Revision 17-11; Effective November 20, 2017

2100 Case Management

Revision 17-1; Effective March 15, 2017

2110 Description of Case Management

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2917 — Clients must meet the eligibility criteria for CCAD services, but they do not have to receive services to receive case management. Ineligible applicants receiving only information and referral are not eligible for case management.

Case management is a set of actions taken by a Texas Health and Human Services Commission (HHSC) case worker to determine:

  • whether a person requesting service is eligible for  HHSC services,
  • what services the person needs, and
  • who will provide those services.

Case management also includes:

  • referring eligibles to service providers and facilitating the referral,
  • monitoring the referral to ensure that the services are initiated,
  • monitoring the service provision to ensure that services are meeting the individual's needs, and
  • periodically reassessing the individual's financial and functional eligibility.

Nine is the lowest score an individual can have and still qualify for a Community Care for Aged and Disabled service on the basis of his score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. An individual must score at least nine on Form 2060 to be eligible for case management only.

2120 Case Management Process

Revision 17-1; Effective March 15, 2017

Case management involves six individual functions.

  1. Intake — Requests for service or information are made by an individual, or someone on the individual's behalf, by telephone, letter or in person. Texas Health and Human Services Commission (HHSC) intake staff:
    • determine exactly what is being requested;
    • record certain information given by the requester;
    • give the requester certain information;
    • determine whether an immediate, expedited or routine response is necessary; and
    • refer the request to the appropriate unit for further action.

For detailed intake procedures, see Section 2200, Intake Procedures.

  1. Assessment — HHSC case workers respond to intake by visiting the person at home or other setting to conduct a face-to-face assessment of eligibility and needs. The assessment process includes:
    • determining financial eligibility;
    • determining functional eligibility relative to performance of activities of daily living;
    • assessing the individual's home, social/environmental supports and resources;
    • determining services the individual needs and whether those needs are currently being met by family or community resources; and
    • assessing the individual's physical condition and determining whether that condition, in combination with the environment, poses any degree of risk.

For detailed assessment procedures, see Section 2400, Assessment Process.

  1. Service planning — After completing the assessment, case workers develop a service plan with each eligible individual. Service planning includes:
    • determining what services and environmental adaptations are required to satisfy the individual's personal unmet needs, health and safety;
    • determining and specifying what services will be secured from whom or from where, how much will be provided and on what schedule;
    • specifying how often the case worker will monitor the provision of services and individual satisfaction; and
    • obtaining the individual's concurrence with the service plan.

For detailed service planning procedures, see Section 2500, Service Planning.

  1. Service authorization
    1. Non-Medicaid services — If non-Medicaid HHSC services are to be purchased as part of the service plan, the case worker:
      • authorizes the services according to program policies and procedures;
      • sends the service plan and individual referral information to the provider selected by the individual; and
      • discusses the plan with the potential provider, as necessary.
    2. Medicaid services — If Medicaid services are to be purchased as part of the service plan, the case worker:
      • designates the services according to Medicaid program policies and procedures;
      • obtains, if necessary, consultation from the regional nurse regarding medical need for services;
      • sends the service plan and individual referral information to the provider selected by the individual;
      • discusses the plan with the provider supervisor, if requested; and
      • discusses the plan with the regional nurse, as necessary.

For detailed service authorization procedures, see Section 2600, Authorizing and Reassessing Services.

  1. Service monitoring and evaluation — The case worker:
    • contacts each individual after service referral, according to case management requirements, to ensure that services were initiated as scheduled and to determine the individual's satisfaction with the service;
    • contacts and visits each individual according to the individualized case management plan or upon request by the individual or others;
    • accompanies regional nurses on utilization review home visits, when requested;
    • evaluates the individual's condition, needs and service provision on an ongoing basis, according to HHSC procedures and individual requirements;
    • requests consultation and joint home visits with the regional nurse or provider nurse, or both, when indicated because of the individual's health condition or risk status;
    • receives information from providers about the individual's ongoing needs and conditions; and
    • reassesses individual's needs and reviews and reauthorizes service plans according to required schedules.

For detailed procedures concerning service monitoring, see Section 2700, Service Monitoring, Changes and Transfers.

  1. The case worker is also responsible for assisting individuals who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. For detailed procedures, see Section 2130, Your Texas Benefits Medicaid Card and Replacement.

2130 Your Texas Benefits Medicaid Card and Replacement

Revision 17-1; Effective March 15, 2017

Form H3087, Medicaid Identification, is no longer issued and has been replaced by the Your Texas Benefits (YTB) Medicaid card.

The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services as the card is not proof of ongoing Medicaid eligibility. Medicaid recipients must take the card to doctor or dental appointments and to the pharmacy. This card is expected to be for permanent use and the Texas Health and Human Services Commission (HHSC) will only issue a new card if the card is lost or if the information printed on the card changes.

The individual may call 1-855-827-3748 if the card is lost and the individual needs a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line, so even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the individual later regains eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form, not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services Forms website for completion of the form. Designated HHSC staff may continue to assist individuals in the following situations:

  • Ongoing Medicaid Recipients — HHSC staff may assist with a manual Form H1027-A upon request because the recipient either lost the YTB Medicaid card or did not receive it. HHSC staff issuing Form H1027-A should inform the recipient of the following:
    • Call 1-855-827-3748 for a replacement card.
    • The burden of verifying Medicaid eligibility is with the provider. An individual who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from his provider or to fill a prescription. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line or by using the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
  • New Medicaid Recipients — Eligibility information is not immediately available for providers/pharmacies to verify after Medicaid is approved. HHSC staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time the eligibility is determined and the time the eligibility is available in the on-line system.

Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time services are requested. The recipient may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage if he is not sure of his eligibility status.

More information about the new card is available at: www.yourtexasbenefits.com.

2200 Intake Procedures

Revision 17-1; Effective March 15, 2017

For interest list procedures involving managed care, see the STAR+PLUS Handbook.

2210 Requests for Services

Revision 17-1; Effective March 15, 2017

A request for services may begin with

  • telephone or written referrals from other agencies, organizations, and HHSC divisions; or
  • telephone, written, or walk-in requests from individuals or their relatives, friends, or other interested persons.

2211 Applications and Referrals Routed from the Austin Document Processing Center

Revision 17-1; Effective March 15, 2017

When the Austin Document Processing Center (DPC) receives an application in which a request for an HHSC referral exists, the DPC will fax the first three pages of the application and a cover sheet to the HHSC local office. Upon receipt of the application, HHSC staff will review each of the referrals and contact the individual to determine if the individual is interested in HHSC services and take the following actions:

  • If it is determined the individual is interested in an HHSC program without an interest list, HHSC staff will complete an intake for the services requested and access the HHSC Benefits Portal to print out the rest of the application.

    To print out the application, access the HHSC Benefits Portal. Click on the PT Inquiry tab. Once the PT Inquiry is open, click on Inbound Correspondence Image Repository Search and search for the individual. Select the appropriate document and click "view." When the PDF document opens, click on the printing icon to print the document.
  • If the individual is only interested in a program with an interest list, the individual will be placed on the interest list and staff will not need to print the remainder of the application.
  • If the individual is not interested in an HHSC program or a program with an interest list, file the fax from DPC following local office procedures.

The document processing center address is:
 
Document Processing Center
P.O. Box 149024
Austin, TX 78714-9024
Fax Number: 877-236-4123

2220 Response to Requests for Service

Revision 17-7; Effective July 1, 2017

When a request for service is received by telephone, written referral or in person, the HHSC staff who conducts intake for community care services or who receives a request for service gives the requester information about HHSC CCAD services and determines what service is being requested and whether HHSC provides that service.

Upon receipt of a written/faxed referral, the applicant or responsible party may be contacted by intake staff or the referral may be accepted, entered in the Intake (NTK) system and assigned to a case worker. The case worker would then make the initial contact, provide information about HHSC and screen for appropriate services.

The intake staff or case worker who conducts intake for community care services or who receives a request for service:

  • gives the requester information about HHSC, including CCAD services, as needed;
  • gives the requester information about the Program of All-Inclusive Care for the Elderly (PACE) when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. (See Appendix XXXIV-F, Program of All–Inclusive Care for the Elderly, for additional information).
  • determines what service is being requested and whether HHSC provides that service;
  • refers the request for non-HHSC services to the appropriate state or community agency and documents the request;
  • screens all applicants indicating a need for skilled services for a nursing facility diversion (NFD) slot placement when slots are available and completes the NFD tab in NTK if the applicant responds there is a chance he would have to move to a facility. If slots are not available, refer the indivdual to the STAR+PLUS HCBS interest list;
  • transfers to appropriate staff any requests for HHSC services other than community care services;
  • identifies reports of suspected need for Adult Protective Services (APS) and immediately provides these reports to APS staff;
  • refers to Medicaid for the Elderly and People with Disabilities (MEPD) staff any requests for assistance with nursing home placement;
  • obtains eligibility-related financial information about the applicant; and
  • gives the requester general information about CCAD eligibility, emphasizing that exact eligibility information cannot be given until the individual is interviewed by a case worker.

If the requester does not want to apply for CCAD services, the requester is transferred to appropriate staff for requests for HHSC services other than community care services or referred to other appropriate resources. See Appendix XV, Services Available from Other State Agencies, and Section 2530, Other Resource Services. The information is not entered into NTK and an intake is not completed. This information is recorded in an Information and Referral Log.

If the individual wishes to apply for CCAD services, the intake person:

  • completes the intake by entering the information into the automated system for intakes or completes Form 2110, Community Care Intake, according to the form instructions, completing only the required sections if some information is not available;
  • documents on the form or on a log any requests for information and referral according to regional procedures;
  • refers walk-in requesters to the appropriate unit for the completion of applications;
  • determines whether the requester can and will complete an application for the applicant;
  • identifies a responsible party who will help with the application process;
  • identifies and documents which persons have no relative or responsible person to help with the application process;
  • assesses the urgency of the request and immediately routes all requests to appropriate units for further action (See Section 2310, Criteria for Immediate or Expedited Responses to Service Requests); and
  • informs the requester that a case worker will contact the applicant to further discuss the application process.

For all individuals who currently do not receive Supplemental Security Income (SSI) or SSI-related Medicaid and are requesting personal attendant services (PAS), the intake screener must assign the intake to a case worker as an application for Community Attendant Services (CAS). Intake screeners must not screen applicants for a specific service or determine if an applicant should only be assigned for Family Care or placed on the interest list for Family Care services. The intake screener does not place the individual on the Family Care interest list. The case worker determines whether the individual will be placed on the interest list, as described below.

All individuals who are not currently receiving Medicaid and wish to apply for PAS must be seen by a case worker and assessed for CAS. During the initial interview, the case worker screens all applicants for potential eligibility for CAS and determines whether or not the applicant will be referred to MEPD for CAS.

Certain services require special intake procedures. For details, see Section 4000, Specific CCAD Services.

2221 Requests for Services in STAR+PLUS Areas

Revision 17-1; Effective March 15, 2017

When the Texas Health and Human Services Commission (HHSC) receives a request for services, staff must assess whether the request for services should be forwarded for processing to the:

  • appropriate HHSC unit;
  • Program Support Unit (PSU); or
  • managed care organization (MCO).

Refer to the charts in the STAR+PLUS Handbook for additional information.

Individuals awaiting managed care enrollment may be assessed for interim services from HHSC.

HHSC will enroll individuals into Primary Home Care (PHC) who meet the PHC immediate or expedited criteria, as described in Section 2310, Criteria for Immediate or Expedited Responses to Service Requests, when they are listed in the Texas Integrated Eligibility Redesign System (TIERS) as a candidate for STAR+PLUS enrollment. However, mandatory STAR+PLUS individuals who are not yet enrolled with an MCO, and do not meet immediate or expedited criteria, will be referred to the Enrollment Broker. Individuals who are already enrolled with an MCO and request PHC or Day Activity and Health Services (DAHS) from HHSC must be advised to contact their MCO.

HHSC will not enroll individuals in DAHS when they are listed in TIERS as a candidate for STAR+PLUS enrollment. Since there are no immediate or expedited criteria for DAHS enrollment, individuals seeking these services will be available upon enrollment into the STAR+PLUS program. DAHS facility initiated referrals which take place for individuals pending STAR+PLUS enrollment will not be reimbursed by HHSC.

2222 Reinstatement Procedures for Individuals Reapplying for Services After Loss of Financial Eligibility

Revision 17-1; Effective March 15, 2017

If an individual has lost categorical or financial eligibility creating a gap in service, the following procedures are applicable.

If financial or categorical eligibility is re-established within 60 days of the denial date and the individual reapplies for services, the case worker may use the information currently on file to determine eligibility. A new Form 2110, Community Care Intake, must be completed. The case worker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date. See Section 3441.2, Reinstatement Procedures After Denial, for complete procedures.

2223 Caregiver Support Assessment Initiative

Revision 17-1; Effective March 15, 2017

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Texas Health and Human Services Commission (HHSC) staff to:

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

SB 271 requires HHSC 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.

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

Completion of the CSQ

The CSQ is available in the Long Term Care Services Intake (NTK) System and is completed at the time of the intake contact, when possible. The CSQ and a script for the interview are available in English and Spanish in Appendix XXXVIII, Caregiver Support Assessment Initiative. 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.

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.

The purpose of the CSQ is to collect the information described above. This information is not being used to determine if the unmet need criteria for Community Care services has been met, and will not be forwarded to the case worker.

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. You 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, you may read aloud the response category headings. Example: "Has caregiving affected your employment schedule, pay, leave, performance or work relationships?" If further clarification is necessary, you 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 the 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 the individual 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/she has legal custody or guardianship, or is raising the child informally; or
    • he/she is caring for an individual age 19-59 with severe disabilities; or
    • he/she is a caregiver for an individual of any age who has Alzheimer's or dementia.

Accessing the CSQ

The manual copy of the CSQ should be used when the automated system is unavailable; however, all information must be entered in the automated system as soon as possible. The version of 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 the AAA, make a referral following regional procedures.

Collection of legislatively mandated information will enable the state to refer caregivers to available support services and to develop additional services to meet caregiver needs.

2230 Interest List Procedures

Revision 17-1; Effective March 15, 2017

Individuals who express interest in a Community Services program which has an interest list will be registered on the Community Services Interest List (CSIL), regardless of the program’s enrollment status. CSIL will record the date and time of the expressed interest. If the individual is first on the list and the region is releasing and enrolling for that program, the individual may be immediately released and assigned for the enrollment process.

If all service authorization slots are filled, consult with the individual to decide whether his needs can be met through other services. If the individual agrees, add the individual’s name to the appropriate interest lists by entering the information in the CSIL system if no other service is available or suitable. Individuals who request placement on an interest list must reside in the state of Texas. An out-of-state address can be used as a contact if the power of attorney/guardian or legally authorized representative is residing out of state. Additional exceptions may be made for individuals who have been placed on an interest list while residing in Texas, and who then move temporarily out of the state because of military assignments.

Individuals on military assignments who are temporarily out of state include:

  • Military member - A member of the United States military serving in the Army, Navy, Air Force, Marine Corps or Coast Guard on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch;
  • Military family member - A person who is the spouse or child (regardless of age) of a military member or a former military member; or 
  • Former military member - A person who served in the United States Army, Navy, Air Force, Marine Corps or Coast Guard who declared and maintained Texas as the person’s state of legal residence in the manner provided by the applicable military branch while on active duty or who was killed in action or died while in service, or whose active duty otherwise ended.

Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted when an individual is released from the interest list.

When an individual on an interest list transfers from one region to another, he must be added to the receiving region's list using the original intake date for the service as documented by the losing region. The staff person who first becomes aware that the individual has transferred to another region (whether losing or gaining) is responsible for notifying the other region. This ensures that both regions' lists are accurate.

When an individual is released from the interest list, the case worker must contact the individual to determine his continued interest in services and if interested, schedule a home visit if required by the service. If the individual is no longer interested in services and voluntarily withdraws, the case worker enters the appropriate CSIL closure code in the CSIL system. No entries in the Service Authorization System (SAS) are required and Form 2065-A, Notification of Community Care Services, is not sent.

During routine interest list contacts, individuals on the interest list who do not reside in Texas should be removed from the list and informed they must be a resident of Texas to be on an interest list. Exceptions may be made for individuals on military assignments who are temporarily residing out of state.

If the individual is interested in services, the case will be processed as a routine intake.

For more information regarding the CSIL system, refer to:

  • Section 2231, Community Services Interest List Bypass Criteria; and
  • Section 2232, The Community Services Interest List System.

Note: The Area Agencies on Aging (AAA) can refer individuals to available services. Service needs, resources and available service providers vary across the state; not all of the services identified by AAA may be available in every area. The applicant/individual should contact the local AAA to determine whether a specific service is available. To find the telephone number for the local AAA, call 1-800-252-9240.

When the Texas Health and Human Services Commission (HHSC) intake staff determine a request for Home and Community-based Services STAR+PLUS Waiver (HCBS SPW) services, the request should be forwarded to the Program Support Unit (PSU) for processing. Staff must submit the request to the PSU mailbox designated for referrals to this program at StarPlusWaiverInterestList@hhsc.state.tx.us.

