continued DAHS services;
12 full days before the case is closed. 12 full calendar days following the date Form 2065-A is mailed. If Day 12 falls on a weekend or holiday, the effective date is the following workday.
  • changes in federal law or state regulations require that services be reduced or terminated for an entire categorical individual group;
Prior to the date of action. Services continue only through the termination date of the categorical individual group, even if appealed.
  • of functional ineligibility for personal attendant services (PAS) or loss of the need for six hours of PAS;
12 full days before the case is closed (only at annual review). 12 full calendar days following the date Form 2065-A is mailed. If Day 12 falls on a weekend or holiday, the effective date is the following workday.
  • an individual moves to a skilled or intermediate care facility, or any other facility where 24-hour supervision is available;
Within two workdays of the date the case worker receives the information that a nursing facility stay is permanent or notification of the effective date. The date the individual entered the facility.
  • an individual threatens the health or safety of himself or others;
  • an individual or someone in his home threatens the department
Within two workdays of the date the case worker receives the information. The date the case worker becomes aware of the action. Services are not reinstated prior to the outcome of the appeal hearing.
  • an individual loses Medicaid and does not qualify for FC;
Within two workdays of the date the case worker receives the information. The last date of eligibility for Medicaid.
  • the Texas Health and Human Services Commission has facts confirming the death of the individual;
Not applicable. Not applicable.
If services are reduced/terminated for any reason not given above: at least 12 full days before services are reduced or terminated.

12 full calendar days following the date Form 2065-A is mailed, unless the individual:

  • requests that services end, or
  • gains a resource that affects unmet need.
Note: When the individual signs the front of Form 2065-A to verify that he has orally requested his services be reduced or terminated, document the individual’s reason in the comments section. The effective date of the adverse action is the date that Form 2065-A is dated and given to the individual. In some cases, the individual might request a specific effective date. If Day 12 falls on a weekend or holiday, the effective date is the following workday.

For denied services, Day 12 is the last day the individual has the right to appeal and is the last day the individual will receive services.  

For reduced services, Day 12 is the last day the individual has the right to appeal and Day 13 is the first day the individual will receive the reduced number in service hours.
 

 

Refer to the instructions for Form 2065-A for the procedures to follow when an individual requests a hearing in writing or in person.

Notes:

  • For terminations, the effective date on Form 2065-A must be the same as the “End Date” on Form 2101.
  • Do not send Form 2065-A when an individual’s forwarding address is unknown, such as situations when the post office sends notification that the individual left no forwarding address.
  • Send Form 2065-A when an individual is transferring from one service to another, regardless of whether the change is considered to be positive or negative.

 

Appendix X, CCAD Case Management Filing Guide

6-2019

 

LEFT SIDE
Retention tab
Form 3052, Practitioner's Statement of Medical Need
Form 3055, Physician's Orders (DAHS)
Form 3050, DAHS Health Assessment/Individual Service Plan
Form 1582, Consumer Directed Services Responsibilities
Form 1584, Consumer Participation Choice
Form 1575, Medicaid Estate Recovery Program Worksheet
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
Form 2061, Notification of Medicaid Estate Recovery Program Status
Form 2307, Rights and Responsibilities
Interdisciplinary Team (IDT) Letters
Guardianship Documents
RIGHT SIDE
Forms Checklist for Attendant Care Programs

2019 tab
All forms created or received during this calendar year that are not required to be filed under the retention tab.

Filing Notes:

The Community Care for Aged and Disabled (CCAD) Case Management Filing Guide is a suggested filing format to promote consistency in CCAD case records.

The objective will be to always have the forms and documents which need to be retained on the top left side under Retention tab. All other forms and documents should be filed under yearly tabs beginning with 2019, 2020 and so on, with the current calendar year on the top right side. The intent of the yearly tabs is to file forms as they are created or received.

Appendix XI, Monthly Income/Resource Limits

Appendix XII, Examples of Methods to Verify Income and Resources

Revision 17-1; Effective March 15, 2017

 

 

Resources — CW-CCAD Handbook Section 3420

Element Verification Sources Documentation
  1. Bank accounts, checking, savings, certificates of deposit (CD), money market
  • Current bank statement
  • Letter or contact with financial institution or bank
  • Medicaid eligibility (ME) Form H1239
  • Current savings statements
  • Recent entry in a savings passbook
  • Owner, if different from applicant's name
  • Type of account
  • Name and address of financial institution, if not listed on application
  • Source of verification
  • Account number, if not listed on application
  • Account balance and date, if different from face-to-face contact
  • If representative contacted, his name and telephone number
  1. Bonds
  • Newspaper
  • Bank or other financial institution
  • Brokerage firm/securities firm
  • Public library's research department
  • For savings bonds, the U.S. Treasury Office or its publication that is used by banks and is available on request
  • Owner, if different from applicant's name
  • Name of bond issuer and type of bond, if not listed on application
  • Source of verification and date, if different from face-to-face contact
  • Number of bonds and serial numbers (if applicable)
  • Current market or cash value. Corporate and municipal bonds may be discounted so the cash value may be less than the face amount. Some U.S. savings bonds must be held for 60 days before being cashed.
  • If representative contacted, his name and telephone number
  1. Cash on hand, safe deposit boxes
  • Statement of individual
  • Statement of individual regarding the contents
  • Date, if different from face-to-face contact
  1. Notes and mortgages (exempt if buyer fulfilling the contractual obligations)
  • Statement of individual
  • Statement of individual regarding the current market value
  • Date, if different from face-to-face contact
  1. Real property (unless in probate) (If property is exempt because the individual is making a good faith effort to sell, then he must supply evidence of the attempt to sell and the worker must verify that the selling price is at fair market value.)
  • Tax bill or assessment notice
  • Tax assessor
  • Local real estate broker
  • Local bank
  • Owner, if different from applicant's name
  • Source of verification and date, if different from face-to-face date
  • Current equity value of individual's interest
  • If collateral used, pertinent name and telephone number
  1. Revocable trust funds
  • Bank statement
  • Trust agreement
  • Will
  • Trustee
  • Bank representative
  • Name of trustee/beneficiary, if not listed on application
  • Source of verification and date, if different from face-to-face date
  • Accessibility of trust
  • Amount held in trust
  • If collateral used, pertinent name and telephone number
  1. Stocks
  • Recent statement from
    1. Brokerage house
    2. Issuing company
  • Securities firm
  • Newspaper
  • Public library's research department
  • Owner, if different from applicant's name
  • Name of company
  • Source of verification and date, if different from face-to-face contact
  • Number and type of shares
  • Market value
  • Use the closing price on the day of application or recertification
  • If collateral used, pertinent name and telephone number
  1. Vehicles (if not eligible for exclusion)
  • "Blue" or National Automobile Dealers Association (NADA) Book (gold)
  • Newspaper ads
  • Auto dealer
  • Finance company, or bank
  • Owner, if different from applicant's name
  • Year, make, and model
  • Source of verification and date, if different from face-to-face date
  • Market value
  • Equity value
  • If collateral used, pertinent name and telephone number
  • Assess $100 value for inoperable junk vehicle if individual's total resources are less than $4,900 for a single person or $5,900 for a couple
  1. Work equipment (excluded if required for employment, self-employment, or self-support)
  • Individual's estimate of value
  • Dealer
  • Owner, if different from applicant's name
  • Description of property, if not on application
  • Individual's estimate of value
  • Equity value
  • Source of verification and date, if different from face-to-face contact
  • If collateral used, pertinent name and telephone number

 

