1. Current Long-Term Services and Supports System
In 2001, Texas established one of the first “Money Follows the Person” (MFP) Initiatives to transition persons in institutional settings to community-based waiver services. Individuals do not have to wait for community-based services, which have long interest lists, and do not affect the wait times of other persons on the interest list. The Texas Promoting Independence Initiative has been the impetus for many of the policy and operational changes to implement the MFP Initiative. Former Governor George W. Bush and current Governor Rick Perry have both issued executive orders establishing and providing guidance to the Promoting Independence Initiative – Texas’ response to the Olmstead decision. The Texas Legislature passed SB 367 in 2001, codifying the initiative. Appendix A provides a list of other legislation that has directed Texas’ efforts at rebalancing its long-term services and supports system.
The Texas Health and Human Services Commission (HHSC) is the Medicaid single state agency. HHSC is also the umbrella agency for four operating agencies, including the Texas Department of Aging and Disability Services (DADS) and the Texas Department of State Health Services (DSHS). HB 2292, 78th Texas Legislature, consolidated 12 health and human services agencies into four operating agencies under the direct oversight of HHSC. HHSC is responsible for determining Medicaid eligibility, overseeing the state 2-1-1 Information and Referral system, and administering Medicaid managed care programs. HHSC has operated the STAR+PLUS program model of acute and long-term managed care in Houston since 1998. STAR+PLUS provides both acute care and long-term services and supports for persons who are aging and/or have physical disabilities based on a single capitated payment. In 2007, Texas will expand STAR+PLUS to include four more metropolitan areas, and a non-capitated managed care model will be implemented in a fifth area.
The Texas Department of Aging and Disability Services (DADS) provides long-term services and supports to aging persons and persons of all ages with physical and intellectual and developmental disabilities. Services are funded by Title XIX, Title XX, the Older Americans Act (OAA) and state general revenue. DADS is responsible for day-to-day implementation of the Promoting Independence Plan and the current MFP Initiative. Consumers access DADS services through: 28 Area Agencies on Aging (AAAs), 39 regional Mental Retardation Authorities (MRAs) and 131 local state agency offices in 11 DADS regions.
AAAs help older Texans access OAA-funded services, provide Benefits Counseling through the Medicare-funded State Health Insurance Program, and provide long-term care ombudsman services.
DADS administers Medicaid community entitlement and 1915(c) waiver programs for persons who are aging and/or have physical disabilities and provides access to community-based services through DADS local offices. If the individual requests community entitlement services (personal care or day activity), a case manager uses a standard assessment to determine functional eligibility and need for assistance with activities of daily living, assists with Medicaid eligibility (if necessary) and assists in choosing appropriate services. If an individual requests any of the waiver programs DADS administers for this population, he or she is placed on an interest list because demand exceeds resources. When an opening becomes available, the individual is assessed, eligibility is determined and, if eligible, enrollment and service planning completed.
Persons seeking nursing facility care may enter the facility on a private pay or prospective basis, while waiting for a Medicaid eligibility determination. Medicaid eligibility for those not on SSI is conducted by HHSC staff, independent of DADS. DADS’ staff administer licensing and regulatory functions for the long-term services and support system.
DADS administers Medicaid institutional entitlement and 1915(c) waiver programs for persons with intellectual and developmental disabilities. DADS directly operates 13 State Mental Retardation Facilities and contracts with other community-operated intermediate care facilities for persons with mental retardation and related conditions (ICFs/MR) to provide entitlement services. DADS administers four waiver programs as an alternative to this category of institutionalization.
The Mental Retardation Authority (MRA) is the single point of access for institutional or community-based services for persons with intellectual or developmental disabilities. MRAs conduct or document a Determination of Mental Retardation to establish eligibility and develop a plan of services using a person-directed planning process to ensure the individual’s needs are addressed.
The Texas Department of State Health Services (DSHS) is the state Mental Health and Substance Abuse Authority and Public Health Authority. It provides services to people with serious mental illness through 39 community-based mental health authorities, seven state hospitals, three state centers and one residential treatment facility for children and adolescents. DSHS services are funded through the federal block grants for mental health and substance abuse, state general revenue and Title XIX.
The Mental Health Authority (MHA) serves as the gateway or “single portal” for accessing state facility services for persons with mental illness. MHAs control state facility bed days under their authority and direct consumers to appropriate care. Under Texas’ Promoting Independence Initiative, DSHS has worked closely with DADS to identify individuals in state mental health facilities who may be appropriate for community placement. DSHS provides screening and referral services for substance abuse treatment through community-based Outreach, Screening, Assessment, and Referral (OSAR) entities. OSARs enable consumers to access substance abuse treatment services from DSHS’ network of contracted treatment providers throughout Texas.
1. An interest list is the same as what is commonly referred to as a “waiting list” in most states. The key difference is that individuals on the interest list have simply declared an interest in services but have not been assessed for eligibility.