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.

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.

 

Revision 21-1; Effective March 1, 2021

Attendant services are inappropriate for an applicant or recipient whose needs exceed the scope of the contract. Community Care Services Eligibility (CCSE) staff use the following examples of appropriate and inappropriate characteristics to decide if an applicant or recipient'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 or contract.	Will be dependent upon the contractor for medical care or health-related tasks that are not within the scope of the service or contract.
Manages their emotional or mental disorder with prescribed drug regimen.	Threatens the safety of themselves or others or does not maintain their medication regimen.
May have occasional periods of forgetfulness, confusion, or disorientation, or lack social 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.

Revision 21-4; Effective December 1, 2021

Workflow and Time Frames for Expediate and Immediate

Time Frames	Action
Intake received and determined to be expedited or immediate	Schedule the visit and assess the applicant within the appropriate time frame for an immediate referral (24 hours) or an expedited referral (five calendar days).
By the next business day after the home visit date	Make an oral request to the provider to begin pre-initiation activities and negotiate a date for the completion of pre-initiation activities (which is less than 14 days). CCSE staff then send the referral packet, including referral Form 2101, Authorization for Community Care Services, with the negotiation information in the comments.
By the negotiated date	The provider calls CCSE staff and provides the information from the completed Form 3052, Practitioner's Statement of Medical Need. CCSE staff and the provider negotiate a start date.
Within five business days after the negotiation contact from the provider	Send the authorization Form 2101 to the provider, entering the negotiated start date in Item 4.
Within two business days from the negotiated start date	Complete and send Form 2065-A, Notification of Community Care Services, to the applicant.
Within seven business days from the negotiation contact	The provider sends CCSE staff Form 3052.

Workflow and Time Frames for a Routine Primary Home Care (PHC) Referral

Time Frames	Action
Within 14 calendar days after receipt of intake	Schedule a visit and complete an assessment. The application must be completed within 30 calendar days from the assessment date.
Within five business days after the home visit (The date of the home visit is day "0.")	Enter the assessment information in the Service Authorization System Online Wizard (SASOW) and send the provider a referral packet. This begins the pre-initiation activities.
Within 14 calendar days after receipt of referral packet	The provider completes the pre-initiation activities, obtains Form 3052 and sends the form to HHSC.
Within five business days after receipt of Form 3052 (The date of receipt of Form 3052 is day "0.")	Review Form 3052. If complete, send authorization Form 2101 to the provider. The "Mail Date" (Item 1) and the "Begin Date" (Item 4) are the same date.
Within two business days of the Begin Date on Form 2101	Complete and send Form 2065-A to the applicant.
Within 30 calendar days of assessment or face-to-face contact	Send the authorization Form 2101 to the provider to complete the application.
Within seven calendar days after Receipt of the authorization Form 2101	The provider initiates services.

Workflow and Time Frames for an Initial Referral for Community Attendant Services (CAS)

Time Frames	Action
Within 14 calendar days after receipt of intake	Schedule a visit and assess the applicant for services. Note: If the intake is immediate or expedited, schedule 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 two business days after receipt of the application form (Date of receipt is day "0.")	Fax Form H1746-A, MEPD Referral Cover Sheet and Form H1200, Application for Assistance – Your Texas Benefits, to the Medicaid for the Elderly and People with Disabilities (MEPD) staff.
Within seven business days after receipt of the eligibility notification from MEPD	Enter the assessment information in the SASOW and send the provider a referral packet. This begins the pre-initiation activities.
Within 14 calendar days after 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 five business days after receipt of completed Form 3052 (The date of receipt of Form 3052 is day "0.")	The HHSC nurse enters the information in SAS and sends the provider authorization Form 2101 with a copy to CCSE staff.
Within two business days after receipt of Form 2101 from the HHSC nurse (The date of receipt is day "0.")	Send the applicant Form 2065-A.
Within seven calendar days after receipt of authorization on Form 2101	The provider initiates services.