Income Eligibility — CW-CCAD Handbook Section 3300

Element Verification Sources Documentation
  1. The individual's total earnings (monthly gross)
    1. Money
    2. Wages
    3. Salary
    4. Armed forces pay
    5. Commissions
    6. Tips
    7. Piece-rate payments
    8. Cash bonuses
  • Employer
  • Oral statement
  • Written statement
  • Viewing check stubs
  • Copies of earnings statements (check stubs)
  • Who is employed, if not indicated on application
  • Name, address, telephone number of employer, if not on application
  • Date verified, if different from face-to-face contact
  • How information was verified
    • If by telephone, include name and telephone number of the contact
    • If by viewing, include description of document and date, if different from face-to-face contact
    • Gross amount
    • Frequency of pay
  • Show your calculations
  1. Net income from non-farm self-employment
  • Business receipts/records maintained by individual
  • Most recent Internal Revenue Service (IRS) Form 1040 (Income Tax Return) (In instances where complete verification of self-employment income is impossible, accept the individual's word if the information seems reasonably valid.)
  • Who is self-employed, if not indicated on application
  • Name and kind of business (address and telephone number if different), if not on application
  • Date verified, if different from face-to-face contact
  • Types of records used and period covered
  • Amount of gross income
  • Amount of expenses
    • Costs of purchased goods
    • Rent, heat, light, power
    • Depreciation charges
    • Wages/salaries paid
    • Business taxes (not personal income taxes or Social Security taxes)
  • If amount of net countable income is anticipated to be different, explain reason.
  • Amount of net countable income and calculations used to arrive at countable income.
  1. Net income from farm self-employment
  • Business receipts/records maintained by individual
  • Most recent IRS income tax return
  • Statements from other knowledgeable sources (e.g., county farm agent)
  • Who is self-employed, if not indicated on application
  • Type of farm income, if not indicated on application
  • Date verified, if different from face-to-face contact
  • Type of records used and period covered
  • Amount of gross income
    • Value of products sold
    • Government crop loans
    • Money from rental of farm equipment to others
    • Incidental money from the sale of wood, sand, gravel, etc. Note: Do not include value of fuel, food, or other farm products used for family living
  • Amount of operating expenses
    • Cost of feed, fertilizer, seed, and other farming supplies
    • Cash wages paid to farmhands
    • Depreciation charges
    • Cash rent
    • Interest on farm mortgages
    • Farm building repairs
    • Farm taxes (not personal income taxes or Social Security taxes)
  • If amount of net countable income is anticipated to be different, explain reason.
  • Amount of net countable income and calculations used to arrive at countable income.
  1. Social Security (Retirement, Survivors, and Disability Insurance (RSDI))
    1. Pensions
    2. Survivor's benefits
    3. Permanent disability insurance
  • Recent award letter
  • Recent cost-of-living increase notice from the Social Security Administration (SSA)
  • RSDI check or direct deposit slip
  • WTPY response
  • Form SSA 1610 (use only if no other source is available)
  • Texas Department of Health and Human Services Commission (HHSC) computer inquiry
  • Contact with SSA representative
  • Payee/beneficiary, if not indicated on application
  • Gross benefit amount before deductions for Medicare insurance
  • Claim number/suffix
  • Date received, if different from face-to-face date
  • Source of verification and date, if different from face-to-face contact
  • If SSA representative contacted, name and telephone number
  1. Railroad retirement (RR)
  • Form 1026
  • Recent award letter from RR Board
  • Contact with representative of RR Board
  • Most recent check or direct deposit slip
  • Payee/beneficiary, if different from applicant's name
  • Gross benefit amount before deductions for Medicare insurance
  • Claim number
  • Date received
  • Source of verification and date, if different from face-to-face date
  • If RR representative contacted, name and telephone number
  1. Dividends
    1. Stocks
    2. Membership in associations
  • Recent check stubs or checks
  • Letter from company making payments
  • Telephone contact with representative of company
  • Recent statement from a brokerage house or the company issuing the stock to verify dividends
  • Payee/beneficiary, if different from applicant's name
  • Payor (company)
  • Source of verification and date
  • Account number, if not listed on application
  • Gross amounts
  • Dates received
  • Frequency
  • Reason for dividend
  • If company representative contacted, name and telephone number
  • If excludable, reason for exclusion
  • If countable, show calculations used to arrive at an average amount.
  1. Net rental income
    1. House, store or other property
    2. Boarders or lodgers
  • Business receipts/records maintained by individual
  • Most recent IRS income tax return
  • Statements from individual and renter
  • Copy of lease or rent check
  • Type of rental income, if not indicated on application
  • Date verified, if different from face-to-face contact
  • Types of records used and period covered
  • Amount of gross income
  • Amount of expenses
    • Property tax receipts
    • Mortgage payment interest
    • Insurance payments
    • Bills for repair and upkeep of property Note: Capital expenditures for additions or improvements and depreciation are not deductible
  • If amount of income is anticipated to be different, explain reason.
  • Amount of net countable income and calculations used to arrive at countable income.
  1. Net income from lease of mineral rights
    1. Gross royalty payments
    2. Yearly lease payments
  • Royalty interest statements (check stubs)
  • Contact with representative of oil company
  • Check stub from lease payments
  • Name of payor/payee, if different from applicant's name
  • Source of verification and date, if different from face-to-face date
  • Account number
  • Amount of yearly lease payments
  • Gross amounts over past 12 months (royalty payments)
  • Dates received
  • Frequency
  • If representative contacted, name and telephone number
  • Deduction amounts
    • Excise taxes
    • Property taxes Note: Federal windfall profits taxes are not deductible—may have to add it back if company deducted it
  • Amount of net countable income and calculations used to arrive at a 12-month average (royalty payments)
  1. Income from mortgages or contracts (notes)
    1. Negotiable and
    2. Non-negotiable
  • Copy of contract
  • Copy of document with the statement of terms of repayment
  • Copy of recent check from payor
  • Contact with bank representative
  • Statements from the individual and payor
  • Name of payee/payor, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Payment amount
  • Frequency
  • Date received
  • If representative contacted, name and telephone number
  1. Public assistance
    1. Temporary Assistance for Needy Families (TANF)
    2. Supplemental Security Income (SSI)
    3. General assistance from county or city
    4. Medicaid Qualified Medicare Beneficiary (MQMB)
    5. Qualified Medicare Beneficiary (QMB) only
    6. Specified Low-Income Medicare Beneficiary (SLMB) only
    7. Qualifying Individuals (QI) coverage
    8. Food stamps
  • HHSC computer inquiry
  • Most recent SSI award letter or SSI check
  • Most recent individual notice or check
  • Contact with a representative
    • Texas Works worker
    • MEPD case specialist
    • SSI representative
    • City or county worker
  • TANF case record
  • Name of recipient, if different from applicant's name
  • Type of benefit
  • Source of verification and date, if different from face-to-face contact
  • Benefit amount
  • Date received
  • If representative contacted, name and telephone number
  1. Private pensions (retirement benefits)
    1. Former employer
    2. Union
    3. Insurance company
  • Current check stub
  • Pension plan
  • Letter from company
  • Contact with company representative
  • Name of payor/payee/beneficiary, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Gross benefits amount
  • Date received
  • Claim number
  • Whether any increase is anticipated
  • If representative contacted, name and telephone number
  1. Civil service annuity (CSA)
  • Recent CSA increase award card
  • Letter from CSA
  • Contact with CSA representative
  • Current check
  • Form 1243
  • Name of payee/beneficiary, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Gross benefit amount before deductions for health insurance
  • Date received
  • Claim number
  • If representative contacted, name and telephone number
  1. Irrevocable trust funds
  • Trust agreement
  • Will
  • Trustee
  • Representative of bank or financial institution managing trust
  • Recent bank statement
  • Name of trustee/beneficiary, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Amount and frequency of income from trust to individual
  • Date of bank statement
  • If trustee or representative contacted, name and telephone number
  1. Veterans Administration (VA) benefits
    1. Pension
    2. Compensation (disability)
    3. Subsistence allowance for education and on-the-job training
    4. Refunds paid to ex-servicemen (GI insurance premiums)
  • Current check or direct deposit slip
  • Recent bank statement
  • Form 1240
  • Recent VA Award Letter
  • Contact with VA representative
  • Name of recipient, if different from applicant's name
  • Type of benefit
  • Source of verification and date, if different from face-to-face contact
  • Gross payment amount and exclusions:
    • Aid-and-attendance benefits
    • VA Homebound Elderly Benefits
    • Payments for purchase of medications
  • Date received
  • Claim number
  • If representative contacted, name and telephone number
  1. Educational loans and grants
  • School
  • Organizations
  • Clubs
  • Institutions
  • Award letter
  • Government loans
  • Beneficiary, if different from applicant's name
  • Payor
  • Type of loan or grant
  • Amount received for current living costs
  • Source of verification and date
  • Date received and period covered (frequency)
  • If representative contacted, name and telephone number
  1. Unemployment compensation
    1. Government
    2. Private
    3. Strike benefits from union funds
  • Texas Workforce Commission Form B-11 or other official correspondence
  • Recent check
  • Recent bank statement
  • Contact with government agency, employer, union
  • Payee/payor, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Gross amount received
  • Date received and period covered (frequency)
  • Claim number
  • If representative contacted, name and telephone number
  1. Worker's compensation and disability payments
  • Recent check
  • Attorney
  • Claim Adjuster
  • Recent bank statement
  • Legal Correspondence
  • Correspondence from insurance company
  • Employer
  • Payee/beneficiary, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Gross amount received
  • Date received and frequency
  • Length of disability
  • Lump-sum settlement
  • If collateral contacted, name and telephone number
  1. Alimony
  • Contact ex-spouse
  • Divorce Decree
  • Court/payment records
  • Recent check
  • Receipts
  • Payor
  • Source of verification and date, if different from face-to-face contact
  • Amount received
  • Date received and frequency
  • If collateral contacted, pertinent name and telephone number
  1. Cash support payments from friends or relatives (regular monthly)
  • Contact or statement from contributor
  • Recent check
  • Receipts
  • Payee/beneficiary, if different from applicant's name
  • Relationship/name/address and telephone number of payor
  • Source of verification and date, if different from face-to-face contact
  • Amount received and frequency (exclude if infrequent or irregular and less than $20/mo.)
  1. Net income from individual's share of life estate
    1. Mineral lease
      1. Bonus payments
      2. Delays rentals
      3. Shut-in royalty
    2. Other types of leases (farming, grazing, hunting)
    3. Rental
  • Lease agreements
  • Rental agreements
  • Oil company representative
  • Check stubs
  • Lessee or tenant (renter)
  • Payee, if different from applicant's name
  • Payor
  • Source of verification and date, if different from face-to-face contact
  • Gross amount
  • Date received and frequency
  • If representative contacted, name and telephone number
  • Address and telephone number of lessee or tenant
  1. Teacher retirement (TRS)
  • Form 1297
  • Contact with TRS employee
  • Recent check if previously verified no deductions
  • Payee/beneficiary, if different from applicant's name
  • Source of verification and date, if different from face-to-face contact
  • Gross benefit amount
  • Claim number
  • Date received
  • If TRS representative contacted, name and telephone number

 

Appendix XIII, Content of Referral Packets

Revision 17-3; Effective May 15, 2017

 

 

Initial Assessment Packet Forms

Family Care (FC), Emergency Response Services (ERS), Meals or Residential Care (RC) Community Attendant Services (CAS), Primary Home Care (PHC) or Day Activity and Health Services (DAHS)
2059 — 1 copy 2059 — 1 copy
2101 — 2 copies 2101 Referral — 1 for provider and 1 for case record
- 2101 — Original and 1 copy
Adult Foster Care (AFC) DAHS Facilitated-Initiated Referrals
2330 — 1 copy 2101 Referral — 1 for provider and 1 for case record
2327 — 1 copy 2101 — Send the original to the regional nurse and 1 copy for case record.

 

Annual Reauthorization/Interim Reassessment Packet Forms

For annual or interim reauthorizations in which a change is being made to the service plan:

Meals, FC, ERS or RC CAS
2059 — 1 copy, if information has changed 2059 — 2 copies, if information has changed
2101 — Original and 1 copy 2101 Referral for
CAS — 1 for provider, 1 for case record and 1 for regional nurse
- 2101 — Original and 1 copy for CAS cases only plus 1 for regional nurse
AFC Non-PHC or DAHS cases
2330 — 1 copy 2101 — Original
2327 — 1 copy -

 

Termination Packet Forms

Meals, FC, ERS or RC CAS
2101 — 2 copies 2101 — Original and 1 copy for CAS cases plus 1 for regional nurse
- PHC or DAHS
- 2101 — Original and 1 for case record

 

Appendix XIV, SAVERR/TIERS Type Program Chart

Revision 17-1 Effective March 15, 2017

 

 

The following chart may be used for the determination of financial eligibility based on automated records. It indicates the type of programs registered on the System for Applications, Verifications, Eligibility Reports and Referral (SAVERR) and the Texas Integrated Eligibility Redesign System (TIERS), and how existing coverage affects eligibility for Community Care for Aged and Disabled (CCAD) services.

 

If the automated record shows:
SAVERR Type Program (TP) and SAVERR Base Plan (BP) or TIERS Type of Assistance ...then the individual has Eligibility for Community Care Program?

01

n/a

TP 01

Temporary Assistance for Needy Families (TANF) and Medicaid (three prescriptions, or unlimited if covered by HMO)

Check SAVERR individual screen to determine if applicant is receiving Regular Medicaid – if so, categorically eligible for Title XIX.

03

13

TP 03

Medicaid for the Elderly and People with Disabilities (MEPD) Medicaid (three prescriptions)

Title XIX categorical eligibility

07

n/a

TP 07

Medicaid only, for 12 months after TANF eligibility ends (three prescriptions, or unlimited if covered by managed care organization (MCO))

Title XIX categorical eligibility

08

n/a

TP 98

Child Protective Services (CPS) Foster Care Medicaid (unlimited prescriptions)

Title XIX categorical eligibility

09

29
31
32
33
34
35
n/a

TP 70
TP 87
TP 88
TP 93
TP 94
TP 97
TP 99

CPS Foster Care Medicaid (unlimited prescriptions)

Title XIX categorical eligibility

10

30
31
32
33
34
35
n/a

TP 52
TP 53
TP 54
TP 57
TP 58
TP 59
TP 70

TANF foster care (unlimited prescriptions)

Title XIX categorical eligibility

11

13

TA 27

Prior Medicaid for an individual applying for institutional or waiver Medicaid

Categorically eligible for Title XIX during the months in which individual has active coverage.

11

13

TP 11

MEPD three-months-prior Medicaid (three prescriptions)

Categorically eligible for Title XIX during the months in which individual has active coverage.

11

n/a

TP PM

Historical prior medical – MEPD or Texas Works (TW)

Categorically eligible for Title XIX during the months in which individual has active coverage.

12

10

TA 06

Manual Supplemental Security Income (SSI) Medicaid for nursing facility resident

Not eligible for Community Care for Aged and Disabled (CCAD) under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a Community Attendant Services (CAS) referral.

12

13

TA 03

Manual SSI recipient waivers

Already covered under a Medicaid Waiver, so may or may not be eligible for CCAD. Community Living Assistance and Support Services (CLASS) cannot receive any CCAD service, except Title XX Day Activity and Health Services (DAHS). See Appendix XX, Mutually Exclusive Services.

12

13

TA 22

Manual SSI

Title XIX categorically eligible

12

15

TA 05

Manual SSI recipient, non-state community based group homes

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact Social Security Administration (SSA) (at the local office or at 1-800-772-1213) to correct the eligibility record.

12

15

TA 07

Medicaid for state hospital resident

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

12

16

TA 09

Medicaid for state supported living center resident

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

12

17

TA 04

Manual SSI recipient, state community based group homes

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

12

n/a

TP 12

Temporary manual SSI

Title XIX categorically eligible

13

10

TP 38

Institutional SSI Medicaid coverage for individuals in nursing facilities (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

13

13

TA 01

Interim SSI denied child

Categorically eligible for Title XIX CCAD services during active months.

13

13

TA 02

SSI recipient waivers

Already covered under a Medicaid Waiver, so may or may not be eligible for CCAD. CLASS cannot receive any CCAD service, except Title XX DAHS. See Appendix XX.

13

13

TP 13

SSI Medicaid for individuals living in the community (three prescriptions)

Title XIX categorical eligibility

13

15

TA 26
TP 39
TP 41

Institutional SSI Medicaid coverage for individuals in ICF/IID facilities (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

13

16

TP 46

Institutional SSI Medicaid coverage for individuals in state supported living centers (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

13

17

TA 08

SSI recipient, state community-based group home

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

13

17

TA 21

SSI Medicaid for recipients in chest hospitals

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then have the individual or authorized representative contact SSA (at the local office or at 1-800-772-1213) to correct the eligibility record.

13

n/a

TP SS

Temporary SSI

Categorically eligible for Title XIX CCAD services during active months.

