Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

 

Purpose

Minor home modifications are physical modifications to a participant’s home that are medically necessary to support the participant’s ability to function independently at home and in the community. MHMs may be used to make necessary accessibility and safety related adaptations to a participant’s home.

Special Requirements

All minor home modifications must adhere to Americans with Disabilities Act (ADA) requirements, meet Texas Accessibility Standards, and meet applicable state and local building codes. The Wraparound facilitator should also ensure that the intervention is the most inclusive and person-centered option and that the Child and Family Team (CFT) agrees with the intervention requested. Documentation of the MHM must be noted in the Wraparound Plan and retained in the participant’s case file.

Restrictive Interventions

Some minor home modifications may be considered a restrictive intervention. Examples of restrictive interventions include, but are not limited to:

  • Door and window alarms added to a participant’s environment
  • Security cameras
  • Locked access
  • Restricted access to personal property

When the request is considered a restrictive intervention, the Comprehensive Waiver Provider must inform the participant of their rights, including how to report abuse, neglect and exploitation. The informed consent and explanation of rights must be included in the participant’s Crisis and Safety Plan and the Wraparound Plan of Care.

Limitations

If a minor home modification is requested and the YES Waiver participant or their legally authorized representative do not own the home where the modification will take place, the Comprehensive Waiver Provider is responsible for and must obtain a written agreement from the homeowner, landlord, or other property owner before a modification is purchased or installed.

For additional requirements, reference the YES Waiver Policy Manual.

 

Procedure

When to Prepare

The Wraparound facilitator shall only complete this form in accordance with the Wraparound Process. Prior to submitting the MHM request form, the MHM should be discussed during the Child and Family Team (CFT) meeting and documented in the Wraparound Plan. Documentation must include brainstorming process.

Submission

If the MHM is less than $500, complete Parts I, II, III and V. If the MHM is more than $500, complete Parts I, II, III, IV and V.

Submit a separate MHM request form for each individual item requested. Complete all sections of the MHM request form accurately. If the WPO does not complete all sections of the MHM request form, it will be considered incomplete and will not be reviewed.

The YES Program Manager must submit the completed form to the HHSC YES Waiver inbox at YESWaiver@hhsc.state.tx.us to be processed.

Review Process

HHSC assigns a unique case number to the submitted request upon receipt of the MHM request form. All requests will be reviewed in accordance with the YES Waiver Policy Manual and Medicaid requirements. If additional information is needed to complete the review process, WPO staff will have 3 business days to provide any additional information or documentation that has been requested. Once HHSC has finished reviewing the request, the WPO will be notified of the decision by email.

 

Detailed Instructions

Part I: Participant Information

The Wraparound Provider Organization completes this section.

Date – Enter the date the service was discussed with the Child and Family Team

CMBHS ID No. – Enter the participant’s Clinical Management for Behavioral Health Services (CMBHS) ID number.

Wraparound Provider Organization – Enter the Wraparound Provider Organization’s name.

Name of Wraparound Facilitator – Enter the wraparound facilitator’s name.

Name of the Wraparound Supervisor – Enter the name of the wraparound supervisor who has reviewed the MHM request form. HHSC will contact the wraparound supervisor with questions about the MHM.

Comprehensive Waiver Provider – Enter the Comprehensive Waiver Provider organization’s name.

Participant Name – Enter the participant’s name.

Participant Address, City, State, ZIP Code – Enter the participant’s full address. This should be the address where the minor home modification will be used.

 

Part II: Property Information

The landlord or owner of the property where the minor home modification is to be made must complete this section before the modification is started.

  1. Does the participant live in a property that is leased? – Check the appropriate box.

    If the answer is yes, approval from the property owner is required.

    Name of Landlord – Enter the name of the landlord or owner of the property. Check the appropriate box.

    Signature of Landlord – The landlord or owner of the property must sign and date the form.

    Note: If the landlord or property-owner does not approve, the minor home modification cannot be made to the residence.

 

Part III: Requested Service

The Wraparound Facilitator completes this section that addresses the related condition and the expected benefits of the requested item/service.