Workflow and Time Frames for a CAS Reassessment

Time Frames	Action
Within 12 months after the previous assessment	Conduct a home visit for the annual reassessment.
Within five business days after the home visit	Send referral Form 2101 to the provider. If there are no changes in the service plan, leave the "Begin Date" blank. If there are changes in the service plan, enter the "Begin Date" according to the action: The effective date for an increase is seven calendar days from the Item 1 (Mail Date) on Form 2101. The effective date for a decrease is 12 days from the Item 1 (Mail Date) on Form 2101. This date must match the date on Form 2065-A. Send Form 2065-A to the person to notify them of the change in the service plan. A person is entitled to be notified 10 days before any reduction or termination of their services, or to have the notification mailed 12 days before the date of reduction or termination.
Within 14 calendar days after receipt of Form 2101 from CCSE staff	The provider sends Form 2101 and signed statement of the agreement or disagreement* with the plan to the HHSC regional nurse.
Within five business days after 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 CCSE staff. * If the provider disagrees with the service plan, within five business days the HHSC nurse negotiates with the provider and CCSE staff 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
Within 14 calendar days after receipt of intake	Schedule a visit or contact the applicant by phone and assess the applicant for services.
Within five business days after the assessment	Enter the assessment information in SASOW and send the provider a referral packet. This begins the pre-initiation activities.
Within 14 calendar days after receipt of the referral packet	The provider sends the prior approval request packet to the HHSC regional nurse, which includes: Form 2101; Form 3050, Day Activity and Health Services (DAHS) Health Assessment/Individual Service Plan; and Form 3055, Physician's Orders (DAHS).
Within five business days after receipt of the packet (The date of receipt of the packet is day "0.")	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 approval or denial to the provider on authorization Form 2101 with a copy to CCSE staff.
Within two business days after receipt of Form 2101 from the HHSC Regional Nurse (The date of receipt is day "0.")	Send the applicant Form 2065-A to notify them of the eligibility determination.
Within seven calendar days after the Begin Date on Form 2101	The provider initiates services, unless the applicant has been attending the facility under a facility-initiated referral.

Revision 21-3; Effective September 1, 2021

Revision 20-4; Effective December 1, 2020

Appendix is available for staff use here.

Revision 21-3; Effective September 1, 2021

Appendix is available for staff use on the LOOP.

Revision 22-3; Effective Sept. 1, 2022

Case Action	Date Form Is Mailed or Given to Applicant or Recipient	Effective Date to be Entered on Form 2065-A, Notification of Community Care Services
If application is denied, includes when the applicant is denied for one service that was requested but granted another service:	Within two business days of denial.	Not applicable for denials.
If application is certified:	Within two business days 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 applicant is determined eligible for Emergency Care, enter the date the applicant was determined eligible.
If a verbal referral is necessary or priority status is added:	Within two business days 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 recipient's request, a decrease in copayment, or addition of a service;	Within two business days of the decision.	The date the action is completed is the date the change goes into effect.
If there is an increase in units:	Within two business days of the decision.	The date must be within seven calendar days after the date on Form 2101, Authorization for Community Care Services.
If the recipient 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 from a community or social network, support system or caregiver which performs all of the previously purchased tasks; recipient becomes financially ineligible; loss of unmet need; or recipient requests that service(s) be terminated;	12 calendar days before the date services are decreased, terminated or transferred, unless the recipient loses Medicaid.	12 calendar days following the date Form 2065-A is mailed. *
If services are decreased or terminated because: a recipient loses CAS eligibility for financial reasons and is not transferred to FC;	Within two business days of the learned denial date	The last day of the final month of CAS eligibility as determined by the Medicaid for the Elderly and People with Disabilities (MEPD) staff.
an interest list person withdraws;	Not applicable.	No notice is sent in this situation.
a DAHS facility-initiated recipient does not want to have the initial paperwork processed for continued DAHS services;	12 calendar days before the case is closed.	12 calendar days following the date Form 2065-A is mailed.*
changes in federal law or state regulations require that services be decreased or terminated for an entire categorical recipient group;	Before the date of action.	Services continue only through the termination date of the categorical recipient group, even if appealed.
of functional ineligibility for personal attendant services (PAS) or loss of the need for six hours of PAS;	12 calendar days before the case is closed (only at annual review).	12 calendar days following the date Form 2065-A is mailed.*
a recipient moves to a skilled or intermediate care facility, or any other facility where 24-hour supervision is available;	Within two business days of the date information that a nursing facility stay is permanent or notification of the effective date.	The date the recipient entered the facility.
a recipient threatens their health or safety or others; a recipient or someone in their home threatens the department	Within two business days of the date information is received.	The date CCSE staff become aware of the action. Services are not reinstated before the outcome of the appeal hearing.
a recipient loses Medicaid and does not qualify for FC;	Within two business days of the date information is received.	The last date of eligibility for Medicaid.
the Texas Health and Human Services Commission has facts confirming the death of the recipient;	Not applicable.	Not applicable.
If services are decreased or terminated for any reason not given above:	at least 12 calendar days before services are decreased or terminated.	12 calendar days following the date Form 2065-A is mailed *, unless the recipient: requests that services end, or enrolled in another program equivalent or better. In some cases, the recipient might request a specific effective date. For decreased services, day 12 is the last day the recipient has the right to appeal. Day 13 is the first day the recipient will receive the decreased service hours. For denied services, day 12 is the last day the recipient has the right to appeal and is the last day the recipient will receive services. Note: When the recipient orally requests their services be decreased or terminated, document the recipient’s reason and obtain their signature in the comments section of Form 2065-A. The effective date of the adverse action is the date that Form 2065-A is dated and given to the recipient.