14

10

TP 17

Institutional Medical Assistance Only (MAO) Medicaid coverage for individuals in nursing facilities (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

10

TP IN

Temporary institutional

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

13

TA 10

Medicaid waivers – Home and Community-based Services (HCS), CLASS, Deaf Blind with Multiple Disabilities (DBMD) (unlimited prescriptions)

Already covered under a Medicaid waiver, so may or may not be eligible for CCAD. CLASS cannot receive any CCAD service, except Title XX DAHS. See Appendix XX.

14

13

TP WA

Temporary waivers

Already covered under a Medicaid waiver, so may or may not be eligible for CCAD. CLASS cannot receive any CCAD service, except Title XX DAHS. See Appendix XX.

14

15

TP 15

Institutional MAO Medicaid coverage for individuals in Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Condition (ICF/IID) (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

15

TP 16

Medicaid for state hospital residents

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

16

TP 10

Institutional MAO Medicaid coverage for individuals in state supported living centers (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

17

TA 12

Medicaid for ICF/IID resident

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

14

20

TP 14

CAS (no prescription coverage)

The CAS program provides PHC, funded through §1929(b)(2)(B) of the Social Security Act.

14

n/a

TP IW

Historical institutional waivers

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

18

13

TP 18

Medicaid for disabled adult children (three prescriptions)

Title XIX categorical eligibility

19

13

TP 19
TA 01

SSI transitional Medicaid for children (three prescriptions)
Interim SSI denied child (three prescriptions)

Title XIX categorical eligibility – will be denied or transferred to other coverage at age 18.

20

n/a

TP 20

Additional four months of Medicaid for the child following denial due to receipt of child support (three prescriptions)

Title XIX categorical eligibility for the child during eligible months

21

n/a

 

Adoption assistance

Not categorically eligible

22

13

TP 21

Disabled widow/widowers – Medicaid (three prescriptions)

Title XIX categorical eligibility

22

13

TP 22

Early Aged widow/widowers – Medicaid (three prescriptions)

Title XIX categorical eligibility

22

13

TP WI

Temporary widow/widowers – Medicaid (three prescriptions)

Title XIX categorical eligibility during eligible months

23

13

TP 23

Specified Low-Income Medicare Beneficiary (SLMB) – Pays Part B premium, but no Medicaid (no prescription coverage)

Title XX categorical eligibility

23

13

TP 26

Qualifying Individual (QI)-1 – Pays Part B premium, but no Medicaid (no prescription coverage)

Title XX categorical eligibility

23

13

TP SL

Temporary SLMB/QI-1

Title XX categorical eligibility

24

13

TP 24

Qualified Medicare Beneficiary (QMB). Pays Part B premium, deductibles, co-insurance, but no Medicaid (no prescription coverage)

Title XX categorical eligibility

25

13

TP 25

Qualified disabled and working individuals

Title XX categorical eligibility

29

n/a

TP 29

Medicaid for 12-18 months after TANF for certain caretakers (three prescriptions, or unlimited if covered by MCO)

Title XIX categorical eligibility during eligible months

30

13

TP 30

Aid and Attendance emergency Medicaid for aliens (three prescriptions)

Title XIX categorical eligibility during eligible months

30

n/a

TP 31

Medicaid for an emergency condition

Title XIX categorical eligibility during eligible months

30

n/a

TP 32

Medicaid for an emergency condition with spend-down

Categorically eligible for Title XIX services for the coverage period if an effective date appears on the SAVERR record. The case worker will be required to confirm continued eligibility on a monthly basis. Failure to confirm eligibility could result in an invalid finding if the case is pulled for casereading and the individual is no longer Title XIX eligible.

If the individual name, but no effective date, appears in the SAVERR record, resource eligibility for Title XX already determined by TANF. Test for income eligibility only for Title XX.

30

n/a

TP 33

Medicaid for an emergency condition for children 1-5

Title XIX categorical eligibility during eligible months

30

n/a

TP 34

Medicaid for an emergency condition – for children 6-18

Title XIX categorical eligibility during eligible months

30

n/a

TP 35

Medicaid for an emergency condition – for children under 1

Title XIX categorical eligibility during eligible months

30

n/a

TP 36

Medicaid for an emergency condition for pregnant women

Title XIX categorical eligibility during eligible months

30

n/a

TP AL

Medicaid for an emergency condition (historical Family Medical Assistance (FMA))

Title XIX categorical eligibility during eligible months

30

n/a

TA 31

Medicaid for an emergency condition for TF-level families

Title XIX categorical eligibility during eligible months

37

n/a

TP 37

Medicaid for 12-18 months after TANF eligibility (three prescriptions, or unlimited if covered by MCO)

Title XIX categorical eligibility during eligible months

40

n/a

TP 40

Medicaid for pregnant women – coverage ends two full months after birth of child (three prescriptions, or unlimited if covered by MCO)

Title XIX categorical eligibility during eligible months

42

n/a

TP 42

Presumptive Medicaid for pregnant women – converted to TP-40 if ongoing coverage is granted (three prescriptions, or unlimited if covered by MCO)

Very short-term Title XIX categorical eligibility during eligibility period – check SAVERR for ongoing TP 40 coverage.

43

n/a

TP 43

Medicaid for children under age 12 months – coverage may convert to another TP at end of eligibility period

Title XIX categorical eligibility for the child

44

n/a

TP 44

Medicaid for children age 6-18 – coverage ends at 19th birthday

Title XIX categorical eligibility for the child

45

n/a

TP 45

Medicaid for newborns – coverage opened by TMHP when mother is covered by Medicaid in birth month. Coverage under this program ends at end of 12th month, although may convert to another TP

Title XIX categorical eligibility

47

n/a

TP 47

Medicaid for children ineligible for TANF based on stepparent or grandparent income

Title XIX categorical eligibility for child

48

n/a

TP 48

Medicaid for children at least 13 months, but under 6 – may convert to another TP at end of eligibility period

Title XIX categorical eligibility for child

51

10

TA 17

Grandfathered institutional MAO Medicaid coverage for individuals in nursing facilities (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

51

13

TA 17

Grandfathered Medicaid individuals in the community who were discharged from an institution setting when the ICF II level was phased out (three prescriptions)

Title XIX categorical eligibility

51

13

TP 50

Grandfathered Medicaid individuals eligible under Rider 51J

Title XIX categorical eligibility

51

13

TP 51

Rider 51 waiver recipients

Already covered under a Medicaid waiver during covered months, so may or may not be eligible for CCAD. CLASS cannot receive any CCAD service, except Title XX DAHS. See Appendix XX.

51

13

TP RI

Temporary Rider 51

Title XIX categorically eligible during eligible months unless receiving waiver services. If so, not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

51

15

TA 15

Grandfathered institutional MAO Medicaid coverage for individuals in ICF/IID facilities (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

51

15

TA 25

Grandfathered institutional MAO Medicaid coverage for individuals in state hospitals (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

51

16

TA 16

Grandfathered institutional MAO Medicaid coverage for individuals in state supported living centers (unlimited prescriptions)

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

51

17

TA 24

Rider 51 ICF/IID state community-based homes

Not eligible for CCAD under this TP/BP. Confirm living arrangement, then check with MEPD staff to determine if they are aware the individual has moved from the facility. They will test for community programs; inform MEPD if this will be a CAS referral.

55

n/a

TP 02

Medicaid for refugees

Categorically eligible for Title XIX during eligible months

55

n/a

TP 55

Medicaid for the medically needy

Categorically eligible for Title XIX during eligible months

55

n/a

TP 56

Medicaid spend-down program – eligibility for CCAD services depends on eligibility status on the SAVERR record.

Categorically eligible for Title XIX services for the coverage period if an effective date appears on the SAVERR record. The case worker will be required to confirm continued eligibility on a monthly basis. Failure to confirm eligibility could result in an invalid finding if the case is pulled for casereading and the individual is no longer Title XIX eligible.

If the individual name, but no effective date, appears in the SAVERR record, resource eligibility for Title XX already determined by TANF. Test for income eligibility only for Title XX.

61

n/a

TP 61

TANF and Medicaid for two-parent households (three prescriptions, or unlimited if covered by MCO)

Title XIX categorical eligibility

63

n/a

 

Medicaid for two-parent households (three prescriptions, or unlimited if covered by MCO)

Title XIX categorical eligibility

71

n/a

TP 71

One-time TANF – no Medicaid coverage (one adult)

Not categorically eligible

72

n/a

TP 72

One-time TANF – no Medicaid coverage (two parents)

Not categorically eligible

n/a

n/a

TP 87

Medicaid Buy-In

Categorically eligible for all Title XX programs, DAHS XIX, PHC and Texas Home Living waiver

 

Individuals with an active Supplemental Nutrition Assistance Program case are also categorically eligible for Title XX benefits.

 

Appendix XV, Services Available from Other State Agencies

Appendix XV-A, Department of State Health Services

Appendix XV-C, Texas Veterans Commission

Appendix XV-D, Texas Department of Housing and Community Affairs

Appendix XV-E, Department of Family and Protective Services

Appendix XV-F, Rehabilitation Technology Resource Center

Appendix XVI, Monitoring Questions

Revision 17-1; Effective March 15, 2017

 

 

Eligibility

Does the individual continue to meet all eligibility requirements for the Community Care for Aged and Disabled (CCAD) services that are authorized?

  • Does the individual continue to be financially eligible? Have there been any changes in income, resources, or categorical status?
  • Does the individual appear still to be functionally eligible? (See "Individual Condition" below.)
  • Does the individual need and want CCAD services?
  • Does the individual still need assistance that would not be met without this CCAD service?

 

Condition

Has there been any change in the individual's condition that affects service delivery or the adequacy of the service plan?

  • What is the individual's current medical, physical and mental condition? Has it changed?
  • Has the individual been hospitalized? Has there been an accident or illness? Is the individual getting medical services as needed?
  • Has there been a change in the individual's degree of self-sufficiency?
  • Has there been a change in the tasks the individual can perform?
  • What are the individual's current needs? Have these changed?
  • What is the individual's risk status?

 

Situation

Has there been any change in the individual's situation that affects service delivery or the adequacy of the service plan?

  • Has the individual moved? Has there been another change in the individual's home or environment? Does any change affect the individual's safety or service needs?
  • Who (if anyone) has moved in with the individual? Who has moved out of the individual's residence?
  • Has there been any change in the individual's social support or resources? Has there been any change in the assistance that is given by family or community resources?
  • Does the individual continue to have the same caregivers? Has there been any change in the amount or type of assistance they give the individual? Has there been any change in the ability, dependability, or availability of the individual's caregiver?

 

CCAD Services

Have CCAD services been delivered according to the service plan?

  • Were services initiated as scheduled? Has the provider agency delivered the correct amount of services at the scheduled times?
  • Is the individual satisfied with the service? Does the service meet the individual's needs?
  • What is the quality of the services that are being provided to the individual? Are there any problems with the quality of the services? Does the paid attendant carry out the required tasks? Does the attendant arrive on time? Is there a problem that needs to be reported to the agency supervisor or the contract manager?
  • Has the individual been away from his residence when in-home services were scheduled? Has the individual used out-of-home services as authorized? Has the individual in some other way prevented the delivery of authorized services?

 

Service Plan

Does the service plan need to be changed?

  • Are the authorized services meeting the individual's current needs?
  • Does the individual still concur with the service plan?
  • Does the individual continue to need the same amount of services?
  • Is the current schedule effective for meeting the individual's needs?
  • Does the individual need additional service(s)?
  • Does the individual need a referral to some other agency or community resource?

