Revision 15-3; Effective March 11, 2015

 

5100 Changes to the Individual Plan of Care (IPC)

Revision 12-3; Effective November 1, 2012

 

 

5110 Interim Plan of Care

Revision 13-2; Effective May 1, 2013

 

When an individual has a significant change in health during the individual plan of care (IPC) period and requests a change to the IPC, the case manager must complete Form 2411, Interim Plan of Care. A change in the individual's Resource Utilization Group (RUG) value does not automatically necessitate a change to the IPC. The case manager must discuss the individual's change in health with the Medically Dependent Children Program (MDCP) nurse. The MDCP nurse will complete a Significant Change in Status Assessment (SCSA) and transmit the assessment to obtain a RUG for the SCSA. The case manager must review the individual's and primary caregiver's needs and determine if a change to the IPC is needed.

If the individual requests a change to the IPC and the case manager determines an IPC change is needed, the case manager completes Form 2411 within 14 days of the change to the Level of Service (LOS) record in the Service Authorization System (SAS). If the case manager manually updated the previous LOS record, the new RUG will not be recorded in SAS. If the case manager manually updated the LOS record in SAS, the case manager must complete Form 2411 within 14 days from the date an updated RUG is received. If there are no errors to the SCSA fields needed to calculate a RUG, the new RUG is calculated upon assessment transmission. It is important for the case manager and MDCP nurse to coordinate their efforts to obtain the updated RUG.

Completion of Form 2411 requires the case manager to calculate a prorated cost limit for the IPC period. The prorated cost limit for the IPC period documented on Form 2411 is based on the cost of authorized services up to the day before the effective date of change, plus the prorated cost limit amount of the new RUG for the remainder of the current IPC period. The prorated cost limit amount for the remainder of the current IPC period is based on the individual's new RUG cost limit divided by the number of days remaining in the IPC period from the Form 2411 effective date.

Case managers must make the effective date on Form 2411, Form 2065-B, Notification of Waiver Services, and all applicable service authorization forms the date the request is processed and approved by the case manager or later. The effective date of the IPC change is the date the case manager processed the request or the date negotiated with the individual, the individual's caregiver and any other person who participates in the individual's care. The date negotiated cannot be a date prior to the date the request was processed.

For example, if a case manager receives a request that results in a change to the IPC on June 5, 2012, and processes the request on June 10, 2012, the effective date on Form 2411 or Form 2412, Budget

Revision, Form 2065-B, and all applicable service authorization forms must be June 10, 2012, or later. The effective date cannot be before June 10, 2012.

Cost of Authorized Services Up to the Day Before the Effective Date of Change

The case manager determines the cost of all authorized services from the IPC begin date up to the day before the effective date of the change by following the instructions on Form 2411.

For Respite and Flexible Family Support Services, the case manager must determine the cost of authorized services by using the weekly units documented in the service authorization forms and multiplying the amount by the number of weeks before the effective date on Form 2411.

To calculate the cost of authorized services for the period before the Form 2411 effective date, the case manager must follow the steps below.

 

Step 1: Review the service authorization form for the amount of waiver service units per week.
Step 2: Determine the total number of days from the start of the IPC and through the date before the Form 2411 effective date.
Step 3: Divide the total number of days by seven to get the number of weeks for the IPC period before the Form 2411 effective date.
Step 4: Multiply the number of weeks by the weekly amount of authorized waiver services to get the number of units authorized for the period before the Form 2411 effective date.
Step 5: Multiply the amount in Step 4 by the unit rate to get the cost of authorized services for the period before the Form 2411 effective date.

Example: An individual's IPC period is Jan. 1, 2011, through Dec. 31, 2011, and the Form 2411 effective date is Aug. 15, 2011.

Step 1: The weekly amount of authorized Respite on Form 2415, Respite Service Authorization, is 25 units per week.
Step 2: The number of days per month: January = 31, February = 28, March = 31, April = 30, May = 31, June = 30, July = 31, August 1-14 = 14, for a total of 226 days.
Step 3: 226 days ÷ 7 = 32.285 weeks
Step 4: Round 32.285 weeks up to 33 weeks
Step 5: 33 weeks × 25 units per week = 825
Step 6: 825 × $10.86 = $8,959.50

$8,959.50 is the cost of Respite authorized up through the day before the effective date of change.

Prorating the Cost Limit Amount for the New RUG

The prorated cost limit amount for the new RUG is based on the number of days from the Form 2411 effective date through the end date of the IPC period.

To calculate the prorated amount for the new RUG, the case manager must follow the steps below.

 

Step 1: Divide the cost limit of the new RUG by the total number of days in the IPC period.
Step 2: Determine the total number of days between and including the Form 2411 effective date and the IPC period end date.
Step 3: Multiply the figure from Step 1 and the figure in Step 2 to get the prorated amount of the new cost limit.

Note: See Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age, if the individual ages out during the IPC period to determine the daily amount for the new RUG cost limit in Step 1 above.

Example: An individual was assessed and received a PE2 RUG value. An individual's IPC period is Jan. 1, 2011, through Dec. 31, 2011, and the Form 2411 effective date is Aug. 15, 2011. The IPC cost limit for PE2 is $22,101.

 

Step 1: $22,101 ÷ 365 days = $60.55 per day
Step 2: The number of days per month: August 15-31 = 17, September = 30, October = 31, November = 30, December = 31, for a total of 139 days.
Step 3: $60.55 × 139 = $8,416.45

$8,416.45 is the prorated cost limit amount available from Aug. 15, 2011, through Dec. 31, 2011.

The case manager adds the cost of authorized services up to the day before the effective date of change to the prorated cost limit amount of the new RUG to obtain the prorated IPC cost limit for the Interim Plan of Care for the IPC period.

Example: Using the amounts in the examples above, $8,959.50 and $8,416.45, the prorated cost limit for this IPC period is $8,959.50 + $8,416.45 = $17,375.95.

Note: The case manager must not complete Form 2411 if the individual's RUG does not change. The case manager completes Form 2412 if there is no change in RUG and an IPC change is needed. See Section 5120, Budget

Revision. If the individual's request for an IPC change includes a change in providers, follow procedures in Section 5140, Provider Transfers During the IPC Period.