  1. Description and Cost of Minor Home Modification (MHM) Request – Enter the individual item or service requested, including details, specification, or brand names as necessary to describe the request. Include the total cost of the request and where the request will be purchased.
  2. Reason for Participant Referral to YES Waiver – Enter the reason the participant was initially referred to the YES Waiver. Include any related mental health condition(s) or diagnosis that pertain to the requested item, service or identified need(s) on the Child and Adolescent Needs and Strengths (CANS) assessment.
  3. Description of Medical Necessity for MHM as it pertains to the reason for referral and prevention of out-of-home placement – Provide a detailed description of the participant’s functional limitation(s) relevant to the requested item. Describe why the item is necessary and how the item benefits the participant in terms of treatment, rehabilitation, or ability to compensate for functional limitations.
  4. A description of how the MHM will supplement services already identified on the Wraparound Plan to help decrease or eliminate barriers to services and increase the participant’s access to their community – Provide a detailed description of how the requested item will supplement authorized services offered included in the YES Waiver service array. Include a description of how the MHM is intended to be used by the participant to address MHM as a part of the plan of care, including how the MHM will be monitored for efficacy.
  5. Description of brainstorming process used to arrive at this MHM. Include strategies and tasks assigned to each team member – Describe how the child and family team has strategized to meet the underlying need, including to the MHM request. Include a description of how the strategies and tasks related to the MHM request will address sustainability.

 

Part IV: Required only for requests that are over $500.

The Wraparound facilitator, with the assistance of the Comprehensive Waiver Provider Organization representative if necessary, completes this section related to cost of item or service requested.

  1. Has the YES Comprehensive Waiver Provider obtained three bids? – Check the appropriate box.

    If the answer is yes, outline bids, including the name of service or item and cost of each item.
     
  2. Is this request or bid the most cost-effective option? – Check the appropriate box.

    If the answer is no, provide the reason for not choosing the most cost-effective option.


Part V: To be completed by the Wraparound Supervisor

The Wraparound supervisor must review the request with the Wraparound facilitator to confirm that the request meets YES Waiver policy criteria and that the Wraparound process has been followed according to the Wraparound model.

  1. Per YES Waiver policy, this request meets criteria for what is an allowable MHM. – The Wraparound supervisor must review the YES Waiver Policy Manual outlining policy requirements for MHM. Check the appropriate box.
  2. MHM requested is tied to the participant’s SED and reason for referral, and is medically necessary and mandatory to prevent institutionalization and out-of-home placement. – Check the appropriate box.
  3. MHM requested is tied to a strategy associated with an underlying need that was identified during Child and Family Team meetings in fidelity to the Wraparound model – Check the appropriate box.
  4. All other strategies, payment, discounts, community resources have been explored and exhausted through the team task assignments and Medicaid is the payer of last resort. – Check the appropriate box.
  5. If the request is made before the first CFT meeting, the requested MHM is tied to a crisis or safety plan and is necessary prior to the first CFT meeting. – Check the appropriate box.

    If answer is yes, explain – Describe how the MHM is included in the crisis or safety plan.

YES Program Supervisor Signature – The YES Program supervisor signs and dates the form.

Comprehensive Waiver Provider (CWP) Signature – The Comprehensive Waiver Provider representative signs and dates the form.


Part V: HHSC Authorization Status

To be completed by HHSC only.

HHSC YES Waiver Staff Determination and Signature – HHSC indicates a decision of the MHM Form.

Approved – Based on information presented, HHSC agrees that the item requested is justified based on necessity and appropriateness of the item/service. The WPO must attach the MHM form, signed by HHSC, into the CMBHS system in the IPC Document. A brief description of the MHM must be included in the IPC MHM justification box.

Note: The Minor Home Modification is not formally authorized until it is approved in CMBHS. Receipts of purchased items and the MHM request form must be retained in the participant’s file.

Denied – Based on information presented, the MHM cannot be authorized because it does not meet HHSC requirements.

  • Do not submit the MHM request into the CMBHS system.
  • The WPO must send Forms 2800 and 2801, Denial of Eligibility and Fair Hearing Request forms to the participant. The WPO must include the reason for denial provided by HHSC.
  • The MHM request form must be retained in the participant’s file.