 

Appendix XVII, Service/Score Code Guide

Revision 17-1; Effective March 15, 2017

 

 

Service Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Score Form 2101, Authorization for Community Care Services, Item 16 Service Code
Adult Foster Care 18 18
Consumer Managed Personal Assistant Services Not required 27
Community Attendant Services (CAS) 24 17D (CAS)
17DS (CAS/SRO)
17DV (CAS/CDS)
Individual Directed Services (CDS) – Financial Management Services Not applicable 63V
63VY (ICM)
CDS – Support Consultation Not applicable 57V (for PHC and CAS)
57CV (for FC)
57V4 (For PHC in ICM)
Day Activity and Health Services Not required 29
29Y (ICM)
Residential Care (RC) 18 19I (RC Bed Hold, Non-Apt., Title XX)
19J (RC, Apt., Title XX)
19L (RC, Non Apt., Title XX)
19M (RC Emergency Care)
19N (grandfathered RC, R&B, Non-Apt.)
19O (grandfathered RC, R&B, Apt.)
Emergency Response Service 20 20
Family Care (FC) 24 17C (FC)
17CS (FC/SRO)
17CV (FC/CDS)
Home-Delivered Meals 20 25
Primary Home Care (PHC)

 

 

24 17 (PHC)
17S (PHC/SRO)
17V (PHC/CDS)
17Y (PHC/ICM)
17SY (PHC/SRO/ICM)
17VY (PHC/CDS/ICM)
Special Services to Persons with Disabilities 9 28

 

Appendix XVIII, Time Calculation

Appendix XIX, Case Management Time Frames

Revision 18-1 Effective June 15, 2018

 

 

Intake Procedures
Section 2320 Visit with individual requiring immediate response: within 24 hours from the date of assignment.
Section 2320 Visit with individual requiring expedited response: within five calendar days from date of assignment.
Section 2320 Visit with individual requiring routine response: within 14 calendar days from date of assignment.

 

Assessment and Reassessment Procedures
Sections 2611, 2611.1 Determine eligibility for Community Care for Aged and Disabled (CCAD) services: within 30 calendar days from date the signed application is received by the Texas Health and Human Services Commission (HHSC). Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. Because the MEPD process can take up to 45 days for regular referrals and 90 days if a disability determination is required, this may delay Community Care for Aged and Disabled (CCAD) certification beyond the 30-day time frame.
Section 2330 Conduct a home visit with all individuals who had initial assessments conducted in a place other than the individual’s home: within 30 calendar days after service initiation.

Section 2711

Reassess the individual's need for CCAD services (Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A):

Case workers coordinating Community Attendant Services (CAS) reassessments with the 90-day monitoring visit will have to complete the reassessment within 90 days of the previous monitoring visit to avoid a monitoring timeliness error.

by the end of the 12th calendar month following the previous functional assessment date on Form 2060.

within 90 days of last monitoring visit.

Section 2810

Notify applicant in writing of eligibility for service:

Reassess individual need and redetermine eligibility with a face-to-face or telephone interview as required by the region:

within two business days of the date of the decision.

Financial: by the end of the 24th month following the date eligibility rules processed on Form 2064, Eligibility Worksheet.

Functional: by the end of the 12th month following the date of the previous assessment.

 

Service Planning Procedures
Section 2344 Obtain a new Form 2307, Rights and Responsibilities:

Adult Foster Care: before services are authorized or reauthorized. A new form must be completed and signed whenever information on the original form becomes outdated or incomplete.

all other services: initially. A new form must be completed and signed whenever information on the original form becomes outdated or incomplete.

Section 2440 Complete or update Form 2060, Part B, for CAS, Primary Home Care (PHC) and Family Care (FC):

at initial assessment;

at each annual review; and

when raising or lowering hours for a task or a service.

 

Authorizations and Reassessments
Sections 2631, 4652.2 Initiate verbal referrals for individuals who meet the criteria for immediate or expedited responses and who need immediate initiation of service: no later than the next business day after the day the individual is visited and it is determined that a verbal referral is necessary.
Section 2631 After initiating verbal referral, send Form 2101, Authorization for Community Care Services, to the provider: within two business days from the date the applicant was determined eligible for a verbal referral.
Section 2632 For applicants who do not require verbal referrals, authorize services by sending Form 2101 to the provider: within five business days from the date the applicant is determined eligible.
Section 2632 For services other than CAS, contact the provider if Form 2101 or another notification of status of referral is not received: by the 21st calendar day from the date of referral.
Section 2611.1 If the eligibility process is delayed past the 30-day time frame due to pending Medicaid for the Elderly and People with Disabilities (MEPD) eligibility: the case worker verifies MEPD status on or before the 25th day from the application date and performs weekly checks  until the eligibility decision is received using the Texas Integrated Eligibility Redesign System (TIERS) records.  The TIERS checks must be documented in the record. 
Sections 2721.4 If a functional reassessment mandates a change in the individual's service plan: the change must be completed as part of that reassessment.

 

Service Monitoring and Evaluation
Section 2710.2 Make a home visit for CAS individuals (regardless of priority): at least every 90 calendar days from the previous home visit.
Section 2710.2

Make a home visit, if required by the region, for priority status individuals (other than CAS individuals):

Make a home visit, if required by the region, for non-priority status individuals (other than CAS individuals):

by the end of the sixth month following the previous monitoring contact.

within six months of the last monitoring contact.

 

Denying or Reducing Services
Section 2810 Notify applicant in writing of ineligibility for service: within two business days of the date of the decision.
Sections  2810, 2811 Notify the individual in writing of reduction or termination of service: at least 12 calendar days before the effective date of the decision. (See Appendix IX, Notification/Effective Date of Decision, or Section 2811, Effective Dates for Service Reduction and Termination, for exceptions to 12 days notice and for effective dates for service reduction or termination in cases of appeal).
Section 2822.1 If an individual enters a nursing facility or an institution, verify the action and determine probable length of stay. If length of stay is likely to be more than 30 days: immediately terminate any authorized CCAD services by submitting Form 2101, using the date of entry into the nursing facility as the termination date and close out on the Service Authorization System (SAS).
Section 2840,
Appendix IX
If an individual threatens his own health or safety or that of others, purchased services may be terminated: send Form 2065-A, Notification of Community Care Services, by the next work day after receiving a notice from the provider that services have been suspended for threats to health and safety. Services may be terminated immediately.  

 

Responding to Requests for Service Interruptions, Suspensions and Reported Changes
Sections 2810, 2814 Notify the individual in writing when there is a change in type or amount of services authorized: any changes in the individual’s service plan. Examples include increases/decreases in units/hours of service, increases/decreases in units/hours of service, increases/decreases in copay, adding a new service or transfers from FC to PHC 
Section 2814,
Appendix IX
Transfers from PHC/CAS to FC: allow 12 calendar days advance notice (See Appendix IX for exceptions).
Section 2821 The provider must notify the case worker of a suspension: on the day of the suspension or by the first workday following the suspension.
Section 2822.1 If an individual enters a nursing facility, hospital or an institution, verify the action and determine probable length of stay. If length of stay is likely to be 30 days or less: suspend services effective the date the individual enters the nursing facility, hospital or institution and send Form 2067, Case Information, to providers.
Section 2721 When learning of a change in the individual's condition/status, revise the service plan or document why no changes are needed: within 14 calendar days of learning of a change.
Sections 4445, 4673.4  When the individual requires an immediate change in CAS, FC or PHC service plan due to situations listed in these sections, respond: for FC, by the next workday and for PHC or CAS, within the same day of receipt of the request.
Section 2736.1 When there is a reason to believe that an individual has been abused, neglected or exploited, make a referral to Adult Protective Services or Child Protective Services, as appropriate: within 24 hours if there is an immediate or imminent threat to the health and safety of the individual.  
Section 2723 When there is a request to change providers: within 14 days of the individual's request.

 

Appendix XX, Mutually Exclusive Services

Appendix XXI, Medicaid Estate Recovery Program (MERP) Script and Cover Sheet

Effective Date 6-2018

 

MERP Script Cover Sheet

MERP Script in English

MERP Script in Spanish

 

MERP Script in English I want to take a few minutes to explain an important state program called the Medicaid Estate Recovery Program, or MERP. You need to be aware of this program because it affects the program that you are applying for today, which is: 

Community Attendant Services (CAS) 

Let me explain why we have MERP. 

Medicaid is a government program that pays for health care services. Services provided could include helping people stay in their own home or moving to a facility, such as a nursing home, if that is what they need. These services can be very expensive. Federal law requires the state to recover the money spent for your care, whenever possible. After your death, a Medicaid claim may be filed to recover the cost of your care. That program is called MERP. MERP applies even if you have a will. 

MERP only applies to the services you receive after the age of 55. The Medicaid claim is filed against your estate, which is property, such as money, a house or other things of value that a person leaves to family members or others (heirs). MERP does not apply to all property that a person may own, such as life insurance policies that name a person to receive the payment, or bank accounts that are paid on death to another person.

In some cases, the state may not ask for anything back. The state will never ask for more money back than it paid for your services. There are situations when the state will not ask for any money back after your death, for example, if your spouse is still alive, the value of your estate is $10,000 or less or the amount of your Medicaid costs was $3,000 or less. The state also makes some exceptions for hardships. 

Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, explains the MERP program in more detail. I will be asking that you sign and date the form. Signing the form will show that you have received information about MERP. If you choose not to sign, your application cannot be denied for that reason, but it is also important to know that if you accept services, the state may still file a claim against your estate after you die. Would you like to take a moment to read Form 8001, or are you ready to sign the form?

[If the individual chooses to sign Form 8001 at this point, obtain the individual’s signature on Form 8001 and proceed to the section asking if the individual has any other questions. If the individual chooses to read Form 8001, allow time for the individual to do so. If the individual still has questions after reading the form, once again review the brief overview of MERP with the individual. Once the individual has read or reviewed the form, proceed to the statement asking the individual to sign the form.] 

Now that you have read and reviewed Form 8001, I am asking that you sign it to show that you received the information.

[Offer the individual the opportunity to sign Form 8001, if not signed after the brief overview. If the individual does not choose to sign the form, document on Form 8001 the individual’s refusal to sign the form.]

Do you have any other questions about MERP?

[You may respond to general questions if the answer is on Form 8001, but not to questions related to the individual’s specific circumstance or estate.]

If you have other questions or need additional information about the estate recovery program, you may call the telephone number or visit the website listed on Form 8001, or you can call the legal hot line for Texans at 1-800-622-2520 (available to persons age 60 and over; Medicare beneficiaries, regardless of age; and low-income victims of violent crime).

Here is a copy of the MERP brochure, Your Guide to the Medicaid Estate Program. It also provides general information about MERP.

Finally, after you pass away, the state will need to contact the executor of your estate or other individual to see if a claim should be filed. The state would like to have the names of two individuals.

[Ask the individual for contacts in this order: (1) executor, (2) legal guardian, (3) power of attorney or (4) other family members who have acted on behalf of the individual. Document the relationship of the contact named, and the contact’s name, address and phone number in the space below. If the individual has an executor identified and recorded in SAS and you confirm the information is current, you do not need to request the executor information. Indicate by the first contact’s name that the executor information is recorded in SAS. Request the information for the second contact and record it below.]

Executor/Contacts For: [enter individual’s name]

Date Contact Information Obtained:

Name of Staff who Obtained the Information:

First Contact’s Name: Recorded in SAS: __ Yes __ No

Relationship: __ Executor __ Legal Guardian __ Power of Attorney __ Other Family Member

Address:

Phone Number:

Appendix XXII, Community Attendant Services Financial Eligibility Requirements

Revision 17-1; Effective March 15, 2017

 

Section 42, Code of Federal Regulations, §431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas State Plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for Medical Assistance Only (MAO) cases.

Therefore, financial eligibility for Community Attendant Services (CAS) is determined exclusively by Medicaid for the Elderly and People with Disabilities (MEPD) staff. However, Community Care for Aged and Disabled (CCAD) staff must make an effort during the initial visit with each applicant to gather as much documentation as possible to hasten the MEPD specialist’s completion of the eligibility determination.

 

I. Income and Resource Eligibility

The following income and resource verifications/documentations must be included in the MEPD specialist’s case record to make a financial eligibility decision for a CAS case.

