To notify the applicant or individual receiving services of:
- initial eligibility for Medically Dependent Children Program (MDCP) waiver services;
- continued eligibility for services at the time of the annual reassessment;
- right to appeal decisions regarding eligibility and services;
- a change in provider authorized to deliver services;
- copayment and room and board charges, if any;
- a reduction or a denial of a specific waiver service (an adaptive aid); and
- changes to the Individual Service Plan (ISP) or Individual Plan of Care (IPC), room and board charges or copayment.
To notify MDCP service providers:
- at the time of the initial enrollment or annual reassessment, of the provider's authorization to deliver services; and
- at the time of a provider change, of the termination date of the authorization for the previous provider and of the effective date of the authorization to the new provider.
When to Prepare
The Texas Health and Human Services Commission (HHSC) case manager prepares Form 2065-B when an applicant is determined to be eligible for a waiver program, when there is a service change, a copayment or room and board change, a provider change or for the individual's annual redetermination of eligibility.
The form must be completed in plain language that can be understood by the applicant or individual. Acronyms for program names may be used on the form only after the complete program name has been spelled out and designated with its acronym.
Note: The case manager prepares Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, when an applicant is denied or an individual is no longer eligible for the program.
Number of Copies
Prepare an original and sufficient copies for all providers and the case record.
Send the original form to the applicant or individual and copies to all applicable providers. Maintain a copy in the case record. Send a copy to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when applicable.
Retain this form according to the terms in the applicable waiver program handbook.
If the applicant's or individual's language preference is clearly documented in the case record, HHSC staff prepare the form in the preferred language. If language is not documented, both English and Spanish forms must be prepared.
Name and Address — Enter the applicant's or individual's name and mailing address in the space provided.
Date — Enter the date the form is completed by the HHSC case manager. This date must match the date entered on the line labeled Date next to the HHSC case manager's signature on the bottom of the form.
HHSC Case Manager — Enter the HHSC case manager's name.
Office Address and Telephone No. — Enter the HHSC case manager's mailing address, including the street address or P.O. Box, Mail Code, city, state, ZIP code and telephone number. Information should be typed or printed legibly.
Notification of Waiver Services
Name of Waiver Program — Enter the name of the waiver program. Enter in the blank provided the name of the program (Medically Dependent Children Program) for which the applicant or individual is eligible. The name of the waiver program is essential when notifying the individual of changes in the Service Plan Changes section of the form.
Check the box(es) appropriate to the action about which the applicant or individual is being notified.
Your eligibility date is — The eligibility date box is only used for applicants at initial enrollment. Enter an X in the box if the applicant is eligible for waiver services, giving the eligibility date in the blank provided. This date is determined by all of the following eligibility factors being met:
- valid medical necessity (MN);
- verified financial eligibility;
- valid medical effective date (MED); and
- IPC/ISP acceptance signed by the applicant and all parties (applicant's or caregiver's signature not required prior to eligibility determination for MDCP).
The eligibility date is the HHSC case manager's signature date.
Your services identified on the attached Individual Service Plan/Individual Plan of Care (ISP/IPC) are effective — Enter an X in the box and enter the effective date for the ISP/IPC.
Effective Date for Initial Enrollment — The effective date is the first date services can be authorized for the ISP/IPC. The effective date may be the same as the eligibility date.
The effective date is negotiated with the provider for the initiation of services. For MDCP, once the case manager determines that all MDCP eligibility requirements are met, the case manager must negotiate the IPC effective date with the applicant, the applicant's parent or guardian, the provider (Home and Community Support Services provider or the Financial Management Services Agency) and the MEPD specialist, if applicable.
For MDCP, the effective date is entered in the Provider Authorization section of Form 2065-B; it is found on Form 2410, Medical-Social Assessment and Individual Plan of Care, IPC Period "From" date and in SAS.
Effective Date for Money Follows the Person (MFP) — Due to MFP provisions, an applicant in the NF must be determined eligible and notified of eligibility before leaving the NF to meet MFP criteria. Therefore, for MFP, the eligibility date must be earlier than the effective date. This is not applicable for MFP Limited Stay in MDCP.