The case manager must send a copy of Form 2411 to all providers affected by the IPC change. The case manager must also document all contact with the individual/primary caregiver in the case file, using Form 2405, Narrative Notes.

The case manager completes applicable service authorization forms and Service Authorization System data entry following procedures in Section 4200, Notification and Service Authorization System.

 

5120 Budget Revision

Revision 13-4; Effective November 1, 2013

 

When a change to the individual plan of care (IPC) needs to be made and there is no change in the individual's Resource Utilization Group (RUG), the case manager must review the individual's and primary caregiver's needs for services.

When the individual requests to add or delete any Medically Dependent Children Program (MDCP) service, the case manager must assess the individual's need for the change and determine if the request for the change meets MDCP service criteria.

If the case manager determines an IPC change is needed, the case manager completes Form 2412, Budget

Revision, within 14 days of the request to change the IPC. The case manager must round the units per week for respite or flexible family support services up to the next quarter-hour on Form 2412. The only exception to this is when rounding up to the next quarter-hour would cause the individual to exceed the cost limit. If this occurs, the case manager must discuss the budget with the individual or primary caregiver and round down to the next quarter-hour.

When making changes to the IPC, case managers must make the effective date on Form 2412, Form 2065-B, Notification of Waiver Services, and all applicable service authorization forms the date the request is processed and approved by the case manager or later. The effective date of the IPC change is the date the case manager processed the request or the date negotiated with the individual, the individual's caregiver and any other person who participates in the individual's care. The date negotiated cannot be a date prior to the date the request was processed.

For example, if a case manager receives a request that results in a change to the IPC on June 5, 2012, and processes the request on June 10, 2012, the effective date on Form 2411 or Form 2412, Form 2065-B, and all applicable service authorization forms must be June 10, 2012, or later. The effective date cannot be before June 10, 2012.

Note: The case manager must not complete Form 2412 if the individual has a change in RUG. The case manager completes, Form 2411, Interim Plan of Care, if the individual has a change in RUG and requests changes to the IPC. See Section 5110, Interim Plan of Care. If the individual's request for an IPC change includes a change in providers, follow procedures in Section 5140, Provider Transfers During the IPC Period.

The case manager must send a copy of Form 2412 to all providers affected by the IPC change. The case manager must also document all contact with the individual/primary caregiver in the case file, using Form 2405, Narrative Notes.

The case manager completes applicable service authorization forms and Service Authorization System data entry following procedures in Section 4200, Notification and Service Authorization System.

 

5130 Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age

Revision 12-1; Effective May 1, 2012

 

Applicants/individuals who turn 21 years of age before the annual reassessment will have services based on a prorated cost (see Form 2410, Medical-Social Assessment and Individual Plan of Care). Minor home modifications and adaptive aids should be pursued before the last individual plan of care (IPC) period, if possible.

The prorated cost is based on the applicant's/individual's cost limit and the total number of days before the applicant's/individual's 21st birthday.

To calculate the prorated cost, the case manager must:

  1. divide the applicant's/individual's cost limit by the total number of days in a year (365 days);
  2. determine the total number of days beginning with the start date of the IPC and ending with the date before the applicant's/individual's 21st birthday; and
  3. multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the IPC period for which the applicant/individual is eligible.

Example: The individual's 21st birthday is July 9, 2012, and his IPC period begins on April 1, 2012, and ends on July 8, 2012. The cost limit is $25,000.

Step 1: $25,000 ÷ 365 days = $68.49 per day
Step 2: The number of days per month: April = 30, May = 31, June = 30, July 1-8 = 8, for a total of 99 days.
Step 3: $68.49 × 99 = $6,780.51

$6,780.51 is the prorated cost limit for the individual for the IPC period.

 

5140 Provider Transfers During the IPC Period

Revision 15-3; Effective March 11, 2015

 

The case manager must follow procedures in Section 5110, Interim Plan of Care, or Section 5120, Budget

Revision, as applicable to complete the provider transfer as a change to the individual plan of care (IPC).

Establishing Effective Dates for Provider Transfers

The case manager must complete the provider transfer within 14 days of the documented date of the individual's request to change providers. The case manager must negotiate the effective date of the change with the individual/caregiver and the providers. If the case manager negotiates a transfer effective date beyond 14 days of the request, the case manager must document the reason on Form 2405, Narrative Notes, and document the individual's/caregiver's participation in the decision regarding the delay. Form 2065-B, Notification of Waiver Services, authorizing the provider transfer, must be signed by the 14th day. Acceptable service authorization delays, such as a delay in receiving information from a contracted provider, must be documented in the case file using Form 2405.

Terminating the Losing Provider's Service Authorization

Upon completion of Form 2065-B authorizing the provider transfer, the case manager must also document the losing provider's authorization termination using:

  • Form 2414, Flexible Family Support Services Authorization;
  • Form 2415, Respite Service Authorization; or
  • Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.

The case manager may use the service authorization form initially used to authorize the service. The case manager terminates the service authorization by checking the box labeled "Your service authorization is cancelled effective" and adds the date, which must be the day before services begin with the gaining provider. The case manager must cancel the losing provider's authorization within the same 14-day time frame to complete the provider transfer.

Updating Service Authorization System (SAS) Service Authorization Records

When an individual transfers from one provider to another, the case manager must verify the number of units or the cost of services delivered by the losing provider from the authorized start date through the day before the IPC change is effective. The case manager must then determine the number of units or the costs of services that will be delivered by the receiving provider from the effective date of the change to the end of the IPC period.

The case manager must use Form 2067, Case Information, to request the:

  • total number of units for Respite and/or Flexible Family Support Services delivered by the Home and Community Support Services provider delivered from the authorized start date through the day before the IPC change effective date;
  • amount of funds allocated from the Financial Management Services Agency, for Respite and/or Flexible Family Support Services; or
  • total cost of adaptive aids, minor home modifications or Transition Assistance Services delivered to the individual up to the IPC change effective date.

The case manager will use the provider's written response to update the SAS Service Authorization records and complete changes to the IPC. If the provider does not respond to the request for information, the case manager must follow up with the provider before the 14th day of the individual's request to change providers. The case manager may follow up with the provider by telephone contact or send an additional Form 2067. See Section 4233, SAS Data Entry Procedures for FMSA Provider Transfers, for SAS procedures.