The email should contain the following data elements:

  • Name;
  • Social Security number (if provided);
  • Address;
  • Contact area code and phone number;
  • Date of birth;
  • Medicaid number, if applicable; and
  • County of residence.

2230.1 Adding Individual's Name Back to CSIL

Revision 17-1; Effective March 15, 2017

An individual's name may be added back to the Community Services Interest List (CSIL) at any time within 90 days after the CSIL service has been closed if the individual contacts the Texas Health and Human Services Commission (HHSC):

  • within 90 calendar days of the closure date, the original date of request can be used; or
  • more than 90 calendar days following the closure date, the current date must be used.

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

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

When an applicant or individual has been denied for a service, the earliest date the applicant/individual may be added back to CSIL for the same program is the date the applicant/individual is determined to be ineligible or is no longer eligible for the program.

If the individual's name is added back to CSIL prior to the last date of program eligibility, the CSIL interface match with the Service Authorization System (SAS) will cause the name to be removed from the interest list for that program. Example: An individual's Family Care (FC) services are denied and end on Aug. 13, 2015. The first date the individual can be added back to the FC interest list is Aug. 14, 2015. If the individual is already on the Home-Delivered Meals (HDM) interest list, the denial date for FC services would not impact the individual's original date on the HDM interest list.

2231 Community Services Interest List Bypass Criteria

Revision 17-1; Effective March 15, 2017

 

Under certain circumstances, individuals are allowed to bypass the interest list to start the enrollment process. The bypass must meet specific criteria and be approved by the regional director.

2231.1 Individuals Who May Receive Title XX Services with Regional Director Approval

Revision 17-1; Effective March 15, 2017

In the following circumstances, an individual may be given a bypass code to be placed at the top of the interest list. The regional director makes the decision if the individual may bypass the interest list and begin the enrollment process.

Personal Attendant Services (PAS)

Individuals who meet criteria for immediate or expedited intakes and need immediate service initiation may be given a bypass code and go to the top of the interest list. Individuals in the following programs may be considered for the criteria:

  • Family Care.
  • STAR+PLUS Waiver (SPW) individuals denied SPW services.
  • Individuals who have been denied Primary Home Care (PHC) due to loss of Medicaid.
  • Individuals denied Community Attendant Services (CAS) due to denial of financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD) for reasons other than failure to cooperate or refusal to sign up for the Medicaid Estate Recovery Program (MERP).

The criteria are:

  • the applicant has no available caregiver; and
  • has personal care needs that are not being met; and
  • cannot go without personal care services for a full day; or
  • the applicant needs personal care and the need for services has increased during the five days prior to the service request, or will increase during the five days following the service request. (See Section 2310, Criteria for Immediate or Expedited Responses to Service Requests, for additional information).
  • An individual authorized for any Title XX service who is transferring to a new region will be allowed to continue receiving that service.
  • An individual in SPW Residential Care facility who is denied SPW may go to CCAD Residential Care. If a bed is not available, the individual is placed on the Community Services Interest List (CSIL) and given a bypass code to move to the top of the interest list.

All individuals meeting bypass criteria will be placed at the top of the specific program interest list. Additionally, the bypass criteria will now apply to individuals meeting the criteria who are no longer eligible for STAR+PLUS or STAR+PLUS Waiver services or individuals denied financial eligibility for CAS. The Regional Director will make the decision whether an individual can be released immediately or will remain on the interest list until the next slot is available. The decision must be documented in the case record.

2231.2 Bypass Criteria for Additional Services

Revision 17-1; Effective March 15, 2017

Individuals in the following circumstances may be given a bypass code and placed at the top of an interest list. The regional director makes the decision whether the individual can be released immediately or will remain on the interest list until the next slot is available. The decision must be documented in the case record.

  • Title XIX Day Activity and Health Services (DAHS) individuals denied Medicaid but who remain eligible for Title XX DAHS.
  • Individuals in a STAR+PLUS Waiver (SPW) Residential Care facility who are denied SPW may go to Community Care for Aged and Disabled (CCAD) Residential Care. If a bed is not available, the individual remains at the top of the interest list until a placement is available.
  • Individuals in an SPW Adult Foster Care (AFC) who are denied SPW may go to a CCAD AFC. If a bed is not available, the individual is placed at the top of the interest list until a placement becomes available.
  • Individuals denied SPW who had received additional services through SPW, such as Home-Delivered Meals or Emergency Response Services, may be given a bypass code for those services.

Individuals authorized for any Title XX service that transfer to a new region will be allowed to continue receiving that service.

2231.3 Individuals Who May Not Bypass the Interest List

Revision 17-1; Effective March 15, 2017

An individual who has been denied Primary Home Care (PHC) because he does not need assistance with a personal care task should be placed on the Family Care (FC) interest list using the date of the PHC denial. He may not bypass the FC interest list.

Individuals leaving a nursing facility are not eligible to bypass the interest list unless they meet the criteria for immediate or expedited as listed in Section 2231.1, Individuals Who May Receive Services with Regional Director Approval.

For individuals who have a temporary loss of categorical status or financial eligibility, follow the procedures in Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 3441.1, Procedures Pending Reinstatement.

2231.4 Bypass Approval

Revision 17-1; Effective March 15, 2017

The final decision on whether an individual is approved to bypass the interest list will be made by the regional director or his designee, rather than the regional budget officer or the contract manager. Releasing a name from the interest list and offering services to an individual still remains subject to available regional funds and slots.

2232 The Community Services Interest List System

Revision 17-1; Effective March 15, 2017

Interest lists for community care services are registered on the Community Services Interest List (CSIL) system.

Initial requests for services are documented using Form 2110, Community Care Intake, or the Long Term Care Service Intake (NTK) system, regardless of whether slots for the requested service exist. If the individual needs a service that is currently unavailable, use the interface on the NTK system or enter the individual on the CSIL. Complete and send the individual:

Only individuals who reside in the state of Texas may be placed on an interest list for Texas Health and Human Services Commission (HHSC) community services. An out-of-state address can be used as a contact if the power of attorney/guardian or legally authorized representative is residing out of state.

Information provided by the individual for the interest list must include a Texas address as the contact location for the individual requesting services. Exceptions may be made for individuals who are temporarily out of the state due to military assignments.

Exceptions involving military members and military family members, as described in Section 2230, Interest List Procedures, apply when:            

  • the applicant is a military family member living outside of Texas:
    • while the military member is on active duty; or
    • for less than one year after the former military member’s active duty ends; or
  • the applicant declines the offer of a Community Services program with an interest list and the applicant is a military family member living outside of Texas:
    • while the military member is on active duty; or
    • for less than one year after the former military member's active duty ends.

If the case worker is making a home visit to assess the individual for other services, it is preferable for the case worker to assist in completing appropriate application forms at that time. If not, this task may be accomplished by mail. If Form 2111 and Appendix XXXV are mailed, they must be sent within two workdays of intake. Forms being filled out in person at the time of the home visit must be completed within the time frames as indicated in Section 2320, Case Worker Response, as determined by intake priority.

Within five workdays of intake, staff enter all relevant data into the CSIL. Staff may choose to use Form 2113, Community Services Interest List Registration and Follow-Up, to manually record interest list information to be data entered. Although use of Form 2113 is not mandatory, regional staff are responsible for entering all applicable data fields it contains into the CSIL.

Staff may not perform functional or financial determinations at the time the individual is being added to the interest list, even if staff are not using the determination to screen the applicant off the interest list. If an individual insists that he be assessed for eligibility immediately, even though staff have assured him that no slot is currently available, staff are required to do so. This action is considered an application, not an interest list case; all notification and civil rights procedures apply.

Individuals on an interest list are contacted annually to confirm that they wish to remain on the list. Form 2247, Interest List Contact Letter, is mailed to the individual.

If an individual does not respond and no update is made to the annual contact date in CSIL within 120 days past the annual contact due date, CSIL will automatically update the individual’s record as inactive. An annual contact is no longer required for individuals in an inactive status. An individual with a status of inactive will not lose his place on the interest list. If/when the CSIL individual record is updated with a current contact date, the record will automatically go back into an active status.

Staff are reminded the CSIL must also be updated within five workdays of the case worker’s determination and the date that a completed Form 2065-A, Notification of Community Care Services, is mailed/given to the individual. Within five workdays of the case action, the case worker records whether the case was certified, application denied or closed without application. If the case was closed or denied, the reason for closure/denial must be indicated.

See Appendix XXV, Community Services Interest List (CSIL) Closure Code User's Guide, or the CSIL User’s Guide found on the intranet (for staff use only).

2240 Regional Procedures

Revision 17-1; Effective March 15, 2017

2241 Supervisor Responsibilities

Revision 17-1; Effective March 15, 2017

CCAD unit supervisors ensure that their units have procedures for

  • receiving service requests;
  • mailing applications to requesters of service, when appropriate; calling requesters to ensure that applications were received; and instructing applicants or their families or both about completing applications;
  • assigning service requests to appropriate case workers, within required time frames;
  • when appropriate, notifying case workers about applicants who may need help in completing applications;
  • ensuring that the intake priority is accurate and reassigning the response category if documentation indicates the need; and
  • monitoring and tracking requests for service, beginning with the date the request is received or assigned.

2242 Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

CCAD case workers are responsible for:

  • establishing a date for a home visit by calling an individual, when feasible;
  • determining if the applicant is categorically eligible through the HHSC automated systems and printing verification, if eligible;
  • mailing an application to the non-categorically eligible applicant who requires a routine response to his service request, if the applicant is capable of completing the form or has assistance available;
  • informing an applicant about the financial documentation, if any, that must be available at the time of the visit, such as verification needed when the applicant is applying for Community Attendant Services (CAS);
  • requesting that a person with knowledge of the individual's financial affairs be available at the time of the visit, if possible and appropriate;
  • requesting that the individual's caregiver be present at the time of the visit, if possible;
  • mailing the appropriate individual letter; and
  • changing the intake priority, if additional information warrants. (Initial and date any changes using a different color ink.)

2243 Conflicts of Interest

Revision 17-1; Effective March 15, 2017

Texas Health and Human Services Commission (HHSC) staff control and direct significant amounts of public funds and must avoid the appearance of impropriety or conflict of interest. This applies to the awarding of Community Care for Aged and Disabled (CCAD) benefits and in determining how these benefits are to be provided.

Staff must not work on or review an ongoing CCAD case, nor assist an applicant or individual to receive CCAD benefits, if the applicant or individual is a relative (by blood or marriage), roommate, dating companion, supervisor or someone under the individual's supervision. Staff may not determine eligibility, need for CCAD services nor the amount of service they may receive. HHSC staff may provide anyone with an application for services and inform them how and where to apply. It is also permissible to help any person gather documents needed to verify eligibility and the need for services. Staff must not perform any other role in determining eligibility for CCAD services.

Case workers must consult with their supervisors if the applicant or individual is a friend or an acquaintance. Generally, staff should not work on cases or applications involving these individuals, but the degree and nature of the relationship should be taken into account.

If staff have a relative (by blood or marriage), roommate, dating companion or close friend who owns or is employed by a provider that contracts with HHSC to provide CCAD services, he must not demonstrate any special consideration toward that provider. Referrals of individuals to a provider must be based strictly on individual preference and the individual's need for the service provided. In addition, instructions (or lack of instructions) to the provider concerning the delivery of service must be based solely on the individual's needs and HHSC policy.

If a staff member suspects that a conflict exists, use Form 2115, Conflict of Interest Notification, to notify the supervisor that a conflict of interest may exist that could result in an unethical or biased business relationship. The supervisor will record on the Supervisory Response section what action, if any, may be necessary and return the signed/dated form to the sender.

All CCAD staff are required to complete Form 2115 regardless of potential conflict of interest when:

  • hired;
  • the annual performance review occurs;
  • transferring between units and/or programs; and
  • assigned to another supervisor.

The form is also used to notify the first-line supervisor whether or not a potential conflict of interest exists that involves provider employees, applicants or individuals, even if staff are not involved in the eligibility determination for the applicant or individual. Staff must complete Form 2115 if the potential conflict involves an individual who is:

  • residing in his home;
  • a dating companion;
  • his supervisor;
  • a relative; or
  • reporting directly to him.

2300 Responding to Requests for Service

Revision 17-1; Effective March 15, 2017

2310 Criteria for Immediate or Expedited Responses to Service Requests

Revision 17-1; Effective March 15, 2017

An individual requires an immediate response to his service request if he has no available caregiver, he has personal care needs which are not now being met, and he is unable to do without personal care services for a full day.

The following examples of situations requiring immediate response are just that — examples. This list, and other lists within this section, are not intended to be all inclusive.

The individual:

  • is totally bedridden or is unable to transfer from bed to chair without help,
  • cannot manage toileting tasks without personal assistance, or
  • is in danger of not receiving daily nourishment because of his need for total assistance in meal preparation or feeding.

An individual requires an expedited response to his service request if he needs personal care, he has no available caregiver, and his need for services has increased during the five days prior to the service request, or will increase during the five days following the service request. For example, the individual:

  • is being or has been released from a hospital or nursing home within five calendar days of the request, and has no available caregiver to provide necessary care,
  • is experiencing or recovering from a major illness and has no available caregiver, or
  • loses his caregiver within five days of the request and has no available substitute.

All persons with AIDS or HIV infection requesting CCAD services should be carefully screened to determine if an immediate or expedited response is needed. CCAD regional nurses can provide consultation if needed. Persons with AIDS or HIV infection are often very ill and may need services initiated as soon as possible. It is essential that intake screeners and CCAD case workers follow the procedures for immediate or expedited responses, for all persons with AIDS or HIV infection who meet the criteria.

2320 Case Worker Response

Revision 17-1; Effective March 15, 2017

Respond to requests for Community Care for Aged and Disabled (CCAD) services according to the following program standards:

If Applicant Requires . . . Then . . .
an immediate response, Program Standard: The case worker to whom the case is assigned visits the applicant within 24 hours of the case assignment to the case worker. (Example: The case worker must respond to a case assignment received at 4 p.m. Tuesday no later than 4 p.m. Wednesday, or must respond to a case assignment received at 11 a.m. Friday no later than 11 a.m. Saturday).
an expedited response, Program Standard: The case worker to whom the case is assigned visits the applicant within five calendar days of the date of the case assignment to the case worker. (Example: A response to a case assignment received on Wednesday must be made no later than Monday, or a response to a case assignment received on Monday must be made no later than Saturday.)
a routine response, Program Standard: The case worker to whom the case is assigned visits the applicant within 14 calendar days of the date of the case assignment to the case worker. (Example: A response to a case assignment on April 1 must be made no later than April 15.)

If the person with AIDS or HIV infection does not need an immediate or expedited response at intake, the case worker should closely monitor the situation during the routine referral process.

If the applicant's health condition suddenly deteriorates, make every effort to obtain services for the individual as quickly as possible.

After talking with the applicant or family, the case worker may alter the urgency of the request, as long as the change is made before the deadline for the intake priority. The case worker may contact the applicant after the period specified above if the:

  • intake states that the applicant or family requests a delay in the visit and the visit is made on the date requested; or
  • case worker makes two attempted contacts within the designated period. One attempted contact must be an attempted face-to-face contact (such as a home, hospital or nursing home visit) with the applicant or the authorized representative, referral source or other knowledgeable party if the applicant is unable to respond to the assessment questions. The second attempted contact must be either another attempted face-to-face contact or an actual telephone contact with the applicant, his authorized representative, referral source or other knowledgeable party, if the intake does not identify an authorized representative for the applicant.

If the case worker contacts the applicant to schedule an appointment and the applicant refuses and states he does not want services, the case worker must close the intake in the Intake (NTK) system. The case worker may use the denial codes from the Community Services Interest List (CSIL) system in the comments in NTK. No entries in the Service Authorization System (SAS) are required and Form 2065-A, Notification of Community Care Services, is not sent.

The case worker should make every effort to ensure that the initial visit is conducted as close as possible to the date of the case assignment to the case worker. For service control purposes, this standard should be measured by comparing the date/time of the case assignment on Form 2110, Community Care Intake, to that on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Use the date of the initial assessment contact for Day Activity and Health Services (DAHS)-only cases. If the intake priority (for all except DAHS) is not checked (or information indicating priority level is not contained in case documentation), it is assumed to be immediate.

Although 14 days are allowed for a routine referral, timelines cannot be used as a justification to delay contact with the individual. If the two attempted contacts both occur near the end of the 14-day period, the case worker or supervisor may choose to call a timeliness error if a justifiable reason for delay is not documented in the case record.

Example: A case assignment for services is received March 1. The case worker makes the first attempted contact on March 11, and the second on March 14. In order to meet the program standard relating to timeliness of initial contact, the case worker must document why the delay could not have been avoided.

2330 Scheduling the Initial Interview

Revision 17-4; Effective May 23, 2017

40 Texas Administrative Code §48.3901(b) — The applicant is entitled to a face-to-face interview during the department's determination of his eligibility for CCAD services.

Determining eligibility for Community Care for Aged and Disabled (CCAD) services normally begins with a face-to-face assessment of the person, preferably in the home. Home visits are required for all CCAD applications, except for applications requesting Emergency Response Services, Home-Delivered Meals, or Day Activity and Health Services. Initial home visits for any one of these three services are required only at the applicant's request. A face-to-face home visit is required if, during the telephone interview, it is determined attendant care is needed or requested, as indicated in Section 2431, Form 2060, Part A, Functional Assessment, and Section 4651, Assessing the Individual’s Needs.

