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Effective Date: 
3/2010

Documents

Instructions

Updated: 3/2010

Purpose

This form is used to:

  • inform the consumer of personal costs with the requested Minor Home Modification (MHM) or Adaptive Aids (AA);
  • authorize the requested MHM or AA;
  • document the amount authorized for the MHM or AA; and
  • authorize the provider to deliver the requested MHM or AA.

Procedure

When to Prepare

Texas Health and Human Services Commission (HHSC) staff complete Form 2416 when authorizing MHM or AA.

Number of Copies

The case manager completes an original for the consumer/primary caregiver and copies for the provider and case file.

Transmittal

If there are no personal costs identified:

  • complete Sections A, B, C and D; and
  • submit an original to the consumer and a copy to the provider.

If personal costs are identified:

  • complete Sections A and B; and
  • submit a copy to the consumer for signature. Upon return from the consumer:
    • complete Section C and D; and
    • submit the completed Form 2416 with the case manager’s original signature to the consumer and a copy to the provider.

Form Retention

Keep a copy of the most recent form for the requested item or service for three years after the case is denied or closed.

Detailed Instructions

Section A: Individual Information

Name— Enter the consumer’s name.

Medicaid Number— Enter the consumer’s Medicaid number.

Parent/Guardian— Enter the name of the consumer’s parent or guardian.

Address— Enter the consumer’s address, including the street number and name, city, state and ZIP code.

County— Enter the consumer’s county of residence.

Area Code and Telephone No.— Enter the consumer’s area code and telephone number.

Section B: Requested Service and Personal Costs

Service Requested— Check the box for the service requested. Select only one service: MHM or AA.

Personal Costs— Select the first box if HHSC staff determine no need for personal costs for the requested MHM or AA and continue form completion in Section C.

Select the second box if HHSC staff determine there are personal costs for the requested MHM or AA. If there are personal costs, send a copy to the consumer for the consumer’s review, signature and date.

Section C: Service Authorization

Individual Plan of Care (IPC) period for which service is authorized— Enter the From and To dates documented in the consumer’s IPC.

Amount previously authorized for MHM— If applicable, enter any previously authorized MHM costs. HHSC staff may not authorize waiver services if the sum of previous and new costs exceed the $7,500 lifetime limit for MHM.

Amount previously authorized for AA— If applicable, enter the amount of AA costs previously authorized for the current IPC period. HHSC staff may not authorize waiver services if the sum of current and new costs exceed the $4,000 limit for AA per IPC period.

Type of Service Authorized— Select the appropriate box for the requested item or service. Specify the location, modification or item as appropriate.

For example:

Checked Box MHM — Bathroom Modification (specify modification): Tub to shower conversion; or
Checked Box AA — (specify item): Feeder seat

Based on the request and the amount of the bids submitted, HHSC authorizes:— Enter the amount of the MHM or AA authorized for the requested item or service.

Case Manager Signature and Information— The case manager signs and dates the form and provides the area code and telephone number, address and area code and fax number.

Your service authorization is cancelled effective:— The case manager uses this section for cancellation of service authorizations. Check the box and enter the date the cancellation becomes effective.

Section D: Provider Information

Contract Number— Enter the provider’s contract number.

Name— Enter the provider’s name.

Area Code and Telephone No.— Enter the provider’s area code and telephone number.

Address— Enter the provider’s address, including the street number and name, city, state and ZIP code.

Area Code and Fax No.— Enter the provider’s area code and fax number.

Signature — Provider Contact and Date— The provider contact signs and dates the form.