YES Waiver FAQs

How do I submit the Inquiry List to HHSC?

The Inquiry List is emailed to YESWaiver@hhsc.state.tx.us on the fifth business day of the month for the month prior.

How long does it take to get approval for a Clinical Eligibility Determination?

HHSC has five business days from the date the CED was placed in "Ready for Review" in CMBHS to make the determination.

How do I submit YES Waiver Service claims for payment?

All YES Waiver service claims — called service notes — are entered into CMBHS for payment.

Can Texas Correctional Office on Offenders with Medical or Mental Impairments funded youth be enrolled in the YES Waiver?

Yes, a person participating in TCOOMMI can also be enrolled in the YES Waiver.

Can I bill for Intensive Case Management before the first wraparound team meeting?

Yes, Intensive Case Management services are reimbursable before the first wraparound team meeting. To learn more, review the presentation Using Wraparound to Provide Intensive Case Management (PowerPoint).

Do I continue to bill regular services (skills training, therapy, psychiatry and intensive case management) through the Medicaid Managed Care Organizations?

Yes, billing for traditional state plan services is not affected by the YES Waiver.

How are critical incidents reported to HHSC?

A YES Waiver Critical Incident Report template is located under Provider Resources/Forms and Templates/ Form 2803: Critical Incident Report. Completed Critical Incident Reports should be sent to YESWaiver@hhsc.state.tx.us and in accordance with the current YES Policy Manual posted on the YES website.

Is there a deadline for submitting critical incident reports?

Local mental health authorities must submit a Critical Incident Report to HHSC within 72 hours of finding out about the critical incident. LMHAs should also submit a Critical Incident Report when there is updated information regarding the critical incident (when a participant is released from the hospital or returns home).

Do I have to update the 90-day Texas Resilience and Recovery Uniform Assessment for people enrolled in YES?

Yes, the recommended level of care generated by the 90-day update uniform assessment should be deviated to an authorized level of care of "LOC-YES" while the child/youth is enrolled in YES. This authorizes TRR services — including intensive case management — which function independently of YES Waiver services.

Is there a specific form or format required for transition plans?

Currently, HHSC doesn't have a form or template for transition plans.

What program documentation is reviewed during HHSC on-site reviews?

HHSC reviews include the following:

  • LMHA maintenance of the Inquiry List
    (including attempts to contact legally authorized representative, complete demographic eligibility and attempts to schedule intake assessment)
  • Progress notes for Intensive Case Management Services
  • Wraparound Plan
  • Progress notes for waiver services
  • Incident Reports and Child and Family Team Meetings addressing incidents
    (to learn more, see the Service Documentation section of the YES Policy Manual).

Do I need to submit outreach and marketing materials to HHSC for approval?

Yes, outreach and marketing information must be reviewed and approved by HHSC. Email them at YESWaiver@hhsc.state.tx.us with the subject line "approval requested: outreach and marketing information." Most approvals are made within five business days.

Do people authorized for LOC-YES count toward overall service targets and performance measures in the LMHA Performance Contract?

Individuals enrolled in LOC-YES are counted toward service targets in the LMHA Performance Contract. However, LOC-YES is not considered a full level of care and is excluded from many of the measures in the LMHA Performance Contract. For questions regarding the LMHA Performance Contract, contact the HHSC Contract Management Unit.

How do I know when HHSC has approved something that was submitted in CMBHS?

Approved documents are placed in the 'Closed Complete' status in CMBHS. If the document requires changes for approval, it will be put back into 'Draft' status by HHSC. It is the responsibility of the LMHA to track the status of approvals in CMBHS.

Do I submit Enrollment Packets through CMBHS?

The Enrollment Packet is not submitted to HHSC, however, it must be kept in the participant case record.

What is a pre-engagement service, and when is it used?

LMHAs can request reimbursement for the time spent enrolling people in Medicaid through the special income group through the waiver who are ultimately denied Medicaid enrollment.

(Note that because participants must already be enrolled in Medicaid to qualify for general revenue-funded programs, pre-engagement services are not available to these programs.)

What impact does enrolling in YES Waiver Services (LOC-YES) have on the person's TRR services?

Individuals enrolled in YES waiver are entitled to all TRR services for which they have a clinical need. LOC-YES authorizes TRR services, which function independently of YES Waiver services. The services and supports that are needed are determined during the Wraparound process, and are often a mix of state plan (TRR) services and YES waiver services.

If a person receives a recommended level of care other than Level of Care - 4, how do I complete the service request/authorization section which asks "Please indicate the recommended level of care generated from the CMBHS system"?

LOC-YES is not currently represented on the service request/authorization section. Providers should include Level of Care – 4 as the recommended level of care generated from the CMBHS system and provider requested level of care for YES participants.

What do I do if a MCO does not approve the LOC-4 for a YES Waiver participant?

MCOs should approve LOC-4 for YES Waiver participants. Refer the managed care organization to their health plan manager at HHSC for policy clarification. All complaints/inquiries should be routed to the Health Plan Management Complaints box at HPM_Complaints@hhsc.state.tx.us for tracking and trending. Include any known names of MCO staff members that have been contacted to avoid duplication of efforts.

In the HHSC process for fair hearings, an LMHA doesn't change the level of care from a higher to lower one for 10-14 days after the determination that a different level of care is appropriate. This is to allow for the Medicaid Fair Hearing letter to be sent and the member time to respond. Will the MCOs allow the current LOC to remain for 14 days before starting the new authorization at the lower level of care?

Based on contract requirements, MCOs must continue services for at least 10 days after the notice has been sent. However, providers should reach out to the MCO to discuss the process, and any specific requirements by the MCO. All complaints/inquiries should be routed to the health plan manager Complaints box for tracking and trending.