When feasible, ask the person's current caregiver to be present during the assessment. Home visits must be scheduled for a time that is convenient to the applicant. Schedule the appointment by telephone or in writing using Form 2068, Application/Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for any reason, the applicant or authorized representative must be notified in advance that the appointment will have to be rescheduled. Do not visit the applicant without informing the person in advance of the visit.

If a case worker contacts an applicant to schedule a home visit and the applicant states he has a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker should schedule a future date for the visit when the applicant thinks he will be better. If unable to schedule the visit for a future date, the case worker must contact the applicant at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

Although a face-to-face visit with a person in a nursing home, hospital, prison or jail facility is acceptable, this visit does not allow the case worker to assess the person in the home environment or to assess family resources and how they function at home. If the initial visit and eligibility determination must be done in a location other than the person's home and in-home services are subsequently initiated, conduct a home visit within 30 days after service initiation and make any necessary revisions to the service plan according to Section 2663, Reassessment of Functional Need. Document the home visit on Form 2059, Summary of Client's Need for Service (Item 4 or 8), or in the case narrative.

A person who is already receiving services from the Texas Health and Human Services Commission (HHSC), or for whom the Social Security Administration has already verified that the individual is financially eligible for Supplemental Security Income (SSI), is not required to submit an application form.

A person who is not receiving services from HHSC, not receiving SSI, or who needs a financial eligibility determination from Medicaid for the Elderly and People with Disabilities (MEPD) must complete an Application for Assistance. The preferred form is Form H1200-EZ, Application for Assistance – Aged and Disabled. If an applicant has completed Form H1200, Application for Assistance – Your Texas Benefits, the case worker may accept those forms and send to MEPD.

The form may be mailed if the applicant is capable of completing the form or has assistance available. If the applicant is not capable of completing the form, it is the case worker's responsibility to provide the form and assist the applicant with completing the form at the initial interview. If the form has been mailed to the applicant, it is the case worker's responsibility at the initial interview to review the form for completion and assist the applicant in completing the form, if necessary.

The official date of application is the date HHSC staff receive a completed, signed and dated Application for Assistance. The application date on the Service Authorization System screen is the date of:

  • receipt of the application, as defined above; or
  • the initial home visit, for categorically eligible applicants for whom an application form is not required.

2331 Information and Referral (I&R)

Revision 17-1; Effective March 15, 2017

If, during the initial interview it is determined that the individual could use services from other agencies in the community, refer him to the appropriate agency or community resource. Fully discuss the referral with him and his family, if they are present. Give complete information about Community Care for Aged and Disabled (CCAD) services and about any other Texas Health and Human Services Commission (HHSC) services (for example, the Supplemental Nutrition Assistance Program (SNAP) or the Qualified Medicare Beneficiary program) that might be helpful. See Appendix XV, Services Available from Other State Agencies.

Always refer an applicant or individual to the Social Security Administration if the individual appears eligible for Supplemental Security Income (SSI) but does not receive SSI. Consult with Medicaid for the Elderly and People with Disabilities (MEPD) staff if there are questions about SSI eligibility.

When referring an individual to other agencies or other HHSC services, fully inform him about where he must go to apply. Help set up his appointment, if necessary. Provide the office address, telephone number, name of the correct person to contact, and the appointment date and time (if known).

Provide I&R services to individuals without regard to their incomes. Do not register with the Service Authorization System (SAS) persons who receive only I&R services. Document I&R services as required by regional policy.

2332 Requests for Services from Individuals Under Age 21

Revision 17-1; Effective March 15, 2017

Children who have a medical need and meet other eligibility requirements may receive Community Attendant Services (CAS). The age requirements that apply to other community care programs do not apply to CAS. However, the applicant under age 21 must meet all other eligibility criteria, including medical, financial, functional and unmet need.

Upon receipt of a request for services from an individual under age 21, the case worker must contact the regional nurse and arrange for a joint visit for the initial home visit assessment. The regional nurse will assist in the screening of the individual for medical need, determine if there are skilled tasks that cannot be performed by a personal attendant, and determine whether the caregiver must be present in the home to perform skilled tasks or react to emergency medical situations while the personal attendant is in the home.

See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information.

2333 Applications

Revision 17-4; Effective May 23, 2017

An application for services has been made if any one of the following occurs:

  • a home visit in relation to an intake or interest list release has occurred;
  • the case worker has completed or has begun to complete any part of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; or
  • an Application for Assistance has been completed.

The preferred form for the Application for Assistance is Form H1200-EZ, Application for Assistance – Aged and Disabled. If an applicant has completed Form H1200, Application for Assistance – Your Texas Benefits, the case worker may accept those forms.

Once an application has begun, the case worker must record the disposition of the application in the Service Authorization System (SAS).

Examples:

Example 1 (Request for Services Only): A hospital social worker contacts HHSC on behalf of a patient who is being discharged the following day. The social worker notes that the patient lives alone and believes the patient's condition will result in a need for personal attendant services (PAS). In response to the social worker's call, an intake specialist contacts the individual and he states that his daughter will be living with him during the weeks following release from the hospital and will be able to provide all his needs. He states that he will call HHSC if PAS is needed at a later time.

This is not an intake but is an example of a request for services that is appropriately screened and determined CCAD services are not needed at this time. Although the intake specialist contacted the individual and some information may have been recorded, Form 2110, Community Care Intake, was not completed in the Intake (NTK) system and a case worker was not assigned to the case. There is no need to send Form 2065-A, Notification of Community Care Services. No entries in SAS are required.

Example 2 (Intake Only): An individual contacts HHSC requesting Home-Delivered Meals (HDM). The intake specialist completes Form 2110 and assigns the intake to a case worker. When the case worker calls to set up an appointment, the applicant states that he has changed his mind and does not want HHSC services. The case worker records the correct denial code (from the Community Services Interest List (CSIL) denial codes) for voluntary withdrawal in the NTK system comments section. There is no need to send Form 2065-A. No entries in SAS are required.

Example 3 (Application): An individual contacts HHSC and requests Primary Home Care. The case worker schedules the home visit and upon arriving at the individual's home, the applicant states he is moving out of state and he does not need services. Because a home visit was made, this is considered an application and must be entered in SAS and Form 2065-A sent to the applicant.

2333.1 Required SAS Entries for Applications Withdrawn Early in the Process

Revision 17-1; Effective March 15, 2017

All applications must be entered in the Service Authorization System (SAS) within 30 calendar days of the home visit date or receipt of the application. See Section 2611, Processing Time Frames, for additional information. This includes situations such as the one described in Example 3 in Section 2333, Applications, where very little information has been gathered. The type of SAS entries required depends on the type and amount of information collected by the case worker.

2340 The Initial Interview and Application Process

Revision 17-1; Effective March 15, 2017

During the initial home visit interview, the case worker:

  • explores the applicant's needs and which services can meet those needs, including services available from other agencies;
  • assists the applicant in the completion of the Application for Assistance, if the applicant is not categorically eligible;
  • screens the applicant for the Community Attendant Services (CAS) program, if requesting attendant services and not categorically eligible;
  • completes the functional assessment, including assessing the applicant's functional eligibility relative to the performance of activities of daily living and assessing the applicant's home, social/environmental supports and resources;
  • presents Appendix XXXV, Long Term Services and Supports;
  • reviews and explains Form 2307, Rights and Responsibilities, including information on confidentiality, and have the applicant sign the acknowledgment;
  • offers to assist the applicant in registering to vote;
  • reviews and explains the available service delivery options and complete the required documentation as explained in Section 6000, Service Delivery Options; and
  • reviews and explains the Medicaid Estate Recovery Program (MERP), if requesting CAS, and has the applicant sign Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement.

If the applicant is only able to sign documents with an "X," the case worker may make the required documentation and then date and initial the entry.

The case worker also must be alert for indications of abuse, neglect or exploitation when assessing CCAD individuals. Anyone who has reason to believe an elderly person or an individual with a disability is being abused, neglected or exploited must report this information to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS) (Title 2, §48.306 of the Texas Resources Code). Immediately notify APS of any reports received that indicate an elderly person or individual with a disability has been abused, neglected or exploited.

If a CCAD individual has been referred to APS in the past and it is possible another referral may be needed now for the same problems, contact APS to discuss the situation before a formal referral is made. Document the APS response in the CCAD case record. See Appendix XV-E, Department of Family and Protective Services (DFPS), for more information.

2341 Financial Application Process

Revision 17-10; Effective October 6, 2017

40 Texas Administrative Code (TAC) §48.3901(c) — Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form. Non-Medicaid applicants or their representatives applying for retroactive reimbursement for Medicaid-covered attendant services must also sign an application for assistance form. The date of application is the date the department receives the signed application. Applicants must provide accurate information about income and resources.

40 TAC §48.3901(e) — Non-Medicaid applicants or their representatives applying for Medicaid-covered attendant services may be reimbursed for services provided up to three months prior to the month of receipt of a completed, signed, and dated application.

If an application is denied for any reason, the previously completed application form is valid for 90 days following the date of denial. A written, dated and signed statement of request to reapply must be obtained from the applicant or authorized representative. The statement must be sent to Medicaid for the Elderly and People with Disabilities by the close of business the second business day. Documentation in the case record must indicate whether any changes have occurred since the original application date.

The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked “Application.” The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for Community Attendant Services. The case worker includes all identifying information on Form H1746-A, and any additional information that will help identify the original application, and faxes Form H1746-A and documentation to the Austin Document Processing Center.

The case worker will also be able to use Form H1200-EZ, Application for Assistance – Aged and Disabled, on file for up to 90 days following the denial date of Form 2065-A, Notification of Community Care Services. The case worker may also use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the additional forms signed at the initial home visit, and verifications on file. The case worker does not need to make an additional home visit, but must review Form H1200-EZ and Form 2060 with the applicant and document any changes which have occurred since the initial visit. The case worker will need to follow appropriate time frames for annual reassessments as the annual reassessment will still be due within 12 months of the initial home visit.

2341.1 Application for Assistance Form

Revision 17-4; Effective May 23, 2017

Individuals applying for services without categorical eligibility status apply for Community Care for Aged and Disabled (CCAD) services by completing Form H1200-EZ, Application for Assistance – Aged and Disabled.

Use Form H1200-EZ for individuals who are:

  • not Medicaid recipients and apply or appear to be eligible for community Attendant Services (CAS); or
  • non-Medicaid applicants who are not categorically eligible and who apply or appear to be eligible for:
    • Title XX CCAD services; or
    • Qualified Medicare Beneficiaries (QMB) or Specified Low-Income Medicare Beneficiaries (SLMB).

Although Form H1200-EZ is the preferred form, a completed Form H1200, Application for Assistance – Your Texas Benefits, should not be refused.

An application is incomplete until it contains the individual's signature. If unable to sign, it is acceptable to allow the individual to make an "X," along with two witnesses' signatures. Unless no other option is available, the case worker should not be one of the witnesses.

If Form H1200 or Form H1200-EZ is being sent to Medicaid for the Elderly and People with Disabilities (MEPD), the signature must be on the form. Unsigned applications will be returned to the sender. HHSC staff must ensure applications are signed prior to referring to MEPD. If MEPD receives an unsigned application from HHSC with either Form H1746-A, MEPD Referral Cover Sheet, or Form 2067, Case Information, MEPD will return the application to HHSC with an annotation on the cover form (Form 2067 or Form H1746-A) that the application is unsigned and must be signed before HHSC can establish a file date. Once HHSC staff receive an unsigned application from MEPD, it is their responsibility to coordinate with the individual in getting the application signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to individuals.

2341.2 Application for Assistance Form Completion and Receipt Date

Revision 17-6; Effective June 28, 2017

The Application for Assistance form may be mailed if the applicant is capable of completing the form or has assistance available. If the applicant is not capable of completing the form, it is the case worker's responsibility to provide the form and assist the applicant with completing the form at the initial interview.

If the Application for Assistance form has been mailed to the applicant, it is the case worker's responsibility at the initial interview to review the form for completion and assist the applicant in completing the form, if necessary.

Ensure that the person completes the entire application, signs and dates it, and understands the penalties for fraud in the event the person deliberately gives false information. Do not make any changes to the Application for Assistance form after the applicant has signed it. Document any changed or additional information on Form 2064, Eligibility Worksheet.

For applicants or individuals requiring a Medical Assistance Only (MAO) determination to be sent to Medicaid for the Elderly and People with Disabilities (MEPD), the case worker must assist the applicant/individual with completion of the application form and provide the most complete packet possible to MEPD. The case worker should ensure the following items are included to facilitate the financial eligibility process:

  • Bank accounts (for Community Attendant Services) – bank name, account number and balance;
  • Award letters showing amount and frequency of income payments;
  • Life insurance policy – company name, policy number, face value or copy of the policy;
  • A signed and dated Form H0003, Agreement to Release Your Facts;
  • Confirmation that Medicaid Estate Recovery Program and Appendix XXXV, Long Term Services and Supports, were shared with the applicant by checking the appropriate boxes on Form H1746-A, MEPD Referral Cover Sheet or Form 2067, Case Information;
  • Preneed funeral plans – name of company, policy/plan number, copy of preneed agreement;
  • Correct up-to-date phone numbers; and
  • Power of Attorney or Guardianship – copy of the legal document.

While it may not be possible to obtain everything on the list, the case worker should gather whatever information is available, as it will prevent the applicant from a delay in certification. The case worker should explain to the applicant that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

When a signed and dated Application for Assistance form is received by the case worker at the home visit, or is mailed or hand delivered to a Texas Health and Human Services Commission (HHSC) office, the date of receipt becomes the official date of application.

If Form H1200-EZ, Application for Assistance – Aged and Disabled, has not been returned by the 30th day from the initial home visit, the case worker may deny the application. The case worker sends Form 2065-A, Notification of Community Care Services, with Rule Reference 40 Texas Administrative Code §48.3901(c): “Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form.” In the comments section, the case worker enters: “HHSC is unable to make an eligibility decision within 30 days due to your failure to furnish information.” The case worker must document all contact in the case record.

When an income eligible individual is receiving services and the individual's spouse subsequently applies, the individual's form (if it is less than one year old) may be used for the spouse. Review the Application for Assistance form to ensure the information is still valid, have the spouse sign and date it for the current application, and complete a new eligibility determination.

2341.3 Categorical Eligibility

Revision 17-1; Effective March 15, 2017

If a financial determination has already been made for the applicant by Social Security or another program within the Texas Health and Human Services Commission (HHSC), then the applicant may be considered categorically eligible. The applicant is categorically eligible if receiving:

  • Supplemental Security Income,
  • Temporary Assistance for Needy Families,
  • Supplemental Nutrition Assistance Program,
  • Medicaid,
  • Medicaid Buy-In (MBI) benefits*,
  • Qualifying Individual (QI) benefits,
  • Specified Low-Income Medicare Beneficiary (SLMB) benefits,
  • Qualified Medicare Beneficiary (QMB) benefits, or
  • other Community Care for Aged and Disabled (CCAD) services.

*Note: Medicaid Buy-In benefits provide categorical eligibility only for the following programs:

  • all Long Term Services and Supports Title XX programs,
  • Day Activity and Health Services Title XIX,
  • Primary Home Care, and
  • Texas Home Living waiver program.

Completion of the Application for Assistance form is not required for a categorically eligible applicant. The date of the initial home visit with the person is considered the date of application.

See Section 7110, TIERS Inquiries, for complete information on how existing coverage affects eligibility for CCAD services.

2341.3.1 Effect of QI Benefits on Eligibility for Community Care Services

Revision 17-1; Effective March 15, 2017

The Qualifying Individuals (QI) program was created by Public Law 105-33, as part of the Balanced Budget Act of 1997. The legislation specifies that QI recipients cannot be eligible under any other Title XIX-funded program and simultaneously receive QI benefits. Therefore, applicants and individuals receiving QI benefits are not eligible for Primary Home Care (PHC), Community Attendant Services (CAS) or Title XIX Day Activity and Health Services (DAHS). QI recipients are eligible to receive Title XX Family Care (FC) or Title XX DAHS, or both, provided all other eligibility criteria are met.

Identification of QI Coverage

At the time of application for Title XIX services and at each subsequent annual reassessment, case workers must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is receiving QI services. TIERS designates QI coverage as Type Program (TP) of Assistance TP-26.

Procedure for Applicants

If an applicant specifically requests PHC, CAS or DAHS, explain that individuals may not receive QI while receiving any other Title XIX-funded service. Inform the individual that there is no prohibition against receiving Title XX FC or DAHS at the same service levels. Applicants requesting DAHS must be certified for Title XX DAHS. Receipt of QI services does not preclude applicants from being placed on any existing interest list.

Procedure for Ongoing Individuals

When it is discovered that an individual receiving a Title XIX Community Care for Aged and Disabled (CCAD) service (CAS, PHC or Title XIX DAHS) has been certified for QI benefits, the case worker must first determine if enrollment in Title XX FC/ DAHS is open or if an interest list exists for the desired service. If no interest list exists, process the request for the desired service. If it is determined that the individual will have to be placed on a Title XX FC/ DAHS interest list, the case worker must contact the individual to give him the choice of service he wants to continue (QI or Title XIX CCAD service).

