Revision 15-9; Effective December 15, 2015

 

 

2100 Initial Requests

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code (TAC) §51.201, MDCP Interest List

Individuals requesting Medically Dependent Children Program (MDCP) services must be placed on the MDCP interest list, regardless of the program's enrollment status, according to the date and time of their request. Individuals are released in order of the request date.

An individual is placed on the MDCP interest list at any time by:

  • calling the Community Services Interest List (CSIL) Unit toll-free at 877-438-5658; or
  • contacting the DADS local office in person or by telephone.

When the regional office receives a request for MDCP services, DADS staff inform the individual about DADS services and the MDCP interest list. DADS staff refer the individual directly to the CSIL Unit at 877-438-5658 for placement on the MDCP interest list.

The applicant’s name is added to the interest list if the applicant is less than 21 years of age and resides in Texas. The interest list request date is determined by following TAC §51.201.

DADS local staff must assist individuals with placement on the MDCP interest list if they are unable to do so or do not wish to call themselves.

DADS removes the applicant’s name from the MDCP interest list, according to TAC §51.201.

 

2100.1 Caregiver Support Assessment Initiative

Revision 12-1; Effective May 1, 2012

 

This policy applies to all intakes processed by regional staff for community service programs.

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Department of Aging and Disability Services (DADS) staff to:

  • raise awareness of services available to caregivers;
  • perform outreach functions to informal caregivers;
  • gather information about the needs of caregivers, including the collection of profile data on informal caregivers;
  • provide referral to support services, when appropriate; and
  • implement the use of a standardized caregiver assessment tool to evaluate the needs of caregivers.

SB 271 requires DADS to use the information collected to refer informal caregivers to available support services and to:

  • evaluate the needs of assessed informal caregivers;
  • measure the effectiveness of certain informal caregiver support interventions;
  • improve existing programs;
  • develop new services as necessary to sustain informal caregivers; and
  • determine the effect of informal caregiving on employment and employers.

Form 1027, Caregiver Status Questionnaire (CSQ), is designed to meet the requirements of SB 271. The information collected will be analyzed and included in DADS' report to the governor and the Legislative Budget Board. DADS is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

When possible, the CSQ will be completed at the time of the intake contact. If not feasible, one additional contact with the caregiver must be attempted within five business days. (In situations where it is necessary to go beyond the five-business-day period, document the reason in the comments section of the CSQ.) When a follow-up contact is made, enter the date on the top right corner of the CSQ, just under the NTK menu bar. Check the appropriate box to indicate if the attempt to contact failed or if the caregiver declined to participate.

The purpose of the CSQ is to collect the information described above. This information is not being used to determine unmet need criteria, and is not forwarded to the case manager.

Question Sensitivity

Some staff may find it awkward to ask some of the questions on the CSQ. While understandable, all the questions must be asked and a response recorded for each. It is not acceptable to skip a question. If an individual seems resistant to answer any of the questions, do not insist on a response. Simply document the individual refuses to answer and continue to the next question.

Caregiver Employment

Check boxes have been provided as a means to record the ways caregiving responsibilities have affected the caregiver's employment. After asking the open-ended question, listen to the caregiver's comments and check all of the boxes that apply. Staff are not expected to read aloud each possible response to the employment question; however, the list can be used as a prompt if the responder is unsure how to answer. If the individual seems uncertain, read aloud the response category headings. For example, "Has caregiving affected your employment schedule, pay, leave, performance or work relationships?" If further clarification is necessary, staff may ask, "For example, have you had to take extra leave or change your work schedule to meet your caregiver responsibilities?"

Referral to the Area Agency on Aging (AAA)

If the individual meets one of the following criteria, he may qualify for services from AAA. If so, and if the individual indicates he would like assistance, make the referral according to regional procedures.

AAA Eligibility Screening Criteria

The individual may qualify for services from AAA if he is:

  • 60 years of age or older and is caring for an individual of any age;
  • 55 years of age or older and is caring for a grandchild under the age of 18 in his/her home because:
    • the biological or adoptive parents are unable or unwilling; or
    • he has legal custody or guardianship; or
    • he is raising the child informally; or
    • he is caring for an individual age 19-59 with severe disabilities; or
  • a caregiver for an individual of any age who has Alzheimer's or dementia.

Accessing the CSQ

A copy of Form 1027 should be used when the automated system is unavailable; however, all information must be entered in the automated system as soon as possible. The CSQ, which includes a script and instructions on recording responses, may be useful for staff completing the CSQ for the first few times. Follow the instructions below to complete the CSQ.

  1. Conduct intake per usual procedures using the NTK system.
  2. At the Client Information screen, document whether the individual requesting services has a caregiver. If there is a caregiver, the CSQ must be completed at the end of the intake process if the caregiver is available. If the caregiver is not available, document the caregiver contact information. At least one follow-up attempt must be made to contact the caregiver at a later date.
  3. Select the "Caregiver" tab on the NTK section selection menu.
  4. Enter the information on the Caregiver screens, as requested.
  5. If, at the end of the CSQ, it appears the individual requesting services may qualify for services from AAA, make a referral following regional procedures.

It is possible that staff could conduct multiple assessments in situations where DADS staff receive more than one request for services for an individual. Staff should always assume there is no assessment and proceed as usual. If the caller states he has completed the caregiver assessment in the past, staff should not ask him to complete the assessment again. Staff may exit the caregiver screen by selecting "yes" at the top of the page to the question: "Caregiver declined to answer?" In the comments section at the bottom of the page, document that an assessment has already been conducted for that caregiver.

