Effective Date: 
6/2011

Instructions

Updated: 6/2011

 

Procedure

The services and supports available through the Texas Home Living (TxHmL) Program are divided into two service categories. Each service category is made up of several TxHmL Program service components. Each service category has an annual cost limit referred to as a service category limit. This means that the annual cost of one or more service components in a service category must not exceed the service category limit, unless the Texas Health and Human Services Commission (HHSC) has approved a request to increase a service category limit.

Even if HHSC approves a request to increase a service category limit, the cost of an individual's Plan of Care (IPC) must not exceed the maximum annual cost ceiling of $17,000 per IPC year. This means that the combined annual cost of all the service components in the two service categories must not exceed $17,000 per IPC year. The service components included in each service category are listed below, as well as the annual service category limits.

 

Detailed Instructions

The Local Authority (LA) will complete all the information on the Request to Increase Authorized Amount IPC Cover Sheet and submit it to HHSC Program Enrollment/Utilization Review (PE/UR), along with Form 8628 and any relevant service justifications.

Date — Enter the date the service coordinator completed Form 8628.

Individual Name (Last, First) — Enter the name of the individual (first and last).

CARE ID No. — Enter the Client Assignment and REgistration (CARE) identification number.

Comp Code — Enter the three-digit component code for the program provider.

Effective/Revision Date — Enter the renewal, revision or transfer date of the IPC.

Requested increase is for: (check one) — Check applicable box indicating which service category is requested to be authorized over the service category limit. Check Community Living (CL), Professional and Technical Supports (PTS), or both.

Note: The above information (except for reason for request) is also entered on Page 2 of Form 8628.

TxHmL Service Categories and Service Components

CL Service Category — Enter the correct information for the current IPC costs, current IPC units and the proposed IPC costs for the following service components: (Annual Service Category Limit = $13,600)

  • Community Support
  • Day Habilitation
  • Employment Assistance
  • Supported Employment
  • Respite
  • Financial Management Services
  • Support Consultation

Service Category Total — Enter the total amount of CL costs.

PTS Service Category — Enter the correct information for the current IPC costs, current IPC units and the proposed IPC costs for any of the following service components: (Annual Service Category Limit = $3,400)

  • Nursing – RN
  • Nursing – Specialized RN
  • Nursing – LVN
  • Nursing – Specialized LVN
  • Behavioral Support
  • Specialized Services
    • Physical (PT)
    • Occupational Therapy (OT)
    • Dietary (DI)
    • Audiology (AU)
    • Speech and Language Pathology (SP)
  • Adaptive Aids (AA)*
  • AA Requisition Fee
  • Minor Home Modifications (MHM)*
  • MHM Requisition Fee
  • Dental*
  • Dental Requisition Fee

Service Category Total — Enter the total amount of PTS costs.

Request to Increase Service Category Limits

When an individual's need for a service or combination of services in one service category is such that the annual cost for the service(s) exceeds the annual service category limit, HHSC may approve a request to increase the service category limit as long as the total annual cost of the individual's plan of care does not exceed $17,000. This means that, with HHSC approval, dollars that are not used in one service category may be moved to the other service category if the total annual cost is less than or equal to $17,000.

Based on decisions of the service planning team, a service coordinator may submit a request to increase a service category limit at the time of an individual's initial enrollment, at the time of an annual renewal of an IPC, or at the time the IPC is revised. (Detailed instructions for submitting the request can be found below.)

Service coordinators may be notified of the need to increase a service category limit by the individual receiving TxHmL services, his or her legally authorized representative (LAR) or family member, or the individual's TxHmL program provider.

Before a request to increase a service category limit is made, the service coordinator and other service planning team members should carefully consider the answers to the following questions.

  • Are there any non-TxHmL sources for the services and supports required?
  • Is the service category increase necessary? For the service category under consideration, are the amounts of other service components in that same service category appropriate and necessary or could one of these components be reduced or eliminated?
  • Is the increase necessary to assure the individual's health and welfare in the community or to prevent admission to institutional services?
  • Has the individual's program provider confirmed that there are sufficient unused dollars in the other service category that can be moved to the category to be increased?
  • Has the team carefully considered the individual's future needs for services covered in the service category that will be reduced if HHSC approves the request to increase the limit for the category under consideration?

Critical Points to Remember

  • A service category increase cannot be approved if the total annual cost of an individual's IPC exceeds $17,000.
  • Service component maximum amounts:
    • Adaptive aids are limited to $6,000 per IPC year.
    • Minor home modifications are limited to a lifetime maximum of $7,500; once that lifetime maximum is reached, $300 per IPC year may be used for additional modifications or repairs of modifications.
    • Dental treatment is limited to $1,000 per IPC year.
    • HHSC will not approve a request to exceed these service component cost limits.
  • Service coordinators and program providers must work together to assure that sufficient unused dollars are available to be moved from one category to the other.
  • Available/unused dollars do not include dollars for services that a program provider has encumbered, for example:
    • billed and been reimbursed;
    • billed but has not yet been reimbursed; or
    • provided but has not yet billed.
  • Program providers must exercise caution in calculating the amount of available/unused dollars. Reimbursement will not be available if the total service billing exceeds the annual cost limit or if services are provided that are not included on an approved IPC.

LA Action

The service coordinator will submit Form 8628 to HHSC PE/UR when an individual's need for services in one of the two service categories, as determined by the service planning team, exceeds the annual limit for that service category. This process will require the service coordinator to:

  • enter the IPC renewal/revision into the CARE system (screen L02);
  • indicate the total cost of the IPC and the new service category totals on Form 8628;
  • review CARE screen C72 – "Service Delivery by IPC: Inquiry" by entering D (dollars) on the header screen and checking to ensure there are sufficient unused funds to move from one service category to another; services provided but not billed must also be factored into the amount of unused dollars available;
  • compare the C72 information with the amount noted on Form 8628;
  • document the justification for the need for the increase to a service category limit on Form 8628 or on the Person Directed Plan (PDP) and note that the increase in the service category limit is necessary to:
    • protect the individual's health and welfare; or
    • prevent the individual's admission to institutional services;
  • secure the service planning team members' signatures on the revised IPC indicating their agreement with the proposed services/increases; and
  • route the following information to HHSC PE/UR:
    • Form 8599, Individual Plan of Care (IPC) Cover Sheet;
    • Form 8628, Request to Increase Service Category Limits Worksheet;
    • a copy of the signed IPC (both pages); and
    • written justification of the services (if not already documented on Form 8628).

HHSC Action

HHSC PE/UR will complete the following:

  • review Form 8628;
  • ensure that non-waiver resources have been utilized as appropriate and available (for example, Texas Health Steps [THS]/Comprehensive Care Program [CCP] and/or school for nursing, dental, OT, PT, SP, etc.);
  • request additional information from the service coordinator, if necessary;
  • approve, reduce or deny the request;
  • check the appropriate box regarding the outcome of the review and sign on the line indicated on the TxHmL Request to Increase Authorized Amount IPC cover sheet; and
  • fax the provider and the LA a copy of the IPC Cover Sheet and IPC indicating what services were authorized by the PE/UR reviewer.

If the request is approved, the service coordinator must notify the program provider/individual/LAR of the approval.

If the request is denied, PE/UR will notify the service coordinator of any non-TxHmL program resources that can and should be used to meet the individual's needs, as well as any adjustments made to the IPC.

Note: PE/UR will notify the individual/LAR via certified letter of any service denial. The certified letter will advise the individual/LAR of the right to request a fair hearing.

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