As verification of: the MEPD specialist:
bank accounts must document the:
  • name of the financial institution and account number;
  • account accessibility by the individual;
  • account balance as of 12:01 a.m. on first day of the appropriate month(s); and
  • source of verification.
cash may accept without verification the individual’s statement about the amount of cash on hand. Ask the individual if he has any cash in a safety deposit box or if any of his cash on hand is in the form of valuable coins.
trusts must document the:
  • name of the trustee, settlor and beneficiary;
  • accessibility of the trust;
  • value of the trust that is accessible;
  • amount and frequency of income from the trust to the individual; and
  • source of verification.
stocks must document the:
  • name of the company, number of shares and type of shares;
  • market value as of 12:01 a.m. on the first day of the appropriate month; and
  • source of verification.
bonds must document the:
  • name of the company, type of bond and serial number;
  • market value as of 12:01 a.m. on the first day of the appropriate month; and
  • source of verification.
promissory notes, loans and property agreements must document the:
  • ownership of the note;
  • accessibility by the individual;
  • term and whether it is negotiable;
  • reason for exclusion, if excluded;
  • current market value of the note; and
  • source of verification.
other real property must document the:
  • location and description of the property;
  • individual’s ownership interest in the property;
  • current equity value of the individual's interest; and
  • source of verification.
life estates must document the:
  • location of the life estate property;
  • current equity value; and
  • source used as verification.
life insurance must document the:
  • name of the insurance company, policy number and face value (including the possibility of dividends, if participating);
  • type of insurance coverage;
  • current cash value; and
  • source used to verify the value.
burial spaces must document the:
  • name of the cemetery;
  • number of vacant spaces and the names and relationships of the designees;
  • ownership;
  • current market value; and
  • source used as verification.
burial funds must document the:
  • type of liquid resource being designated;
  • amount of assets being designated;
  • written statement from the individual or responsible person designating the asset for burial, unless the resource being designated is a prepaid burial contract or a bank account styled "for burial"; and
  • copy of the insurance policy if a funeral home is listed as the beneficiary.
mineral rights must document the:
  • location of the property;
  • percentage of interest in mineral rights;
  • individual’s accessibility to the interest in mineral rights;
  • current equity value of the individual's interest; and
  • source of verification.
earned income must document the:
  • gross earned income (if income fluctuates, amounts for the previous six months or less, depending on the review cycle);
  • sources of all earnings; and
  • source of verification.
support and maintenance provided to individuals living outside of an institution must document the:
  • name(s) of the person(s) who provided support and maintenance and type of in-kind benefit given to the individual;
  • amount of any payment or contributions made by the individual; and
  • actual market value of the in-kind benefit.
farm income must document the:
  • type of farm income and the individual's interest and accessibility of the farm income;
  • amount of gross income and allowable expenses from the previous six months;
  • reason, if the amount of income is anticipated to be different; and
  • source of verification.
Social Security benefits must document the:
  • amount of the gross benefit and the amount of the Supplementary Medical Insurance Benefit (SMIB) premium, if appropriate;
  • claim number;
  • source of verification; and
  • gross benefit verification (for applications).
Railroad Retirement benefits must document the:
  • gross amount of the benefit and the amount of the SMIB premium, if appropriate;
  • railroad retirement claim number; and
  • source of verification.
Veterans Affairs (VA) compensation and pensions must document the:
  • gross amount of the benefit and the amount of any deductions, if appropriate;
  • amount of aid-and-attendance or housebound benefits, if any;
  • VA claim number; and
  • source of verification.
other annuities, pensions and retirements plans must document the:
  • source of payments;
  • amount of the gross benefit;
  • claim number, if a civil service annuity; and
  • source of verification.
interest and dividends must document the:
  • name of the financial institution or other source of interest or dividend income;
  • account number, if received from a financial institution;
  • frequency of receipt and the amounts paid in the last six months; and
  • source of verification.
rents must document the:
  • type of rental income and the individual's interest and accessibility of the income;
  • amount of gross income and expenses from the previous six months;
  • reason for the difference in the income, if the amount is anticipated to be different; and
  • source of verification.
royalties must document the:
  • name, payor and reason for payment;
  • frequency of payment and the amounts paid during the previous six or 12 months; and
  • source of verification.
gifts, inheritances, support and alimony determines whether the gift, inheritance, support or alimony is to be treated as a lump sum payment, infrequent or irregular income, or regular and predictable income. He documents the:
  • source of the income;
  • frequency received and the amount; and
  • expected continuation.
notes and mortgages must document the:
  • name of the person making note payments and whether income is accessible to the individual;
  • amount of payment and the frequency of the payments; and
  • source of verification.
the home as a countable resource must document the location and ownership of the homestead.

 

II. Citizenship Requirements for Eligibility

Public Law 109-171, Deficit Reduction Act of 2005, requires that documentation be provided at the initial determination, and for ongoing cases, at the next redetermination of eligibility for all Medicaid cases. Verification of citizenship and identity for eligibility purposes is a one-time activity. Once verification of citizenship is established and documented by MEPD staff, verification is no longer required, even after a break in eligibility.

Long Term Services and Supports (LTSS) case workers must be prepared to assist individuals with this process by informing LTSS individuals of the requirement and helping to identify the documentation needed to prove citizenship and identity. Information available at the time of the home visit must be collected and submitted with the application for an MEPD determination. Individuals may obtain and forward copies to HHSC for transmittal to MEPD staff.

MEPD staff accept copies and faxes only if clear and legible. If the LTSS case worker receives an affidavit as verification, ensure that the reason the applicant or recipient is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form 2067, Case Information, along with the affidavit. The case worker must ensure the applicant/individual is signing the affidavit under penalty of perjury.

 

Acceptable Documentation for Both Citizenship and Identity

Supplemental Security Income (SSI) Recipients State Data Exchange (SDX) contains the needed information to verify citizenship. For any active Supplemental Security Income (SSI) recipient, MEPD staff are able to use SDX as verification of both citizenship and identity. For any denied SSI recipient, SDX can be used as a valid verification source of both citizenship and identity when the denial is for any reason other than citizenship. The SDX printout will show action code N13 if the denial is for citizenship.

Medicare Recipients – Active Medicare recipients are exempt from the requirement to provide evidence of citizenship and identity. The Social Security Administration documents citizenship and identity for Medicare recipients.

For any individual entitled to or enrolled in Medicare Part A or B, and subsequently denied Medicare, use the State On Line Query (SOLQ) or Wire Third Party Query (WTPY) System as documentation of both citizenship and identity when the denial is for any reason other than citizenship. If there is an end date listed for Medicare, the individual must provide documentation regarding the loss of Medicare.

All Other Individuals – The following primary documents may be accepted as proof of both identity and citizenship:

  • U.S. passport,
  • Certificate of Naturalization (N-550 or N-570), or
  • Certificate of U.S. Citizenship (N-560 or N-561).

Documents that establish citizenship are divided into second, third and fourth levels based on the reliability of the evidence:

  • One document that establishes U.S. citizenship, and
  • One document that establishes identity.

 

Hierarchy of Approved Documentation Sources

Primary Evidence of Citizenship and Identity
  • U.S. passport
  • Certificate of Naturalization
  • Certificate of U.S. citizenship
  • SDX for denied SSI recipients when the denial reason is for any reason other than citizenship (N13)
  • SOLQ/WTPY and documentation on reason for Medicare denial

If primary evidence of citizenship is not available, the individual must provide two documents – one to establish U.S. citizenship and one to establish identity, as outlined below. Begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

 

Second Level of Evidence of Citizenship (Use only when primary evidence is not available)
  • A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986) - Contact Bureau of Vital Statistics (BVS) for an individual born in Texas. If an individual’s date of birth is earlier than 1903 or if the birth was out of state, accept a legible/non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; usbirthcertificate.net or the toll-free number, 1-888-736-2692.
  • Report of Birth Abroad of a U.S. Citizen (FS-240)
  • Certification of Birth Abroad (FS 545 or DS-1350)
  • U.S. Citizen identification card (Form I-179 or I-197)
  • Northern Mariana identification card (I-873)
  • American Indian card (I-872) issued by Department of Homeland Security with classification code “KIC”
  • Final adoption decree showing the child’s name and U.S. place of birth
  • Evidence of U.S. Civil Service employment before June 1, 1976
  • U.S. Military record showing a U.S. place of birth (Example: DD-214)

 

Third Level of Evidence of Citizenship (Use only when primary and second level evidence is not available)
  • Hospital record of birth showing a U.S. place of birth
  • Life, health or other insurance record showing a U.S. place of birth
  • Religious record of birth recorded in the U.S. or its territories within three months of birth, which indicates a U.S. place of birth showing either the date of birth or the individual's age at the time the record was made

 

Fourth Level of Evidence of Citizenship (Use only when primary, second level and third level evidence is not available)
Any listed documents must include biographical information including a U.S. place of birth.
  • Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual’s age (generally for individuals born 1900-1950)
  • Seneca Indian Tribal census record showing a U.S. place of birth
  • Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth
  • U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth
  • Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth
  • Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth
  • Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth
  • Affidavits from two adults regardless of blood relationship to the individual (use only as a last resort when no other evidence is available)

 

Evidence of Identity
  • Driver license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color
  • School identification card with a photograph
  • U.S. Military card or draft record
  • Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color
  • Birth certificate
  • Hospital record of birth
  • Military dependent’s identification card
  • Native American Tribal document
  • U.S. Coast Guard Merchant Mariner card
  • Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information
  • Data matches with other state or federal government agencies (for example, Employee Retirement System and Teacher Retirement System)
  • Adoption papers or records
  • Work identification card with photograph
  • Signed application for Medicaid (accept the signature of an authorized representative or a responsible person acting on the individual’s behalf)
  • Health care admission statement
  • School records for children under age 16, which may include nursery or day care records
  • An affidavit signed by a parent or guardian for a child under age 16, stating the date and place of birth of the child (use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship)

In the hierarchy of approved documentation sources, some documents listed to verify citizenship are also acceptable to verify identity. When using the hierarchy of approved documentation sources, the same document cannot be the source to verify both citizenship and identity.

If an individual is unable to provide any other documentary evidence of citizenship, an affidavit signed under penalty of perjury will only be accepted as a last resort. MEPD staff are required to document the reason another source is not available to verify citizenship. If the LTSS case worker is provided an affidavit, ensure the reason the applicant or recipient is unable to produce documentary evidence of citizenship and identity is documented on the affidavit. If the affidavit does not contain this information, the reason another source is not available is documented and transmitted to MEPD staff on Form 2067, along with the affidavit. The copies of the affidavit form, available online at https://hhs.texas.gov/laws-regulations/forms, are to be made available in all HHSC benefits offices.

 

Reasonable Opportunity to Provide Verification

The LTSS case worker must inform all applicants if MEPD staff do not receive documentation of citizenship and identity by the application due date, certification may be delayed and eventually denied if verification documentation is not provided.

Inform ongoing recipients that they will be asked to provide documentation verifying citizenship and identity at the redetermination. If an ongoing recipient cannot provide the required verification(s) at the initial request, eligibility will continue until the next redetermination. Eligibility will be denied if the recipient does not provide the required verification(s) at the next complete redetermination.

 

Assistance to Individuals in Obtaining Documentary Evidence

To assist an individual who is unable to provide documentary evidence of citizenship and identity in a timely manner because of incapacity of mind or body or the lack of a representative to assist, staff may make referrals to the following entities:

  • Department of Family and Protective Services, Adult Protective Services
  • Legal Aid
  • Community-based organizations
  • Social Security Administration
  • 2-1-1

For individuals born out of state, some sources to obtain a birth certificate are:

  • BirthCertificate.com
  • Vitalchek.com
  • Usbirthcertificate.net or the toll free number, 1-888-736-2692

When assisting the individual in providing documentary evidence of citizenship and identity, use any available documents, regardless of level of evidence.

 

Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services

Revision 17-1; Effective March 15, 2017

 

 

The case worker completes Form 2101 to renew the prior approval process for all ongoing Primary Home Care individuals (including transfer cases) not certified as Community Attendant Services (CAS) individuals. Instructions for items other than numbers 4 and 5, are covered in the instructions for Form 2101 in the Forms and Reports section.

Renewals Item 4 "Begin" date Item 5 "End" date
Renewal — no service plan change NA — Do not send Form 2101. NA — Do not send Form 2101.
Renewal with increase Seven days from date mailed or negotiated date. Leave blank — date remains the same as current authorization.
Renewal with decrease 12 days from the Form 2101 date unless appealed. Leave blank — date remains the same as current authorization.

 

Service plan change between assessments Item 4 "Begin" date Item 5 "End" date
Increase Seven days from the Form 2101 date or negotiated date. Leave blank — date remains the same as current authorization.
Decrease 12 days from the Form 2101 date unless appealed. Leave blank — date remains the same as current authorization.