 

2110 Interest List Release and Notification

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.211, Enrollment

The DADS Community Services Interest List (CSIL) Unit:

  • identifies the individuals to be released from the MDCP interest list;
  • conducts a Texas Integrated Eligibility Redesign System (TIERS) inquiry to determine each individual's Medicaid enrollment status; and
  • sends a list by email of individuals released from the MDCP interest list to the appropriate regional MDCP supervisor for assignment to a case manager.

Within five calendar days of receipt of designated names from the CSIL Unit, the regional MDCP supervisor assigns case managers and returns the list of names and assigned case managers to the CSIL Unit.

Within three business days of receipt of the assigned case managers, the CSIL Unit:

  • mails an enrollment packet and letter notifying the individual of release from the MDCP interest list and provides the name of the assigned case manager; and
  • notifies the regions the individuals have been released from the MDCP interest list.

The enrollment packet sent to the individual contains:

  • an interest list release notification letter identifying the individual's assigned case manager and a request for a response to confirm interest in applying for MDCP services;
  • Form 2439, Selection Acknowledgement, to confirm interest in applying for MDCP services;
  • an MDCP frequently asked questions (FAQ) information sheet;
  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form 0003, Authorization to Furnish Information.

The individual has 60 days from the date of the MDCP interest list release notification letter to complete and return enrollment materials to the case manager. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services, the individual may request to remain on the MDCP interest list, but will be placed at the bottom of the list.

 

2110.1 Rural Addresses

Revision 12-1; Effective May 1, 2012

 

The U.S. Postal Service (USPS) is phasing out rural route addresses as a result of local 9-1-1 systems converting business and residential rural routes to street-style addresses. Mail carriers will continue to deliver mail showing either address to allow time for changing to the Coding Accuracy Support System (CASS) standardized address. Since this address change is not the result of a residential move, a change of address form is not required.

In July 2008, official USPS notices were sent to affected rural route addresses notifying residents of the address change. In August 2008, the new addresses were introduced in the USPS address database. At some time in the future, mail addressed to rural routes not showing the new CASS address will be returned to the sender with the notice "Undeliverable as Addressed."

 

2110.2 Referrals from Midland Document Processing Center

Revision 13-1; Effective February 1, 2013

 

When the Document Processing Center (DPC) receives an application in which a request is made for a Department of Aging and Disability Services (DADS) program or service, the DPC will fax only the first three pages of the application and a cover sheet to the DADS local office. DADS staff will review each of the referrals and contact the applicant to determine if he is interested in a DADS program or service.

If it is determined the applicant is interested in a DADS program or service without an interest list, DADS staff will complete an intake for the program or service requested and access the Health and Human Services Commission (HHSC) Benefits Portal to print a complete copy of the application.

To print the application, DADS staff must access the HHSC Benefits Portal and select the PT Inquiry tab. Once the PT Inquiry is open, select Inbound Correspondence Image Repository Search and search for the applicant. Select the appropriate document and click view. When the document opens, click on the printing icon to print the application.

If the applicant is interested in a program or service with an interest list, the applicant will be placed on the interest list and DADS staff will not need to print a copy of the application.

If the applicant is not interested in a DADS program or service or one with an interest list, DADS staff must file the fax from DPC following local office procedures.

 

2120 Transfer of Individuals Between Waiver Interest Lists

Revision 12-1; Effective May 1, 2012

 

If an individual is denied MDCP based on medical necessity, the case manager will inform the individual that he may be placed on an interest list for an alternate program with the original MDCP request date. Regional staff will provide Form 2121, Long Term Services and Supports, and explain alternate service options to the individual.

If the individual requests placement on another program's interest list, the case manager must contact the state office Community Services Interest List (CSIL) Unit staff, the designated regional interest list staff, or the Local Authority serving the individual's county of residence for placement on the requested program's interest list, as applicable.

 

2130 Conflict of Interest

Revision12-1; Effective May 1, 2012

 

DADS staff have an obligation to report any relationship in which a conflict of interest may exist that could result in an unethical or biased business relationship. This applies to all staff involved in awarding benefits and determining eligibility for MDCP benefits.

DADS staff must not work on or review an ongoing MDCP case, nor assist an applicant/individual/responsible party to receive MDCP benefits, if the applicant or individual is a relative (by blood or marriage), roommate, dating companion, supervisor or someone being supervised. DADS staff may not determine eligibility, the need for MDCP services or the amount of services authorized to an applicant/individual in which the relationship may result in a conflict of interest.

DADS staff may provide anyone with an application for MDCP services and information on how and where to apply. DADS staff may help anyone gather any documents the applicant/individual needs to verify eligibility and need for services, but must not take any other role in determining eligibility for MDCP services for an applicant/individual with whom a relationship may result in a conflict of interest.

DADS staff must consult with a supervisor if the applicant or individual is a friend or acquaintance. Generally, case managers should not work on cases or applications involving these applicants/individuals, but the degree and nature of the relationship must be reviewed by the supervisor to determine if a conflict of interest exists.

If DADS staff have relatives (by blood or marriage), roommates, dating companions or close friends who are contracted with DADS to provide MDCP services or who own or are employed by a provider that contracts with DADS to provide MDCP services, staff must not demonstrate any special consideration toward that provider. Referrals to a provider must be based strictly on applicant/individual preference and the applicant's/individual's need for the service the provider offers. In addition, instructions (or lack of instructions) to the provider concerning the delivery of service must be based solely on the applicant's/individual's needs and DADS policy.

DADS staff must complete Form 2115, Conflict of Interest Notification, to inform the supervisor of the relationship. The first-level supervisor must complete the supervisory response section of the form outlining what action, if any, may be necessary and return the signed/dated form to the DADS staff person who initiated the form.