 

5141 FMSA Transfers During the IPC Period

Revision 15-3; Effective March 11, 2015

 

When an individual requests to transfer Financial Management Services Agency (FMSAs), the case manager must request the following on Form 2067, Case Information, from the losing FMSA for each service delivered through the Consumer Directed Services (CDS) option and each employee type the:

  • amount of funds allocated in the individual's budget based individual plan of care (IPC) up until the day before the transfer date; and
  • number of units and the amount of funds remaining in the individual's budget for each service available on and after the scheduled transfer date.

Completing the IPC Change Form

Use Form 2412, Budget

Revision, to complete the provider transfer. If the individual has a change in the Resource Utilization Group (RUG) that coincides with a request to change the FMSA, the case manager must use Form 2411, Interim Plan of Care. On the applicable IPC form, the case manager uses the FMSA response regarding funds allocated in the individual's budget up until the day before the transfer date to complete the information for services authorized before the date of the IPC change. The case manager uses the FMSA response regarding the number of units and the amount of funds remaining in the individual's budget for each service available on and after the scheduled transfer date to complete the information for services authorized on the date of the IPC change.

If the transfer date occurs on any date other than the first of the month, the case manager uses the same procedures above to document Respite and/or Flexible Family Support Services delivered through the CDS option on the IPC form. To document the monthly Financial Management Services (FMS) fee, the case manager must document the number of whole months plus half a unit for the period before the transfer date and after.

Example: An individual whose IPC period is January through December requests an FMSA change effective August 5. On the IPC form, the case manager documents 7.5 units of FMS for the losing FMSA and 4.5 units of FMS for the gaining FMSA.

The sum of both units must equal the total number of calendar months in the individual's IPC period. The case manager does not change the total number of FMS units in the individual's IPC to complete this provider transfer.

The case manager sends the IPC form to the individual/primary caregiver and the gaining FMSA.

Completing Service Authorization Forms

The case manager uses the FMSA response for the number of units and the amount of funds remaining in the individual's budget for each service available on and after the scheduled transfer date to complete Form 2402, Consumer Directed Services Option – Services Authorization, for the period effective the transfer date through the end of the IPC. The case manager completes Form 2065-B, Notification of Waiver Services. In the Beginning on field, the case manager enters the transfer date and in the comments, indicates Change in Financial Management Services Agency. In the Provider Authorization field, the case manager lists the losing FMSA with the date effective the first day of the current IPC the FMSA was authorized to deliver services and the termination date is the day before the transfer date. The case manager lists the gaining FMSA with the effective date the same as the transfer date. The termination date for the gaining FMSA may be left blank or the case manager documents the last day of the current IPC period.

The case manager sends both Form 2402 and Form 2065-B to the individual/primary caregiver and the gaining FMSA. The case manager sends Form 2065-B to the losing FMSA. The case manager does not send Form 2402 to the losing FMSA.

See Section 4233, SAS Data Entry Procedures for FMSA Provider Transfers, for SAS procedures.

 

5142 Assessing an Individual's Satisfaction When a Change in Provider is Requested

Revision 12-1; Effective May 1, 2012

 

When a request to change providers is made, within the 14-day time frame to complete the change to the service plan for provider transfers, the case manager must contact the individual and the provider to determine:

  • the individual's reason for dissatisfaction; and
  • whether the individual's satisfaction can be accomplished without changing providers.

The case manager must first attempt to resolve any problems the individual may have with the current provider before he processes the transfer.

The case manager must consider if the dissatisfaction is due to services not being provided according to the service plan, problems with the attendant, problems with the provider or the individual's failure to comply with the service plan.

The case manager may request a meeting with the individual, primary caregiver and others participating in the individual's care to discuss and find a resolution to the service delivery issues, if possible.

Within the 14-day time frame to process the service plan change, the case manager authorizes the transfer if:

  • he determines that the individual's satisfaction cannot be met without the individual changing providers and services do not have to be terminated based on failure to comply with the service plan; or
  • the individual continues to request a provider transfer and the case manager determines that services do not have to be terminated based on failure to comply with the service plan.

The individual will continue to have the freedom to choose/change providers without restriction. However, the case manager should follow current program procedures to terminate the individual's services if the individual repeatedly refuses to comply with the service delivery provisions by directly, or knowingly and passively, condoning unacceptable behavior of someone in his home.

The case manager must follow Section 5140, Provider Transfers During the IPC Period, for information related to provider transfers and Section 5400, Convening a Meeting to Resolve Issues, for information related to convening a meeting with applicable individuals.

 

5143 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 12-3; Effective November 1, 2012

 

A provider may report it will no longer serve the individual due to health and safety concerns. In some situations, the case manager may initiate services with a new provider. The case manager must make a referral to a new provider and must determine how much information to share with the new provider regarding the previous actions.

The case manager must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

The case manager must use good judgment in determining the needed information to share and, if in doubt, consult with his supervisor for guidance.

 

5200 Service Delivery Issues Reported to DADS Staff

Revision 15-3; Effective March 11, 2015

 

Case managers must report program provider service delivery issues reported or generated by:

  • the individual/individual's representative;
  • Department of Aging and Disability Services (DADS) staff, including issues discovered by the case manager, or reports received during monitoring contacts; and
  • other individuals, including the individual's family/friends.

Service delivery issues include any dissatisfaction expressed by the individual regarding a service delivery provider. The individual may express dissatisfaction about:

  • the quality of a service provided (care, treatment or services received);
  • aspects of interpersonal relationships, such as rudeness; or
  • the service provider's failure to:
    • respect the individual's rights;
    • follow terms of the contract or applicable rules; or
    • provide services which may or may not have had an adverse affect on the individual.

This list is not all inclusive.

Within five working days of receiving a report or becoming aware of service delivery issues, the case manager must respond to the individual and the provider either by phone or face-to-face contact to discuss the issues. The case manager must inform the provider of the service delivery issues and discuss resolutions. The case manager convenes an interdisciplinary team (IDT) meeting, if appropriate. The case manager coordinates with the individual and provider to implement actions required to resolve the issues. The case manager must document the receipt of the report and contacts with the individual and the provider in the case record. The case manager must document any barriers or hindrance by either party that interferes with resolution of the issues. The resolution of the issues and/or attempts to resolve the issues must be documented.