 

Terminations Item 4 "Begin" date Item 5 "End" date
Loss of Medicaid eligibility Remains unchanged. Last day of month in which individual is determined ineligible for Medicaid.
Other eligibility criteria change (i.e., type of residence, functional eligibility, unmet need) Remains unchanged. 12 days from the Form 2065 date, unless appealed.
Individual or someone in home threatens health or safety of provider Remains unchanged. Date case worker becomes aware of action.

 

Appendix XXIV, Legal Basis for Community Care Programs

Revision 17-1; Effective March 15, 2017

 

 

All rules referenced below appear in the Texas Administrative Code (TAC), Title 40, Part I.

Adult Foster Care is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2913

Contracting rule base: TAC Chapter 48, Subchapter K

Community Attendant Services is provided under Title XIX of the Federal Social Security Act (relating to grants to states for medical assistance programs) at 42 USC §1396t (relating to home and community care for functionally disabled elderly individuals). This program was formerly known as §1929(b) or Frail Elderly.

Case management rule base: TAC §48.2918

Contracting rule base: TAC Chapter 47

Consumer Managed Personal Attendant Services is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Rule base: TAC Chapter 44

Day Activity and Health Services is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2915

Contracting rule base: TAC Chapter 98, Subchapter H

Emergency Care is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2921

Emergency Response Services is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2928

Contracting rule base: TAC Chapter 52

Family Care is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2911

Contracting rule base: TAC Chapter 47

Home-Delivered Meals is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq. Additional funding is provided by local resources and contractor match.

Case management rule base: TAC §48.2912

Contracting rule base: TAC Chapter 55

Primary Home Care is provided under Title XIX of the Federal Social Security Act (relating to state plans for medical assistance) at 42 USC §1396a.

Case management rule base: TAC §48.2918

Contracting rule base: TAC Chapter 47

Residential Care/Assisted Living is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397.

Case management rule base: TAC §48.2920

Contracting rule base: TAC Chapter 46

Special Services to Persons with Disabilities is provided under Title XX of the Federal Social Security Act (relating to block grants to states for social services) at 42 USC §1397 et seq.

Case management rule base: TAC §48.2914

Contracting rule base: TAC Chapter 58

 

Appendix XXV, Community Services Interest List (CSIL) Closure Code User's Guide

Revision 17-1; Effective March 15, 2017

 

Use the attached guide for closures on the Community Services Interest List and for closure codes in the Intake (NTK) system. These codes may also be found in the CSIL User’s Guide on the intranet (for staff use only).

Community Services Interest List (CSIL) Closure Code User's Guide

Appendix XXVI, Determining Unmet Need

Revision 17-1; Effective March 15, 2017

 

Determining Unmet Need

 

Appendix XXVII, HHSC Benefits Portal and TIERS Inquiry Desk Guide

Appendix XXVIII, Do Not Hire

Revision 17-1; Effective March 15, 2017

 

Do Not Hire

 

Appendix XXX, Income and Resource Exemptions for Determining Financial Eligibility

Revision 17-8 Effective September 1, 2017

 

 

Income and Resource Exemptions

Exempt income is not included in the income eligibility calculation. Once identified and documented, caseworkers will not be required to monitor exempt income at subsequent financial redetermination. Sources of exempt income include:

(1) interest income.

(2) cash received from the sale of a resource. This cash is a resource, not income.

(3) income of minor children who are supported by or dependent upon the client.

(4) refunds from the Internal Revenue Service for earned income tax credit.

(5) reimbursement from an insurance company for health insurance claims.

(6) any cash from a non-governmental medical or social services organization if the cash is:

for medical or social services already received by the individual and approved by the organization, and which does not exceed the value of those services; or a payment restricted to the future purchase of a medical or social service.

(7) proceeds of either a commercial loan or an informal loan, for which repayment is required with or without interest. The proceeds (amount borrowed) are not counted as income in the month in which they are received, but are considered to be a resource in the following month(s). To claim exemption of the proceeds of a loan, a client must prove that he acknowledges an obligation to repay and that some plan for repayment exists. If these conditions can be verified, no written contract is required.

(8) the amount of the cost-of-living increase in any pension or benefit, received on or after January 1, 1985, that would cause the client to be ineligible for continued services. This exclusion applies only to community care clients who are already receiving services or case management and would become ineligible because of the increase. It does not apply to applicants.

(9) in-kind income, such as food, clothing, shelter, rent subsidies.

(10) one-time or lump-sum payments from any source.

(11) funds from the Transition to Life in the Community Program.

(12) payments from the Agent Orange Settlement Fund or any other fund established in settlement of the Agent Orange product liability litigation. Public Law 101-239 exempts the payments from countable income and resources. The law is retroactive as of January 1, 1989.

(13) any payment received under the Radiation Exposure Compensation Act (Public Law 101-246).

(14) any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

(15) payments to volunteers under the Domestic Volunteer Services Act. This exclusion applies to any payments to volunteers in the Retired Senior Volunteer Program, and Foster Grandparent Program, and the Senior Companion Program. Also included are payments under Title III of the same act, which includes the Service Corps of Retired Executives (SCORE), the Active Corps of Executives (ACE), and the Action Cooperative Volunteer Program (ACV).

(16) interest or other earnings on any designated account established for Supplemental Security Income (SSI) clients under age 18 for retroactive benefits, as required by Public Law 104-193, effective August 22, 1996.

(17) payments by the Federal Disaster Assistance Administration authorized by the Disaster Relief Act, as amended.

(18) value of any housing assistance paid on a house under the United States Housing Act of 1937, the National Housing Act, the Housing and Urban Development Act of 1965, §101, or Title V of the Housing Act of 1949, as authorized by Public Law 94-375.

(19) home energy assistance, except food or clothing, under Public Laws 97-377 and 97-424. Home energy assistance is assistance in cash or in-kind that is provided by a private, nonprofit organization or a utility company. Some examples of home energy assistance are heating, cooling, weatherization, storm windows, and blankets.

(20) reparation payments received by Holocaust survivors from the Federal Republic of Germany. The payments may be made periodically or as a lump sum. The Texas Department of Human Services accepts the client's signed statement of amounts involved and dates of payment. Public Law 101-508 established this exemption effective January 1, 1991.

(21) payments from a state-administered fund to aid victims of crime. Public Law 101-508 established this exemption effective May 1, 1991.

(22) payments a state or local government may make as relocation assistance. Public Law 101-508 established this exemption effective October 15, 1990.

(23) hazardous duty pay of a spouse or parent absent from the home because of active military service.

(24) restitution payments made by the United States government under Public Law 100-383 to Japanese-American (or, if deceased, to their survivors) who were interned or relocated during World War II.

(25) reparation payments received under §§500-506 of the Austrian General Social Insurance Act.

(26) payments under the Netherlands' Act on Benefits for Victims of Persecution 1940-1945 (Dutch acronym, WUV).

(27) payment from any source made to individuals because of their status as victims of Nazi persecution. Public Law 103-286 established this exemption effective August 1, 1994.

Emergency or Disaster Relief

Payments precipitated by an emergency or major disaster are not counted as income or resources when determining financial eligibility.
A major disaster is any natural catastrophe such as a hurricane or drought, or, regardless of cause, any fire, flood or explosion, which the President determines causes damage of sufficient severity and magnitude.

An emergency is any occasion or instance for which the President determines that federal assistance is needed to supplant state and local efforts and capabilities to save lives and to protect property and public health and safety, or to lessen or avert the threat of a catastrophe.

Disaster Unemployment Assistance is emergency assistance authorized under Public Law (P.L.) 100-107 and received by individuals who are unemployed as a result of a major disaster. Individuals receiving Disaster Unemployment Assistance are not eligible for other unemployment compensation and cannot receive both at the same time.

If precipitated by an emergency or a major disaster, do not consider the following as income:

  • Payments received under the Disaster Relief Act of 1974 (P.L. 93-288, Section 312(d)), as amended by the Disaster Relief and Emergency Assistance Amendments of 1988 (P.L. 100-707, Section 105(i)) and disaster assistance comparable to these payments provided by states, local governments and disaster assistance organizations
  • Payments from the Federal Emergency Management Agency (FEMA), Individual and Family Grant Assistance program (IFG), grants or loans by the Small Business Administration (SBA), voluntary disaster assistance organizations, such as the Red Cross, or private insurance payments for losses due to a major disaster such as flood, wind, land movement
  • Each payment made to farmers under the Disaster Assistance Act of 1988 (P.L. 100-387) for crop losses or failure in a disaster
  • Income received from public and private organizations by individuals working in disaster relief efforts and funded under a National Emergency Grant by WIA, Title 1 (P.L.105-220)
  • Disaster Unemployment Assistance
  • Payments for flood mitigation received by a homeowner under the National Flood Insurance Act of 1968, as amended by P.L. 109-64
  • Government payments designated for the restoration of a home damaged in a disaster.

 

Additional Exemptions

Income from the following sources is exempt as income and as a resource and must not be considered in determining eligibility. Exempt the following payments:

  • Payments from the Ricky Ray Hemophilia Relief Fund
  • Alaska longevity bonus
  • Payments from the Energy Employees Occupational Illness Compensation Act (EEOICA) (Public Law 106-398, October 2000) for medical benefits and compensation
  • Filipino Veterans Equity Compensation Fund created by the American Recovery and Reinvestment Act of 2009.
  • The value of assistance to children under the National School Lunch Act (60 Stat. 230, 42 U.S.C. 1751 et seq.) as amended by Public Law 90-302 (82 Stat. 117, 42 U.S.C. 1761(h)(3))
  • Any grant or loan to any undergraduate student for educational purposes made or insured under any program administered by the commissioner of education, as provided by Section 507 of the Higher Education Amendments of 1968, Public Law 90-575 (82 Stat. 1063)
  • Incentive allowances received under Title I of the Comprehensive Employment and Training Act of 1973 (87 Stat. 849, 29 U.S.C. 821(a))
  • Compensation provided to volunteers by the Corporation for National and Community Service (CNCS), unless determined by the CNCS to constitute the minimum wage in effect under the Fair Labor Standards Act of 1938 (29 U.S.C. 201 et seq.), or applicable state law, pursuant to 42 U.S.C. 5044(f)(1)
  • Value of federally donated foods distributed pursuant to Section 32 of Public Law 74-320 or Section 416 of the Agriculture Act of 1949 (7 CFR 250.6(e)(9), as authorized by 5 U.S.C. 301)
  • All funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to a member of that tribe under Public Law 98-64
  • Funds held by Alaska Native Regional and Village Corporations (ANRVC) are not held in trust by the Secretary of the Interior and therefore ANRVC dividend distributions are not excluded from resources under this exclusion.
  • Home energy assistance payments or allowances under the Low-Income Home Energy Assistance Act of 1981, as added by Title XXVI of the Omnibus Budget Reconciliation Act of 1981, Public Law 97-35 (42 U.S.C. 8624(f))
  • Student financial assistance for attendance costs received from a program funded in whole or in part under Title IV of the Higher Education Act of 1965, as amended, or under Bureau of Indian Affairs student assistance programs if it is made available for tuition and fees normally assessed a student carrying the same academic workload, as determined by the institution, including:
    • costs for rental or purchase of any equipment;
    • materials or supplies required of all students in the same course of study; and
    • an allowance for books, supplies, transportation and miscellaneous personal expenses for a student attending the institution on at least a half-time basis, as determined by the institution, under Section 14(27) of Public Law 100-50, the Higher Education Technical Amendments Act of 1987 (20 U.S.C. 1087uu), or under Bureau of Indian Affairs student assistance programs.
  • Amounts paid as restitution to certain individuals of Japanese ancestry and Aleuts under the Civil Liberties Act of 1988 and the Aleutian and Pribilof Islands Restitution Act, Sections 105(f) and 206(d) of Public Law 100-383 (50 U.S.C. app. 1989 b and c)
  • Any matching funds and interest earned on matching funds from a demonstration project authorized by Public Law 105-285 that are retained in an Individual Development Account, pursuant to Section 415 of Public Law 105-285 (112 Stat. 2771)
  • Any earnings, Temporary Assistance for Needy Families matching funds, and accrued interest retained in an Individual Development Account, pursuant to Section 103 of Public Law 104-193 (42 U.S.C. 604(h)(4))
  • Payments made to individuals who were captured and interned by the Democratic Republic of Vietnam as a result of participation in certain military operations, pursuant to Section 606 of Public Law 105-78 and Section 657 of Public Law 104-201 (110 Stat. 2584)
  • Payments made to the children of women Vietnam veterans who suffer from certain birth defects, pursuant to Section 401 of Public Law 106-419 (38 U.S.C. 1833(c))
  • For the nine months following the month of receipt, any unspent portion of any refund of federal income taxes under Section 24 of the Internal Revenue Code of 1986 (relating to the child care tax credit), pursuant to section 431 of Public Law 108-203 (118 Stat. 539)
  • Wages and salaries from Title V of the Older Americans Act, such as Green Thumb and the Senior Texan Employment Program (STEP), are not exempt income. See (15) in the section above.