If the applicant is given oral approval, Form 2065-B must be completed on the same day. In rare extenuating circumstances, it may be necessary to notify the applicant of eligibility determination before service plans are finalized. In that situation, Form 2065-B giving the eligibility date is sent to the applicant. Once the service arrangements are finalized, a second Form 2065-B giving the effective date is sent to the individual and a copy sent to the provider authorizing services.
Effective Date for MFP Limited Stay in MDCP — The eligibility date and effective date are the same.
Individuals Aging Out of MDCP or the Comprehensive Care Program (CCP), when the Applicant’s 21st Birthday Falls on a Weekend or Holiday — Once all criteria are met with the exception of the age requirement, the case manager completes and sends Form 2065-B to the applicant, providers and interdisciplinary team (IDT) members no earlier than seven working days before the applicant’s 21st birthday, using the following guidelines:
- Date: Date of case manager's signature on Form 2065-B;
- Eligibility Date: Date of applicant's 21st birthday;
- Effective Date: Date of applicant's 21st birthday; and
- Signature – HHSC staff: Date the case manager completes and signs the form
In the Form 2065-B Comments section, the case manager writes, "The individual will meet all eligibility requirements on (date of 21st birthday). Services may begin on that date." The case manager must not complete and send Form 2065-B before the seven-working-day time frame.
Effective Date for Annual Reassessments — For an annual reassessment, enter the first day of the new ISP/IPC year. For MDCP, this is the same date entered on Form 2410, IPC Period "From" date.
Room and Board/Copayment
You must pay for room and board — Enter an X in the box if the individual is going into either an AFC home or AL facility and must pay room and board. Enter the amounts to be paid in the blanks provided for the first month and ongoing room and board. The date for the initial room and board payment is entered as the date of the entry of the individual into the AL or AFC setting for the lines "You must pay ___ for room and board by ... (date)." The date for the ongoing room and board payment is entered as the first of the next month on the line "... and then pay ___ per month beginning ... (date)."
Complete this section also to notify an individual of a change in room and board charges.
For annual reassessments, enter the beginning date of the ISP/IPC year in the date field for the initial room and board payment on the line "You must pay ___ for room and board by ... (date)." The date for the ongoing room and board payment is entered as the first of the next month on the line "... and then pay ___ per month beginning ... (date)."
You must pay for copayment — Enter an X in the box if the individual is going into either an AFC home, an AL facility or has a Qualified Income Trust (QIT) and must pay a copayment for care. Enter the amounts to be paid in the blanks provided for the first month and ongoing copayment. The dates for initial copayment should be entered as the date of the entry of the individual into the AL or AFC setting for the lines "You must pay ___ for copayment by ... (date)." The date for the ongoing copay is entered as the first of the next month on the line "... and then pay ___ per month beginning ... (date)."
Complete this section to notify an individual of copayment changes.
For QIT and annual reassessments, enter the beginning date of the ISP/IPC year in the date field for the initial copayment on the line, "You must pay ___ for copayment by ... (date)." The first day of the next month is entered as the date for an ongoing copay on the line "... and then pay ___ per month beginning ... (date)."
Service Plan Changes
Effective ___________ your waiver service plan will include the following changes — Enter an X in the box if there is to be a change in the services the individual receives. Enter the effective date for the change and describe the change in the blank provided. For ISP changes, this is the effective date in the Provider Authorization section for the affected provider as discussed below. For all services except MDCP, this is the date of the case manager's signature or a documented negotiated date or special circumstance requiring a retroactive date such as emergency delivery of personal assistance services (PAS), medical supplies (MS) or adaptive aids (AA).
For MDCP IPC changes, this date is the same date as entered on Form 2411, Interim Plan of Care, Interim Plan of Care Effective Date, or Form 2412, Budget Revision, Budget Revision Date, and the effective date in the Provider Authorization section for the affected provider as discussed below.