* If day 12 falls on a weekend or holiday, the effective date is the following business day.

Refer to the instructions for Form 2065-A for the procedures to follow when a recipient 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 a recipient’s forwarding address is unknown, such as situations when the post office sends notification that the recipient left no forwarding address.
• Send Form 2065-A when a recipient is transferring from one service to another, regardless of whether the change is considered to be positive or negative. 

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 Services Eligibility (CCSE) Case Management Filing Guide is a suggested filing format to promote consistency in CCSE 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.

Revision 17-1; Effective March 15, 2017

Resources — CCSE Handbook Section 3420

Element	Verification Sources	Documentation
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
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
Cash on hand, safe deposit boxes	Statement of individual	Statement of individual regarding the contents Date, if different from face-to-face contact
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
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
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
Stocks	Recent statement from Brokerage house 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
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
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 — CCSE Handbook Section 3300

Element	Verification Sources	Documentation
The individual's total earnings (monthly gross) Money Wages Salary Armed forces pay Commissions Tips Piece-rate payments 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
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.
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.
Social Security (Retirement, Survivors, and Disability Insurance (RSDI)) Pensions Survivor's benefits 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
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
Dividends Stocks 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.
Net rental income House, store or other property 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.
Net income from lease of mineral rights Gross royalty payments 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)
Income from mortgages or contracts (notes) Negotiable and 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
Public assistance Temporary Assistance for Needy Families (TANF) Supplemental Security Income (SSI) General assistance from county or city Medicaid Qualified Medicare Beneficiary (MQMB) Qualified Medicare Beneficiary (QMB) only Specified Low-Income Medicare Beneficiary (SLMB) only Qualifying Individuals (QI) coverage 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
Private pensions (retirement benefits) Former employer Union 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
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
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
Veterans Administration (VA) benefits Pension Compensation (disability) Subsistence allowance for education and on-the-job training 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
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
Unemployment compensation Government Private 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
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
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
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.)
Net income from individual's share of life estate Mineral lease Bonus payments Delays rentals Shut-in royalty Other types of leases (farming, grazing, hunting) 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
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

Revision 21-4; Effective December 1, 2021

Initial Referral Packet Forms

The initial packet must Include:

• a cover sheet;
• the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake; and
• a copy of the following Service Authorization System Online Wizards (SASOW) generated forms.

Community Attendant Services (CAS) Primary Home Care (PHC) Day Activity and Health Services (DAHS) DAHS Facility -Initiated Referrals	Family Care (FC) Residential Care (RC)	Emergency Response Services (ERS) Home Delivered Meals (HDM)	Adult Foster Care (AFC)
Form 2059, Summary of Client's Need for Service; Provider Referral Supplement; Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and referral Form 2101, Authorization for Community Care Services. Note: For DAHS, Form 2060 and Task/Hour Guide are not required.	Form 2059; Provider Referral Supplement; Form 2060; Task/Hour Guide; and authorization Form 2101.	Form 2059; Provider Referral Supplement; and Form 2101 as an authorization.	Authorization Form 2101; Form 2327, Individual/Member and Provider Agreement; Form 2330, Assessment and Service Plan Approval for Adult Foster Care.

Annual Reauthorization and Interim Reassessment Packet Forms

Must include a cover sheet and a copy of the following SASOW generated forms.