In the income eligibility budget, do not count the hostile fire pay or imminent danger pay portion from military income. For the nine-month period following the month of receipt, exclude the unspent portion of any retroactive payment (see (23) above) of:

  • hostile fire and imminent danger pay (pursuant to 37 U.S.C. 310) received by the ineligible spouse or parent from one of the uniformed services; and
  • family separation allowance (pursuant to 37 U.S.C. 427) received by the ineligible spouse or parent from one of the uniformed services as a result of deployment to or while serving in a combat zone.

Other exemptions include:

  1. Payments from the Remembrance, Responsibility and Future Foundation of Germany.
  2. Interest or other earnings on any designated account established for Supplemental Security Income (SSI) individuals under age 18 for retroactive benefits, as required by Public Law 104-193, effective August 22, 1996.
  3. Payments made in the class settlement of the Susan Walker vs. Bayer Corporation lawsuit, as required by Public Law 105-33, effective August 5, 1997.
  4. Payments from the Department of Veterans Affairs made to or on behalf of certain Vietnam veterans' natural children regardless of their age or marital status, for any disability resulting from spina bifida suffered by such children as required by Public Law 104-204, effective October 1, 1997.
  5. Gifts from tax-exempt organizations, such as the Make-A-Wish Foundation, to children with life-threatening conditions, as required by Public Law 105-306, effective retroactively to October 28, 1996. The exclusions apply to children under age 18. The gift must be from an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986 and which is exempt from taxation under Section 501(c). The case manager documents the case record with an oral or written statement from the organization that the gift was made based on the child having a life-threatening condition. No additional verification of medical eligibility is necessary.
  6. The following gifts to or for the benefit of a child described above are excluded from income:
    1. any in-kind gift, not converted to cash; and
    2. a cash gift to the extent that the cash excluded under this provision does not exceed $2,000 in any calendar year. Cash in excess of $2,000 received in a calendar year is included in the income eligibility budget.
  7. Payments for foster care of a child if the child:
    1. is not eligible for SSI; and
    2. was placed in the individual's home by a public or private, non-profit child-placement or child-care agency.
  8. Benefits received under Title III, Public Law 100-175, which amends the Older Americans Act of 1965 to authorize appropriations for the fiscal years 1988-1991.
  9. Value of benefits provided under the Child Nutrition Act of 1966.

There are also a number of legislatively-mandated exemptions that apply to members of recognized Native American tribes.

 

§48.2908. Indian-related Exemptions.

(a) Type of payment. The following statutes provide that certain types of payments made to members of Indian tribes are exempt from income and resources as specified in paragraphs (1)-(4) of this subsection, or only from income as specified in paragraph (5) of this subsection.

(1) Indian Judgment Funds Distribution Act — Public Law 93-134. Effective October 19, 1973, per capita distribution payments to members of Indian tribes who are due judgment funds, according to a plan of the Secretary of the Interior (or legislation, when a plan cannot be prepared or is not approved by the Congress) are exempted from income and resources. This does not include payments of funds distributed or held in trust (i.e., in the possession or care of a trustee) according to public laws enacted before October 19, 1973.

(2) Distribution of Indian Judgment Funds — Public Law 97-458. Effective January 12, 1983, Indian judgment funds held in trust (i.e., in the possession or care of a trustee) or distributed per capita, pursuant to an approved plan, or their availability, are exempted from income and resources. Indian judgment funds include interest and investment income accrued while the funds are held in trust. Initial purchases made with distributed judgment funds are exempted from resources.

(3) Per Capita Act — Public Law 98-64.

(A) Effective August 2, 1983, per capita distributions of all funds held in trust by the Secretary of the Interior to members of an Indian tribe are exempted from income and resources.

(B) Any local tribal funds that a tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of the Interior (e.g., tribally managed gaming revenues) are not exempted from income and resources under this provision.

(4) Alaska Native Claims Settlement Act (ANCSA) — Public Law 100-241.

(A) Effective February 3, 1988, the following items received from a native corporation are exempted from income and resources:

(i) cash received from a native corporation (including cash dividends on stock received from a native corporation) to the extent it does not exceed $2,000, per individual per year;

(ii) stock (including stock issued or distributed by a native corporation as a dividend or distribution on stock);

(iii) a partnership interest;

(iv) land or an interest in land (including land or an interest in land received from a native corporation as a dividend or distribution on stock); and

(v) an interest in a settlement trust.

(B) The ANCSA also provides that up to $2,000 in retained distributions from a native corporation may be exempted from resources for each year beginning with 1988.

(5) Payments from Individual Interests in Trust or Restricted Lands — Public Law 103-66.

(A) Effective January 1, 1994, up to $2,000 per year received by Indians that is derived from individual interests in trust or restricted lands is exempted from income.

(B) Interests of individual Indians in trust or restricted lands are exempted from resources.

(b) Payments to specific Indian tribes and groups. The following statutes provide that certain payments made to members of specified Indian tribes and groups are exempt from income and resources.

(1) Distribution of Per Capita Funds — Public Law 85-794. Effective August 28, 1958, per capita payments to members of the Red Lake Band of Chippewa Indians from the proceeds of the sale of timber and lumber on the Red Lake Reservation are exempted from income and resources.

(2) Distribution of Judgment Funds — Public Law 92-254. Effective March 18, 1972, per capita distribution payments by the Blackfeet and Gros Ventre tribal governments to members, which resulted from judgment funds to the tribes, are exempted from income and resources.

(3) Distribution of Claims Settlement Funds — Public Law 93-531 and Public Law 96-305. Effective December 22, 1974, settlement fund payments to members of the Hopi and Navajo Tribes, and the availability of such funds, are exempted from income and resources.

(4) Receipts from Lands Held in Trust for Indian Tribes — Public Law 94-114.

(A) Effective October 17, 1975, receipts derived from the following trust lands and distributed to members of designated Indian tribes are exempted from income and resources.

(B) The first four Indian groups had lands conveyed with mineral rights prior to Public Law 94-114; that law conveyed the rest of the land to the remaining Indian groups.

(5) Distribution of Judgment Funds — Public Law 94-189. Effective December 31, 1975, judgment funds distributed per capita to, or held in trust for, members of the Sac and Fox Indian Nation, and the availability of such funds, are exempted from income and resources.

(6) Distribution of Judgment Funds — Public Law 94-540. Effective October 18, 1976, judgment funds distributed per capita to, or held in trust for, members of the Grand River Band of Ottawa Indians, and the availability of such funds, are exempted from income and resources.

(7) Distribution of Judgment Funds — Public Law 95-433. Effective October 10, 1978, any judgment funds distributed per capita to members of the Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation are exempted from income and resources.

(8) Receipts from Lands Held in Trust — Public Law 95-498. Effective October 21, 1978, receipts derived from trust lands awarded to the Pueblo of Santa Ana and distributed to members of that tribe are exempted from income and resources.

(9) Receipts from Lands Held in Trust — Public Law 95-499. Effective October 21, 1978, receipts derived from trust lands awarded to the Pueblo of Zia and distributed to members of that tribe are exempted from income and resources.

(10) Distribution of Judgment Funds — Public Law 96-318. Effective August 1, 1980, any judgment funds distributed per capita or made available for programs for members of the Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma are exempted from income and resources.

(11) Maine Indian Claims Settlement Act — Public Law 96-420. Effective October 10, 1980, all funds and distributions to members of the Passamaquoddy Tribe, the Penobscot Nation, and the Houlton Band of Maliseet Indians under the Maine Indian Claims Settlement Act, and the availability of such funds, are exempted from income and resources.

(12) Distribution of Judgment Funds — Public Law 97-95. Effective December 17, 1981, any distributions of judgment funds to members of the San Carlos Tribe of Arizona are exempted from income and resources.

(13) Distribution of Judgment Funds — Public Law 97-371. Effective December 20, 1982, any distributions of judgment funds to members of the Wyandot Tribe of Indians of Oklahoma are exempted from income and resources.

(14) Distribution of Judgment Funds — Public Law 97-372. Effective December 20, 1982, distributions of judgment funds to members of the Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, the Eastern Shawnee Tribe of Oklahoma, and the Cherokee Band of Shawnee descendants) are exempted from income and resources.

(15) Distribution of Judgment Funds — Public Law 97-376. Effective December 21, 1982, judgment funds distributed per capita or made available for programs for members of the Miami Tribe of Oklahoma and the Miami Indians of Indiana are exempted from income and resources.

(16) Distribution of Judgment Funds — Public Law 97-402. Effective December 31, 1982, distributions of judgment funds to members of the Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribal Community, and the Jamestown Band of Clallam Indians) are exempted from income and resources.

(17) Distribution of Judgment of Funds — Public Law 97-403. Effective December 31, 1982, judgment funds distributed per capita or made available for programs for members of the Pembina Chippewa Indians (Turtle Mountain Band, Chippewa Cree Tribe, Minnesota Chippewa Tribe, and Little Shell Band of Chippewa Indians of Montana) are exempted from income and resources.

(18) Distribution of Judgment Funds — Public Law 97-408. Effective January 3, 1983, per capita distributions of judgment funds to members of the Gros Ventre and Assiniboine Tribes of Fort Belknap Indian Community, and the Papago Tribe of Arizona, are exempted from income and resources.

(19) Distribution of Judgment Funds — Public Law 97-436. Effective January 8, 1983, up to $2,000 of per capita distributions of judgment funds to members of the Confederated Tribes of the Warm Springs Reservation are exempted from income and resources.

(20) Distribution of Judgment Funds — Public Law 98-123. Effective October 13, 1983, judgment funds distributed to the Red Lake Band of Chippewa Indians are exempted from income and resources.

(21) Distribution of Judgment Funds — Public Law 98-124. Effective October 13, 1983, funds distributed per capita or family interest payments for members of the Assiniboine Tribe of the Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana are exempted from income and resources.

(22) Distribution of Claims Settlement Funds — Public Law 98-432. Effective September 28, 1984, judgment funds and income therefrom distributed to members of the Shoalwater Bay Indian Tribe are exempted from income and resources.

(23) Distribution of Claims Settlement Funds — Public Law 98-500. Effective October 19, 1984, all distributions to heirs of certain deceased Indians under the Old Age Assistance Claims Settlement Act are exempted from income and resources.

(24) Distribution of Judgment Funds — Public Law 98-602. Effective October 30, 1984, judgment funds distributed per capita or made available for any tribal program, for members of the Wyandotte Tribe of Oklahoma and the Absentee Wyandottes, are exempted from income and resources.

(25) Distribution of Judgment Funds — Public Law 99-130. Effective October 28, 1985, per capita and dividend payment distributions of judgment funds to members of the Santee Sioux Tribe of Nebraska, the Flandreau Santee Sioux Tribe, and the Prairie Island Sioux, Lower Sioux, and Shakopee Mdewakanton Sioux Communities of Minnesota are exempted from income and resources.

(26) Distribution of Judgment funds — Public Law 99-146. Effective November 11, 1985, funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi are exempted from income and resources.

(27) Distribution of Claims Settlement Funds — Public Law 99-264. Effective March 24, 1986, distributions of claims settlement funds to members of the White Earth Band of Chippewa Indians as allottees, or their heirs, are exempted from income and resources.

(28) Distribution of Judgment Funds — Public Law 99-346. Effective June 30, 1986, payments or distributions of judgment funds, and the availability of any amount for such payments or distributions, to members of the Saginaw Chippewa Indian Tribe of Michigan are exempted from income and resources.

(29) Distribution of Judgment Funds — Public Law 99-377. Effective August 8, 1986, judgment funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi are exempted from income and resources.