Form 2115 must be completed even if no conflict of interest exists when:

  • a new employee is hired;
  • employee or supervisor transfers occur; and
  • employee evaluations are completed annually.

Staff must complete Form 2115 anytime a potential conflict of interest exists.

 

2140 Creating the Case File

Revision 12-1; Effective May 1, 2012

 

The case manager will create a case file for each referral and information packet provided by the Community Services Interest List (CSIL) Unit.

The case file will include:

  • information received from the CSIL Unit; and
  • progress notes (Form 2405, Narrative Notes) with all entries in chronological order, signed and dated.

If the individual applies and is certified for MDCP services, the active case file will include:

  • a copy of Form 2410, Medical-Social Assessment and the Individual Plan of Care;
  • individual plan of care forms, as appropriate;
  • follow-up documentation of all contacts with the applicant/individual; and
  • other case-specific information, such as correspondence.

All documents must be kept in chronological order with the most recent information on top, progress notes on the left and all other documentation on the right.

Case files are confidential and all health information pertaining to the applicant/individual is subject to the Health Insurance Portability and Accountability Act (HIPAA). Case files for applicants denied MDCP services are retained until the end of the fiscal year, plus five years. Case files for an active MDCP individual are retained for seven years after case closure.

 

2200 Initial Contact

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.211(f), Enrollment

The individual has 60 days from the date of the notification of release from state office to complete and return the required enrollment materials to the case manager.

Staff must contact the individual by telephone within 14 days of the date of the notification from state office or the Community Services Interest List (CSIL) database to determine if the individual received the enrollment packet and confirm interest in applying for MDCP services. The first attempt to contact the individual must be made during the first seven-day period and the second attempt, if needed, must be made during the second seven-day period. All contacts and attempted contacts must be documented in the case file using Form 2405, Narrative Notes.

If staff are unable to contact the individual within 14 days of the date the notification from state office, they must complete Form 2442, Notification of Interest List Release Closure. Form 2442 must include the release date and release closure date, and must indicate that staff have not been able to contact the individual to begin the eligibility determination process. Staff must mail Form 2442 30 days after the date of the notification from state office or the CSIL database.

Staff continue to attempt contact with the individual weekly through the duration of the 60-day period.

Staff should not attempt to contact an individual if DADS receives information about the individual's death. The effective date of the release closure is the date staff received information of the individual's death. Staff must follow procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2210 Scheduling a Home Visit

Revision 15-9; Effective December 15, 2015

 

During the initial telephone contact, staff should schedule a home visit that must be completed by the case manager and regional nurse within seven days of the initial telephone contact with the applicant. If the individual has not received the enrollment packet, the case manager must provide an enrollment packet for completion during the home visit. If the individual has not yet decided to apply for MDCP services, the case manager must review MDCP services with the individual during the home visit.

When scheduling the home visit, staff must request:

  • directions to the home;
  • information required for the Medical Necessity and Level of Care (MN/LOC) Assessment, such as height, weight and blood pressure; and
  • attendance of the individual's primary caregiver.

An individual's delay in obtaining the requested documentation must not delay scheduling the home visit.

If the individual cannot meet within seven days, staff must inform the individual that the home visit must occur within the 60-day period listed on Form 2440, Release from the MDCP Interest List, or the release will be closed. If the individual can meet within the 60-day period, staff must schedule the home visit.

If the individual cannot meet within the 60-day period, but is interested in applying for MDCP services, staff must ask the individual the reason for the delay. Staff must inform the individual that the individual must mail Form 2439, Selection Acknowledgement, indicating interest in MDCP services within the 60-day period and that the individual's request for the delay will be forwarded to the MDCP supervisor.

If the individual cannot meet within the 60-day period and has not made a decision to apply for MDCP services, staff must ask the individual what concerns are preventing the individual from applying for MDCP services. Staff may address the concerns or schedule a telephone interview that will include DADS staff to address the individual's concerns. Staff must inform the individual to contact staff or mail Form 2439 with a decision to either apply or decline MDCP services within the 60-day period or the release will be closed.

If the individual indicates that the enrollment packet has not been received and the individual is unable to meet within the 60-day period, staff must request the current address.

If the address is the same as recorded on the notification from state office or the Community Services Interest List (CSIL) database, complete and mail:

  • Form 2440, Release from the MDCP Interest List (using the release date identified by state office);
  • Form 2439, Selection Acknowledgement;
  • Appendix XIV, MDCP Frequently Asked Questions;
  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form 0003, Authorization to Furnish Information.

If the address does not match DADS records, case managers complete Form 2440 using the date of contact as the mail date on Form 2440. Case managers document a new 60-day time frame on the "Remember to sign and date all of the forms and return them by" section on Form 2440, using 60 days from the date of contact as the date entered in this field. Case managers must mail the enrollment packet with Form 2440 to the individual on the date of contact and continue application procedures using the new date identified on Form 2440.

The case manager and nurse should complete the home visit together whenever possible. The home visit must be conducted on the earliest possible date. If the case manager and nurse cannot visit the applicant's home on the same day, they may conduct separate home visits to prevent delays in determining eligibility for MDCP, but both must complete the home visit within seven days of the initial telephone contact with the applicant.

An individual's request to delay a home visit or inability to keep scheduled home visits is subject to the MDCP supervisor's review, as indicated in Section 2210.1, Scheduling a Home Visit after the Release Closure Date.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2210.1 Scheduling a Home Visit after the Release Closure Date

Revision 15-9; Effective December 15, 2015

 

The initial home visit must be scheduled no later than the release closure date, which is the 61st day after the date of the email notification from state office or the date in the Community Services Interest List (CSIL) database. If the case manager receives the enrollment packet or is contacted by the individual after DADS last attempted telephone contact, but before the release closure date, staff must schedule a home visit within seven days of receiving the notice or contact.