The case worker's next actions will depend on the individual's decision:

  • If the individual elects to continue receiving the Title XIX CCAD service, explain that this will require that his QI benefits be denied. Send Form 2067,
  • Case Information, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to let MEPD know the individual's decision.
  • If the individual decides to transfer to a Title XX service in order to keep his QI benefits, grant that service (if regional budgetary conditions allow) without placing him on the interest list. Otherwise, the individual should be placed at the top of the interest list. Title XIX service cannot remain open while the individual waits for an available slot.
  • Follow up with written notification using Form 2065-A, Notification of Community Care Services.

2341.4 Refusal to Cooperate with the Application Process

Revision 17-1; Effective March 15, 2017

If the applicant refuses to sign Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, or otherwise refuses to participate in the assessment process, do not proceed with the application process. Advise the applicant that he will receive a notice of ineligibility in the mail. Send the applicant Form 2065-A, Notification of Community Care Services. Use Code 17, "You failed to provide the necessary information."

2341.5 Retroactive Payment Process

Revision 17-1; Effective March 15, 2017

The retroactive payment process is an option that an individual and/or the provider may use if the individual has an immediate need for assistance with personal care task(s) pending the Texas Health and Human Services Commission's eligibility decision for Medicaid eligibility. See Section 2348, Retroactive Payments.

2342 Screening for Primary Home Care and Community Attendant Services

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must screen all applicants and individuals for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC) or continuing with an authorization for FC. If appropriate, the case worker makes a referral for PHC eligibility or services.

40 Texas Administrative Code §48.2911(d) — To be eligible for family care, the individual must not be eligible to receive attendant care services funded through Medicaid.

Screening Applicants

During the initial interview, determine if the applicant is currently receiving Medicaid or is potentially eligible for CAS. If the applicant is receiving Medicaid, use the additional screening criteria to determine if a referral to PHC is appropriate.

If the individual's income and resources appear to be within the Supplemental Security Income (SSI) limits (refer to Appendix XI, Monthly Income/Resource Limits), and the individual appears to have a medical need for assistance with personal care, refer the individual to the Social Security Administration for an SSI application. However, the individual should not be denied services for refusing to apply for SSI.

If the applicant is not receiving Medicaid and his income and resources are above SSI limits, complete an Application for Assistance form during the interview or review the application form mailed to the applicant for completion. Assist the applicant in the completion of the form and obtain all required verifications that are available.

If the applicant cannot complete the application form during the interview, explain to the applicant the importance of returning the form and requested verifications as soon as possible since his eligibility for services cannot be determined until the form is received.

Forward the completed Application for Assistance form promptly to the local Medicaid for the Elderly and People with Disabilities (MEPD) office, as specified in Section 2342.2, Timely Referral to MEPD.

Screening Ongoing Family Care Cases

At each financial recertification of FC cases (or whenever the individual's circumstances change), review the individual's situation to determine if he is potentially eligible for:

  • CAS. If so, a referral to MEPD must be sent within three business days of becoming aware of the change.
  • PHC. If so, the transfer must be completed within 14 calendar days.

Minor changes in the individual's situation do not require a referral to MEPD if it obviously will not affect the individual's eligibility. If any doubt exists, make the referral to MEPD.

2342.1 Receipt Date of the Application Form

Revision 17-1; Effective March 15, 2017

The date of the official application is the day the application form is received by the case worker at a home visit, or received by mail or hand delivered to a Texas Health and Human Services Commission office.

See Section 2333, Applications, for a list of acceptable applications.

If the case worker receives the application form during the home visit, the case worker enters the date in the "Date Form Received" box at the top of the form.

2342.2 Timely Referral to MEPD

Revision 17-1; Effective March 15, 2017

All new Medicaid for the Elderly and People with Disabilities (MEPD) applications statewide must be processed using the Texas Integrated Eligibility Redesign System (TIERS). A new application is defined as "an individual not currently authorized services in TIERS."

All communication to MEPD must include Form H1746-A, MEPD Referral Cover Sheet. Form 2067, Case Information, is not an acceptable means of communication to MEPD staff.

Prior to the home visit, the case worker must check TIERS to determine if a prior application has ever been completed for the applicant. If there is no active record, then the application is considered a "new" application.

The date of receipt of the application form is considered as day zero.

New Applications

No later than the close of business on the second business day after receipt of the completed application form, the case worker must:

  • Fax the completed application and verification documents to the Austin Document Processing Center (DPC) using Form H1746-A.
  • Retain the original Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

Prior Applications

If a record of the applicant is found in TIERS, including current individuals requesting a program transfer, then no later than the close of business on the second business day after receipt of the completed application form, the case worker must fax the completed application and verification documents to the Austin DPC, using Form H1746-A as a cover sheet. The case worker retains the original Form H1200 or Form H1200-EZ with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

Transmittal

If Form H1746-A is not completed correctly, an incorrect assignment to MEPD staff could result.

The case worker must follow the guidelines below to ensure a correct assignment is made:

  • When the case worker submits case information and supporting documentation to MEPD concerning an applicant or individual receiving services, Form H1746-A must be included as the cover sheet.
  • All information included on Form H1746-A must be typed, not handwritten.
  • The case worker must not send more than one Form H1746-A to MEPD requesting the same action because this creates a new task, possibly resulting in multiple assignments to different MEPD specialists. The documents scanned by the Document Processing Center (DPC) are imaged in the Texas Health and Human Services Commission (HHSC) Benefits Portal within three business days. The case worker must allow this time for the documents to be imaged.
  • If the case worker determines the documents imaged into the Portal did not transmit correctly or completely by reviewing inbound correspondence using the PT Inquiry tab in the Portal, the case worker must resend the documents to the DPC. Prior to resending the documents, the case worker must determine if an MEPD specialist has already been assigned a task by thoroughly reviewing TIERS Case Comments and Active Tasks using the PT Inquiry tab in the Portal.
  • If the case worker determines a task has not been created for the MEPD specialist, he must resend the documents to the DPC with a new Form H1746-A and include the original fax confirmation page, if available. In the comments section of the new Form H1746-A, the case worker must indicate the date the documents were originally sent to MEPD and the reason the documents are being sent again. If a task has been created, the case worker must resend the documents to the DPC with “Supporting Documents” marked on a new Form H1746-A to ensure the documents are linked to the task. The case worker can work from a saved version of Form H1746-A on his desktop when a new form has to be created. The form allows sender information to be saved. Each time the form is opened from the desktop, a unique bar code will be generated.
  • The case worker must follow current policy and procedures to determine when information must be faxed to MEPD rather than mailed.
  • The case worker must complete the “Applicant/Consumer Information” section on Form H1746-A as thoroughly as possible. Select the appropriate action based on the type of information being submitted to MEPD and program type depending on which program is requiring MEPD action. Only one action and program type can be selected.
  • To ensure the MEPD specialist has accurate contact information for HHSC, the sender information must be completed in full with HHSC as the selected agency and the sender’s name as it appears in the Outlook Global Address List.
  • The case worker should provide specific comments in the “Additional Comments” section to aid the MEPD specialist in processing the information being submitted.
  • If multiple applications are faxed to MEPD, the case worker must fax each application with its corresponding Form H1746-A separately. Form H1746-A must be the first document in the packet. The case worker must not send multiple applications in a single fax because they will be electronically stored as one document under the case number for the first one.
  • If multiple applications are mailed to the DPC, the case worker must attach Form H1746-B, Batch Cover Sheet, to the top of each batch containing more than one Form H1746-A and application. All applications submitted in a batch using Form H1746-B must be mailed to the DPC and cannot be faxed.

Do not fax and mail the same documents. This will cause duplication in the system. Use two-sided faxing when possible.

If unusual circumstances exist in which the original must be mailed to MEPD after faxing, staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 or Form H1200-EZ and sending by electronic mail is prohibited. The time frames for submission of the form and all other requirements remain the same.

The case worker must keep a copy of the application form, any verifications and Form H1746-A in the case record.

Any applications received by HHSC or MEPD for Medical Assistance Only (MAO) programs must be retained. Applications are part of the Code of Federal Regulations (CFR) maintenance of record requirements and must be added to the MEPD case record (original or copy, if faxed), even if the individual is already on Medicaid or has not determined which, if any, services he is requesting. In these circumstances, clearly document the situation on Form H1746-A. The best practice is to perform an inquiry to determine if the individual already has Medicaid coverage prior to the contact, thus avoiding unnecessary completion of an application.

Part 413 Subpart A – Code of Federal Regulations §431.17, Maintenance of records.

(b) Content of records. A State plan must provide that the Medicaid agency will maintain or supervise the maintenance of the records necessary for the proper and efficient operation of the plan. The records must include –

(1) Individual records on each applicant and recipient that contain information on –

  1. Date of application;
  2. Date of and basis for disposition;
  3. Facts essential to determination of initial and continuing eligibility;
  4. Provision of medical assistance;
  5. Basis for discontinuing assistance;
  6. The disposition of income and eligibility verification information received under Social Security Part 413 Subpart A - Code of Federal Regulations §435.940 through §435.960 of this subchapter;

Refer to Appendix XXXII, Medicaid Program Actions, for additional information. This chart provides instructions for sending Form H1746-A to MEPD when a case action is needed and indicates when a new Form H1200 needs to be attached to the cover sheet.

For program transfers, Appendix XLV of the Office of Social Services MEPD Website, provides a guide to determine when Form H1200, along with Form H1746-A, are needed by the MEPD specialist to complete the program transfer.

Refer to Appendix XXVII, HHSC Benefits Portal and TIERS Inquiry Desk Guide, for instructions on how to complete the inquiries described in this memorandum, as well as other types of inquiries through the Portal and TIERS.

2342.3 Exception Criteria for Referrals to PHC or CAS

Revision 17-10; Effective October 6, 2017

The case worker must screen all applicants for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC). The case worker applies the following exception criteria to determine if the applicant has a reason not to be referred for CAS, or if on Medicaid, would not be eligible for PHC.

To determine if the applicant is not appropriate for a referral to PHC or CAS, screen the applicant for the following criteria:

  • Does the applicant specifically state that he will accept care only from his spouse as the paid attendant, and unmet need policy does not preclude this arrangement?
    • If yes, the applicant is referred for FC or placed on the Family Care interest list and is not referred for CAS. If no, then continue the screening process.
  • Does the applicant receive Qualifying Individual (QI) benefits?
    • If yes, explain the choices of benefits according to Section 2341.3.1, Effects of QI Benefits on Eligibility for Community Care Services. If the applicant elects to keep the QI benefits, he may be referred for FC or placed on the FC interest list. If the individual elects to be referred to CAS, continue the screening process.

Other Criteria:

  • Does the applicant meet the citizenship requirements needed to establish eligibility for Medicaid-funded programs?
  • Does the applicant have a need for at least one personal care task?
  • Does the applicant have a medical condition causing a functional impairment in performing personal care tasks?
  • Does the applicant have a medical diagnosis other than mental illness, intellectual disability, or both?
  • Does the applicant have a practitioner willing to sign a statement that the applicant has a medical need for assistance with personal care tasks and other activities of daily living?
  • Does the applicant require at least six hours of service per week or meet exemptions listed in Section 4633, Functional Eligibility?

If the applicant answers “Yes” to all other criteria, then a referral for PHC or CAS is made. If the applicant answers “No” to any one of the other criteria, then the individual is referred for FC or placed on the FC interest list and is not referred for PHC or CAS.

Placement on the FC Interest List

Within five workdays of screening for CAS or PHC, using the original date of the request for services, assigned staff must enter all relevant data into the Community Services Interest List (CSIL) if:

  • FC enrollment is open and the applicant does not meet the screening criteria for CAS or PHC, or the case worker will authorize FC while CAS financial eligibility is pending; or
  • FC enrollment is not open and the applicant does not meet the screening criteria for CAS or PHC.

The original date of the request for services is the date the applicant called in requesting services, listed on Form 2110, Community Services Intake.

FC Services Pending the CAS Eligibility Decision

If FC enrollment is open in a region, the case worker assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending from Medicaid for the Elderly and People with Disabilities (MEPD). If an individual placed on the FC interest list is released from the interest list, the case worker must screen the individual for CAS and refer to MEPD, if screening criteria are met. The case worker also assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending.

If the individual is determined eligible for CAS, the case worker follows the policy in Section 4652.3, Initial Referrals for Community Attendant Services, and negotiates a transfer from FC to CAS. The case worker sends Form 2065-A, Notification of Community Care Services, noting the transfer of services. If the individual is not eligible for CAS, the case worker continues FC services, unless the individual was denied CAS for refusal to cooperate.

Refusal to Cooperate with MEPD

If the individual is denied for refusal to cooperate with the financial eligibility determination process, including refusal to furnish information or withdrawing the CAS application, the case worker must follow up with the individual to explore why the individual did not cooperate. If the individual states he is unwilling to cooperate with the financial eligibility determination process, then the case worker must advise the individual his application for services is denied and if he reapplies in the future, he will be referred for CAS again. The case worker documents all contacts in the case record and sends Form 2065-A to the individual citing rule reference 40 Texas Administrative Code §48.2911 (a)(3). In the Comments section, the case worker includes the following statement: “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. Medicaid for the Elderly and People with Disabilities has notified HHSC you failed to provide the necessary information to determine eligibility for Medicaid-funded services.” If the individual requests to be placed on the FC interest list, the individual may be placed on the list, but he must be informed that he will be referred to CAS when his name is released from the list.

If the individual is receiving FC services pending the MEPD eligibility decision and the individual refuses to cooperate with the financial eligibility determination process as described above, the case worker must deny FC services. The case worker documents all contacts in the case record and sends Form 2065-A to the individual citing rule reference 40 Texas Administrative Code §48.2911 (a)(3). In the Comments section, the case worker includes the following statement: “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. You failed to provide the necessary information to determine eligibility for Medicaid-funded services.”

If the individual states that he cooperated and thought he submitted all requested information, the case worker may check the Comments section in the Texas Integrated Eligibility Redesign System (TIERS). The case worker may need to assist the individual in obtaining any missing requested documentation.

The individual can reapply for CAS for up to 90 days from the date of the MEPD denial without completing a new Form H1200-EZ, Application for Assistance – Aged and Disabled. The case worker must obtain a written, dated and signed statement of request to reapply from the applicant or authorized representative to establish the date of application. The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked “Application.” The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for CAS. The case worker includes all identifying information on Form H1746-A, and any additional information that will help identify the original application. Fax Form H1746-A and documentation to the Austin Document Processing Center.

Applications Denied by MEPD

If a referral is sent to MEPD and the individual is denied CAS eligibility for reasons other than refusal to cooperate with the financial eligibility determination process, then the individual remains eligible for FC or is placed on the FC interest list. The assigned staff enter the information into the CSIL using the original request date for services when placing the individual on the interest list.

If the individual who was denied CAS eligibility for reasons other than refusal to cooperate is released from the FC interest list within 90 days of the application date, the case worker may use Form H1200-EZ, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the additional forms signed at the initial home visit, and verifications on file to determine eligibility for FC. The case worker must review all the information provided and note any changes on Form 2064, Eligibility Worksheet. The case worker must establish that the individual meets all financial eligibility requirements for Title XX services. The case worker does not need to do an additional home visit, but must review Form H1200-EZ and Form 2060 with the applicant and document any changes which have occurred since the initial visit. The case worker will need to follow appropriate time frames for annual reassessments as the annual reassessment will still be due within 12 months of the initial home visit.

FC Annual Reassessments

See Section 4447, Reassessment, for FC reassessment procedures.

2342.4 Spouse Attendant in Family Care Services

Revision 17-1; Effective March 15, 2017

If an individual states he will accept care only from his spouse, then the individual may be assessed for Family Care services or placed on the Family Care interest list and not referred to Primary Home Care (PHC) or Community Attendant Services (CAS).

Individuals on Medicaid may elect to receive Family Care services to have a spouse attendant. The policy that states, “"To be eligible for Family Care, the individual must not be eligible to receive attendant care services funded through Medicaid",” does not apply if the individual elects to have a spouse attendant. Even though these individuals meet the criteria to be referred to CAS, they may elect to receive Family Care services and not be screened or referred to Medicaid for the Elderly and People with Disabilities (MEPD) for a financial determination.

Unmet need policy applies and the case worker must carefully evaluate tasks provided and tasks not currently provided by the spouse to determine the service plan purchased through Family Care services. See Section 2513, Caregiver as the Paid Attendant, and Section 2514, Who Cannot Be Hired as the Paid Attendant, for additional information. The policy must be followed and the spouse assessed as any other caregiver. One exception to the policy is that on Form 2101, Authorization for Community Care Services, the case worker must note the individual is requesting the spouse as the paid attendant.

If the arrangement for the spouse as the attendant ends, then the individual must be referred for the appropriate Medicaid funded service.

2342.5 Disability Determination for Individuals Under Age 65 Applying for CAS

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker is required to assist certain individuals under age 65 to complete the forms required by HHSC for a disability determination. Individuals age 65 or over may qualify for Medicaid or Medicaid-funded programs, such as Community Attendant Services (CAS), without a disability determination.

