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Effective Date: 
9/2020

Documents

 

Instructions

Updated: 9/2020

 

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.

The enrollment process is not complete until the person’s status shows as “active” or “denied” in the Client Assignment and Registration (CARE) System C61, Consumer Demographics Inquiry screen, or the person’s interest list status shows as “7-withdrawn” or “8-declined” in the CARE W21, Interest List Services, or 397, Request Client ID Information, screens.

 

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.  

 

Submittal

The LIDDA emails the completed form to LiddaRequests@hhsc.state.tx.us using a secure email method. To ensure the form is assigned appropriately, the LIDDA must include the slot type number and assigned slot monitor’s name in the subject line. If the slot monitor’s name is unknown, the LIDDA must email LiddaRequests@hhsc.state.tx.us to ask for the slot monitor’s name.

If the LIDDA does not have access to a secure email method, the LIDDA emails HHSC at LiddaRequests@hhsc.state.tx.us 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.

HCS or TxHmL — Check the appropriate box to indicate the program being offered.

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).

Requested Extension Date – Enter the date the LIDDA is requesting HHSC to extend the due date.

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 CARE System.

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 skip to Medicaid Application Date.

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

Medicaid Effective Date — Enter the person’s Medicaid effective date as shown in CARE C63, Medicaid Eligibility Search.

Medicaid Application Date — If no results are shown in CARE C63, Medicaid Eligibility Search, 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 — Check the appropriate box 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.

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

Current Services Received through a Mutually Exclusive Program — Check the appropriate box to indicate whether mutually exclusive services are being received. Refer to LIDDA Handbook Appendix I, Mutually Exclusive Services,. Do not leave this field blank or enter “NA” or “Unknown.”

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 and enter the applicable date. Do not leave the date field blank or enter “NA” or “Unknown.”

Form 8601, Verification of Freedom of Choice (VFC), received? — Check “Yes” or “No” to indicate whether the LIDDA has received a VFC form from the person or LAR. If “Yes,” enter the date the LIDDA received the form. If “No,” document the reason for the delay in Section 4.
 

VFC Uploaded to the Secure File Transfer Protocol (SFTP) site? — Check “Yes” or “No” to indicate whether the LIDDA has uploaded the VFC form to the SFTP site. If “Yes,” enter the date the LIDDA uploaded the form. If “No,” document the reason for the delay in Section 4.
 
CARE L01, Consumer Enrollment, entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L01. If “Yes,” enter the date the LIDDA completed the data entry. If “No,” document the reason for the delay in Section 4.

New Determination of Intellectual Disability (DID) needed? — Check “Yes” or “No” to indicate whether a new DID is needed. DID Status: If “Yes,” check the appropriate response to indicate the status of the new DID. If the box for “Scheduled” is selected, enter the date of the upcoming appointment. If the box for “Completed” is selected, enter the date the DID was completed. If the box for “Not Scheduled” is selected, document the reason for the delay in Section 4.

CARE L23, Waiver Intellectual Disability/Related Condition (IDRC), entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L23. IDRC Status: If “Yes,” check the appropriate response to indicate the status of the ID/RC. If the box for “Returned” is selected, enter the date the LIDDA submitted the requested documentation to Program Eligibility and Support (PES) or document the reason for the delay in Section 4. If the box for “Approved” is selected, enter the date PES approved the ID/RC. If the box for “Entered/Pending” is selected, document the reason for the delay in Section 4.

Form 1049, Initial Provider Choice Request, signed and received or Form 1052, Public Provider Choice Request — Check the appropriate form to indicate the person’s or LAR’s choice of provider. If a provider has not been chosen, document the reason for the delay in Section 4. If Form 1049 has been received, enter the provider’s component code and the date the LIDDA received the form. Otherwise, check the appropriate response to indicate the status of Form 1052. If “Submitted” is selected, enter the date the LIDDA submitted the form. If the box for “Approved” is selected, enter the date of HHSC’s approval. If the box for “Not Submitted” is selected, document the reason for the delay in Section 4.

Enrollment Meeting Status — Check the appropriate response to indicate the status of the enrollment meeting. If the box for “Scheduled” is selected, enter the date the of the upcoming appointment. If the box for “Completed” is selected, enter the date the meeting was completed. If the box for “Not Scheduled” is selected, document the reason for the delay in Section 4.

CARE L02, Individual Plan of Care, entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L02. If “Yes,” enter the date the LIDDA completed the data entry. If “No,” document the reason for the delay in Section 4.

CARE L03, Enrollment Packet Checklist, entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L03. If “Yes,” enter the date the LIDDA completed the data entry. If “No,” document the reason for the delay in Section 4.    

CARE L09, Register Client Update, entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L09. If “Yes,” enter the date the LIDDA completed the data entry. If “No,” document the reason for the delay in Section 4.

CARE L05, Provider Choice, screen entered? — Check “Yes” or “No” to indicate whether the LIDDA has completed CARE screen L05. If “Yes,” enter the date the LIDDA completed the data entry. If “No,” document the reason for the delay in Section 4.        

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 additional information regarding the actions the LIDDA has taken to resolve the delays, the current predominant reason for delay and the potential for future delays.

Section 5, HHSC Use Only — These fields are completed by HHSC staff only.