If service delivery issues cannot be resolved within 10 working days of the initial receipt of a report or becoming aware of service delivery issues, the case manager must:

  • report the service delivery issues to the Consumer Rights and Services (CRS) hotline at 1-800-458-9858;
  • inform the individual of his right to call the CRS hotline to register a complaint regarding the provider, including a Financial Management Services Agency (FMSA); and
  • inform the individual of his right to choose another provider.

The case manager must make the report to CRS within three working days after the 10- working-day resolution period ends.

In situations where service delivery issues may compromise the individual's health and safety, the case manager must call CRS as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case manager must also contact Adult Protective Services or Child Protective Services within 24 hours if there is an immediate or imminent threat to the health and safety of the individual. The case manager must continue to work with the individual and provider to resolve the issues within the 10-working-day time frame.

The case manager must identify the specific service the provider is delivering when calling CRS to report a complaint. For example, the case manager identifies the provider as an "MDCP provider" when making a referral to CRS that involves MDCP service delivery issues. The case manager must provide specific information related to the service delivery issue, including actions taken to resolve the issues and why the actions did not resolve the issue. CRS will log the information into the automated system and forward the complaint to the appropriate DADS division for action.

 

5300 Service Delivery Issues Reported by the Provider

Revision 12-1; Effective May 1, 2012

 

§51.417

(a) Required notification. A provider must notify the case manager if:

(1) the individual's primary caregiver refuses to comply with the IPC;

(2) the provider is unable to verify the individual's Medicaid eligibility as required in §51.405 of this chapter (relating to Monitoring Medicaid Eligibility);

(3) the provider is unable to begin services on the service initiation date. This notification must include:

(A) an explanation of why there is a delay in the service initiation date; and

(B) an expected date that services will begin; or

(4) the provider makes any changes in service delivery.

(b) Method and deadline for notification.

(1) The provider must notify the case manager orally or by fax about any circumstance described in subsection (a) of this section no later than one working day after awareness.

(2) If the provider's notification is oral, the provider must speak directly with the case manager. If the provider is unable to speak directly with the case manager, the provider may leave a telephone message. If the provider leaves a telephone message, the provider must document all attempts to meet the deadline and make a follow-up contact with the case manager within one working day.

(3) If the provider's notification is oral, the provider must send written notification to the case manager within five working days of the oral notification.

The Department of Aging and Disability Services (DADS) requires a provider to notify the case manager of issues that impact service delivery. The provider may notify the case manager of any changes either orally or by written documentation. If the provider notifies the case manager orally, the provider must follow up with written documentation.

 

5310 Primary Caregiver Refuses to Comply with the IPC

Revision 12-1; Effective May 1, 2012

 

The provider may notify the case manager if the primary caregiver does not follow the individual plan of care (IPC). The case manager must contact the primary caregiver to discuss the situation within 14 days of receiving a report of service delivery issues from the provider. The case manager must explain Medically Dependent Children Program (MDCP) service criteria if the primary caregiver does not understand the need and use of MDCP services. If the case manager determines a change to the individual's IPC is necessary, the case manager changes the IPC following Section 5100, Changes to the Individual Plan of Care (IPC). If the issue continues after the initial contact, the case manager must convene a meeting to address the issue. See Section 5400, Convening a Meeting to Resolve Issues.

The case manager must document all contact with the primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5320 Provider is Unable to Verify Individual's Medicaid Status

Revision 12-1; Effective May 1, 2012

 

Each month, the Department of Aging and Disability Services (DADS) requires the provider to verify the individual's Medicaid eligibility. The provider may verify the individual's status by using the current systems available through the Health and Human Services Commission (HHSC).

If the provider is unable to access the individual's Medicaid status after attempting the options available to the provider, the case manager may verify the individual's Medicaid status via the Texas Integrated Eligibility Redesign System (TIERS).

If the case manager is unable to determine the individual's Medicaid status through a database inquiry, the case manager must contact the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works staff if the individual's Medicaid eligibility was previously determined by HHSC staff. If the individual's Medicaid eligibility is based on receipt of Supplemental Security Income (SSI), the case manger contacts the individual to determine if there was a change in the individual's SSI.

If the individual lost Medicaid eligibility, the case manager must follow procedures in Section 5500, Loss of Medicaid.

The case manager must send Form 2067, Case Information, to the provider indicating the individual's Medicaid status. The case manager must send Form 2067 within two working days of determining whether or not the individual was Medicaid eligible. The case manager must also inform the provider if an application for Medicaid will be completed. The case manager must not confirm whether or not the individual will retain Medicaid certification.

The case manager must document all contact with the individual/caregiver in the case file, using Form 2405, Narrative Notes.

 

5330 Provider is Unable to Begin Services on the Service Initiation Date

Revision 12-1; Effective May 1, 2012

 

For an individual with an initial individual plan of care (IPC), if the provider is unable to begin delivering services on the service initiation date, the provider must notify the case manager and explain the reason for the delay in service delivery and identify an expected date that services will begin.

The case manager must contact the individual within three working days of notification by the provider and inform the individual of the delay in services. The individual has the right to choose another service provider if he requests a change in the provider.

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5340 Provider Initiated Changes to the Delivery of Services

Revision 13-2; Effective May 1, 2013

 

If the provider notifies the case manager of any changes in service delivery, the case manager must determine if the change in service delivery requires a change to the individual's individual plan of care (IPC). If the change in service delivery does not require a change to the IPC, the case manager documents the provider's reason for the change in the case file. The case manager must contact the individual if the change in service delivery requires a change to the IPC. If the individual agrees with the change, the case manager completes the change to the IPC following procedures in Section 5100, Changes to the Individual Plan of Care (IPC). If the individual does not agree with the change, the case manager must contact the provider and resolve the provider's change in service delivery. The provider may not exceed the amount of services already authorized on the IPC.

If the change in service delivery results in a 50 percent increase of monthly services, the case manager follows procedures in Section 4114, Respite Service Schedule Changes, if the request is for Respite, or Section 4126, Service Schedule Changes to Flexible Family Support Services, if the request is for Flexible Family Support Services. If the individual did not prior request the service schedule change, the provider did not follow the IPC or the service authorization form. If the provider did not follow the IPC or the service authorization form, the case manager follows provider complaint procedures identified in Section 5200, Service Delivery Issues Reported to DADS Staff.