Community Attendant Services (CAS) Primary Home Care (PHC) Day Activity and Health Services (DAHS) DAHS Facility -Initiated Referrals	Family Care (FC) Residential Care (RC)	Emergency Response Services (ERS) Home Delivered Meals (HDM)	Adult Foster Care (AFC)
Even if there is not a change for CAS send: Form 2101 (For DAHS and PHC only send Form 2101 if there is a change with appropriate forms) Only if information has changed send: Form 2059; Provider Referral Supplement; Form 2060; and Task/Hour Guide. Note: For DAHS, Form 2060, and Task and Hour Guide are not required.	Only if information has changed send: Form 2059; Provider Referral Supplement; Form 2060; Task/Hour Guide; and Form 2101	Only if information has changed send: Form 2059; Provider Referral Supplement; Form 2060; Task/Hour Guide; and Form 2101	Even if there is not a change send: Form 2101; and Form 2330 Only if information has changed send: Form 2327

Termination Packet Forms

Must include a cover sheet and a copy of the following SASOW generated forms.

Community Attendant Services (CAS) Primary Home Care (PHC) Day Activity and Health Services (DAHS) DAHS Facility-Initiated Referrals	Family Care (FC) Residential Care (RC)	Emergency Response Services (ERS) Home Delivered Meals (HDM)	Adult Foster Care (AFC)
Authorization Form 2101	Authorization Form 2101	Authorization Form 2101	Authorization Form 2101

Note: In the SASOW, the following forms are generated as two forms:

• Form 2059 is generated as Form 2059 and the Provider Referral Supplement.
• Form 2060 is generated as Form "2060 and the Task/Hour Guide."

Revision 22-4 Effective Dec. 1, 2022    

The following chart may be used for the determination of financial eligibility based on automated records. The chart indicates the type program (TP) or type assistance (TA) a person may be receiving in Texas Integrated Eligibility Redesign System (TIERS), and how existing coverage affects eligibility for Community Care Services Eligibility (CCSE) services.

SNAP

TIERS Type Program or Type Assistance	Description	Long Description	Eligibility for Community Care Services Eligibility
TA 51	SNAP-CAP/FS-CAP	Supplemental Nutrition Assistance Program Combined Application Project	Title XX categorically eligibility.
TA 53	TSAP/FS-TSAP	Texas Simplified Application Project for SNAP Food Benefits	Title XX categorically eligibility.
TP 06	SNAP (PA)/FS-PA	Supplemental Nutrition Assistance Program Public Assistance	Title XX categorically eligibility.
TP 09	SNAP/FS-NPA	Supplemental Nutrition Assistance Program	Title XX categorically eligibility.

TANF

TIERS Type Program or Type Assistance	Description	Long Description	Eligibility for Community Care Services Eligibility
TP 01	TANF Basic	Cash assistance for caretakers and deprived children with income below TANF recognizable needs	Title XX categorically eligible.
TP 60	One-Time TANF for Relatives	Once in a lifetime TANF payment for certain relatives who are the caretaker or payee of a related dependent child certified for TANF	Not categorically eligible.
TP 61	TANF State Program	Cash assistance for two-parent household with income below TANF recognizable needs	Title XX categorically eligibility.
TP 71	OTTANF – 1 Adult	One-Time TANF (OTTANF) payment for households with one parent	Not categorically eligible.
TP 72	OTTANF – 2 Parents	OTTANF payment for households with two parents	Not categorically eligible.

Medical Assistance or Programs — Texas Works (TW)