If staff cannot schedule a home visit within seven days due to the individual's schedule, staff must inform the individual that a notice will be mailed and that the home visit must be completed within the time frame on the notice or the release will be closed. Regional staff must complete and mail Form 2442, Notification of Interest List Release Closure, notifying the individual to contact the case manager and be available for a home visit within 10 days of the date on Form 2442 or the release will be closed. If the individual is available for a home visit after the seven-day time frame, but before the 10-day time frame, staff must schedule the home visit and complete and mail Form 2442.

Any requests to exceed the 10-day home visit time frame must be reviewed by the MDCP supervisor. The MDCP supervisor will consider the individual's reason for delaying the application process. The date of the home visit cannot exceed 45 days past the 60 days from the date of the email notification from state office or the date in the CSIL database. Staff must close the release the day it is determined that the home visit cannot be completed during the extended time frame. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed due to inability to conduct a home visit within the required time frame.

Staff must document all attempts to contact the individual in the case file, including certified mail return receipts, using Form 2405, Narrative Notes.

 

2210.2 Outbreak of Transmittable Disease in the General Population

Revision 12-1; Effective May 1, 2012

 

During the time when Texas experiences an increase in serious transmittable diseases in the general population, certain precautions are necessary to ensure the health and welfare of the case manager who may come in contact with an individual reporting he has a contagious illness. While it is important that the required home visit is performed on a timely basis, there may be circumstances that could place the case manager at risk for contracting contagious illnesses.

If a case manager contacts an individual to schedule a home visit and the individual states he has a contagious illness, such as influenza, the case manager must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case manager should schedule a future date for the visit when the individual thinks he will be better. If unable to schedule the visit for a future date, the case manager must contact the individual at least weekly until the home visit can be made. The home visit must be conducted in time for the case manager to redetermine MDCP eligibility and develop a new Individual Plan of Care (IPC) prior to the end date of the current IPC.

Each contact must be documented in the case file on Form 2405, Narrative Notes. This documentation will be considered as an acceptable reason for delaying a required home visit.

 

2220 Declining MDCP Services

Revision 15-3; Effective March 11, 2015

 

Staff must attempt to contact the individual following the contact time frames before the release closure date, which is the 31st day after the date of the email notification from state office or the date in the Community Services Interest List (CSIL) database. If the individual does not confirm interest in MDCP services before the release closure date, regional staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442, Notification of Interest List Release Closure, informing the individual that the release was closed due to not submitting the enrollment materials within the 30 day time frame.

If the individual chooses not to apply for MDCP services during the home visit, the case manager must obtain a signed Form 2439, Selection Acknowledgement, indicating that the individual does not wish to apply for MDCP services. The case manager informs the individual that the release will be closed on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed because the individual does not wish to apply for MDCP services.

If the individual completes and mails Form 2439 indicating no interest in applying for MDCP services, staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed due to being informed that the individual no longer wishes to apply for MDCP services.

If the individual at any time declines MDCP services before the release closure date, staff must close the release on the release closure date. On or before the fifth day after the release closure date, staff must complete and mail Form 2442 informing the individual that the release was closed because the individual does not wish to apply for MDCP services.

If the individual changes his mind after declining MDCP services and contacts the case manager or returns the enrollment materials to apply for services before the release closure date, staff must schedule a home visit within seven days of contact to continue the application process. Staff must follow the home visit time frames as indicated in Section 2210.1, Scheduling a Home Visit after the Release Closure Date, if the home visit cannot be scheduled before the release closure date.

Staff must follow procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2230 Failure to Contact the Individual

Revision 15-9; Effective December 15, 2015

 

Staff must close the release by the release closure date, if staff have not:

  • been able to contact the individual within 60 days of the date of the email notification from state office or the date in the Community Services Interest List (CSIL) database;
  • received confirmation of interest in applying for or declining MDCP services; or
  • received a response after mailing Form 2442, Notification of Interest List Release Closure, requesting a response from the individual.

Within three days after closing the release, staff must notify the CSIL Unit of the release closure following procedures in Section 2500, Contacting the CSIL Unit for Interest List Release Activities.

Staff must not send Form 2442 to the responsible party if the release was closed due to death of the individual.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2300 Initial Home Visit

Revision 13-3; Effective August 1, 2013

 

§51.215 — After DADS mails the enrollment materials as described in §51.211 of this chapter (relating to Enrollment), the case manager and a DADS RN conduct a home visit to:

(1) complete the medical assessment;

(2) complete the social assessment;

(3) develop the IPC as described in §51.217 of this chapter (relating to Individual Plan of Care); and

(4) assist the family in completing the application for Medicaid, if necessary.

The case manager and nurse should complete the home visit together whenever possible following the time frames in Section 2210, Scheduling a Home Visit. If the case manager and nurse cannot visit the applicant's home on the same day, they may conduct separate home visits to prevent delays in determining MDCP eligibility.

Note: DADS staff must not discard the original Form 2410, Medical-Social Assessment and Individual Plan of Care, or any other form or document completed during the face-to-face visit. The case manager must file the original handwritten document in the case file even if the form is typed after returning to the office.

 

2310 Reviewing the Enrollment Materials

Revision 15-3; Effective March 11, 2015

 

Staff must review the enrollment materials with the applicant and provide assistance in completing the required forms.