The case manager must resolve all actions including all contacts and any IPC change within 14 days of the provider's first method of notification.

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5400 Convening a Meeting to Resolve Issues

Revision 12-1; Effective May 1, 2012

 

The case manager may request a meeting with the individual, primary caregiver and others participating in the individual's care to resolve issues or concerns regarding the individual's care.

Depending on the nature of the issue or concern, the case manager may:

  • counsel the individual/primary caregiver regarding program requirements or service criteria;
  • advocate on the individual's behalf with the provider; or
  • advocate on the individual's behalf with those delivering third-party resources.

The case manager must document all contact with the individual/caregiver and provider in the case file, using Form 2405, Narrative Notes.

 

5500 Loss of Medicaid

Revision 12-1; Effective May 1, 2012

 

When the case manager is made aware of the individual's loss of Medicaid, the case manager should immediately contact the individual to:

  • inform him of the loss of MDCP services;
  • discuss possible continuation of Medicaid benefits based on individual options identified in this section; or
  • confirm his decision to terminate MDCP services if no longer needed.

See Section 1340, Financial Eligibility, for financial eligibility criteria. The case manager must determine the reason for the loss of Medicaid and follow the procedures below.

If the case manager is made aware an individual is pending a Medicaid denial, the case manager should immediately inform the individual to submit any necessary documentation to continue Medicaid eligibility to avoid the risk of losing MDCP eligibility.

The case manager must document all contact with the individual/primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

Loss of Medicaid ME-Waivers

An individual who loses Medicaid ME-Waivers eligibility must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. The Department of Aging and Disability Services (DADS) will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on Medicaid ME-Waivers and he loses Medicaid, the individual has two options. The individual may:

  • appeal the Medicaid denial and the MDCP denial; or
  • accept the loss of Medicaid and MDCP services.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual or contact the Medicaid for the Elderly and People with Disabilities (MEPD) staff to verify this information.

If the individual has Medicaid ME-Waivers financial eligibility determined by MEPD staff and loses the eligibility, the MEPD specialist sends the individual Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, with a copy to the case manager as notification of the Medicaid denial. The case manager must coordinate the MDCP denial date with the Medicaid denial effective date established by the MEPD specialist. MDCP services cannot continue past the last date of Medicaid coverage.

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232, Service Authorization System (SAS) Data Entry for Service Reductions, Suspensions, Denials and Case Closures.

See Section 9611, Case Manager and Designated Data Entry Representative Procedures, and Section 9611.1, Procedures for Loss of Medicaid, for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

  • Medicaid denial and Medicaid coverage continues; and
  • MDCP denial within 30 days from the date of the notification letter.

The case manager sends Form 2067, Case Information, to the provider(s), indicating MDCP services may continue until a fair hearing decision is made, within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued. See Section 9621.1, Action Taken on Fair Hearing Decision, for procedures after the fair hearing decision.

The case manager should discuss ME-Waivers gaps with the MEPD specialist to determine how long the gap will affect MDCP services. SAS records may remain open if the case manager documents the individual is in the process of providing requested information to MEPD to support continued Medicaid eligibility. If there will be a gap in ME-Waivers coverage, as determined and notified by the MEPD specialist, the case manager follows procedures under Medicaid Recertification below to reinstate MDCP services after the gap period.

The case manager must document all contact with MEPD in the case file, using Form 2405.

Loss of Medicaid Established by MEPD Other than ME-Waivers

When an individual whose MDCP eligibility is based on Medicaid other than ME-Waivers loses Medicaid, he must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. DADS will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on Medicaid other than ME-Waivers and he loses Medicaid, the individual has three options. The individual may:

  • appeal the Medicaid denial and the MDCP denial;
  • apply for Medicaid ME-Waivers; or
  • accept the loss of Medicaid and MDCP services.

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual or contact MEPD staff to verify this information.

See Section 9611 and Section 9611.1 for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

  • Medicaid denial and Medicaid coverage continues; and
  • MDCP denial within 30 days from the date of the notification letter.

The case manager sends Form 2067 to the provider(s), indicating MDCP services may continue until a fair hearing decision is made, within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued. See Section 9621.1.

For an individual whose program eligibility was established by an applicable Medicaid program other than ME-Waivers or Temporary Assistance for Needy Families (TANF), MEPD staff may not know the individual is receiving MDCP services and therefore, may not notify DADS of the loss of Medicaid. The individual may be eligible for TP14/BP13 and a referral may be made to MEPD. When notifying the individual and provider of loss of program eligibility, the case manager must indicate denying services on Form 2065-C in the comments section, and that an application may be submitted to MEPD to determine Medicaid eligibility for MDCP and the possibility of continuation of services once the individual becomes eligible for ME-Waivers. (See below if the individual loses TANF-related Medicaid.)

The case manager must document all contact with MEPD in the case file, using Form 2405.

Loss of Supplemental Security Income (SSI)

If an individual's MDCP eligibility is based on SSI and he loses SSI Medicaid, the individual has two options. The individual may:

  • apply for Medicaid ME-Waivers; or
  • accept the loss of SSI Medicaid and MDCP services.

An individual who becomes financially ineligible for SSI loses SSI Medicaid. For an individual whose eligibility is based on SSI, the case manager does not complete Form 2065-C when he becomes aware of the loss of SSI.

Upon receipt of monthly loss of eligibility reports or notification that an individual is being denied Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. The case manager may contact the individual, obtain a copy of the letter from the Social Security Administration (SSA) or contact the local SSA office to verify this information.

If the individual accepts the loss of SSI Medicaid and MDCP services, the case manager completes and sends Form 2065-C, notifying the individual of denied MDCP services.

If Medicaid will be reinstated the beginning of the next month without a gap in coverage, no further case manager action is required.

For an individual whose loss of Medicaid will result in a gap or SSI will be denied ongoing, the case manager must immediately begin the ME-Waivers financial eligibility process with MEPD. The case manager must obtain Form H1200, Application for Assistance – Your Texas Benefits, and as much verification documentation as possible and send to the MEPD specialist. No later than the close of business on the second working day following the date of receipt of Form H1200, the case manager must fax or mail Form H1200 to the Midland Document Processing Center (DPC).