TIERS Type Program or Type Assistance	Description	Long Description	Eligibility for Community Care Services Eligibility
TA 31	MA – Parents and Caretaker Relatives – Emergency	Medicaid for an emergency condition for parents and caretaker relatives who do not meet alien status requirements and are caring for a dependent child who receives Medicaid	Title XIX and Title XX categorical eligibility during eligible months. Note: Title XIX applicants must meet citizenship criteria.
TA 41	Health Care – Healthy Texas Women	Healthy Texas Women (HTW) for women 15–44 with income at or below the applicable income limit	Title XX categorical eligibility. Can apply for Title XIX CAS, not eligible for Title XIX DAHS or PHC as not full Medicaid.
TA 66	MA – MBCC – Presumptive	Medicaid for Breast and Cervical Cancer – Presumptive	Title XX categorically eligible. Mandatory to STAR+PLUS.
TA 67	MA – MBCC	Medicaid for Breast and Cervical Cancer – Presumptive	Title XX categorically eligible. Mandatory to STAR+PLUS.
TA 74	MA – Children Under 1 Presumptive	Short-term Medicaid for children under 1 with income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TA 75	MA – Children 1–5 Presumptive	Short-term Medicaid for children 1–5 with income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TA 76	MA – Children 6–18 Presumptive	Short-term Medicaid for children 6–18 with income at or below the applicable income limit	Title XX categorically eligible at 18. Title XIX categorically eligible for CAS only. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 77	Health Care – FFCHE	Health Care for Former Foster Care in Higher Education with income at or below the applicable income limit	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 82	MA – Former Foster Care Children	Medicaid for former foster care children 18–25	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 83	MA – FFCC Presumptive	Short-term Medicaid for former foster care children 18–25	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 84	CI – CHIP	The Children’s Health Insurance Program (CHIP) is health care coverage for children under 19 who are ineligible for Medicaid due to income and who have income at or below the applicable income limit	Title XX categorically eligible at 18.
TA 85	CI – CHIP perinatal	CHIP perinatal is health care coverage for unborn children whose mother is ineligible for Medicaid or CHIP due to income or immigration status and whose income is at or below the applicable income limit	Not categorically eligible.
TA 86	MA – Parents and Caretaker Relatives Presumptive	Short-term Medicaid for parents and caretaker relatives caring for a dependent child	Title XIX and Title XX categorical eligibility during eligible months.
TP 07	MA – Earnings Transitional	Twelve months of transitional Medicaid resulting from an increase in earnings	Title XIX and Title XX categorical eligibility.
TP 08	MA – Parents and Caretaker Relatives	Medicaid for parents and caretaker relatives caring for a dependent child with income at or below the applicable income limit	Title XIX and Title XX categorical eligibility.
TP 20	MA Alimony/Spousal Support Transitional	Up to four months of post Medicaid resulting from an increase in alimony or spousal support	Title XIX and Title XX categorical eligibility during eligible months.
TP 32	MA – MN w/Spend Down – Emergency	Medicaid for an emergency condition for children or pregnant women who do not meet alien status requirements and who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the Medically Needy Income Limit (MNIL)	Title XIX and Title XX categorical eligibility during eligible months. Note: Title XIX applicants must meet citizenship criteria.
TP 33	MA – Children 1–5 – Emergency	Medicaid for an emergency condition for children 1–5 who do not meet alien status requirements and who have income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorical eligibility CAS during eligible months. Note: CAS applicants must meet citizenship criteria.
TP 34	MA – Children 6–18 – Emergency	Medicaid for an emergency condition for children 6–18 who do not meet alien status requirements and who have income at or below the applicable income limit	Title XX categorically eligible at 18. Title XIX categorically eligible for CAS only during eligible months. Note: CAS applicants must meet citizenship criteria.
TP 35	MA – Children Under 1 – Emergency	Medicaid for an emergency condition for children under 1 who do not meet alien status requirements and who have income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only during eligible months. Note: CAS applicants must meet citizenship criteria.
TP 36	MA – Pregnant Women – Emergency	Medicaid for an emergency condition for pregnant women who do not meet alien status requirements and who have income at or below the applicable income limit	Title XX categorical eligibility during eligible months. Title XIX categorically eligible for CAS only during eligible months. Note: CAS applicants must meet citizenship criteria.
TP 40	MA – Pregnant Women	Medicaid for pregnant woman with income at or below the applicable income limit	Title XIX and XX categorical eligibility during eligible months.
TP 42	MA – Pregnant Women Presumptive	Short-term Medicaid for pregnant women with income at or below the applicable income limit	Title XIX and XX categorical eligibility during eligible months.
TP 43	MA – Children Under 1	Medicaid for children under 1 with income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TP 44	MA – Children 6–18	Medicaid for children 6 –18 with income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TP 45	MA – Newborn Children	Medicaid for children through 1 who are born to a Medicaid-eligible mother	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TP 48	MA – Children 1–5	Medicaid for children 1–5 with income at or below the applicable income limit	Not eligible for Title XX programs. Title XIX categorically eligible for CAS only.
TP 56	MA – MN w/Spend Down	Medicaid for children or pregnant women who are ineligible for any other type of Medicaid, but who have medical expenses that spend down their income to below the MNIL	Title XIX and Title XX categorically eligibility during the coverage period.  Note: For Title XX must be 18.
TP 70	Medicaid for the Transitioning Foster Care Youth	Medicaid for Transitioning Foster Care Youth people with income at or below the applicable income limit	Title XIX and Title XX categorical eligibility. Note: For Title XX must be 18.
TPAL	MA – Historical FMA – Emergency	N/A	Title XIX and XX categorical eligibility during eligible months.
TPDE	MA – Deceased Prior Medical	Medicaid for a deceased person	Not categorically eligible.
TPPM	MA/ME – Historical Prior Medical	Three months of prior Medicaid – not currently eligible	Title XIX and XX categorical eligibility during eligible months.