Form 2439, Selection Acknowledgement — Staff must verify the applicant's choice to apply for MDCP services. Staff must review MDCP services and eligibility requirements, and answer questions if the applicant remains unsure about applying for MDCP.

Form H1200, Application for Assistance – Your Texas Benefits — Staff must follow procedures listed in Section 2360, Applicant Without Medicaid, if the applicant does not currently receive Medicaid. If the applicant is a Medicaid recipient, staff must review the Texas Integrated Eligibility Redesign System (TIERS) to verify the applicant's current Medicaid status.

Form 0003, Authorization to Furnish Information — Staff must obtain written authorization to request and receive applicant information. On Form 0003, the applicant authorizes staff to request and receive information from non-DADS entities to determine program eligibility. Form 0003 must include the applicant's name and signature, if the applicant is 18 or older. A parent, guardian or responsible party must sign for a minor child or adult applicant who is not able to sign the form. The applicant's signature on Form 0003 does not authorize staff to release information.

 

2310.1 Individual is Still Unsure about Applying for MDCP Services

Revision 15-9; Effective December 15, 2015

 

If the individual has not yet decided to apply for MDCP services, the case manager must continue with the home visit and provide and obtain as much information as possible to develop the Individual Plan of Care (IPC). The case manager must inform the individual that a response is needed within 60 days of the date on Form 2440, Release from the MDCP Interest List.

Within three DADS workdays of the home visit, staff must complete and mail Form 2442, Notification of Interest List Release Closure, to the applicant. Staff must attempt weekly contact with the individual up to the release closure date or until a decision is made regarding the application for MDCP.

If the individual decides to apply for MDCP, continue with the application process.

If the individual does not respond or decides not to apply for MDCP services within 60 days of the date on the email notification from state office or the date in the CSIL database, see Section 2220, Declining MDCP Services.

 

2310.2 Explaining Long Term Services and Supports

Revision 15-9; Effective December 15, 2015

 

When conducting the initial assessment, case managers must present Form 2121, Long Term Services and Supports. Document in the case record and on Form H1746-A, MEPD Referral Cover Sheet, that Form 2121 was presented. Send Form H1746-A to Medicaid for the Elderly and People with Disabilities (MEPD) at the same time the financial application is sent for processing.

 

2320 Initiating the Individual Plan of Care

Revision 13-2; Effective May 1, 2013

 

§51.217

(a) The IPC is developed by:

(1) the individual;

(2) the individual's parent or guardian;

(3) the case manager;

(4) a DADS RN; and

(5) any other person who participates in the individual's care, such as the provider, a representative of the school system, or other third-party resource.

§51.219

(a) To maintain enrollment in MDCP, the individual or the individual's parent or guardian must:

(2) Ensure that there is not a 60-day break in services delivery, unless the 60-day break in service is due to extenuating circumstances and the case manager has approved the 60-day break in service.

The case manager determines the services the applicant needs and whether those needs are currently being met by family or other community resources. The case manager must identify the applicant's need for services and discuss service delivery options through MDCP and non-waiver resources.

Before planning the extent of services to be provided through MDCP, the case manager must identify any other sources of services that the applicant may be receiving, including the family's contribution to care giving. Other sources may include:

  • private health insurance;
  • Texas Health Steps – Comprehensive Care Program (CCP);
  • Texas Health Steps – Case Management for Children and Pregnant Women (CPW);
  • community care services (for example, Primary Home Care, Day Activity and Health Services, In-Home and Family Support Program);
  • Early Childhood Intervention (ECI); and
  • school district services.

The case manager must ask the applicant what current sources of services are available or are currently being used. The case manager must also inform the applicant of the requirement to use all possible non-waiver resource options that are either currently available to the applicant or that may become available once the applicant's eligibility is determined.

Case managers must not refer individuals to Local Authorities (LAs) for case management or service coordination. Per Title 40 Texas Administrative Code, Chapter 2, Subchapter L, service coordination funded by Medicaid targeted case management may not be provided to an individual who is receiving waiver services through any waiver program except the Texas Home Living (TxHmL) Program.

With the exception noted above, case managers may continue referring individuals for services not already covered by MDCP following the LA referral process. DADS allows each LA to determine whether an individual may receive general revenue services. For this reason, general revenue services available to the individual may vary throughout the state.

The case manager reviews definitions, criteria and limitations of MDCP services. The case manager must inform the applicant that he must have a need for either Respite or Flexible Family Support services and, if determined eligible, must use either service without a 60-day break in the service.

During the initial home visit, the case manager completes Form 2410, Medical-Social Assessment and Individual Plan of Care, Page 2, Part IIA, Social Assessment, and Page 3, Part IIB, MDCP Schedule Planning Grid.

The MDCP nurse completes Form 2410, Page 1, Part I, Medical Assessment.

 

2330 Assessment for Medical Necessity

Revision 13-4; Effective November 1, 2013

 

§ 51.207

(a) An entity contracted by HHSC determines medical necessity.

(b) A determination that an individual meets medical necessity is valid for one year. An individual must receive a determination of medical necessity annually to remain eligible for MDCP.

If the applicant does not have a current medical necessity (MN) determination, the MDCP nurse must complete the Medical Necessity and Level of Care (MN/LOC) Assessment. The MDCP nurse must inform the applicant that the MN/LOC Assessment requires a physician's signature. The applicant's assistance may be needed to obtain the physician's signature.