If the case manager faxes Form H1200 to DPC, he must not send the original to the DPC. DADS staff must retain the original Form H1200 with the individual's valid signature in the case file. The original form must be kept for three years after the case is denied or closed. Case managers must also retain a copy of the successful fax transmittal confirmation in the case file.

If unusual circumstances exist in which the original must be mailed to DPC after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case file. Scanning Form H1200 and sending by electronic mail is prohibited. The day DADS receives the Medicaid application form is day zero and starts the two working day time frame.

The case manager requests financial eligibility determination for MDCP on Form H1746-A, MEPD Referral Cover Sheet. All available verifications provided by the individual must be attached. The case manager keeps a copy of all documents and documents the date the application was faxed, hand delivered, or mailed in the case file.

When MEPD receives the Medicaid application form, the MEPD specialist will determine ongoing Medicaid eligibility and/or eligibility for the gap period.

If the individual does not have Medicaid during the period MEPD is determining ME-Waivers eligibility or the individual is working with the SSA to reinstate SSI Medicaid, MDCP services are suspended by sending Form 2067 to the MDCP providers. If the ME-Waivers application form is not received from the individual, financial eligibility is denied or SSI Medicaid will not be reinstated, the case manager must:

  • notify the individual via telephone (or letter, if the individual does not have a telephone) of the termination of MDCP services;
  • complete and send Form 2065-C to the individual and provider(s), denying MDCP services based on no Medicaid coverage effective the last date of Medicaid coverage; and
  • ensure MDCP services are terminated in SAS.

An individual may appeal the ME-Waivers and MDCP denials; however, MDCP services may not continue during the appeal process due to lack of Medicaid coverage.

SAS records may remain open if the case manager documents the individual is actively in the process of applying for ME-Waivers eligibility or providing requested information to support continued SSI Medicaid eligibility.

Some individuals may be ineligible for SSI for a short period before SSI is reinstated. This might occur when eligibility is based on the parent(s)' earned weekly income, normally with four paychecks although five paychecks are received in some months. In these situations, the case manager must work with the individual and MEPD to prevent a gap in waiver coverage. The case manager must assist the individual in submitting the Medicaid application form. If ME-Waivers eligibility criteria are met, the MEPD specialist will certify the individual for Medicaid for waivers, and notify the case manager of the Medicaid eligibility for the gap in SSI coverage. If an SSI Medicaid gap period reoccurs, MEPD will use the same application to determine eligibility for the subsequent gap periods for up to a year from receipt of the Medicaid application form.

The case manager must document all contact with SSA and MEPD staff in the case file, using Form 2405.

Loss of TANF-Related Medicaid

An individual who loses TANF-related Medicaid must be denied MDCP services and provided notification of lost program eligibility. The case manager must complete and send Form 2065-C within two working days of verifying the loss of Medicaid to the individual and the provider(s). The case manager must coordinate the MDCP denial date with the Medicaid denial effective date. MDCP services cannot continue past the last date of Medicaid coverage. The case manager also sends all applicable service authorization forms to the provider(s) cancelling the authorization. The MDCP denial effective date is the last date of Medicaid coverage. DADS will not reimburse providers for services delivered when the individual does not have Medicaid, even if the individual files a timely appeal.

If an individual's MDCP eligibility is based on TANF-related Medicaid and he loses Medicaid, the individual has three options. The individual may:

  • appeal the Medicaid denial and the MDCP denial;
  • apply for ME-Waivers; or
  • accept the loss of Medicaid and MDCP services.

Upon notification that an individual was denied or is being denied TANF-related Medicaid, the case manager must determine if Medicaid will be reinstated at the beginning of the following month without a gap, if the loss is for one month, or if the Medicaid denial is ongoing. An individual whose eligibility is met with TANF-related Medicaid will not appear in the monthly loss of eligibility reports sent to the region. The case manager may contact the individual, obtain a copy of the denial letter from Texas Works (Form H1017, Notice of Benefit Denial or Reduction, or TF0001, Notice of Case Action), or contact the local Texas Works office to verify this information.

If the individual does not appeal the Medicaid and MDCP denials, no further case manager action is required. The case manager updates SAS records following procedures in Section 4232.

If TANF-related Medicaid will be reinstated the beginning of the next month without a gap in coverage, follow procedures below regarding Medicaid Recertification.

See Section 9611 and Section 9611.1 for policy when an individual appeals both the Medicaid denial and MDCP denial.

If requested by the individual, DADS may continue MDCP services if the individual appealed the:

  • Medicaid denial and Medicaid coverage continues; and
  • MDCP denial within 30 days from the date of the notification letter.

Within two working days from the day the case manager verified the individual requested a fair hearing to appeal the Medicaid and MDCP denials and Medicaid benefits continued, the case manager sends Form 2067 to the provider(s) indicating MDCP services may continue until a fair hearing decision is made. See Section 9621.1.

For individuals whose loss of TANF-related Medicaid will result in a gap or Texas Works benefits will be denied ongoing, the case manager must immediately begin the ME-Waivers financial eligibility process with MEPD following the procedures identified in Loss of Supplemental Security Income (SSI), above. In the comments section of Form 2065-C denying services, the case manager must inform the individual that an application may be submitted to MEPD to determine Medicaid eligibility for MDCP, and the possibility of continuation of services if the individual is eligible for ME-Waivers.

The case manager must document all contact with Texas Works staff in the case file, using Form 2405.

Medicaid Recertification

Upon notification the individual's Medicaid status is reestablished and provided all eligibility criteria are met, the case manager completes Form 2065-B, Notification of Waiver Services, since Form 2065-C was completed to notify the individual and providers of loss of eligibility. In the comments section of the form, the case manager indicates MDCP services may resume effective the date of the Medicaid recertification effective date. The case manager completes and sends Form 2065-B to the individual and the provider(s) within two working days of verifying Medicaid recertification. The case manager must also send all applicable service authorization forms to the individual and provider(s). The case manager does not change the number of units on the new service authorization form. If the individual had a gap in services due to Medicaid ineligibility, the case manager documents in the comment field services were suspended for the duration the individual did not have Medicaid. Example: Waiver services were suspended from May 1, 2012, to May 31, 2012, due to gap in Medicaid coverage.