The case worker must review an individual's disability status by using the State On-Line Query (SOLQ) or Wire Third Party Query (WTPY) systems. An individual has a disability established by Social Security if there is a disability onset date on the SOLQ or WTPY systems. If the individual under age 65 does not have a Social Security established disability, the case worker must assist the individual with completing Form H1200-EZ, Application for Assistance – Aged and Disabled, Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact when assessing eligibility.

To determine a disability, HHSC must review evidence, signed by the individual's treating physician (that may include medical reports), detailing the degree and history of the individual's diagnosis. The case worker must inform the individual when scheduling the initial face-to-face contact that the case worker will need the required evidence at the initial contact with the individual. If the case worker schedules the face-to-face contact at least seven calendar days in advance, the case worker must send Form 2423, Request for Medical Evidence, to the individual on the same day of the telephone contact to advise the individual of the evidence requirement. If the case worker schedules the face-to-face contact less than seven calendar days in advance, the case worker must present Form 2423 at the face-to-face contact. The case worker must not delay the face-to-face contact for the purpose of allowing the individual time to obtain the medical evidence.

The case worker should include the completed Form H3034, Form H3035 and any evidence obtained at the initial face-to-face contact with Form H1200-EZ following current transmittal procedures to Medicaid for the Elderly and People with Disabilities (MEPD). If evidence was not available at the initial face-to-face contact, the case worker documents "No evidence was obtained" in the Section I, Comments about your disability, on Form H3034 prior to submitting to HHSC for a disability determination.

2343 Confidentiality

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(a) — Information collected to determine eligibility for services, whether collected by DHS staff or provider agencies, is confidential.

Information concerning Texas Health and Human Services Commission (HHSC) applicants and individuals is confidential and can only be used for purposes directly connected to administration of HHSC services. HHSC routinely shares confidential information with providers because the information shared is directly connected with service administration.

Information can also be shared with other entities if it is determined that the purpose is directly tied to the administration of services. Consult the unit supervisor before making the decision to share information with individuals other than the providers.

Code of Federal Regulations, Title 42, Part 431, Subpart F – Safeguarding Information of Applicants and Recipients – (a) Section 1902(a) (7) of the Act requires that a state plan must provide safeguards that restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan.

Refer to Section 1140, Disclosure of Information, regarding national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2344 Individual Rights and Responsibilities

Revision 17-1; Effective March 15, 2017

During the initial visit with the applicant and, as appropriate, the responsible person (RP), discuss the information contained in Form 2307, Rights and Responsibilities. Ensure the applicant understands the significance of his rights and responsibilities.

If the applicant appears unable to understand this information or the complaint process, it is important to give the RP a copy of Form 2307. Sharing the applicant's rights and responsibilities with the RP is particularly important if it appears the applicant may not be able to fully understand his rights and responsibilities. An RP may be a guardian, family member or other individual who assists in the development of the care plan and/or who maintains regular communication with the applicant or department regarding the applicant's well-being.

The applicant must:

  • provide all information needed to establish eligibility and develop a service plan. Falsifying information is illegal and may result in criminal charges filed against the applicant.
  • promptly report changes in income, living arrangements, family size, loss of assistance grants or Medicaid benefits, or other changes that affect eligibility. If the applicant willfully fails to report changes that affect eligibility and receives services for which he is not eligible, he may be prosecuted for fraud.

Rights and Responsibilities Documentation Requirements

At Application

At the initial home visit, the case worker must clearly and fully explain the information in the following forms with the applicant. Maintain copies in the case record and review with the applicant/RP as indicated in the instructions for each form.

Individuals must receive the following forms:

  • Form 2307, Rights and Responsibilities;
  • Form 1581, Consumer Directed Services Option Overview; and
  • Form 1584, Consumer Participation Choice, if applying for personal attendant services (PAS).

If the applicant selects the Consumer Directed Services (CDS) option on Form 1584, he must also receive:

  • Form 1582, Consumer Directed Services Responsibilities; and
  • Form 1583, Employee Qualification Requirements; and
  • Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option.

If the applicant selected the Service Responsibility Option on Form 1584, he must also receive:

  • Form 1581-SRO, Service Responsibility Option (SRO) Overview; and
  • Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

See Section 6000, Service Delivery Options, for complete information and requirements on CDS and SRO.

Individuals applying for Family Care, Community Attendant Services or Primary Home Care, Emergency Response Services (ERS) and Adult Foster Care (AFC) services must be given the following forms for the requested service:

  • Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities;
  • Form 2307-B, ERS Eligibility Criteria and Responsibilities; or
  • Form 2307-F, AFC Rights and Responsibilities.

All applicants must receive Form 2065-A, Notification of Community Care Services, notifying them of the eligibility decision.

Annual Reassessments and Changes

  • Clearly document in the case record that the individual's rights and responsibilities were reviewed at the annual reassessment.
  • Keep the current Form 2307 on file at the annual reassessment if nothing has changed affecting the individual's services. Telephone numbers and staff names do not constitute a change for completing a new Form 2307, although it is important that the individual knows how to reach the case worker (business cards are suggested).
  • If the individual's services have changed, the individual/RP must complete and sign a new Form 2307.
  • As appropriate, review the information on Form 2307-A, Form 2307-B or Form 2307-F with the individual/RP. Complete new forms if PAS, ERS or AFC are being added as new services.
  • With the exception of ERS and Home-Delivered Meals (HDM), a home visit is required to add a service to the individual's service plan.
  • Review and offer the choice of service delivery options at the annual reassessment and obtain a new signed and dated Form 1581.
  • Clearly document in the case record that the choice of service delivery options was reviewed at the annual reassessment.
  • Obtain a new signed and dated Form 1584 at any time the individual changes his service delivery option. The case worker will also need to complete Form 1581, (or Form 1581-SRO), Form 1582, (or Form 1582-SRO) and Form 1583, as appropriate.
  • Send Form 2065-A if the case action includes:
    • the addition of a new service;
    • a change in the amount of service;
    • a change in the amount of the individual's copayment;
    • a change in priority status; or
    • termination of the case or service.

See Appendix IX, Notification/Effective Date of Decision, for additional details or exceptions.

2345 Registering to Vote

Revision 17-1; Effective March 15, 2017

The National Voter Registration Act (NVRA) of 1993 requires that the Texas Health and Human Services Commission (HHSC)  offer each individual applying for HHSC services the opportunity to register to vote, to record the individual's decision on Form 1019, Opportunity to Register to Vote/Declination, and to file it in the case record. Additionally, HHSC case workers must also offer the individual an opportunity to register to vote at annual reassessments and when notified of a change of address.

The HHSC case worker must provide the same degree of assistance, including bilingual assistance, to help the individual complete the voter registration forms as is provided with the completion of any HHSC forms.

The case worker may not make a determination about an individual's eligibility for voter registration other than a determination of whether the person is of voting age, which is 18 years of age, or is a U.S. citizen. An individual's age or citizenship may be verified by the case worker if the age or citizenship can be readily determined from information filed with HHSC for purposes other than voter registration. An individual must be offered voter registration assistance as provided by the NVRA if the individual's age or citizenship cannot be determined.

At the time an individual applies for services, at annual reassessments or when changing addresses, he must be given the opportunity to:

  • complete Form 0030, Application for Voter Registration, and mail it to the voter registrar; or
  • complete Form 0030 and provide it to HHSC staff to mail to the voter registrar.

If the individual wishes to complete Form 0030 during the interview, the case worker must review the form for completeness in the presence of the individual. If the form does not contain all the required information, including the required signature, the case worker returns it to the individual for completion. If the individual requests the case worker to mail the form, Form 0030 must be sent to the appropriate county voter registrar within five working days of signature by the individual.

When HHSC staff offer individuals the opportunity to register to vote, as required by the National Voter Registration Act, they must also inform individuals of the option of requesting a ballot by mail. Individuals may request a ballot by mail if they are:

  • out of the county during early voting and on Election Day;
  • age 65 or older;
  • sick or disabled; or
  • confined to jail.

He or she can print an application for a ballot by mail (PDF) from the Texas Secretary of State website and mail it to the Early Voting Clerk. HHSC staff must also provide assistance in completing any form while an individual is registering to vote as prescribed in current voter registration policy.

Declining to Register

If the individual does not wish to complete Form 0030, he must complete and sign Form 1019. If the individual refuses to sign Form 1019, the case worker must document the refusal on the form. The case worker must keep each declination form in the case record for at least 22 months after the date of signing.

Annual Reassessments Conducted by Telephone

If the individual receiving services wishes to register to vote during an annual reassessment that is conducted by telephone, the case worker must mail Form 0030 to the individual within three working days after the date of the phone call. If the individual does not wish to register to vote, the case worker must ask the individual to complete and sign Form 1019. The case worker must mail him Form 1019 within three working days after the date of the phone call. The case worker must inform the individual that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the individual refuses to sign the declination form, or the case worker does not receive the form within 30 calendar days after the date of the phone call with the individual, the case worker must enter on Form 1019 that the individual refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the individual's case record for at least 22 months after the date of signing.

Change of Address

The case worker must contact the individual by phone within five working days after receiving notification of a change of address and offer the opportunity to register to vote. If the individual does not have a phone, the case worker must mail Form 0030 and Form 1019 within five working days after being notified of a change in address. If the case worker does not receive either Form 0030 or Form 1019 within 30 days of mailing the forms to the individual, the case worker must complete Form 1019 indicating that the individual failed to return Form 1019.

If the individual wishes to register to vote, the case worker must mail Form 0030 to the individual within three working days after the date of the phone call. If the individual does not wish to register to vote, the case worker must ask the individual to complete and sign Form 1019. The case worker must mail him Form 1019 within three working days after the date of the phone call. The case worker must inform the individual that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the individual refuses to sign the declination form, or the case worker does not receive the form within 30 days after the date of the phone call with the individual, the case worker must enter on Form 1019 that the individual refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the individual's case record for at least 22 months after the date of signing.

Additional Guidelines

The case worker must not:

  • influence an individual's political party preference;
  • display any political party preference or allegiance; or
  • make any statement or take any action for the purpose or effect of:
    • discouraging the individual from registering to vote; or
    • leading the individual to believe that a decision of whether to register has any bearing on the availability of or eligibility for HHSC services or benefits.

If the individual has any questions regarding the voter registration process that the case worker cannot answer, the case worker must:

  • advise the individual to call the Office of the Texas Secretary of State toll-free at 1-800-252-8683; or
  • give the individual the telephone number of the local county voter registrar.

2346 Service Delivery Options

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) offers applicants and individuals three options for the delivery of personal attendant services (PAS). It is the case worker's responsibility to present information on all available service delivery options to the applicant at the initial interview and to ongoing individuals at the annual review, or whenever requested.

The service delivery options include the:

  • Consumer Directed Services (CDS) service delivery option, managed by the individual;
  • Service Responsibility Option (SRO), co-managed by the individual and the agency in the specific pilot area; and
  • Agency Option (AO), managed by the agency.

If the applicant/individual chooses an option other than the AO, the case worker will conduct special casework procedures including, but not limited to:

  • providing an overview of the option(s) the applicant/individual is interested in by using Form 1581, Consumer Directed Services Option Overview, for CDS; and/or Form 1581-SRO, Service Responsibility Option (SRO) Overview, for SRO; and
  • reviewing the individual's roles and responsibilities under the chosen option by using Form 1582, Consumer Directed Services Responsibilities, for CDS; and/or Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, for SRO.

Once the applicant/individual has made a choice, the case worker asks the applicant/individual to sign Form 1584, Consumer Participation Choice, to document the choice of option. Additional casework procedures are detailed in:

2347 Texas Medicaid Estate Recovery Program (MERP)

Revision 17-1; Effective March 15, 2017

2347.1 Introduction

Revision 17-1; Effective March 15, 2017

On March 1, 2005, Texas implemented the Medicaid Estate Recovery Program (MERP) in compliance with federal Medicaid laws. The Texas Health and Human Services Commission (HHSC) manages the program.

Under this program, the state may file a claim against the estate of a deceased Medicaid recipient, age 55 and older, who applied for certain long-term care services on or after March 1, 2005. Claims include the cost of services, hospital care and prescription drugs supported by Medicaid under the following programs:

  • nursing facility (NF);
  • intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID), which include state supported living centers;
  • 1915(c) waiver programs
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD) Medicaid Waiver;
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL) Program;
    • STAR+PLUS Waiver services; and
  • Community Attendant Services (CAS).

In addition to information provided in this handbook, staff may also consult the MERP website at https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program.

2347.2 Presentation of Information to Community Attendant Services Applicants

Revision 17-9; Effective September 15, 2017

Medicaid Estate Recovery Program (MERP) information must be shared with all Community Attendant Services (CAS) applicants and, in some cases, ongoing individuals, regardless of age, unless the applicant or individual is determined to have "grandfathered" status. (See Section 2347.3, Determining Grandfathered Status).

For all CAS applications received on or after March 1, 2005, the case worker is responsible for presenting MERP information to the applicant and authorized representatives.

1 Texas Administrative Code §373.301, Notice Upon Application

(a) Written notice of the MERP provisions will be provided to:

(2) Individuals for Medicaid-covered Home and Community-Based Services (§1915(c), Social Security Act) and Community Attendant Services (§1929(b), Social Security Act):

(A) prior to an individual's signing an election statement for Home and Community-Based Services, as an alternative to institutionalization; or

(B) at the initial home visit for Community Attendant Services.

MERP information is shared at the initial home visit or face-to-face contact. MERP information must be presented in person, not over the phone. Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, must not be mailed with the application packet.

Questions about MERP received before the face-to-face contact with the applicant should be promptly addressed; however, applicants expressing concern about the estate recovery program should be encouraged to allow an in-person contact in order to have a more extensive discussion of the policy, including the exemption and the undue hardship provisions.

At the initial home visit for a CAS applicant, the Texas Health and Human Services Commission (HHSC) case worker must present the MERP script in Appendix XXI, Medicaid Estate Recovery Program (MERP) Script and Cover Sheet. Staff will follow the MERP script to present MERP information and to request the individual to sign Form 8001. The script also provides guidance on how to handle questions or the individual's refusal to sign Form 8001.

Staff are not required to follow the script if the individual chooses to sign Form 8001 after a brief overview of MERP.

During the interview, the case worker will ask if the individual would like to read Form 8001. If the individual chooses to read the form, the case worker allows time for the individual to read the form. The case worker must clearly state that Form 8001 is informational material only. After MERP and Form 8001 are shared, the case worker asks the individual to sign Form 8001 to acknowledge MERP information was shared. If the individual refuses to sign the form, the case worker documents the individual's refusal by checking the box on the bottom of Form 8001. The case worker explains to the individual that refusal to sign Form 8001 does not exempt the individual from estate recovery.

Also during the interview, the case worker must obtain and document executor information. Executor information must be recorded in the Service Authorization System (SAS) by creating an "Executor" address type. If the individual has already identified an executor and this information has been recorded in SAS, confirm with the individual that this information is correct. If the individual does not have a will and executor, the case worker asks for the name of the person whom the state should contact after the individual's death to determine whether recovery is appropriate. The order of preference for contacts after executor is: (1) legal guardian, (2) power of attorney (POA) or (3) other family members who have acted on behalf of the individual. A space is provided on the MERP script to record two names and addresses of the persons the individual identifies. If the individual does not have an executor, the case worker enters the information about the first preferred contact in SAS "Executor" address record. The case worker files the page from the MERP script that lists the contact information in the case record.

The case worker explains program requirements related to sharing MERP information, but does not make recommendations about MERP or speculate whether MERP will be applicable upon the individual's death, if the individual has this type question. The case worker provides to the individual additional sources for MERP information, including:

  • the telephone number or website listed on Form 8001; or
  • Legal Hotline for Texans at 1-800-622-2520 (available to persons age 60 and over, Medicare beneficiaries, regardless of age, and low-income victims of violent crime.)

Along with Form 8001, the case worker must share a copy of the MERP brochure, Your Guide to the Medicaid Estate Recovery Program.

Applicants or family members with access to the Internet can obtain information about MERP at https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program.

Regional and local staff can obtain information about MERP procedures and estate recovery policy information at https://hhs.texas.gov/medicaid-estate-recovery-program-faqs.

2347.3 Determining Grandfathered Status

Revision 17-1; Effective March 15, 2017

An individual's estate is not subject to the Medicaid Estate Recovery Program (MERP) if the individual applied for one of the following programs/services subject to MERP prior to March 1, 2005. An individual who meets these criteria is considered to be "grandfathered" (or protected) from MERP. The services are:

  • nursing facility (institutional Medicaid) services
  • intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID), which include state supported living centers
  • Community Attendant Services (CAS)
  • 1915(c) waiver programs:
    • Community Living Assistance and Support Services (CLASS)
    • Deaf Blind with Multiple Disabilities (DBMD)
    • Home and Community-based Services (HCS)
    • Texas Home Living (TxHmL)
    • STAR+PLUS Waiver (SPW) services

Form 1575, Medicaid Estate Recovery Program Worksheet, and instructions, have been developed to document verification of an applicant's or individual's grandfathered status. The case worker completes Form 1575 for CAS applicants or individuals to document whether the applicant or individual is considered to have grandfathered status. This form is completed at the initial home visit for applicants or at the next annual reassessment for ongoing individuals if there is not a Form 1575 in the case record. The following procedures apply:

  • For applicants, if the case worker cannot determine whether an applicant has grandfathered status, the case worker must present MERP information to the applicant and complete Form 1575 and Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement.
  • For ongoing individuals, if the case worker cannot determine whether the individual has grandfathered status and there is no Form 8001 in the case record, the case worker must present MERP information to the individual and complete Form 8001 and Form 1575.
  • If it is determined the applicant or individual has grandfathered status, the case worker must complete Form 1575.
  • If, for ongoing individuals, there is a Form 8001 in the case record but no Form 1575, the case worker must complete Form 1575.
  • If it is determined the applicant or individual does not have grandfathered status and there is no Form 8001 in the case record, the case worker must present MERP information to the applicant or individual and complete Form 8001 and Form 1575.