The MDCP nurse must also complete and sign Part I – Medical Assessment, of Form 2410, Medical-Social Assessment and Individual Plan of Care. The MDCP nurse may attach additional health information pages, as needed. The MDCP nurse should also complete Form 3653, Cover Letter for the Physician Signature Page, and submit it with the MN/LOC Assessment to the applicant's physician. Included on Form 3653 is a list of MDCP services, the items on the MN/LOC Assessment that require the physician's review and the MDCP nurse's contact information.

Within three DADS workdays of the home visit, the MDCP nurse must submit the MN/LOC Assessment to the applicant's physician for review and signature. At a minimum, staff must attempt weekly contacts with the physician until the MN/LOC Assessment has been returned to DADS. These contacts should be documented in the case file.

Licensed physicians currently practicing in Veterans Affairs (VA) hospitals/facilities and/or military facilities can sign orders for community services even when they do not have a Texas license. This includes signatures on the MN/LOC Assessment.

Within three DADS workdays of receipt of the MN/LOC Assessment, the MDCP nurse must submit the form electronically to Texas Medicaid & Healthcare Partnership (TMHP) for MN determination and Resource Utilization Group (RUG) calculation using TMHP's web-based online portal. TMHP is the entity contracted by the Health and Human Services Commission to determine MN. It is important for the MDCP nurse to review all entries for accuracy before transmitting the MN/LOC Assessment. An MN determination will not appear in the Service Authorization System (SAS) when information on the MN/LOC Assessment does not meet all the required SAS data entry criteria.

An approved initial MN determination is valid for 120 days from submission of an MN/LOC Assessment by the regional nurse to TMHP. If enrollment occurs within 120 days of an MN determination, the case manager does not take further action.

Enrollments After 120 Days of the Initial MN Determination

When enrollment occurs after 120 days and before 181 days of the initial MN determination, the case manager must ask the regional nurse to contact the applicant to determine if there are any significant changes in the applicant’s condition. The regional nurse may conduct a telephone contact, face-to-face contact, or both, to make this determination. A significant change is a decline or improvement in an applicant’s condition that could potentially impact the current MN determination or resource utilization group (RUG) value. The regional nurse will use professional judgment to determine if the applicant has a significant change in condition and inform the case manager of the result. If the regional nurse determines there is no significant change in the applicant’s condition, the regional nurse must inactivate the previously submitted MN/LOC Assessment, create a new initial MN/LOC Assessment using the “Use as template” feature and submit it to the TMHP portal.

If the regional nurse determines there is a change in condition, the regional nurse must make a face-to-face contact to complete a new MN/LOC Assessment. The nurse will inactivate the previously submitted MN/LOC Assessment, create a new initial MN/LOC Assessment using the “Use as template” feature and submit it to the TMHP portal. The nurse must inform the case manager that the new initial MN/LOC Assessment was submitted. The case manager must also adjust the Individual Plan of Care (IPC) if a change to the IPC is warranted.

Enrollments After 180 Days of the Initial MN Determination

When enrollment occurs after 180 days of the initial MN determination, the case manager must ask the regional nurse to make a face-to-face contact to complete a new MN/LOC Assessment. The nurse will inactivate the previously submitted MN/LOC Assessment, and create a new initial MN/LOC Assessment using the “Use as template” feature and submit to the TMHP portal. The nurse must inform the case manager that the new initial MN/LOC Assessment was submitted. The case manager must also adjust the IPC if a change to the IPC is warranted.

Applicants Residing in Nursing Facilities

Some applicants who currently reside in nursing facilities (NF) and receive Medicaid reimbursed NF services will not need an MN/LOC Assessment for MN determination. MDCP recognizes the applicant's current MN and RUG if the applicant begins receiving MDCP services within 60 days of discharge from the NF.

 

2330.1 Authorization to Release Medical Records

Revision 14-1; Effective February 3, 2014

 

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of medical information and gives applicants and individuals privacy rights. HIPAA sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an applicant or individual and that relates to the:

  • past, present or future physical or mental health or condition of the applicant or individual;
  • provision of health care to the applicant or individual; or
  • past, present or future payment for health care delivered to the applicant or individual.

Under HIPAA, agency staff should use standardized forms. The following forms, available in Spanish and English, can be accessed at:

https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms

The privacy notice explains individual privacy rights, DADS responsibility to protect an individual’s health information and how DADS may use or disclose health information. HIPAA requires that DADS distribute the notice to MDCP applicants. The privacy notice is available in both English and Spanish at https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms.

  • Form 1131, Individually Identifiable Health Information Fax Transmittal, must be used by all DADS staff when transmitting protected health information (PHI) by fax.
  • Form 1826-D, Case Information Release, is an authorization to release all or part of an individual's record, which may include PHI. This form is completed when the community services manager receives a request to release information about an individual.

The MDCP nurse must review and provide the applicant with copies of HIPAA-related forms.

An applicant authorizes DADS to obtain or release medical records by completing and signing Form 2076, Authorization to Release Medical Information. The applicant's authorization is necessary for completing and transmitting the Medical Necessity and Level of Care (MN/LOC) Assessment. The MDCP nurse must assist the applicant with completing Form 2076.

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of applicant and individual medical information from DADS records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or individual authorizes release of income verification, including disability income, do not release related case medical information, unless specifically authorized by the applicant or individual.

 

2340 Freedom of Choice

Revision 12-1; Effective May 1, 2012

 

Case managers must review Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, with the applicant. The applicant is given the opportunity to make a free choice between institutional care and the services of the waiver. The applicant signs Form 2417 acknowledging his rights and choice of MDCP services.

If the applicant chooses institutional services, the case manager assists by providing the information on medical necessity and Medicaid to the applicant to take to the nursing facility of his choice.