Medical Assistance or Programs — Texas Department of Family and Protective Services (DFPS)

TIERS Type Program or Type Assistance	Description	Long Description	Eligibility for Community Care Services Eligibility
TP 52	MA – State Foster Care – A	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 53	MA – State Foster Care – B	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 54	MA – State Foster Care – 32	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 57	MA – State Foster Care – D	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 58	MA – State Foster Care – JPC	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 78	PCA Medicaid – Federal Match – No Cash	Permanency Care Assistance (PCA) Medicaid – Federal Match – No Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 79	PCA Medicaid – No Federal Match – No Cash	PCA Medicaid – No Federal Match – No Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 80	PCA Medicaid – Federal Match – With Cash	PCA Medicaid – Federal Match – With Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TA 81	PCA Medicaid – No Federal Match – With Cash	PCA Medicaid – No Federal Match – With Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 88	MA – Non-AFDC Foster Care – JPC	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 90	MA – State Foster Care	Medicaid	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 91	Adoption Assistance – Federal Match – No Cash	Adoption Assistance – Federal Match – No Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 92	Adoption Assistance – Federal Match – With Cash	Adoption Assistance – Federal Match – With Cash	Title XIX and Title XX categorical eligibility. May be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 93	Foster Care – Federal Match – No Cash	Foster Care – Federal Match – No Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 94	Foster Care – Federal Match – With Cash	Foster Care – Federal Match – With Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 95	Adoption Assistance – No Federal Match – No Cash	Adoption Assistance – No Federal Match – No Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 96	Adoption Assistance – No Federal Match – With Cash	Adoption Assistance – No Federal Match – With Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 97	Foster Care – No Federal Match – No Cash	Foster Care – No Federal Match – No Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 98	Foster Care – No Federal Match – With Cash	Foster Care – No Federal Match – With Cash	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TP 99	MA – Non-AFDC Foster Care	Medicaid	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.
TPAS	MA – Historical Adoption Subsidy	Medicaid	Title XIX and Title XX categorical eligibility may be on CFC or PCS verify no duplicate services are provided using Appendix XX, Mutually Exclusive Services.

Medical Assistance or Programs — Social Security Administration (SSA)

TIERS Type Assistance or Type Program	Description	Long Description	Eligibility for Community Care Services Eligibility
TA 02	ME – SSI Waivers	SSI Recipient Waivers	Title XIX DAHS categorical eligibility CLASS, DBMD, HCS, MDCP, and TxHmL. Title XX HDM categorical eligibility for TxHmL only. See Appendix XX, Mutually Exclusive Services.
TA 03	ME – Manual SSI Waivers	Manual SSI Waivers	Title XIX DAHS categorical eligibility CLASS, DBMD, HCS, MDCP, and TxHmL. Title XX HDM categorical eligibility for TxHmL only. See Appendix XX, Mutually Exclusive Services.
TA 04	ME – Manual SSI State Group Home	Manual SSI Recipient State Community-based Group Homes	Not eligible for CCSE.**
TA 05	ME – Manual SSI Non-State Group Home	Manual SSI Recipient Non-State Community-based Group Homes	Not eligible for CCSE.**
TA 06	ME – Manual SSI Nursing Facility	Medicaid for Nursing Facility Resident	Not eligible for CCSE.**
TA 07	ME – Manual SSI State Hospital	Medicaid for State Hospital Resident	Not eligible for CCSE.**
TA 08	ME – SSI State Group Home	SSI Recipient State Community Based Group Home	Not eligible for CCSE.**
TA 09	ME – Manual SSI State Supported Living Center	Medicaid for State Supported Living Center Resident	Not eligible for CCSE.**
TA 22	ME – Manual SSI	Manually certified SSI — processed by SSA	Title XIX categorically eligible.
TA 26	ME – SSI Non-State Group Home	SSI Non-State Community-based Group Homes	Not eligible for CCSE.**
TP 13	ME – SSI	SSI (processed by SSA)	Title XIX categorical eligibility. See Appendix XX, Mutually Exclusive Services.
TP 38	ME – SSI Nursing Facility	Medicaid for Nursing Facility Resident	Not eligible for CCSE.**
TP 39	ME – SSI State Hospital	Medicaid for State Hospital Resident	Not eligible for CCSE.**
TP 46	ME – SSI State Supported Living Center	Medicaid for State Supported Living Center Residents	Not eligible for CCSE.**

