Form 1045, Request for Extension of Enrollment Offer Due Date

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Documents

Effective Date: 7/2022

 

Instructions

Updated: 7/2022

Purpose

Form 1045 is used by the local intellectual and developmental disability authority (LIDDA) to request the Texas Health and Human Services Commission (HHSC) extend the LIDDA’s due date for completing a Home and Community-based Services (HCS) or Texas Home Living (TxHmL) program enrollment offer.

Procedure

The LIDDA receives written notice from HHSC when the LIDDA must offer HCS or TxHmL enrollment to a person. The notice contains a due date by which the LIDDA must complete the enrollment offer process.

When to Prepare

If the enrollment offer process will not be completed by the due date provided to the LIDDA in the notice from HHSC, the LIDDA must submit a request to extend the due date. If approved, the LIDDA receives written notice of the extended due date from HHSC. If the LIDDA is unable to complete the enrollment offer process by the extended due date, the LIDDA must submit another request to extend the due date. Until the enrollment offer process is complete, the LIDDA must submit subsequent requests to HHSC before the approved extended due date.

HHSC considers the enrollment process to be "complete" when the person’s enrollment has been processed by HHSC. The person's Community Services Interest List (CSIL) record for the program is "Closed" with the applicable closure reason.

Submittal

A completed Form 1045 must be submitted in separate attachments for each person, and the LIDDA must name each completed Form 1045 with the following file naming convention:

  • The individual's last name;
  • The individual's first name;
  • Slot type number;
  • Ext; and
  • Date of the extension request.

Example: SmithBob114ext10-05-2021

Note: Multiple extensions sent in one PDF will be returned without being processed.

The LIDDA emails the completed form to LiddaRequests@hhs.texas.gov using a secure email method. To ensure the form is assigned appropriately, the LIDDA must include the slot type and slot number in the subject line.

If the LIDDA does not have access to a secure email method, the LIDDA emails HHSC at LiddaRequests@hhs.texas.gov to request a secure email. The LIDDA can reply to a secure email from HHSC to submit the form.

Detailed Instructions

Section 1, LIDDA Information

LIDDA Name — Enter the name of the LIDDA.

LIDDA Comp — Enter the component code of the LIDDA.

Program— Select the program being offered from the drop-down menu.

Slot Type No. — Enter the slot type number. Refer to the notice from HHSC.

Name of Person Completing Form — Enter the name of the person completing the form.

Area Code and Phone No. — Enter the area code and phone number of the person completing the form.

Email — Enter the email address for the person completing the form.

Today’s Date — Enter the date the form is submitted to HHSC.

Date HHSC Notified LIDDA — Enter the date the LIDDA received the written notice from HHSC. Refer to the notice from HHSC.

Original Enrollment Due Date — Enter the original due date stated on the notice received from HHSC. Refer to the notice from HHSC.

Date LIDDA Notified Person/LAR — Enter the date of the LIDDA’s enrollment offer letter to the person or legally authorized representative (LAR).

Note: If the enrollment offer was received by transfer from another LIDDA, enter the next field.

Date Change of Residence (COR) was Completed (if transferred) — Enter the date the LIDDA completed the COR in the CSIL application.

Section 2, Person's Information

Name — Enter the first and last name of the person.

Client Assignment and Registration (CARE) ID — Enter the person’s CARE ID number.

Date of Birth — Enter the person’s date of birth. Do not leave this field blank or enter "NA" or "Unknown."

Age — Enter the person’s current age. Do not leave this field blank or enter "NA" or "Unknown."

Note: Check CARE screen C63, Medicaid Eligibility Search, to enter the information in the fields below:

Medicaid No. — Enter the person’s Medicaid number as shown in CARE C63, Medicaid Eligibility Search. If no Medicaid eligibility search results are shown, leave blank or enter "none" and "Is Medicaid Active?" section.

Medicaid Type — Enter the person’s Medicaid coverage code and program type as shown in CARE C63, Medicaid Eligibility Search.

Is Medicaid Active? Check and complete applicable section. — If the individual's Medicaid is active, check "Yes" and enter the Medicaid Effective Date as shown in CARE C63, Medicaid Eligibility Search. If no results are shown in CARE C63, check "No" and enter the date an application for Medicaid or Supplemental Security Income (SSI) was submitted. If an application has not been submitted, document the reason for the delay in Section 4.

Current Living Situation — Select the appropriate response from the drop-down menu to indicate whether the person currently resides in his/her own home or family member’s home (OHFH), an ICF/IID, state supported living center (SSLC) state hospital, nursing facility, or other. Do not leave this field blank. If "Other" is selected from the drop-down menu, describe the current living situation in the "Comments."

Projected Facility Discharge Date — If the person is residing in a facility, enter the projected facility discharge date. Do not leave this field blank.

Current Services Received through a Mutually Exclusive Program — Select the appropriate response from the drop-down menu to indicate whether mutually exclusive services are being received. Refer to LIDDA Handbook Appendix I, Mutually Exclusive Services. Do not leave this field blank. If "Other" is selected from the drop-down menu, enter the program or service in the "Comments."