 

2350 Choosing a Provider

Revision 13-2; Effective May 1, 2013

 

§51.233

(a) The individual or the individual's parent or guardian must choose the provider. The case manager gives a list of providers to the individual or the individual's parent or guardian.

(b) If the individual or the individual's parent or guardian chooses an entity that is not on the case manager's list of providers for a particular service, that service may not begin until the entity contracts with DADS to provide that service.

Case managers must provide a list of MDCP providers to the applicant at the home visit. Applicants/individuals may access the Consumer Directed Services (CDS) option, a Home and Community Support Services Agency (HCSSA), or both for Respite and Flexible Family Support Services. An applicant/individual may only have one HCSSA and one financial management services (FMS) provider.

The applicant must choose a provider within 14 days of the initial home visit. If the applicant is unable to choose a provider during the home visit, a selection must be made within 14 days of the home visit; the case manager must contact the applicant seven days after the home visit to determine if the applicant selected a provider. If the applicant is unable to make a selection on the 15th day, the case manager must offer a provider to begin services from the list of providers on a rotating basis.

For areas in which there is more than one MDCP provider for a specific service, the applicant or individual may choose and/or change providers without restriction.

If the applicant wishes to receive services from an entity that is not on the list, the applicant may encourage the entity to apply for an MDCP provider contract with DADS. The applicant or individual may change providers when the entity becomes an MDCP provider.

 

2360 Applicant Without Medicaid

Revision 12-1; Effective May 1, 2012

 

If the applicant is not eligible for Medicaid, the case manager may assist the applicant in completing the forms required to determine financial eligibility.

Form H1200, Application for Assistance – Your Texas Benefits — The case manager should remind the applicant that questions regarding income and resources are specific for any income or resources under the applicant's name.

Form H3034, Disability Determination Socio-Economic Report — The case manager should remind the applicant that questions regarding socio-economic information are specific for the applicant. Staff must assist applicants in completing Form H3034; however, this form should not contain any DADS staff information.

Form H3035, Medical Information Release/Disability Determination — The case manager should inform the applicant that Page 2 of Form H3035 will authorize release of medical information necessary to determine if the applicant's condition meets Medicaid requirements. Staff must assist applicants in completing Form H3035. The applicant may provide any or all information on Page 2 of Form H3035.

Case managers must refer all questions to the Texas Health and Human Services Commission's Medicaid for the Elderly and People with Disabilities (MEPD) staff.

Case managers must send the completed forms to MEPD staff, as outlined in Section 3110, Medicaid Eligibility for the Initial Application.

 

2370 Explaining Electronic Visit Verification Requirements

Revision 14-1; Effective February 3, 2014

 

Individuals requesting attendant services from a Home and Community Support Services Agency (HCSSA) in mandatory Electronic Visit Verification (EVV) areas are required to participate in EVV by allowing the attendant to use his home telephone to report the start of work and the end of work. If an individual does not have a telephone, the individual must agree to a fixed visit verification device placed in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services. Mandatory areas for EVV may be found at https:hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/electronic-visit-verification.

The case manager must review the EVV information on Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and adequately explain the EVV requirements to the applicant. In areas where EVV is not yet implemented, the case manager explains that this section of Form 2417 is not applicable at this time. The case manager must explain the following points:

  • EVV will not change the services the individual receives.
  • The attendant will need the individual’s permission to use the telephone to call a toll-free number at the start and at the end of work.
  • EVV helps DADS make sure the individual is receiving authorized services.
  • In the regions where EVV has been implemented, EVV is mandatory for all HCSSAs and individuals receiving services from an attendant, unless the individual receives services through the Consumer Directed Services (CDS) option. Failure to cooperate will result in the suspension or termination of services.
  • If the individual does not have a telephone or does not want the attendant to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the attendant’s start and end of work.
  • If the individual has additional questions, the case manager refers him to the selected HCSSA or Financial Management Services Agency (FMSA) for additional information on how EVV works.

If the applicant is interested in the CDS option, the case manager explains that the individual receiving services or a designated representative (DR) is the employer of record and can choose if he wants to use the EVV system or use paper time sheets. The three choices are:

  • Phone and Computer (Full Participation): The CDS employees use the telephone portion of EVV and the employer of record uses the computer portion of the system to perform visit maintenance.
  • Phone Only (Partial Participation): This option allows the employer of record to participate in EVV, but provides some help from the FMSA with visit maintenance. The CDS employee calls in when he or she starts work and calls out when ending work. The employer uses a paper time sheet to document service delivery. The FMSA performs visit maintenance to make sure the EVV system matches the paper time sheet.
  • No EVV Participation: If the employer of record does not have access to a computer, assistive devices or other supports, or feels he cannot fully participate in EVV, he may choose to use a paper time sheet to document service delivery.

The FMSA will have the employer of record complete Form 1722, Employer's Selection for Electronic Visit Verification (EVV), to indicate his choice.

 

2400 Initial Presentation of the Consumer Directed Services Option

Revision 14-1; Effective February 3, 2014

 

§51.235 — An individual may choose to participate in a payment option that allows the individual or the individual's parent or guardian to direct the recruiting, hiring, management, and termination of the individual's attendant or nurse as described in Chapter 41 of this title (relating to Consumer Directed Services Option). The consumer directed services option is available only for respite or adjunct support services.

Case managers must review the Consumer Directed Services (CDS) option with all applicants during the initial home visit. MDCP services available through the CDS option are Flexible Family Support Services and Respite.

Case managers must review Form 1581, Consumer Directed Services Option Overview, with the applicant. The applicant must sign Form 1581, Page 2, acknowledging review and receipt of the form.