If the individual's Medicaid status is re-established due to an appeal, follow procedures in Section 9621.3, Procedures for Reversed Decisions.

 

5510 Coordination of Fair Hearings with the CRU

Revision 12-1; Effective May 1, 2012

 

The Centralized Representation Unit (CRU) represents the Health and Human Services Commission (HHSC) in all Medicaid fair hearings regarding Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works determinations. The CRU replaces the MEPD and Texas Works specialist in specific steps related to denial of Medicaid applications and ongoing cases. The CRU:

  • represents HHSC Office of Eligibility Services (OES) in fair hearings;
  • completes and implements all Medicaid case actions based on fair hearings decisions; and
  • coordinates actions required with regional MEPD or Texas Works staff and Department of Aging and Disability Services (DADS) staff.

The case manager must coordinate all appeals involving loss of Medically Dependent Children Program (MDCP) eligibility due to loss of Medicaid with the CRU.

The following procedures must be used by the case manager to coordinate appeal actions with the CRU in cases for which MEPD or Texas Works staff determine Medicaid eligibility. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

The applicant/individual may appeal a decision orally, in person or in writing. The case manager is responsible for completing Form 4800-D, DADS Fair Hearing Request Summary. DADS staff file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/individual requests a fair hearing. The method in which the form is completed depends on the action being appealed. The case manager must determine if the appealed action is:

  • a non-Medicaid program denial (excludes MDCP denials based on Medicaid denials); or
  • a program denial based on Medicaid financial eligibility (MDCP denials based on a Medicaid denial action).

If the appealed action is related to a non-Medicaid program denial, the case manager completes Form 4800-D and enters his name as the Agency Representative. In the Other Participants field, DADS staff enter the CRU supervisor and CRU administrative assistant. The CRU supervisor and assistant names must be entered by using the MOR Search function. This will assure that all of the correct information is populated in TIERS and CRU staff will receive the notice of appeal.

If the appealed action is a program denial based on Medicaid financial eligibility, the case manager completes Form 4800-D. In Section 6 of Form 4800-D, DADS staff must select Yes to the question, "Are you an OES Texas Works or MEPD employee?" (DADS staff are responding to this question on behalf of the CRU.) On the Agency Representative page, select Yes in the drop down. Failure to answer yes to this item will result in the CRU not being notified of the fair hearing. DADS staff continue completing Form 4800D and enter the CRU supervisor as the Agency Representative. DADS staff must enter this information through the MOR Search function for the CRU to receive the fair hearing information. DADS staff must list the case manager's name and title in the Other Participants section. The case manager does not enter the name of the local MEPD or Texas Works specialist on Form 4800-D for MEPD financial appeals. DADS staff must include the job title, such as DADS case manager or DADS supervisor. Enter the DADS staff email address and include the CRU administrative assistant in Other Participants. The CRU administrative assistant's information must be entered through the MOR Search function.

When Form 4800-D is sent to the designated data entry representative, DADS staff send an email notification to the CRU supervisor with a copy to the CRU administrative assistant regarding the request for an appeal to the CRU.

The email must include the:

  • applicant's/individual's name;
  • Medicaid number, if available;
  • name of the waiver program; and
  • specific information requesting the Medicaid financial case remain active/open during the appeal, if the applicant/individual appealed in a timely manner. For example, the financial case or application may need to remain open pending an appeal decision regarding medical or functional eligibility. DADS staff must notify the CRU to keep the Medicaid case open pending the fair hearings decision.

Upon receipt of notification of an appeal, the CRU requests the Medicaid evidence packet from the local MEPD or Texas Works specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent HHSC at the fair hearing, if required, and takes steps to ensure the appropriate Medicaid financial case action is taken once a fair hearings officer's decision is rendered.

When an MDCP denial fair hearings decision is rendered by the fair hearings officer, DADS staff (staff name entered as Agency Representative) will be notified via email of the decision by the fair hearings officer. Based on the fair hearings decision, the case manager determines the appropriate action for MDCP services according to specific time frames. The case manager may need to coordinate effective dates of reinstatement with the CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. DADS staff report the implementation of the fair hearings decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

For individuals with Medicaid ME-Waivers, the local MEPD specialist will continue to notify DADS staff if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to the CRU to handle during the appeal process. Once the appeal decision regarding the Medicaid eligibility is rendered by the fair hearings officer, the CRU will notify DADS staff via email of the fair hearings decision, including decisions that are sustained, reversed or withdrawn. Based on the fair hearings decision, the case manager determines the appropriate action for MDCP. The email sent by the CRU will include:

  • the applicant's/individual's name;
  • Medicaid number;
  • a copy of the fair hearings decision; and
  • the effective or denial date of Medicaid eligibility.

DADS staff must not put an applicant/individual back on the MDCP interest list while a Medicaid denial is in the appeal process. The case manager must take appropriate action to certify or deny the case, or resume services once the Medicaid fair hearings decision is rendered. The individual may choose to be added back to the MDCP interest list once the case manager denies MDCP.

 

5520 Case Manager Responsibilities and Effective Dates of Appeal Decisions

Revision 12-1; Effective May 1, 2012

 

Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must verify the fair hearings officer's decision by obtaining a copy of the decision that is to be filed in the case file.

Sustained Appeal Decisions

When the fair hearings officer's decision sustains the denial of Medically Dependent Children Program (MDCP) services, the case manager must:

  • notify the individual via telephone (or letter, if the individual does not have a telephone) of the fair hearings officer's decision and the termination effective date of MDCP services;
  • notify all providers via Form 2067, Case Information, to deliver services through the MDCP termination effective date if services were continued during the appeal process; and
  • ensure MDCP services are terminated in the Service Authorization System (SAS).

Do not send another Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to notify the individual of the sustained denial.