Projected Program Discharge Date — If mutually exclusive services are being received, enter the projected discharge date for the mutually exclusive services. If the date is unknown, document the reason for delay in Section 4. Note: To avoid service interruption, the service coordinator must contact the case manager of the other program to coordinate begin and end dates. Refer to the LIDDA Handbook.

Section 3, Enrollment Activities — For each enrollment activity, check the appropriate response. If "Yes" is selected, enter the date the action was completed and select the current status from the drop-down menu.

Is Form 8601, Verification of Freedom of Choice (VFC), signed? — Check "Yes" or "No" to indicate whether the person or LAR has signed the form. If "Yes," enter the date and status of the form. If "No," document the reason for the delay in Section 4.

Form Status drop-down menu options include:

  • Signed but not received from person/LAR;
  • Signed and received, but not uploaded to SFTP; and
  • Received and uploaded to SFTP.

Is the HCS or TxHmL Pre-Enrollment form submitted?— Check "Yes" or "No" to indicate whether the LIDDA has submitted the Pre-Enrollment form into the TMHP site. If "Yes," enter the date the LIDDA completed the data entry and the status of the form as shown in TMHP. If "No," document the reason for the delay in Section 4. If the status requires explanation, document in Section 4.

Form Status drop-down menu options include:

  • Pre-enrolled;
  • Rejected by CSIL;
  • Pending Enrollment; and
  • Other.

Is the Determination of Intellectual Disability (DID) Completed? — Check "Yes" or "No" to indicate whether a DID has been completed. If "Yes," enter the date the DID was completed and select "Completed" from the Current Status drop-down menu. If "No," select whether the DID appointment is scheduled from the Current Status drop-down menu. If scheduled, enter the appointment date. If not scheduled, document the reason for delay in Section 4.

Form Status drop-down menu options include:

  • Not Scheduled;
  • Scheduled; and
  • Completed.

Is the Waiver Intellectual Disability/Related Condition (IDRC) Purpose Code 2, submitted? — Check "Yes" or "No" to indicate whether the LIDDA has submitted the IDRC into the TMHP site. If "Yes," enter the date the LIDDA completed the data entry and select the status of the form as shown in TMHP from the Current Status drop-down menu. If the status requires explanation, document in Section 4.

Form Status drop-down menu options include:

  • Pending DADS Review;
  • Pending IPC Match;
  • Pending Medicaid Eligibility Verification;
  • Medicaid Eligibility Verification Inactive;
  • Remanded to Submitter;
  • Submitted to SAS;
  • Rejected by SAS;
  • Provider Action Required; and
  • Other.

Form 1049, Initial Documentation of Provider Choice — If the person or LAR chooses a private provider, enter the provider’s component code, the date the LIDDA receives the form and the current status of the form. If a provider has not been chosen, document the reason for the delay in Section 4.

Form Status drop-down menu options include:

  • Not completed; and
  • Completed.

Is Form 1052, Public Provider Choice Request, completed? — If the LIDDA public provider has been chosen, check the appropriate response to indicate if the form has been completed. If "Yes," enter the date the form was completed and the status of the form.

Form Status drop-down menu options include:

  • Not Submitted;
  • Submitted; and
  • Approved.

Is the Enrollment Meeting Completed? — Check the appropriate response to indicate if the enrollment meeting has been completed. If "Yes," enter the completion date. If "No," select the applicable status and enter the appointment date if the meeting is scheduled. Document the reason for the delay in Section 4.

Form Status drop-down menu options include:

  • Not Scheduled;
  • Scheduled; and
  • Completed.

Is Form 3608 or 8582 Individual Plan of Care (IPC) submitted? — Check "Yes" or "No" to indicate whether the LIDDA has submitted the IPC into the TMHP site. If "Yes," enter the date the LIDDA completed the data entry and the status of the form as shown in TMHP. If "No," document the reason for the delay in Section 4. If the status requires explanation, document in Section 4.

Form Status entries can include:

  • Pending DADS or Coach Review;
  • Pending IDRC Match;
  • Remanded to Submitter;
  • Submitted to SAS;
  • Pending SAS Update;
  • Rejected by SAS;
  • Provider Action Required;
  • Medicaid ID Pending;
  • Medicaid ID Check Inactive;
  • Pending Location Capacity Verification;
  • Pending Location Availability Verification;
  • Pending Contract Capacity Check;
  • Pending Medicaid Eligibility Verification;
  • MI/ME Check Expired;
  • MI/ME Check Restarted; and
  • Other.

Expected Time Frame for Completion (HHSC will send notification with approved extension date) — Select the appropriate number of days needed to complete the enrollment. The reason for the extension request and any delays in completing the enrollment should be detailed in Section 4. The slot monitor has final approval on the number of days extended. HHSC will send a notification with the approved extension date.

Section 4, Reason(s) for Delay(s) — Describe the reason(s) for delay(s) in each enrollment activity with a "No," "Not Scheduled" or "Not Submitted" response and provide specific information regarding the actions the LIDDA has taken to resolve the delays, the current predominant reason for delay and the potential for future delays.