Form 1575 and Form 8001 must be filed and kept in the most current volume of the case record. The information documented on Form 1575 includes the:

  • individual's name;
  • program/service the individual is applying for;
  • grandfathered status, including application date and/or program/service and dates received that support the individual's MERP grandfathered status;
  • source of verification of MERP grandfathered status; and
  • date verified.

The case worker must provide Form 2061, Notification of Medicaid Estate Recovery Program Status, to individuals who meet grandfathered status to alleviate concerns and to confirm the applicant's/individual's MERP status. Form 2061 must only be provided if the applicant's/individual's grandfathered status has been researched, verified and documented on Form 1575. A copy of Form 2061 must be placed in the case record along with Form 1575.

2347.3.1 Determining the Application Date for MERP Grandfathered Status

Revision 17-4; Effective May 23, 2017

This section provides guidelines on the program application dates that may be used to determine if individuals have Medicaid Estate Recovery Program (MERP) grandfathered status.

An individual's estate is not subject to MERP if the individual applied for programs/services subject to MERP prior to March 1, 2005. An individual who meets this criteria is considered to be "grandfathered" (or protected) from MERP. The application date used to determine if an individual has grandfathered status is based on specific program/service application dates, and must clearly indicate the application process for the program/service that was initiated on that date.

For Community Attendant Services (CAS), the application date is when:

  • a home visit in relation to an intake has occurred;
  • the case worker has completed or has begun to complete any part of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; or
  • an Application for Assistance (Form H1200, Application for Assistance – Your Texas Benefits, Form H1200-EZ, Application for Assistance – Aged and Disabled, has been completed.

In CAS, home visits or completion of the application are more clearly documented events; however, if case documentation (prior to March 1, 2005) clearly shows the case worker began the application process by completing or starting to complete Form 2060 (by phone) prior to the home visit or completion of the application for assistance, this documented date can be used to designate the individual as grandfathered status. This scenario should be rare.

The earliest verified and confirmed program/service application date can be used to determine the individual's grandfathered status.

There could be scenarios when Form H1200 was mailed to the individual requesting CAS but Form H1200 was mailed back to Medicaid for the Elderly and People with Disabilities (MEPD). The case worker uses the earliest date of receipt, by MEPD or the Texas Health and Human Services Commission (HHSC), as the application date. Applying for Qualified Medicare Beneficiary (QMB) and Specified Low-income Medicare Beneficiary (SLMB) prior to applying for a MERP service does not automatically constitute an application for a MERP service. The case worker must confirm the application date used to determine that an individual has grandfathered status is clearly related to the initiation of the application process for the MERP service.

Note: All application dates must be verified, confirmed and documented on Form 1575, Medicaid Estate Recovery Program Worksheet. If there is no clear verification of the application date, the individual must not be designated as grandfathered status.

2347.4 Medicaid Estate Recovery Program Exemptions

Revision 17-1; Effective March 15, 2017

Undue Hardship Waivers

The Medicaid Estate Recovery Program (MERP) does not recover costs from estates when it would result in undue hardship. An undue hardship waiver request form is provided as part of the MERP Notice of Intent to File a Claim form. The state considers a full or partial waiver of recovery when:

  • the estate property:
    • is a family business, farm or ranch for at least 12 months before the death of the recipient;
    • is the primary income-producing asset of the heirs;
    • produces at least 50 percent of the livelihood for the heirs; and
    • recovery by the state would affect the property and result in the heirs losing their primary source of income;
  • heirs or legatees of the estate will be eligible for public or medical assistance if recovery claim is collected;
  • allowing one or more heirs to receive the estate enables them to discontinue eligibility for public or medical assistance;
  • the Medicaid recipient received medical assistance as the result of being a crime victim; or
  • other compelling reasons exist.

A waiver request specific to the descendant's homestead will be considered when one or more siblings or lineal heirs have gross family income less than 300 percent of the federal poverty level. The waiver will be proportionate to each qualifying heir's share.

Waivers based on hardship are evaluated at the time of death, not at the time of application for services. Exception: Estates of individuals who applied for services through programs subject to MERP before March 1, 2005, are permanently exempt from recovery.

Grandfathering Exemptions

How individuals qualify for Medicaid (Supplemental Security Income (SSI) or Medical Assistance Only (MAO)) is irrelevant to evaluating MERP exemption status. The determining factor is the program in which the individual is enrolled. The MERP-covered programs are:

  • 1915c waiver programs
    • Community Living Assistance and Support Services (CLASS)
    • Deaf Blind with Multiple with Disabilities (DBMD)
    • Home and Community-based Services (HCS)
    • Texas Home Living (TxHmL) Program
    • STAR+PLUS Waiver (SPW) services
  • Community Attendant Services (CAS)
  • Nursing Facility (NF)
  • Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Condition (ICF/IID)

See Section 2347.3, Determining Grandfathered Status.

2347.5 MERP Claims and the Filing Process

Revision 17-1; Effective March 15, 2017

Medicaid Estate Recovery Program (MERP) claims will not be filed when it is not cost-effective. Claims that are not considered cost-effective are those where the:

  • value of the estate is $10,000 or less;
  • recoverable amount of Medicaid costs is $3,000 or less; or
  • cost of the sale of the property would be equal to or greater than the value of the property.

The acceptance of Medicaid medical assistance provides a basis for a Class 7 probate claim, as defined in §322 of the Texas Probate Code. The MERP files claims in accordance with the requirements contained in §298 and §301 of the Texas Probate Code. Additionally, a claim may not be filed under MERP if there is:

  • a surviving spouse;
  • a surviving child or children under 21 years of age;
  • a surviving child or children of any age who are blind or permanently and totally disabled under Social Security requirements; and/or
  • an unmarried adult child residing continuously in the Medicaid recipient's homestead for at least one year before the time of the Medicaid recipient's death.

MERP claims are filed within 70 days after MERP receives notice of the death of a Medicaid recipient, age 55 and older, and who after March 1, 2005, applied for certain Medicaid long-term care services. A MERP Notice of Intent to File a Claim form is sent to the contacts on file in the Texas Integrated Eligibility Redesign System (TIERS) and the Service Authorization System (SAS) within 30 days of notification of the death of a Medicaid recipient. The notice includes a program overview, an estate questionnaire regarding possible exemptions and information on the estate property. An undue hardship waiver request form is also included.

An heir has up to 60 days from the date of the notice to submit an undue hardship waiver request. Determination of an undue hardship waiver is evaluated on a case-by-case basis and is completed within 40 days of receipt of the request and supporting documentation. Should an undue hardship waiver be denied, the heir may submit a written appeal. Both the application and written appeal, when applicable, should be sent to:

Texas Health and Human Services Commission
Accounts Receivable – Mail Code E-411
P.O. Box 149030
Austin, TX 78714-9030

An appeal of denial must be submitted within 60 days of the date of the decision letter.

If no exemptions or full waivers apply, the lesser of the claim amount or estate value will be recovered after higher priority estate debts are paid. §322 of the Texas Probate Code contains the classification and priority of claims from a decedent's estate. The acceptance of certain Medicaid long-term care services provides a basis for a Class 7 claim after:

  • last illness and funeral expenses;
  • estate administration expenses;
  • secured claims, including tax liens;
  • child support;
  • taxes, penalties and interest due; and
  • expenses from cost of penal confinement.

An estate, according to the Texas Probate Code, is the real and personal property of an individual, such as a home or car. It typically does not include insurance policy proceeds; retirement accounts (such as IRAs), pension plans, financial institution accounts, mutual funds or deferred compensation plans when there is a designated beneficiary. MERP may compromise, settle or waive any claim upon good cause shown.

2347.6 Allowable Claim Deductions

Revision 17-1; Effective March 15, 2017

Under the Medicaid Estate Recovery Program (MERP), certain deductions from the claim amount are considered. These include necessary and reasonable expenses for home maintenance, including real estate taxes; real estate insurance, excluding liability; utility bills; home repairs and other maintenance expenses such as lawn care. Additionally, deductions from the claim amount may be considered for necessary and reasonable expenses for the direct payment of the costs of care (including payment of personal attendant care) provided for the Medicaid recipient that enabled the recipient to remain at home, thereby delaying the need for institutionalization.

The estate representative must provide supporting documentation for the requested deductions within 60 days following the date of the notice of intent to file a claim to recover Medicaid costs.

See Section 2347.5, Claim Filing Process, for additional information.

2347.7 Transfer of Assets

Revision 17-1; Effective March 15, 2017

Giving away assets without compensation may result in non-payment of nursing facility, intermediate care facilities for individuals with an intellectual disability or related conditions and 1915(c) waiver services. Assets transferred up to 60 months before application for long-term care or institutional services may affect an individual's entitlement to payment of services. There may be no transfer penalty if a recipient transfers a home to a:

  • spouse living in the home (the transfer penalty applies when the community-based spouse transfers the home without full compensation);
  • child or children under age 21;
  • child or children over age 21 living in the home for at least two years before the individual's institutionalization and who provided care to prevent institutionalization;
  • child or children of any age that meet the Supplemental Security Income (SSI) rule for disability/blindness; or
  • brother or sister with equity interest in the home and who lived there for at least one year before the individual's institutionalization.

Questions regarding the transfer of assets policy should be referred to the eligibility specialist at the local Medicaid for the Elderly and People with Disabilities office.

2347.8 Documenting Executor Information in SAS for CAS Individuals

Revision 17-1; Effective March 15, 2017

Within thirty days of notification of the death of a Medicaid recipient, the Texas Health and Human Services Commission (HHSC) sends notice of intent to file a claim to the executor or other estate representative of the Medicaid recipient. To facilitate this notification process, the case worker enters in the Service Authorization System (SAS) the name, address and telephone number of all Community Attendant Services (CAS) individuals' executors or estate representatives, if the individuals have them. Executor information is entered in the Address folder as follows:

  • Address Type: EX-EXECUTOR;
  • Address Line 1: Name of executor – First, Middle, Last;
  • Address Line 2: First line of mailing address (street number or post office box);
  • Address Line 3: Second line of mailing address (apartment number, block); and
  • Address Line 4: Telephone number of executor (Format ###-###-####).

Other information, such as directions, comments or executor's relationship to the individual must not be entered.

  • City: Type the city;
  • State: Select the state.

2347.9 Additional MERP Information

Revision 17-1; Effective March 15, 2017

If applicants or their family members with access to the internet would like more information about the Medicaid Estate Recovery Program (MERP), direct them to: https://hhs.texas.gov/services/aging/long-term-care/your-guide-medicaid-estate-recovery-program

Additional information about MERP can also be obtained by calling the MERP hotline at 1-800-641-9356 or by calling the Legal hotline for Texans at 1-800-622-2520 (available to persons age 60 and over; Medicare beneficiaries, regardless of age; and victims of violent crime).

2348 Retroactive Payments

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §47.85 (c)(1) — The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS's Application for Assistance – Aged and Disabled form is received:

(A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and

(B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

If an application is received for retroactive attendant care services, the following actions apply. Upon receipt of a completed, signed and dated application or request for services, send Form H1236, Notification of Receipt of Application, to the provider currently serving the applicant. The notice advises the provider that its individual:

  • has applied with the Health and Human Services Commission (HHSC) for services, and
  • is interested in applying for retroactive payments.

The case worker must send the completed application to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) or Community Care for Aged and Disabled (CCAD) regional staff so that a decision can be made regarding the applicant's financial eligibility.

Note: An individual who may complete or sign an application for an applicant or individual may not be on the list of people to whom HHSC can release the applicant's individually identifiable health information. See Section 1150, Personal Representatives, for individuals who may receive or authorize the release of individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

A Medicaid-eligible or categorically eligible individual does not have to complete an application when requesting services. Also, an individual who requests facility-initiated Day Activity and Health Services (DAHS) does not have to complete an application if he has stopped receiving services by the time he is contacted. The DAHS facility can be reimbursed for facility-initiated DAHS provided to an individual who was Medicaid eligible when service was received, even if the individual does not complete an application.

The following applies to individuals receiving Primary Home Care (PHC) or DAHS through provider or facility-initiated services.

If a request for DAHS is received from a Medicaid-eligible individual who is not required to complete a written application and is receiving DAHS services, then the individual must allow staff to process the initial paperwork if the individual plans to continue receiving services.

If the individual refuses to participate or allow staff to process the initial paperwork:

  • for DAHS, send Form 2065-A, Notification of Community Care Services, for facility-initiated DAHS individuals with a denial date that is 12 days from the form date.
  • for PHC, follow procedures in Section 4644, Applicant Approved for Retroactive Payment and Denied Continued Services by the Case Worker, to deny individuals who are receiving PHC and are applying for retroactive reimbursement.

For situations listed above, deny DAHS or PHC individuals on Form 2101, Authorization for Community Care Services, with a reason for withdrawal of services.

See Section 4640, Retroactive Payments, for complete procedures relating to retroactive payments.

2349 Procedures for Applicants Aging Out of PCS to PHC

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) has an agreement with the Texas Department of State Health Services (DSHS) for individuals receiving Personal Care Services (PCS) to be referred for Primary Home Care (PHC) two months prior to the individual's 21st birthday. See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information and a listing of DSHS offices.

This time frame has been set to ensure there will not be a gap in services. The DSHS case worker will make the referral for intake 60 days prior to the individual's 21st birthday. Referrals from DSHS must be accepted, Form 2110, Community Care Intake, must be completed and the intake assigned to a case worker. Regional staff must also check the quarterly Age Out list, in case the referral from DSHS is not timely.

Since there are differences in PCS and PHC services, the HHSC case worker will thoroughly explain the allowable PHC services at the time of the initial PHC assessment. PHC may not offer some of the services provided through the PCS program.

The applicant must meet all PHC eligibility criteria, including medical, functional and unmet need. If the applicant is eligible, PHC services are negotiated to begin on the individual's 21st birthday. PCS services should end at midnight on the day before the individual's birthday. Coordinate the transition with the PCS case worker and applicant to ensure there are no gaps in services.

All time frames are applicable and processing of the intake must not be delayed. The case worker must make the home visit within 14 calendar days and send a referral Form 2101, Authorization for Community Care Services, to the selected provider within five business days. Currently, the Service Authorization System (SAS) will not allow the processing of referral Form 2101 due to the age edit in the system. Therefore, Form 2101 must be completed manually. This edit will be modified in the future to allow completion of the case prior to the individual's 21st birthday.

Upon receipt of Form 3052, Practitioner's Statement of Medical Need, and final eligibility determination, the case worker negotiates the start of care date for the individual's 21st birthday, completes a manual authorization Form 2101, and sends it to the provider. Form 2065-A, Notification of Community Care Services, is sent within two business days of sending authorization Form 2101. Since SAS entry cannot be completed until the individual's 21st birthday, the case worker is allowed up to five business days after the 21st birthday to complete the data entry.

If the PCS Individual Is Ineligible for PHC

If the individual is not eligible for PHC due to a low score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, requests voluntary withdrawal or has no unmet need, the denial code must be entered in SAS. These cases are tracked for reporting purposes.

PCS Caregiver as the Paid Attendant

Refer to Section 2422.5, Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program, for special procedures regarding caregivers as paid attendants in PCS cases. If a parent or other caregiver has been the paid attendant through PCS, he may meet the criteria to continue to be the paid attendant and would not be listed as "Do Not Hire." Caregiver support may also be appropriate in some cases.

2400 Assessment Process

Revision 17-1; Effective March 15, 2017

2410 Overview of the Assessment Process

Revision 17-1; Effective March 15, 2017

The purpose of the assessment process is to determine whether the applicant meets all eligibility requirements, including:

  • financial eligibility;
  • functional eligibility; and
  • having an unmet need for services.

The assessment process should produce a case record that clearly documents the results of the case worker's determination. All processes that can be performed in the Service Authorization System (SAS) Wizards must be performed in the system to consider that action complete, including:

  • Form 2059, Summary of Client's Need for Service;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2064, Eligibility Worksheet.

Lack of case record documentation in the following areas is considered inadequate, unless the case is being denied for an unrelated reason.

Example: The case worker conducts a home visit in response to an intake request. After completing the Form 2060 assessment, it is determined that the individual's score is too low to qualify for any of the requested services. Since the individual has already been determined functionally ineligible, it is not necessary to evaluate financial eligibility. If an Application for Assistance form has been completed, the form must be retained in the case record.

