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Effective Date: 
11/2015

Documents

Instructions

Updated: 11/2015

Purpose

This form is used by the following programs:

  • Community Living Assistance and Support Services (CLASS),
  • Deaf Blind with Multiple Disabilities (DBMD),
  • Home and Community-based Services (HCS),
  • Medically Dependent Children Program (MDCP), and
  • HCBS STAR+PLUS Waiver (SPW).

This form is used to:

  • record the individual's basic essential needs for Transition Assistance Services (TAS);
  • provide estimated amounts for items and services; and
  • authorize the TAS provider to purchase items and services.

Non-waiver/third-party resources must be used before TAS services are provided.

Procedure

When to Prepare
This form is completed by the waiver case manager, HCS service coordinator, or managed care organization (MCO) service coordinator at the time of the initial face-to-face contact with an individual or the individual's legally authorized representative (LAR) who is applying for waiver services to transition from the nursing facility to the community. Applicants enrolling in HCS must be transitioning from a nursing facility, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or a General Residential Operation (GRO).

Transmittal
For the CLASS and DBMD programs, the form is sent to the Texas Health and Human Services Commission (HHSC) Program Enrollment/Utilization Review (PE/UR) for approval. PE/UR staff send the approved form to the waiver case manager, who will maintain a copy of the form and send the form to the TAS provider. The TAS provider will provide the items/services, obtain the signature of the individual/LAR in Item 17 and send a completed copy back to the waiver case manager.

For the HCS program, Form 8604 is sent to PE/UR for approval. PE/UR staff send the approved form to the HCS service coordinator, who will maintain a copy of the form and send a copy to the HCS program provider. If the HCS program provider has subcontracted a TAS provider, the HCS program provider will send the form to the TAS provider. The HCS provider or the TAS provider will deliver the items/services listed on the authorized TAS form. Once items and services have been delivered, the signature of the individual/LAR in Item 17 confirms the items and services were received. In the event that a TAS provider is subcontracted, the TAS provider will send a completed copy back to the HCS provider with the individual/LAR signature.

For the SPW and MDCP programs, the original is sent to the TAS provider and copies are provided to the individual/LAR. A copy is maintained in the case folder without the individual signature in Item 17. The TAS provider will send a copy that is signed by the individual in Item 17 to the case manager/service coordinator for the case record once the items/services have been delivered.

Form Retention
The waiver case manager, HCS or MCO service coordinator and the TAS provider or HCS program provider will keep Form 8604 in the case record according to the retention requirements found in the appropriate waiver handbook.

Detailed Instructions

Select applicable program: — Self-explanatory.

1. Individual Name — Enter the name of the individual.

2. Medicaid No. — Enter the nine-digit Medicaid number.

3. Assessment Date — Enter the date the form is completed during the face-to-face interview.

4. Proposed Date of Discharge — Enter the date the individual plans to move from the nursing facility to the community.

5. Current Facility Address — Enter the name and address of the facility where the individual is currently living.

6. Area Code and Telephone No. — Enter the area code and telephone number where the individual or the individual's LAR can currently be reached. If the individual has no representative, enter the area code and telephone number of the facility.

7. Planned Community Address — Enter the address where the individual plans to move in the community, if known.

8. Area Code and Telephone No. — Enter the area code and telephone number of the individual's planned community address, if known.

9. Location Code — Enter the location code.

10. Assessment for TAS — In this section, the case manager or HCS service planning team will carefully review the individual's existing plans for moving to the community and assess if the individual needs assistance with any of the items or services covered under TAS.

Services Required
If the individual knows the exact amount of the items or services, use that amount. If the individual does not know the exact amount of the items or services, estimate the amount. The amounts, either the exact or estimated, must be less than or equal to $2,500. If the individual is an HCS applicant moving into a host home/companion care home or a 3- to 4-person group home, TAS is limited to an exact or estimated total cost of less than or equal to $1,000. Items and services identified on the service authorization are the only items and services that are billable by the TAS provider.
Note: For HCS TAS services, the one-time benefit for the individual in his/her own home/family home is $2,500, and in a host home/3- to 4-person group home is $1,000.

11. Deposit Type — Enter security deposits for rental, utility and other services. In the "Description" box, enter the name and address of the rental facility, utility company or telephone company.
Subtotal for Deposits — This is the total for all entries in this category. When this form is filled out electronically, the total is automatically calculated and entered in this field.

12. Household Items — Household needs include basic items to furnish a home. The case manager must be as specific as possible when describing what items are needed. The description should include size, color, specific types or any other identifying information, as specified by the individual, that will assist the TAS agency in meeting the individual's needs.
Subtotal for Household Items — This is the total for all entries in this category. When this form is filled out electronically, the total is automatically calculated and entered in this field.

13. Site Preparation Services — Site preparation services include moving and delivery expenses. If the individual is in need of furniture or large appliances, a delivery expense may be necessary.
Subtotal for Site Preparation Services — This is the total for all entries in this category. When this form is filled out electronically, the total is automatically calculated and entered in this field.

14. Totals — This is the grand total of all subtotals for Items 10-12. When this form is filled out electronically, the total is automatically calculated and entered in this field. This is the amount that will be authorized to the TAS agency or HCS program provider (not to exceed $2,500).

Individual's Information
Enter the individual's identifying information from Page 1.

15. Individual Statement and Signature — The individual or the individual's LAR must sign and date the form. The case manager also signs and dates the form. If applicable, the TAS or HCS provider signs and dates the form.

16. TAS Provider Selection

TAS Provider Name – Enter the contracted name of the TAS provider.
TAS Vendor No. – Enter the vendor number of the TAS provider.
Completion Date – Enter the date two days before the individual's planned discharge date from the nursing facility to the community. This is the same date as the proposed date of discharge on Page 1. This is the date in which the TAS provider should have all the items and services listed on Page 1 delivered or completed.
Total Amount Authorized – Enter the grand total listed in Item 13.

17. HHSC/MCO Use Only — Enter the name, mailing address, area code and telephone number of the HHSC/MCO staff. HHSC/MCO staff must sign and date the form to authorize the TAS provider to deliver services.

18. Individual Signature — The provider must obtain the individual's signature and date on this form verifying that the individual received the items and services listed prior to billing for them.

Note: The case manager/service coordinator mails or faxes the form to the TAS provider.
Allow five days between authorization and the completion date.