Medical Assistance or Programs — Medicaid for the Elderly and People with Disabilities (MEPD)

TIERS Type Assistance or Type Program	Description	Long Description	Eligibility for Community Care Services Eligibility
TA 10	ME – Waivers	Home and Community-Based (HCBS) Medicaid	Title XIX DAHS categorical eligibility CLASS, DBMD, HCS, MDCP, and TxHmL. Title XX HDM categorical eligibility for TxHmL only. See Appendix XX, Mutually Exclusive Services.
TA 12	ME – State Group Home	Medicaid for ICF/IID Resident	Not eligible for CCSE.*
TA 27	ME – Prior Medicaid Institutional/Waiver	Prior Medicaid for person applying for Institutional or Waiver Medicaid	Categorically eligible for Title XX during eligible months.
TA 88	ME – Medicaid Buy-In for Children (ME-MBIC)	Medicaid for eligible children with disabilities up 19 years old who pay a share of the Medicaid premium to be eligible for Medicaid	Title XX and Title XIX categorical eligibility for DAHS, PHC and TxHmL waiver. See Appendix XX, Mutually Exclusive Services.
TP 03	ME – Pickle	RSDI COLA Disregard Programs — considered eligible based on the 1977 Pickle Amendment	Title XIX categorical eligibility.
TP 10	ME – State Supported Living Center	Medicaid for State Support Living Center Resident	Not eligible for CCSE.*
TP 11	ME – SSI Prior	SSI, two or three months prior, as appropriate	Categorically eligible for Title XIX during eligible months. See Appendix XX, Mutually Exclusive Services.
TP 14	ME – Community Attendant	Community Attendant Services	Title XIX CAS program provides PHC, funded through §1929(b)(2)(B) of the Social Security Act.
TP 15	ME – Non-State Group Home	Medicaid for ICF/IID Resident	Not eligible for CCSE.*
TP 16	ME – State Hospital	Medicaid for State Hospital Resident	Not eligible for CCSE.*
TP 17	ME – Nursing Facility	Medicaid for Nursing Facility Resident	Not eligible for CCSE.*
TP 18	ME – Disabled Adult Child	Adult children at least 18 who have a disability and who were denied SSI due to an entitlement to or an increase in their RSDI Disabled Adult Child (DAC) benefits and who are eligible for Medicaid to ensure continued coverage	Title XIX categorical eligibility.
TP 21	ME – Disabled Widow(er)	Widows, widowers or surviving divorced spouses who are at least 50 and less than 60 with a disability and who are ineligible for Medicare and were denied SSI due to an increase in their RSDI widow or widower benefits. They are eligible for Medicaid under TP 21 until they reach 60 or become eligible for Medicare, whichever occurs first	Title XIX categorical eligibility.
TP 22	ME – Early Aged Widow(er)	Early age widows, widowers or surviving divorced spouses who are 50–65 and ineligible for Medicare and who were denied SSI due to an increase in their RSDI widow or widower benefits. They are eligible for Medicaid under TP 22 until they reach 65 or become eligible for Medicare, whichever occurs first	Title XIX categorical eligibility.
TP 23	MC – SLMB	Medicare Savings Program — Specified Low-Income Medicare Benefits	Title XX categorical eligibility.
TP 24	MC – QMB	Medicare Savings Program — Qualified Medicare Beneficiary	Title XX categorical eligibility.
TP 25	MC – QDWI	Qualified Disabled and Working Individuals — A special Medicare savings program that pays Part A Medicare premiums for certain working people under 65 who have a disability and are no longer eligible for free Medicare Part A because of earnings	Title XX categorical eligibility.
TP 26	MC – QI 1	Medicare savings program — Qualified people	Title XX categorical eligibility.
TP 30	ME – A and D Emergency	Emergency Medicaid for a nonqualified alien	Title XIX and Title XX categorical eligibility during eligible months. Note: Title XIX applicants must meet citizenship criteria.
TP 87	ME – Medicaid Buy In (ME-MBI)	Working people with disabilities who pay a share of the Medicaid premium to be eligible for Medicaid.	Title XIX DAHS categorical eligibility CLASS, DBMD, HCS, MDCP, and TxHmL. Title XX HDM categorical eligibility for TxHmL only. See Appendix XX, Mutually Exclusive Services.