2411 Required Documentation

Revision 17-1; Effective March 15, 2017

The following must be documented in the case record:

  • Individual's eligibility based on his categorical status in the Texas Integrated Eligibility Redesign System (TIERS) or current financial and functional status (Form H1200-EZ, Application for Assistance – Aged and Disabled; Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; Form 2064, Eligibility Worksheet).
  • Individual's medical, social, environmental and/or physical conditions that are relevant to his particular functional status (Form 2110, Community Care Intake; Form 2059, Summary of Client's Need for Service, Form 2060 and the case narrative).
  • Individual's degree of self-sufficiency and the tasks he can perform (Form 2110, Form 2059 and Form 2060).
  • Environmental adaptations that are being used or could be used to help the individual achieve or maintain his maximum level of self-sufficiency (Form 2059).
  • People who are resources, including family, friends and community networks, that the individual now uses or who are available to perform or help with activities of daily living (Form 2059 and Form 2060, Part A).
  • Agency resources in the community available to provide any of the services needed by the individual (Form 2059 and Form 2060, Part A)
  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, for Community Attendant Services applicants or responsible parties.

In some areas of Texas, the Area Agency on Aging may submit a completed Form 2060 based on the assessment for services it provides. If a completed Form 2060 is received, it must be reviewed for information as part of the assessment process.

Note: For detailed explanations of financial eligibility assessment and determination procedures, see Section 3000, Eligibility for Services.

2420 Assessing the Applicant's Needs

Revision 17-1; Effective March 15, 2017

During the initial home visit, as required in Section 2300, Responding to Requests for Service, the case worker completes the following assessment procedures.

2421 Review of the Community Care Intake Form

Revision 17-1; Effective March 15, 2017

Review Form 2110, Community Care Intake, for all relevant information. Make sure the practitioner is the applicant's current practitioner and the name, address and telephone number listed are correct. If the applicant provided a rural route address, ask for the updated street address. If the individual states he does not have a new address, continue to use the address provided. Take no action if the street-style address is not provided. Ask the individual to update his information with the Texas Health and Human Services Commission if he is notified by the U.S. Postal Service of a new address.

Verify that the responsible party is the primary contact for the applicant and the name, address and telephone number are correct. On Form 2110, list any other family members or informal supports who can be contacted if the applicant cannot be reached. Review the requested services and address those during the interview and in documentation.

2422 Form 2059, Summary of Client's Need for Service

Revision 17-1; Effective March 15, 2017

The purpose of Form 2059, Summary of Client's Need for Service, is to document the applicant's:

  • medical diagnosis and physical condition;
  • functional limitations;
  • home environment;
  • living arrangements; and
  • family and community supports.

Record all information reported by the applicant or informal supports during the home visit on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into the Service Authorization System Wizards (SASW) and will generate Form 2059.

Carefully observe and use interviewing skills during the initial home visit and throughout the assessment process. This is necessary to collect critical information about the individual's functional and mental abilities, and community and family resources. Individuals may demonstrate functional abilities while responding to questions about their home and living environment or medical problems. They may reveal information about family resources while responding to questions about financial eligibility. They may reveal intellectual and developmental disabilities or lack of mental clarity in the way they respond to questioning throughout the interview. During the interview, be alert for any indications of abuse, neglect or exploitation. If any of these conditions are present, refer the individual to the Texas Department of Family and Protective Services (DFPS), Adult Protective Services.

2422.1 Medical Diagnosis and Functional Limitations

Revision 17-1; Effective March 15, 2017

Ask the applicant for information regarding his medical diagnosis and physical and functional limitations. Record this information on Form 2059-W, Summary of Individual's Need for Service Worksheet.

2422.2 Home Environment

Revision 17-1; Effective March 15, 2017

The individual's functional status is always relative to the home circumstances in which the individual performs the activities of daily living. For example, the individual may have physical limitations that would not affect his abilities to perform certain personal care tasks if he lived in a home complete with all modern conveniences. If, however, his home contains only minimal household equipment, his inability to perform his personal care tasks could be compounded. Always assess an individual's functional capacity in relation to the home environment in which the tasks are performed daily. Service plans are developed to be carried out in specific home environments and each plan should relate specifically to a functional assessment done in that particular environment.

Observe and ask questions about the individual's home and immediate environment to assess his ability to perform activities of daily living. Determine whether the environment affects the individual's ability to perform these activities or otherwise affects his health and safety.

Guidelines for Assessing the Home Environment

Using the following guidelines, assess the home environment and document the results on Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered in the Service Authorization System Wizards (SASW). When observing the individual's home and immediate environment, assess the following:

  • Does the structure of the house or dwelling create an environment that is safe and adequate for the individual's unique needs?
  • Are there assistive devices and equipment necessary for the individual to live safely or that would improve his safety? Note: These include ramps, grab bars, wide doors, lowered light switches and adequate light for safe visibility.
  • Is the home clean enough and orderly enough to be safe for the individual's lifestyle?
  • Does the home pose any critical health hazards?
  • Does the individual have neighbors who are or might be resources to help with any special monitoring the individual might need because of some unique health or physical problem?
  • Is the neighborhood safe to allow the individual to move safely in and out of his home as needed?
  • Is the individual safe from physical harm in his own home?

Home Arrangement

Is the individual the owner of his home or does he reside in an apartment or live with friends or relatives? The individual may pay rent, own the home or live cost free.

Is the individual homeless and no friend or relative is available to provide a home? If the individual has insufficient income to rent a suitable home, he may be living in a public shelter or an exposed setting. Refer the individual to Adult Foster Care (AFC), Residential Care (RC), public housing or other community living resources. A referral to Adult Protective Services (APS) may be needed.

Home Condition

Is the individual's home:

  • Adequate — Physically safe and arranged or equipped so the individual lives safely and performs normal activities of daily living? Although adjustments may be desirable, they are not necessary for safety.
  • Inadequate Questionable — Residence presents serious limitations in conducting activities of daily living and/or safety hazards exist because of a need for major repairs, addition of utilities or assistive devices. Check the appropriate boxes on Form 2059-W.
  • Inadequate Unsafe — Residence is an unsafe environment for the individual. The structure is in a severe state of disrepair, contains critical health hazards or prevents one from performing the normal activities of daily living. The individual may need to be moved for his health and safety. A referral to APS may be appropriate. Check the appropriate boxes on Form 2059-W.

2422.3 Living Arrangement

Revision 17-1; Effective March 15, 2017

The case worker documents on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 4, if the applicant lives alone, with a spouse, with family or friends, or if he is in adult foster care or a residential care facility. In Item 5, list the name and relationship of all household members and indicate with a "Y" that they are in the household. Note if any of the household members receive services or are applying for services.

 

2422.4 Documentation of Caregivers

Revision 17-1; Effective March 15, 2017

Ask the individual if he receives assistance with his activities of daily living and list the name and relationship of all caregivers. These people may be family members, friends or neighbors. List the tasks performed by each caregiver on Form 2059-W, Summary of Individual's Need for Service Worksheet. Under Caregiver Status, indicate if there is a reason the caregiver cannot meet all of the individual's needs, such as working full time, ill health, needing caregiver support or providing continual care. For household members who are not performing any caregiver tasks, leave the caregiver status blank. If a household member states he is unwilling to assist the individual with any tasks, note this in the Caregiver Status on Form 2059-W.

The caregiver will be assessed during the functional assessment. See Section 2433.1, Assessment of the Caregiver.

Determine if the caregiver needs caregiver support as defined in Section 2512, Caregiver Support, and develop the service plan accordingly.

2422.5 Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program

Revision 17-1; Effective March 15, 2017

For individuals applying for Community Care for Aged and Disabled (CCAD) personal attendant services (PAS) and the caregiver has been the paid attendant in that program, the following guidelines must be applied to individuals who are transitioning from the following programs:

  • Individuals who are no longer eligible for STAR+PLUS or STAR+PLUS Waiver (SPW), who are being assessed for Primary Home Care, Community Attendant Services or Family Care; and
  • Individuals transitioning from the Texas Health Steps Comprehensive Care Program (THS-CCP) Personal Care Services (PCS).

The applicant must meet the unmet need criteria like any other applicant, but the current circumstances will be considered.

During the initial interview, if the caregiver has been the ongoing paid attendant and would like to continue as the paid attendant, the case worker will ask the caregiver the following question: "Would you continue to provide care if you are not being paid to provide the care?"

If the response is "No," determine the tasks for which the caregiver has been paid in the previous program and whether the individual still needs assistance with those tasks. Determine which tasks will continue as caregiver tasks and develop the service plan accordingly. Document the caregiver's response and send Form 2067, Case Information, along with the referral packet, to the provider advising that the caregiver had previously been the paid attendant and is eligible to be the paid attendant.

If the response is "Yes," evaluate if there is any unmet need or if caregiver support is required. If services continue, the caregiver cannot be hired. If there is no need for caregiver support or no unmet need, the applicant is denied services.

The case worker must follow this policy for individuals applying for HHSC Primary Home Care (PHC), Community Attendant Services (CAS) or Family Care (FC) who are transitioning from one of the programs listed above.

2422.6 Common Household Tasks, Duplicate Services and Services Provided to Other Family Members

Revision 17-1; Effective March 15, 2017

If an individual lives with others, do not purchase services that duplicate services normally provided as part of the household routine. For example, meal preparation, shopping, laundry and housekeeping for the individual are performed daily as part of the family routine. Unless the individual has unique needs, these tasks will not be purchased.

If an individual lives with others, determine whether he has needs for unique tasks that are performed apart from the household's tasks and whether performing these tasks imposes additional burdens of time and responsibility on the household members. Unique tasks are attributable to the individual's problems. Examples include incontinence, a need for a special diet, food preparation, extra shopping or special housecleaning caused by the individual's behavior. Allowable tasks also include cleaning up after personal care tasks, cleaning the individual's room and the bathroom used by the individual. If it is determined the individual's needs impose special and extra activities on the household members, document these needs on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Services Provided to Other Family Members

Identify whether services are being provided to any other family member by the Texas Health and Human Services Commission (HHSC) or another agency. If services are being provided, assess whether they meet some of the individual's needs and would affect his service plan.

Example: An individual's spouse receives Community Care for Aged and Disabled Family Care services and an attendant performs housecleaning, laundry and meal preparation as part of that service plan. Some of those services also benefit the individual or duplicate services that he needs. In this case, divide the time for common tasks between the individuals and authorize the task for both individuals. Refer to the maximum times listed on Form 2060 for companion cases.

Refer to Section 4400, Family Care Services, and Section 4600, Primary Home Care and Community Attendant Services, for specific information about situations in which two persons in the same household receive attendant services.

2422.7 Assessment of Social and Community Resources

Revision 17-1; Effective March 15, 2017

Assess the individual's community and social network resources, such as churches, civic clubs and voluntary affiliations to determine whether any of these entities provide services or would be able to do so. Also, identify available service agencies that serve the elderly and disabled and might be able to provide a service needed by the individual. Always determine whether any of these sources can help the individual before services from the Texas Health and Human Services Commission (HHSC) are authorized. See Appendix XV, Services Available from Other State Agencies, for assistance in identifying alternate sources of assistance. When possible, refer to local resource directories for information about services in an individual's community. Document the use of or referral to other service agencies on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7.

All other services available to the individual must be considered and used before HHSC services are authorized.

2423 Guardianship

Revision 17-1; Effective March 15, 2017

A Community Care for Aged and Disabled individual may need a guardian if he:

  • appears to be incompetent; or
  • is so incapacitated that he is unable to care for himself or manage his property and financial affairs.

If the individual's incompetence or incapacity results in his being in a state of abuse, neglect or exploitation, the case worker must make a referral to Adult Protective Services (APS). Unless ordered by a court to do so, the case worker must not file a petition for guardianship or assume guardianship of the person or the estate of a Texas Health and Human Services Commission (HHSC) individual.

If the court intends to appoint the case worker as guardian, the case worker must advise the court that serving in that capacity will violate HHSC policy. If the case worker is appointed guardian by the court, the supervisor and regional attorney must be notified immediately. If a referral to APS, Texas Department of Family and Protective Services, has not already been made, one should be made at this time.

2430 Functional Assessment

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2907(a) — The Client Needs Assessment Questionnaire is used to determine an individual's functional need for CCAD services.

Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is used to make several determinations regarding the individual's eligibility. The completed form will determine:

  • the individual's functional eligibility;
  • his ability to carry out activities of daily living;
  • what he should continue to do for himself to maintain his current level of self-sufficiency;
  • what he cannot do for himself because of physical limitations, mental limitations or both;
  • which resources are available to help with specific tasks;
  • if the individual has an unmet need; and
  • how much service the individual will receive, if eligible.

An individual's functional level is based on:

  • his physical condition;
  • his medical problems and the functional limitations they impose;
  • his mental clarity and limitations and the effect they have on performing activities of daily living; and
  • the condition of his home environment.

The age of the individual being assessed for services should not be considered when determining the level of functional need. For example, the applicant is a 3-month-old infant whose mother is applying for Community Attendant Services (CAS) for the child. Obviously, the infant will need help with most of the activities of daily living and would, therefore, score a "3" on those tasks. The fact that the functional need is the direct result of the individual's age should not be taken into consideration when assigning a score for the particular task.

If the person appears to be eligible for Community Care for Aged and Disabled services on the basis of age, income and resources, and he requests services beyond Information and Referral, complete Form 2060, Part A, to determine the functional eligibility for services. This assessment helps determine whether the person has functional needs, what kinds of functional limitations he experiences, which tasks he needs help with and whether his mental clarity contributes to his need for help.

2431 Form 2060, Part A, Functional Assessment

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must score each item on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Assessment, and then accurately compute the total score to determine whether the individual is eligible for Community Care for Aged and Disabled services. Use the spaces under each item, as needed, to explain the person's limitations or his accommodations for his disability. For detailed information about scoring Form 2060, Part A, refer to the form instructions. Appendix XVII, Service/Score Code Guide, indicates the score requirement for each service.

During a face-to-face interview, ask the individual each question on Form 2060, Part A, as the question is stated on the form. Then, ask further questions to gain a more complete understanding about the degree of the individual's ability or inability to carry out activities of daily living. Careful assessment of the individual reveals what he can do for himself, what he should continue to do for himself to maintain his current level of self-sufficiency, and what he cannot do for himself because of physical limitations and/or mental limitations. When conducting an assessment, use the following scale of disability and follow the detailed definitions of impairment levels found in the instructions for Form 2060, Part A.

0 = No impairment. The individual is able to conduct activities without difficulty and has no need for assistance.
1 = Minimal/mild impairment. The individual is able to conduct activities with minimal difficulty and needs minimal assistance.
2 = Extensive/severe impairment. The individual has extensive difficulty carrying out activities and needs extensive assistance.
3 = Total impairment. The individual is completely unable to carry out any part of the activity.

To determine the severity of the individual's impairment, consider the following factors:

  1. Individual's Perception of the Impairment — Does the individual view the impairment as a major or minor problem?
  2. Congruence — Is the individual's response to a particular question consistent with the individual's response to other questions and also consistent with what has been observed?
  3. Individual History — Probe for an understanding of the individual's history as it relates to the current situation and the individual's attitude about the severity of the impairment. For example, has the individual always kept a messy house and is not, therefore, concerned because he is unable to perform housekeeping tasks? Has the individual always eaten only one meal a day and is not, therefore, interested in eating more often? How has the impairment changed the individual's lifestyle?
  4. Individual's Right to Self-Determination versus Danger to Self — Consider the consequence to the individual if he chooses not to take medications, bathe, adhere to a special diet, etc.
  5. Lack of Facilities — Absence of facilities for bathing, laundry, telephone calls or meal preparation may indicate an impairment. The impairment and its degree will depend on the individual's accessibility to the facility, ability to use the facility and ability to make satisfactory accommodations in the absence of the facility.
  6. Adaptation — If the individual has adapted his physical environment or clothing to the extent that he is able to function without assistance, the degree of impairment will be lessened, but the individual will still have an impairment.
    Note: Medication is not considered an adaptation to the individual's functioning in the same way a walker would be. The individual is not considered to have an impairment if the medication is working. The individual is rated on how he is functioning at the time of the interview, regardless of the status of taking medication.

The following chart provides a general guide for assessment. Whether the individual is taking medication, forgetting or refusing medication, or taking medication incorrectly, he is still assessed on his current level of functional ability.

Situation: The individual has problems with dizziness and balance, which could affect scoring on the transfer/ambulation and balance questions.

If the individual: then:
is taking medication and has no problems with dizziness, score 0 on impairment.
is taking medication but still has occasional episodes of dizziness, score 1 on impairment.
is taking medication, but still has major problems with dizziness and balance, score 2 on impairment.
has a prescribed medication, but is forgetting to take the medication or is taking the medication incorrectly, the individual is still assessed based on his current level of functioning.

The case worker must clearly document the reason in situations where the task score on Form 2060 is clearly inconsistent with the amount of time allotted for that task. For example, a case reader may decide to rate Standard 10 unmet if an individual scores 1 on all Form 2060 tasks, yet the maximum amount of hours for each are purchased and case documentation does not explain the discrepancy.

2432 Scoring Persons Who Cannot Respond

Revision 17-1; Effective March 15, 2017

On some occasions, the case worker may need to assess small children, infants or individuals who are comatose or otherwise non-responsive. Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to conduct these assessments, even though the instrument may not seem to apply. Allow the caregiver to respond if the individual cannot do so. In scoring each item, use the caregiver's response, the case worker's observations and any knowledge the case worker may have about the individual from other sources.