Rule/Handbook Reference — Enter the Rule reference when a service or service item is denied. Enter the appropriate handbook, waiver or Code of Federal Regulation reference only when there is no rule for the action taken. Document the reason for denial or changes in the service or service item in the "Effective" section or in "Comments.”
Rules citations must include the Texas Administrative Code (TAC) Title reference and the rule number. For example, MDCP rules are found in Title 40 of the TAC.
Comments — Enter any comments appropriate to the applicant's or individual's eligibility, services authorized or changed, the room and board payment, copayment or provider change(s).
Comments must be entered to clearly explain to the applicant or individual the denial of his request for a particular adaptive aid, medical supply, minor home modification or other service.
Provider — Enter the name of the provider(s) authorized to provide services to the individual. If there is a provider change, enter the name of the provider who no longer is authorized to deliver services and the name of the new provider. Example: If the individual is moving from one AFC home to another, the name of the new AFC provider is entered along with the Type, Vendor No. and Effective Date. A Termination Date is not entered for the new provider. The name of the previous AFC provider is entered along with the Type, Vendor No. and Termination Date.
Type — Enter the type of provider:
- AA — Adaptive Aids (for MDCP only)
- AFC — Adult Foster Care
- AL — Assisted Living
- ERS — Emergency Response Services
- FMS — Financial Management Services
- HCSSA — Home and Community Support Services Agency
- HDM — Home Delivered Meals
- MHM — Minor Home Modifications (for MDCP only)
- OHR — Out-of-Home Respite
Vendor No. — Enter the vendor number of the provider.
Effective Date — Enter the effective date in the blank provided.
The effective date of the provider cannot be before the effective date of the ISP/IPC, the waiver eligibility date, the medical necessity begin date or the medical effective date for the Medicaid eligibility.
The effective date is the earliest date that waiver services are authorized and can be reimbursed. This date must match the effective date located in the effective section in the top portion of this form.
For Initial Determinations
The effective date is the first date services can be authorized for the ISP/IPC. The effective date may be the same as the eligibility date. The effective date is negotiated with the provider for the initiation of services.
There may be reasons to make the effective date of the provider authorization a date other than the date the form is sent to the providers.
- The date for initiation of services to the applicant has been negotiated.
- The applicant may not plan on leaving a hospital or NF until a particular date and services need to start on that same day.
- The termination of Primary Home Care (PHC) services and the initiation of waiver services must be coordinated to assure there is no gap in services.
- The applicant moves into an AFC or AL setting on a particular date.
If there is a compelling reason that services begin on a specific date, the service initiation date must be negotiated with the provider. The negotiated service initiation date is documented on Form 2067, Case Information, and sent to the provider.
For an initial MDCP IPC, this effective date should match Form 2410, IPC Period "From" date, and the effective date discussed above.
For Changes of Service or Providers
For the effective date, enter the date the change in service or provider takes effect, the first date the changes to the ISP/IPC take effect or the first date the new provider can deliver service. For an MDCP IPC change, this effective date should match the Form 2411, Effective Date, or Form 2412 Budget Revision Date and the date of the IPC change as discussed above.
For Annual Reassessments of the ISP/IPC
For the effective date, enter the beginning date of the new ISP/IPC effective period. For an MDCP annual reassessment IPC, this effective date should match Form 2410, IPC Period "From" date, and the effective date discussed above.
Termination Date — Enter the termination date if services by a particular provider are to be terminated. This date will be the "TO" date on the ISP/IPC.
If services by a particular provider are no longer authorized, enter the date the termination takes effect for the provider listed on that line. The termination date is the last date the provider is authorized to deliver services.
If all services to an individual are being terminated, use Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services.
Signature and Date — The case manager must sign and date on the date the case manager completed Form 2065-B. The case manager's signature date is the case action decision date.
Name — Enter the name of the applicant or individual from Page 1.
Number — Enter the applicant's or individual's identification number. This is the client number, Medicaid number or individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or SAS.
Request for Fair Hearing — The applicant or individual checks the box if he wishes to appeal. The applicant or individual prints his name, signs and dates the form and returns it to HHSC staff.