Form 2814, Youth Empowerment Services (YES) Waiver Transitional Services Funding (TSF) Request

 

Instructions

Updated: 1/2020

 

Purpose

Transitional Services Funding (TSF) assists participants to transition to independent living in the community. A participant can use the funding to establish a basic household if they are transitioning from an institution, provider operated setting or family home, to their own private community residence.

A participant may be eligible for transitional funding if they currently live in an institutional setting, provider operated setting or family home and they:

• plan to rent an apartment or house and will be directly responsible for their own living expenses;
• are transitioning into another independent living situation;
• have a home that needs cleaning, pest eradication or allergen control before it can be occupied again; or
• need belongings moved from an institution or provide operated setting to their new residence in the community.

TSF may include payment for:

• security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
• essential furnishings for the apartment or house, including furniture, window coverings, food preparation items, and bed and bath linens;
• moving expenses required to move into the house or apartment; and
• site preparation services, such as pest eradication, allergen control, or one-time cleaning before occupancy.

TSF is limited and may not be used for:

• monthly rent or mortgage expenses;
• current or future use of utilities;
• service upgrades;
• food items;
• any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TSF is a one-time request that may not exceed $2,500. For additional requirements, reference the YES Waiver Policy Manual.

 

Procedure

When to Prepare

The Wraparound facilitator completes this form in accordance with the Wraparound Process. Prior to submitting the TSF request form, the TSF should be discussed during the Child and Family Team (CFT) meeting and documented in the Wraparound plan. The Wraparound plan must clearly outline how the CFT will support the participant’s transition into the community, including strategies and tasks assigned to each CFT member.

Submission

The Wraparound Provider Organization must submit a copy of the participant’s Wraparound, including the crisis and safety plan, with the TSF request. All sections of the TSF request form must be completed accurately. If the WPO does not complete all sections of the TSF 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 will assign a unique case number to the submitted TSF request once it is received. 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 three business days to provide any additional information or documentation that has been requested. When the TSF request includes non-billable items, HHSC may ask the WPO to revise the TSF request to meet policy requirements. 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 TSF request form. HHSC will contact the Wraparound supervisor with questions about the TSF.

Comprehensive Waiver Provider – Enter the comprehensive waiver provider organization’s name.

Participant Name – Enter the participant’s name.

Current Address – Enter the full address where the participant is currently living.

Type of Housing – Select the type of residence where the participant is living.

Planned Community Address – Enter the address where the participant plans to move in the community.

Proposed Date of Move – Enter the expected date of move.

Type of Housing – Enter a brief description of the type of housing the participant will move to such as apartment or single-family home.

 

Part II: Requested Service

The Wraparound facilitator, with the assistance of the comprehensive waiver provider organization representative, completes this section related to cost of item or service requested.

1. Describe the need for TSF request, including the reason for the move – Provide a summary describing the participant’s move. Include where the participant is now living, where participant is expecting to move, and how the CFT has been a part of the transition process. Include a description of the strategies and tasks designed to support the participant’s transition to the community or their own private residence.

Item Requested – In each row, enter the individual item requested including details, specification, or brand names as necessary to describe the request. If the request is for a deposit or site preparation service, enter the name of the organization to whom payment will be made. The Wraparound facilitator should be as specific as possible when describing each item or the request may be returned.

Cost – Enter the cost of the item requested.

Purpose – Select the purpose for the item from the approved categories in the drop-down menu.

Total for Deposits – This is the total for all entries in this category.

Total for Household Items – This is the total for all entries in this category.

Total for Site Preparation Services – This is the total for all entries in this category.

Total – This is the grand total of all subtotals. This is the amount that will be authorized to the Comprehensive Waiver Provider. This amount must not exceed $2,500.

 

Part III: Signatures

Participant Signature – The participant signs and dates the form. If the participant is currently in an institutional setting, the participant’s LAR may sign and date the form.

Wraparound Facilitator Signature – The Wraparound facilitator signs and dates the form.

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 IV: HHSC Authorization Status

To be completed by HHSC only.

HHSC YES Waiver Staff Determination and Signature—HHSC indicates a decision of the TSF Request.

Approved – The TSF meets all HHSC requirements and is authorized for purchase. The WPO must attach the TSF form, signed by HHSC, into the CMBHS system in the IPC Document. A brief description of the TSF must be included in the IPC TSF justification box.

Note: The Transitional Services Funding request is not formally authorized until it is approved in CMBHS. Receipts of purchased items and the TSF request form must be retained in the participant’s file.

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

• Do not submit the TSF 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 TSF request form must be retained in the participant’s file.