STAR+PLUS members are entitled to Title XX services if all eligibility criteria are met. However, CCSE staff must first ensure that approval of the request would not result in a duplication of services.

STAR members are entitled to Title XIX and Title XX services if all eligibility criteria are met. However, CCSE staff must first ensure that approval of the request would not result in a duplication of services.

CCSE staff must not authorize any Title XX services for people enrolled in the STAR+PLUS HCBS program.

Note: When Medicaid type indicates facility or institutional living arrangement the person is not eligible for CCSE services. See asterisks below for specific instructions for reporting changes.

 * Not eligible for CCSE programs under this type assistance (TA) or type program (TP). Confirm living arrangement with the person or authorized representative (AR), send H1746-A to MEPD staff to process the change in living arrangement and referral. MEPD staff will test for community programs.

** Not eligible for CCSE under this TA or TP. Confirm living arrangement with the person or AR, then have them contact SSA (at the local office or at 800-772-1213) to correct the living arrangement.

Note: HHSC is not responsible for making SSA changes, all changes need to be reported to SSA.

 

Revision 17-1; Effective March 15, 2017

Eligibility

Does the individual continue to meet all eligibility requirements for the Community Care Services Eligibility (CCSE) 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 CCSE services?
• Does the individual still need assistance that would not be met without this CCSE 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?

CCSE Services

Have CCSE 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?

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

Revision 18-1; Effective June 15, 2018

Intake Procedures

Section	Type of Response Visit with Individual	Time Period
2320	immediate	within 24 hours from the date of assignment.
2320	expedited	within five calendar days from date of assignment.
2320	routine	within 14 calendar days from date of assignment.

Assessment and Reassessment Procedures

Section
2611, 2611.1	Determine eligibility for Community Care Services Eligibility (CCSE) 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 Services Eligibility (CCSE) certification beyond the 30-day time frame.
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.
2711	Reassess the individual's need for CCSE 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.
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.
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

Section
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.
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.
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.
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.
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.
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.
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.
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).
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 CCSE 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).
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

Section
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
2814, Appendix IX	Transfers from PHC/CAS to FC:	allow 12 calendar days advance notice (See Appendix IX for exceptions).
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.
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.
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.
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.
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.
2723	When there is a request to change providers:	within 14 days of the individual's request.

Revision 20-4; Effective December 1, 2020

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 Services Eligibility (CCSE) 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)

• 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.

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.

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

Revision 21-3; Effective September 1, 2021

Appendix is available for staff use on the LOOP.

Revision 21-3; Effective September 1, 2021

Appendix is available for staff use on the LOOP.

Revision 21-3; Effective September 1, 2021

Revision 21-3; Effective September 1, 2021

Appendix is available for staff use on the LOOP.

Revision 21-3; Effective September 1, 2021

Appendix is available for staff use on the LOOP.

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.

Revision 17-1; Effective March 15, 2017

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

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, 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 or 3	1301 South Bowen Road, Suite 200 Arlington, TX 76013	817-264-4627	817-264-4911
Region 4 or 5 North	1517 West Front Street Tyler, TX 75702	903-533-5231	903-595-4706
Region 6 or 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 or 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

Revision 18-1; Effective June 15, 2018 

Comparison charts for the Texas Long-term Services and Supports (LTSS) programs.

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.

Revision 21-3; Effective September 1, 2021

Revision 17-1 Effective  March 15, 2017

As described in 2223, Caregiver Support Assessment Initiative, below are the forms for completing the caregiver support assessment.

• Form 1027, Caregiver Status Questionnaire, and Instructions (English PDF),
• Form 1027-S, Caregiver Status Questionnaire, and Instructions (Spanish PDF)

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

• Attachment One, Caregiver Status Questionnaire Script (English PDF)
• Attachment Two, Caregiver Status Questionnaire Script (Spanish PDF)