Sustained Appeal Decisions – Effective Dates

When services are terminated at the annual reassessment due to the individual not meeting financial eligibility criteria and services are continued until the appeal decision is known, the MDCP termination date is:

  • 30 days from the fair hearings officer's decision date, the date the order is signed, as recorded on Page 1 of Form H4807, Action Taken on Hearing Decision, when the fair hearing officer's decision date is less than 30 days before the end of the individual plan of care (IPC) in effect when the appeal was filed;
  • 30 days from the fair hearings officer's decision date, as recorded on Page 1 of Form H4807, when the fair hearings officer's decision date is after the end of the IPC in effect when the appeal was filed, and a new IPC was developed to continue services past the IPC end date until the appeal decision was made; or
  • at the end of the IPC in effect at the time the appeal was filed in cases where the fair hearings officer's decision is 30 days or more prior to the end of the IPC in effect when the appeal was filed.

When services are denied during the IPC period, the MDCP termination date is the effective date of the fair hearings officer's decision as recorded on Page 1 of Form H4807.

Reversed Appeal Decisions

When the fair hearings officer's decision reverses the MDCP denial, the case manager must:

  • notify providers via Form 2067, as appropriate, to provide services to individuals as directed in the decision;
  • complete and send Form 2065-B, Notification of Waiver Services, to the individual who was denied at the annual reassessment and all providers to notify them that the denial decision was reversed and the individual is eligible for MDCP services for the new IPC period;
  • complete and send all applicable service authorization forms to the individual and providers;
  • assure the IPC is registered or updated in SAS with the correct services and effective dates; and
  • provide the accurate IPC to the individual and providers.

Reversed Appeal Decisions – Effective Dates

The fair hearings officer's decision date recorded on Form H4807 is considered the eligibility or effective date of MDCP services for all reversed decisions involving services:

  • terminated at the annual reassessment due to the individual not meeting eligibility criteria, regardless if services continued during the appeal process or not.
  • denied during the IPC period.

 

5600 Change of Address

Revision 13-1; February 1, 2013

 

For an individual receiving Supplemental Security Income (SSI) with a change in address, the case manager must inform the individual or his primary caregiver to contact the Social Security Administration (SSA) to request the residence address change. DADS staff must not send address change requests for SSI recipients to the Midland Document Processing Center (DPC).

If the individual does not have SSI Medicaid, the case manager must correct the individual’s address in the Service Authorization System (SAS). See Section 11210, Address Area – Initial Service Authorization, for a change of address request for an individual with Medicaid other than SSI.

 

5700 Change in Primary Caregiver

Revision 13-3; August 1, 2013

 

If an applicant’s/individual’s primary caregiver changes after the initial visit, the case manager must contact the new primary caregiver and schedule a face-to-face visit with the new primary caregiver within 14 calendar days of receiving the notification of this change. The case manager must review Medically Dependent Children Program (MDCP) services with the new primary caregiver during the face-to-face visit and evaluate the need for services based on the criteria found in Section 4100, Medically Dependent Children Program (MDCP) Services. The need for services may change and must be assessed while taking into account the new primary caregiver’s schedule. The case manager must assess the individual’s living arrangement to ensure it meets policy outlined in Section 1380, Living Arrangement.

The case manager does not need to coordinate the visit with the nurse. There is no need for the nurse to collect additional medical information or submit a new Medical Necessity and Level of Care (MN/LOC) unless the change in primary caregiver also coincides with a significant change in health status of the individual or an annual reassessment.

The case manager must present Form 2121, Long Term Services and Supports, to the new primary caregiver and complete the following forms with the new primary caregiver:

  • Form 0003, Authorization to Furnish Information;
  • Form 2410, Medical-Social Assessment and Individual Plan of Care, Pages 2-6; and
  • Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual.

The case manager must present the Consumer Directed Services (CDS) Option to the new primary caregiver following policy in Section 2400, Initial Presentation of the Consumer Directed Services Option.

Since the new primary caregiver’s schedule and need for services may differ from previously authorized services, a change to the individual plan of care (IPC) may be necessary. The case manager must follow policy in Section 5100, Changes to the Individual Plan of Care, if a change to the IPC is required.

Note: DADS staff must not discard the original Form 2408, Individual Plan of Care (IPC) Service Review, 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 the form is typed after returning to the office.

 

5800 Use of Services Outside the Provider's Contracted Service Delivery Area

Revision 14-1; Effective February 3, 2014

 

Services Outside of the Contracted Service Delivery Area

When an individual makes a request for services outside the contracted service delivery area to the provider, the provider may accept or decline this request. If the provider accepts the individual’s request, the provider may provide the allowed service to the individual during a period of no more than 60 consecutive days. The provider is not required to pay for expenses incurred by the provider’s employee who is delivering services outside the contracted service delivery area. Within three working days after the provider begins providing services outside the contracted service delivery area, the provider is required to send a written notice to the case manager notifying him:

• the individual is receiving services outside the provider’s contracted service delivery area;
• the location where the individual is receiving services;
• the estimated length of time the individual is expected to be outside the provider’s contracted service delivery area; and
• contact information for the individual.

The case manager will receive written notification from the provider when the individual has returned to the provider’s contracted service delivery area within three working days after the provider becomes aware of the individual's return.

If the provider declines the individual's request for services outside the service delivery area, the provider will inform the individual or his primary caregiver, parent, guardian or responsible party, orally or in writing, of the reason(s) for declining the request. The provider’s notice will also indicate that the individual or his primary caregiver, parent, guardian or responsible party may request a meeting with the case manager and the provider to discuss the reasons for declining the request. The provider will also inform the case manager in writing, within three working days after declining the request, that the request was declined and the reason(s) for declining the request.

If the individual requests an interdisciplinary team (IDT) meeting, the case manager must convene an IDT meeting with the provider and the individual or his primary caregiver, parent, guardian or responsible party to discuss delivery of services outside the provider’s contracted service delivery area and possible resolutions. The case manager must document the contacts with the individual and the provider in the case record. If a resolution cannot be reached, the case manager must offer the individual choice of providers or the Consumer Directed Services (CDS) option for respite following current procedures.

Out of Area Service Limitations

If an individual receives services outside the provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that service delivery area before the provider may agree to another request from the individual for the provision of services outside the provider's contracted service delivery area.

If the individual intends to remain outside the provider's contracted service delivery area for a period of more than 60 consecutive days, the case manager must follow current procedures and transfer the individual to a provider selected by the individual that has a contracted service delivery area that includes the area in which the individual is receiving services.