(30) Distribution of Judgment Funds — Public Law 100-139. Effective October 26, 1987, judgment funds distributed to members of the Cow Creek Band of Umpqua Tribe of Indians are exempted from income and resources.

(31) Aleutian and Pribilof Islands Restitution Act — Public Law 100-383. Effective August 10, 1988, per capita restitution payments made to eligible Aleuts who were relocated or interned during World War II are exempted from income and resources.

(32) Distribution of Claims Settlement Funds — Public Law 100-411. Effective August 22, 1988, per capita payments of claims settlement funds to members of the Coushatta Tribe of are exempted from income and resources.

(33) Hoopa-Yurok Settlement Act — Public Law 100-580. Effective October 31, 1988, funds distributed per capita for members of the Hoopa Valley Indian Tribe and the Yurok Indian Tribe are exempted from income and resources.

(34) Distribution of Judgment Funds — Public Law 100-581. Effective November 1, 1988, judgment funds held in trust by the United States, including interest and investment income accruing on such funds, and judgment funds made available for programs or distributed to members of the Wisconsin Band of Potawatomi (Hannahville Indians Community and Forest County Potawatomi) are exempted from income and resources.

(35) Distribution of Money and Land — Public Law 101-41. Effective June 21, 1989, all funds, assets, and income from the trust fund transferred to the members of the Puyallup Tribe under the Puyallup Tribe of Indians Settlement Act of 1989 are exempted from income and resources.

(36) Distribution of Judgment Funds — Public Law 101-277. Effective April 30, 1990, judgment funds distributed per capita, or held in trust, or made available for programs, for members of the Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Indians of Florida, and the independent Seminole Indians of Florida, (plus any interest and investment income accruing on the funds held in trust), and the availability of those funds, are exempted from income and resources.

(37) Distribution of Settlement Funds — Public Law 101-503. Effective November 3, 1990, payments, funds, distributions, or income derived from them under the Seneca Nation Settlement Act of 1990 are exempted from income and resources.

(38) Distribution of Settlement Funds — Public Law 101-618. Effective November 16, 1990, per capita distributions of settlement funds under the Fallon Paiute Shoshone Indian Tribes Water Rights Settlement Act of 1990 are exempted from income and resources.

(39) Distribution of Settlement Funds — Public Law 103-116. Settlement funds, assets, income, payments or distributions from trust funds to members of the Catawba Indian Tribe under the Catawba Indian Tribe of South Carolina Land Claims Settlement Act of 1993 are exempted from income and resources.

(40) Distribution of Settlement Funds — Public Law 103-436. Effective November 2, 1994, settlement funds held in trust, including interest and investment income accruing on such funds, and payments made to members of the Confederated Tribes of the Colville Reservation under the Confederated Tribes of the Colville Reservation Grand Coulee Dam Settlement Act are exempted from income and resources.

If the total resources are not within $100 of the eligibility limit, no additional documentation is required in order for payments and benefits to be excluded from resources. If total resources are within $100 of the eligibility limit, then additional verification documentation of the funds is required in order for the payments and benefits to be excluded.

 

Appendix XXXI, It's Your Choice: Deciding How to Manage Your Personal Assistance Services

Revision 17-1; Effective March 15, 2017

 

 

This information at the link below assists consumers to compare available service delivery option features.

https://hhs.texas.gov/services/disability/consumer-directed-services

 

 

Appendix XXXII, Medicaid Program Actions

Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age

Revision 17-1; Effective March 15, 2017

 

 

Since Sept. 1, 2007, Primary Home Care (PHC) has not been available for individuals under 21 years of age with full Medicaid benefits. Individuals requiring personal attendant services receive benefits through the Texas Health and Human Services Commission (HHSC) Personal Care Services (PCS).

 

Referring Requests for PCS Services

Any requests for services for Medicaid eligible individuals under age 21 must be referred to the appropriate Texas Department of State Health Services (DSHS) PCS regional office. A current list of regional offices and contact information follows.

For non-Medicaid eligible individuals under age 21:

  • refer to the Social Security Administration to apply for Supplemental Security Income (SSI), if the individual has not previously applied; and
  • begin the application process for Community Attendant Services (CAS) as outlined in the Community Care for Aged and Disabled Handbook, Section 2332, Requests for Services from Individuals Under Age 21.

If the individual subsequently becomes eligible for Medicaid, he must be referred to PCS and CAS services must be terminated.

 

Requests for Services from Individuals Turning 21 Years of Age

Individuals who will be turning 21 years of age within two months of the initial request for services should be given a choice to apply for either PCS or PHC services. If the individual chooses to apply for PCS, explain that two assessments will be required; one for PCS and one for PHC. If the individual decides to apply for PHC, begin the application process. All PHC policy and procedures apply. If eligible, services may begin as soon as the applicant is 21 years of age and certified for services.

 

PCS Eligible Individuals Turning 21 Years of Age

For individuals already receiving PCS who are interested in PHC, the regional PCS case worker will encourage the individual/family to contact the HHSC at least two months before the individual’s 21st birthday. Since there are differences in PCS and PHC services, the HHSC case worker will thoroughly explain the allowable PHC services at the time of the initial PHC assessment. PHC may not offer some of the services provided through the PCS program.

The applicant must meet all PHC eligibility criteria, including medical, functional and unmet need. If the applicant is eligible, PHC services are negotiated to begin on the individual’s 21st birthday. PCS services should end at midnight on the day before the individual’s birthday. Coordinate the transition with the PCS case worker and applicant to ensure there are no gaps in services.

 

DSHS PCS Regional Office Contact Numbers

DSHS Region Address Telephone Number Fax Number
Region 1 PO Box 60968, WT AMU
Canyon, TX 79016
806-655-7151 806-655-0820
Region 2/3 1301 South Bowen Road, Suite 200
Arlington, TX 76013
817-264-4627 817-264-4911
Region 4/5 North 1517 West Front Street
Tyler, TX 75702
903-533-5231 903-595-4706
Region 6/5 South 5425 Polk Avenue, Suite J
Houston, TX 77023-1497
713-767-3111 713-767-3125
Region 7 2408 South 37th Street
Temple, TX 76504-7168
254-778-6744 254-778-4066
Region 8 7430 Louis Pasteur Drive
San Antonio, TX 78229
210-949-2155 210-949-2047
Region 9/10 401 East Franklin, Suite 210
El Paso, Texas 79901-1206
915-834-7675 915-834-7804
Region 11 601 West Sesame Drive
Harlingen, TX 78550
956-423-0130 956-444-3294

 

Appendix XXXIV, Program Descriptions

Revision 18-1; Effective June 15, 2018 

Comparison charts for the Texas Long-term Services and Supports (LTSS) programs are found at:

https://hhs.texas.gov/doing-business-hhs/provider-portals/resources/compare-long-term-services-supports-ltss-programs.

Appendix XXXV, Long Term Services and Supports

Appendix XXXVI, Roles and Responsibilities of the Regional Complex Needs Coordinators

Revision 18-1; Effective June 15, 2018

 

 

Community Care Services Eligibility (CCSE) asked each region to designate a complex needs coordinator. This appendix provides a description of the role and expectations of the designated complex needs coordinator.

While there are other situations which require the expertise of the coordinator, the primary responsibilities are in the coordination of high needs individuals transitioning from children's programs to adult programs. Due to the complexity of some of these situations, the skills of the complex needs coordinator are necessary.

Outlined below are the duties of the complex needs coordinator. Regional directors may assign additional staff to assist with these duties, but the designated coordinator will be the point of contact for issues and questions.

 

Quarterly Comprehensive Care Program (CCP) Transition Report

The designated complex needs coordinator is responsible for:

  • completing the quarterly CCP Transition Report for the region and submitting it back to the state office Special Initiatives coordinator by the designated due date. The report includes all transitioning individuals, including Personal Care Services (PCS) to Primary Home Care (PHC) applicants;
  • being the point of contact for any questions on the quarterly CCP Transition Report;
  • ensuring the 12-month visit and contacts are made and reporting back to the state office CCSE contact any individuals who may potentially be over the cost limit based on current services;
  • identifying the high needs individuals and ensuring all aging out assessments are started on time and remain on track; and
  • submitting frequent progress reports to the state office CCSE contact on the individuals who have been identified as high needs.

 

Identification and Tracking of High Needs Aging Out Individuals

The complex needs coordinator is responsible for:

  • identifying the aging out individuals who may be close to the cost limit or have other issues that may complicate the development of an acceptable individual service plan (ISP);
  • coordinating the regional interdisciplinary team (IDT) meetings, as needed;
  • being the regional contact person for state office staff for questions on pending applications or ongoing individuals with high needs;
  • requesting and participating in the state office IDT, including assuring the chronology and other required documentation are submitted; and
  • assisting with collecting and submitting the required medical and service documentation if a physician's clinical visit is required for the Rider 36 General Revenue (GR) process.

 

Providing Assistance and Overview of High Needs Assessments

The complex needs coordinator is responsible for:

  • working with the assigned case worker and other regional staff on all high needs assessments;
  • reviewing the draft ISP packet to check for the following;
    • Are the Medical Necessity/Level of Care (MN/LOC) and Resource Utilization Group (RUG) levels set correctly? Is the individual a ventilator patient and if so, is the RUG coded correctly for the 6 to 23-hour or 24-hour vent care?
    • Are the nursing hours calculated correctly? Are the registered nurse (RN) required hours included? Has the type of nursing (specialized or non-specialized) been discussed and set up correctly?
    • Do the nursing hours reflect the informal support hours the family has agreed to, and is this information reflected the same on Form 8598, Non-Waiver Services? Is the family in agreement with the plan and is Form 8598 signed in agreement with the overall plan?
  • assisting regional staff in working with provider agencies and contract management to assure a cost effective ISP is developed that assures health and safety and is ready to be implemented on the age out date; and
  • working with state office staff if the Rider 36 process is initiated.

 

Regional Complex Needs Coordinators Procedures for Individuals in the STAR+PLUS Program

The role of the complex needs coordinator is different in STAR+PLUS areas due to the differences in STAR+PLUS procedures. Listed below are the complex needs coordinator's responsibilities for individuals in STAR+PLUS.

 

Quarterly CCP Transition Report

The designated complex needs coordinator is responsible for:

  • completing the quarterly CCP Transition Report for the region and submitting it back to the state office Special initiatives coordinator by the designated due date;
  • being the point of contact for any questions on the quarterly CCP Transition Report; and
  • ensuring all STAR+PLUS Home and Community Based Services (HCBS) aging out referrals (Form H3676, Managed Care Pre-Enrollment Home Health Assessment Authorization) are sent on time.

 

Identification and Tracking of High Needs Aging Out Individuals

The complex needs coordinator will be responsible for coordinating with the STAR+PLUS Support Unit (SPSU) supervisor for:

  • identifying the aging out individuals who may be close to the cost limit or have other issues that may complicate the development of an acceptable ISP and reporting this information to HHSC-MCO and state office staff;
  • being the regional contact person for state office and HHSC-MCO staff for questions on pending applications or ongoing individuals with high needs;
  • assisting with collecting and submitting the required medical and service documentation for an IDT or for when a physician's clinical visit is required for the Rider 36 GR process;
  • working with HHSC-MCO and state office staff if the Rider 36 process is initiated.

 

Appendix XXXVII, Instructions and Access to CARE

Appendix XXXVIII, Caregiver Support Assessment Initiative

Revision 17-1 Effective  March 15, 2017

 

 

As described in Section 2223, Caregiver Support Assessment Initiative, below are the forms for completing the caregiver support assessment. Form 1027, Caregiver Status Questionnaire, and Instructions
Form 1027-S, Caregiver Status Questionnaire (Spanish), and Instructions

For assistance in completing the questionnaire, staff may use the Caregiver Status Questionnaire Script, provided in both English and Spanish.

Attachment 1 – English
Attachment 2 – Spanish

 

 

Appendix XXXIX, Examples of HHSC Envelopes

3-2017

 

Texas Health and Human Services Commission staff must take examples of the Time Sensitive envelopes to face-to-face contact visits so individuals can become familiar with the appearance of the envelopes. For more information, refer to Section 2662.1, Financial Reassessments for Community Attendant Services.

Attachment 1 – Example of Time Sensitive Address Service Requested Envelope
Attachment 2 – Example of Time Sensitive Electronic Service Requested Envelope