If the applicant is interested in the CDS option, the case manager must review Form 1582, Consumer Directed Services Responsibilities, with the applicant. After completing the self-assessment portion of Form 1582 with the applicant, the case manager must assist to determine if the applicant is able to meet requirements for CDS. If the applicant chooses to pursue the CDS option, the case manager reviews Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice.

Refer to Section 2370, Explaining Electronic Visit Verification Requirements, for talking points on explaining Electronic Visit Verification requirements to the applicant requesting the CDS option.

If the applicant is not interested in the CDS option, the case manager informs the applicant that a request to change to the CDS option can be made at any time and will be reviewed annually during the Individual Plan of Care reassessment. The case manager leaves a copy of Form 1581 with the applicant and files the form with the applicant's signature in the case file. The case manager must also review Form 1584 with the applicant and select the "Program Provider – Agency Option" as the choice for MDCP service delivery.

 

2500 Contacting the CSIL Unit for Interest List Release Activities

Revision 12-1; Effective May 1, 2012

 

Staff must notify the Community Services Interest List (CSIL) Unit to change the status of an interest list release.

 

2510 Contacting the CSIL Unit to Report the Status of Interest List Releases

Revision 12-3; Effective November 1, 2012

 

Staff request closure of Community Services Interest List (CSIL) records when an individual cannot complete the application process or when the individual receives an MDCP determination.

CSIL closures are documented on Form 2419, Community Services Interest List (CSIL) Closure Communication, and must be mailed, faxed or emailed to the designated CSIL staff in the state office CSIL Unit. Case managers must use the CSIL closure codes found in the CSIL Closure User Guide. The guide can be found at http://dadsview.dads.state.tx.us/handbooks/csil.

Staff must notify the CSIL Unit of the closure within three calendar days of staff's determination of a need to change the status of the interest list release.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2520 Closing the Interest Release for an Applicant Choosing CLASS

Revision 12-1; Effective May 1, 2012

 

When an individual is offered both MDCP and Community Living Assistance and Support Services (CLASS) and the individual chooses CLASS, Form 2419, Community Services Interest List (CSIL) Closure Communication, is completed to close the MDCP release effective the date DADS is notified of the decision to apply for CLASS. Within three calendar days of this notification, Form 2442, Notification of Interest List Release Closure, must be mailed to the CLASS applicant with a copy of Form 2419 that was mailed, faxed or emailed to the state office CSIL Unit. A copy of Form 2442 must be filed in the MDCP case file. Once Form 2442 is sent to the CLASS applicant, no follow-up contacts with the individual/family are necessary.

If the CLASS application is denied, Form 2442 instructs the individual to contact DADS if he/she wishes to apply for MDCP. When the individual contacts DADS, he/she will be reinstated on the MDCP interest list using the procedures in Section 2530, Contacting the CSIL Unit to Reopen an Interest List Closure.

 

2530 Contacting the CSIL Unit to Reopen an Interest List Closure

Revision 12-1; Effective May 1, 2012

 

Staff must submit a request to the Community Services Interest List (CSIL) Unit to reopen an individual's closed CSIL record for the following reasons.

  • Regional staff were not able to contact the individual before the release closure date.
  • The individual received a dual offer, did not meet eligibility for the alternate waiver program and wishes to apply for MDCP services.

Within three days of receiving the request to apply for MDCP services, staff must fax a completed Form 2067, Case Information, to 512-438-3549 and must include:

  • the release date;
  • the release closure date;
  • the reason for the closure; and
  • the reason for requesting to reopen an individual's closed CSIL record; or
  • a statement indicating that the application for an alternate waiver program was denied and the individual now wishes to apply for MDCP.

The CSIL Unit will notify regional staff the outcome of the request. If an exception is granted, staff must contact the individual and schedule a home visit within seven days of the exception to begin the application process.

If a time frame deadline falls on a weekend or DADS holiday, extend the time frame to the following DADS business day. Staff must document all time frame extensions in the case file using Form 2405, Narrative Notes.

 

2540 Adding Names Back to CSIL

Revision 15-9; Effective December 15, 2015

 

Texas Administrative Code §51.201(e)(f)(g), MDCP Interest List

An individual's name may be added back to the Community Services Interest List (CSIL) when the name has been removed because staff are unable to locate or the individual's failure to respond to attempted contacts. A name is added back if the individual:

  • contacts DADS within 90 calendar days of the closure date and expresses continued interest, the name will be added back with the original date of request; or
  • contacts DADS more than 90 calendar days following the closure date and expresses continued interest, the name will be added back with the current date as the request date.

When the closure occurred during "release" or "assigned" status and the individual is added back to the list, the name may be released for eligibility determination as needed to ensure the region is fully utilizing the slot allocation.

Any exceptions for adding names back to the CSIL with the original date after a 90 day period must be approved by the state office Program Enrollment manager.

 

2540.1 Earliest Date for Adding an Individual Back to CSIL After Denial

Revision 12-1; Effective May 1, 2012

 

The earliest date an applicant may be added back to the Community Services Interest List (CSIL) for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program.

Example: The applicant is released from the MDCP interest list on Aug. 2, 2011. The case manager determines the applicant is not eligible for MDCP on Aug. 28, 2011, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the MDCP interest list is Aug. 28, 2011.

The earliest date an individual may be added back to the CSIL for the same program the individual is denied is the first date the individual is no longer eligible for the program denied. If the individual's name is added back to the interest list prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System will cause the name to be removed from the interest list for that program.

Example: An individual's MDCP services are denied due to denial of medical necessity and end on July 31, 2011. The first date the individual can be added back to the MDCP interest list is Aug. 1, 2011.