 

2433 Determining Unmet Need in the Service Arrangement Column

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2907(b) — Regardless of a client's functional eligibility as determined by his score on the client needs assessment questionnaire he receives CCAD services only if he has an unmet need for those services.

Unmet need is defined as a requirement for assistance with activities of daily living that cannot be adequately met on an ongoing basis by friends, relatives, volunteers or other service agencies.

For any task listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the Service Arrangement Column will determine if the individual has an unmet need in order to determine the individual's overall eligibility based on unmet need. Review questions 1 through 15 and ask the individual the following additional questions.

If the impairment score is "1" – Ask the individual if he is able to perform the task by himself, even though it may be difficult for him.

  • If the answer is "Yes," enter "S" in the service arrangement.
  • If the answer is "No," ask the individual who helps him with this task. If the individual states that a caregiver assists him, enter "C" for "Caregiver" in the service arrangement. List the caregiver's name, relationship and task on Form 2059-W, Summary of Individual's Need for Service Worksheet, if it is not already entered.
  • If the individual states he receives help from another agency, enter "A" for "Other Agency" in the service arrangement. List the name of the agency on Form 2059-W.
  • If the answer is "No" and the individual states he has no help from any source and needs help to perform the task, enter "P" for "Purchased" in the service arrangement.

If the impairment score is "2" or "3" – Ask the individual if he receives help with this task.

  • If the answer is "Yes," ask the individual who helps him with the task. If the individual states a caregiver helps with the task, enter "C" for "Caregiver" in the service arrangement. List the caregiver's name, relationship and task on the worksheet, Form 2059-W, if it is not already entered.
  • If the individual states he receives help from another agency, enter "A" for "Other Agency" in the service arrangement. List the name of the agency on Form 2059-W.
  • If the answer is "No" and the individual states he has no help from any source and needs help to perform the task, enter "P" for "Purchased" in the service arrangement.

If the individual states he receives some help from others but it does not meet all of his needs for a specific task, enter "P/C." Document the part of the task performed by the caregiver in the "Tasks Performed" section on Form 2059-W.

2433.1 Assessment of the Caregiver

Revision 17-1; Effective March 15, 2017

For each task marked "C" on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, assess the capability, dependability, availability and willingness of the caregiver. Consider and discuss family and job responsibilities, as well as the physical demands of caregiving. For each task, determine by observation and by asking the applicant or caregiver the following questions:

  1. Is the caregiver physically and mentally able to perform the task?
  2. Is the caregiver dependable in performing the task on the required schedule?
  3. Is the caregiver available at the time the individual needs the task performed (either scheduled or on demand)?
  4. Is the caregiver willing to perform the task on a regular and ongoing basis?

It may be necessary to talk with the applicant's current caregiver in order to accurately assess his contribution to the applicant's care needs. If the caregiver cannot join the applicant for the initial face-to-face visit, get as much information as possible from the applicant and contact the caregiver by telephone to verify that the caregiver is willing to provide the tasks. Do not delay service initiation if the caregiver cannot be reached.

If, for any task, it appears the caregiver is not able to adequately meet the applicant's needs, discuss with the applicant if some or all of the task should be purchased. If the applicant states the caregiver is currently performing the task, but it is apparent from case worker observation that the task is not being adequately performed, discuss if the task should be purchased.

Be sensitive to any indications of abusive or neglectful behavior on the part of the caregiver and make a referral to Adult Protective Services, if necessary.

2433.2 Exploring Other Resources for Meeting the Applicant's Needs

Revision 17-1; Effective March 15, 2017

Explore other possibilities for resources with the individual. Ask if family members pay someone to help the individual and if the current assistance is adequate. Use observations about the caregiving arrangement to determine whether needed tasks are being adequately performed. If an individual's need for help with a particular task is being adequately met and the assistance can reasonably be expected to continue, do not authorize purchased services for that task. If the need for help with a particular task is not being met or is only partially met, ask the individual and family if there is anyone who would voluntarily provide the needed help. Explore the use of any identified volunteers. If voluntary help cannot be obtained, explore the use of community resources and consider service options from other groups or agencies. See Section 2535, Involvement of Volunteer Resources, and Section 2530, Other Resource Services, for possible resources to meet the individual's needs. If the individual's need for help cannot be met in any other way, enter "P" for the task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. If Home Delivered Meals is the only service being purchased, complete the service arrangement column and do not allocate time on Form 2060.

If an individual's needs for help are now being met and the individual or family determines the present care arrangements cannot be continued, inform the individual or family that the individual may reapply for services when the current arrangement is discontinued. If, during the initial interview, the individual or his family knows the present care arrangements will discontinue within 30 calendar days, proceed with the application process.

Examples:

  • An individual's sister, who is providing the care, has taken a job and will begin work on a specified date.
  • A live-in relative, who is providing the care, plans to leave town on a certain date.
  • A family member has been paying a caregiver but will soon be unable to continue because of new financial obligations, which will begin on a certain date.

If someone who has been paying for care intends to discontinue the arrangement on a specific date within 30 days, proceed with the application. Otherwise, offer to take an application at the time the care arrangement is discontinued. If someone will continue to purchase some of the care, determine if the applicant has an unmet need for any additional care. If someone is willing to pay for services only while the individual is on an interest list, this does not affect the individual's unmet need for services purchased by the Texas Health and Human Services Commission (HHSC). However, if someone is willing to pay for services after the individual comes off the interest list, there is no unmet need.

In some situations, a caregiver may quit employment to stay home and provide care for the applicant and is requesting to be the paid attendant. In this situation, the case worker must obtain verification that the individual quit employment within 30 days before or after the application date. The caregiver may be considered as a potential attendant. In the Service Arrangement column of Form 2060, note the tasks that the caregiver will voluntarily provide and those tasks that will be purchased. See Section 2513, Caregiver as the Paid Attendant, for additional information.

This policy also applies for ongoing cases in which a caregiver has been working full time and quits employment to stay home and provide care for the individual. The case worker must obtain verification that the individual quit employment within 30 days of the request for the change.

When the Service Arrangement Column of Form 2060 is completed, review the results to determine if the individual has an unmet need. If all responses are "S," "C" or "A," the individual has no unmet need and is not eligible for services. Advise the individual he is not eligible at this time and may reapply if his circumstances change. Be sure to adequately document this information in the Service Authorization System Wizards with the appropriate denial code and send the applicant Form 2065-A, Notification of Community Care Services.

If there are tasks marked "P" on Form 2060, continue to the Task/Hour Guide section.

2434 Support Score and Establishing Priority

Revision 17-1; Effective March 15, 2017

If an applicant for Primary Home Care (PHC), Family Care (FC) or Community Attendant Services (CAS) has a functional score of "3" and the service arrangement for a priority task (feeding, toileting, transfer, meal preparation) is a "P," then a support score must be entered for these tasks on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Determine the likelihood of that task being done if the attendant does not show up during a normally scheduled service shift. Using the following scale, enter the score in the Form 2060 Support Score box by the appropriate item.

1 = It is very likely that the task would be done even if the attendant does not show up.
2 = The task will probably be done if the attendant does not show up.
3 = The task will probably not be done if the attendant does not show up.
4 = It is very unlikely that the task will be done if the attendant does not show up.

In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the individual's home if the attendant was not there. Do not enter a support score for an item if either the task is not purchased or the individual's score for that task is not "3."

If the support score is "4" on any of the priority tasks, then the individual will be designated as a priority individual. See Section 2540, Priority Status Individuals, for further information.

2440 Use of Form 2060, Part B, Task/Hour Guide, and Part C, Task/Minute and Subtask Guide

Revision 17-1; Effective March 15, 2017

For all personal attendant services (PAS) cases, the case worker uses Part B and Part C of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to determine the quantity of purchased services needed by an individual.

The Part C, Task/Minute and Subtask Guide, provides a uniform approach in the authorization of services based on a minute range per task and impairment score. Each impairment score for each task has a minimum and maximum time that can be allotted. It is mandatory to follow the minute guideline and check the subtasks for each task as a way of documenting the type of assistance needed and to support the time allocated for that task. See the Form 2060 Instructions for complete directions for completing the form.

Form 2060, Pages 1-5, must be manually completed during the home visit initial assessment for an applicant who will receive PAS. Review the Task/Minute and Subtask Guide at each reassessment and initial the form. When there is a change in hours, either complete a new Form 2060 manually or update the current Part B and Part C.

Refer to Form 2060, Part C, for guidelines on the number of minutes to be allowed per task. The amount of time allowed for any particular task should be determined by taking into account:

  • the amount of assistance the individual will usually need;
  • the availability of anyone else to assist with the task;
  • which specific subtasks (activities) need to be purchased;
  • environmental/housing factors that may hinder (or facilitate) service delivery; and
  • the individual's own unique circumstances.

Discuss fully with the individual each service task to determine whether he needs assistance with that task, how much time is required to perform each task, and how often each week the task must be performed. The total time allowed for each task must be within the minimum and maximum time limits for the impairment score, as indicated on Form 2060.

Negotiate service authorizations with individuals to reach an agreement about:

  • the number of tasks and activities for which the individual needs assistance;
  • how often the assistance is needed; and
  • the amount of time needed by the provider to carry out those tasks and activities per week.

All appropriate subtasks must be checked to indicate the specific tasks the individual needs. An individual scoring a 2 or 3 may need all subtasks under the impairment score for 1 and additional subtasks under the impairment score of 2. The time allotted must be within the range for the impairment score.

Time outside the minute range (either above or below) may not be allotted without documented supervisory approval.

2440.1 Requesting Supervisory Approval for Time Outside the Minute Range

Revision 17-1; Effective March 15, 2017

In situations in which the individual has extenuating circumstances and requires a deviation in the time range, the case worker may request supervisory approval to authorize time above or below the minute range for the task and impairment score. The case worker must document the reason why the individual requires minutes outside the range for the task/impairment score level. The documentation is sent to the supervisor in writing or electronic mail (email) and the supervisor must approve or disapprove in writing or by email. The documentation and the supervisor's response must be filed in the case record.

2441 Circumstances When Supervisory Approval is Not Required

Revision 17-1; Effective March 15, 2017

In some situations, the individual may have extenuating circumstances and a compelling reason that require subtasks in a lesser impairment score to be authorized for a task. The two situations in which the case worker may allot time for subtasks in a lesser impairment score without supervisory approval are:

  • if the individual has extenuating circumstances and is requesting only subtasks in a lesser impairment score; or
  • if the individual has a caregiver or other agency providing some of the subtasks.

The case worker documents the individual's extenuating circumstances and the reason tasks in a lesser impairment score are authorized, or documents the part of the task the caregiver or other agency provides.

2441.1 Exception for a Compelling Reason

Revision 17-1; Effective March 15, 2017

In some situations, an individual may request tasks not be performed for him even though he has an impairment and may not be able to perform the task for himself.

If an individual has a compelling reason for not wanting any of the subtasks under the appropriate impairment score, but only wants subtasks listed in a lower impairment score, the case worker must document the individual's request and allocate minutes in the minute range for the subtasks selected. The case worker must document the reason, and no supervisory approval is required.

Example: The individual scores a 2 on bathing. She needs assistance with drying. However, when discussing subtasks, she states she would like standby assistance for safety and drawing of water, all under the impairment score of 1. She states her skin is very sensitive and she would not allow help with drying as she is afraid it would hurt her. The subtasks checked are all under the impairment score of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.

See Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Instructions, for additional information.

2441.2 Exception for Assistance from a Caregiver or Other Agency

Revision 17-1; Effective March 15, 2017

If an individual has a caregiver or other agency performing part of a task and only subtasks in a lower impairment score are needed, the case worker must document the individual's request and allocate minutes in the minute range for the subtasks selected. The case worker must document the reason and the part of the task the caregiver or other agency performs. No supervisory approval is required.

Example: The individual scores a 2 for bathing, but only wants assistance with laying out supplies and drawing water because her daughter provides all hands-on assistance with the bathing task. The task is marked P/C. The subtasks under the impairment score of 1 are checked and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance.

2441.3 Time Allocation for Companion Cases

Revision 17-1; Effective March 15, 2017

For companion cases, time allocated for general household tasks, including cleaning, shopping and meal preparation, is based on the companion minute range on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, rather than the individual range. Time is assigned per individual based on the individual's impairment score. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation and/or shopping to indicate that time is authorized for these tasks to the companion case. In situations where there are more than two companions in the household, assign time based on the individual's impairment score using the companion minute ranges.

In situations where there are more than two individuals in the household, the case worker continues to use the companion minute range based on the individual's impairment score.

Example: On cleaning, Mr. Jones scores a 3 and Mrs. Jones scores a 1. Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under impairment score 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score 3 in the companion range.

See Form 2060 Instructions for additional examples and guidance on companion cases.

2442 Calculation of Time to be Authorized

Revision 17-1; Effective March 15, 2017

Use the following procedures to calculate the total amount of time needed each week.

  1. Multiply the number of minutes needed to conduct each task by the number of times the task will be conducted each day to reach a daily total of minutes for each task. Times must be shown in five-minute increments. If necessary, round the time up to the next five-minute increment.

    Example: If an individual needs meal preparation twice a day and the meal preparation requires the maximum amount of time, multiply 30 minutes by two to reach a daily total of 60 minutes.
  2. Multiply the daily total of minutes for each task by the number of days per week the attendant will conduct that task. Again, times must be shown in five-minute increments and rounded up to the next five-minute increment, if necessary.
  3. Add the required weekly minutes for all tasks and divide the total by 60 minutes to determine the weekly total in hours.
  4. Round the weekly number of hours to the next highest half unit to determine the number of units to be authorized. Example: If an individual needs 7 hours and 10 minutes of service each week, authorize 7.5 units of service. The number of hours must be correctly rounded up to ensure accurate authorization of services.

Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to calculate the hours of service to be purchased. The correct number of hours must be authorized on Form 2101, Authorization for Community Care Services. Write comments in the Service Authorization System (SAS) "Impairment Scoring" window in the Functional Wizard.

Tasks/services identified as needing to be purchased must be authorized on Form 2101. Tasks marked "P" in the "Service Arrangement" column of Form 2060 must also be marked on Form 2101. The meal preparation task may be marked "P" on Form 2060 and not marked on Form 2101, as long as the individual is receiving home-delivered meals. A separate Form 2101, authorizing meals, is sent to the home-delivered meals agency.

2443 Balancing Incentive Program, Level II Assessment

Revision 17-1; Effective March 15, 2017

The Balancing Incentive Program (BIP) provides additional Federal Matching Assistance Percentage (FMAP) funds to states that initiate reforms to increase nursing home diversions and access to non-institutional long-term services and supports. As part of the effort to increase access to additional federal funds and meet BIP requirements, the Texas Health and Human Services Commission (HHSC) administers the Level II Assessment to all individuals requesting or receiving Primary Home Care (PHC), Community Attendant Services (CAS) and Day Activity and Health Services (DAHS) Title XIX. The Level II Assessment consists of:

  • Part A of the Functional Assessment of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2060-B, Needs Assessment Addendum.

The BIP was created by the Affordable Care Act of 2010 and improves the state’s ability to serve more individuals by increasing access to non-institutional long-term services and supports. The BIP allows states to adhere to the integration mandate of the Americans with Disabilities Act (ADA), as required by the Olmstead decision.

The case worker will complete the Level II Assessment, Form 2060-B, for initial assessments, annual reassessments and for a significant change request for a new service.

For changes in services, the case worker will complete:

  • Form 2060, Part A, Functional Assessment, if applicable;
  • Form 2060, Part B, Task/Hour Guide;
  • Form 2060, Part C, Task/Minute and Subtask Guide; and
  • Form 2060-B.

The following are examples of the forms that are completed when a request is made for a change in service:

Examples:

  • Example A – An individual receiving CAS calls the case worker requesting transportation assistance. The case worker will complete Form 2060, Part A and Form 2060-B. Form 2060, Part B and Part C, would only need to be completed, if applicable. In reviewing the required forms, the individual is only requesting transportation and does not wish to have the service plan for his attendant care services changed. The case worker will send a referral for transportation only. No other action is required.
  • Example B – An individual receiving CAS calls the case worker requesting home-delivered meals. The case worker will complete Form 2060, Part A, and Form 2060-B, and, if applicable, Form 2060 Part B and Part C. In reviewing the required forms, the case worker places the individual’s name on the Home-Delivered Meals Interest List and also increases the time allotted for meal preparation for his attendant services. The case worker will complete the change per Section 2721.4, Revising the Service Plan, and Section 2721.6, Authorizing and Documenting Changes.

The case worker determines whether a referral is needed for HHSC services or non-HHSC services based on the information collected from Form 2060-B. The case worker discusses and obtains approval to make a referral with the individual to non-HHSC services. Referrals may include:

  • Behavioral Health Services;
  • Supported Employment/Employment Assistance;
  • Transportation Assistance;
  • assistance with instrumental activities of daily living; and
  • assistance for other medical conditions not previously addressed.

The case worker documents the referrals made on behalf of the individual in Section III of Form 2060-B, including any need for referrals that were identified but refused by the individual. No data entry is required in the Service Authorization System (SAS) resulting from the completion of the Form 2060-B only.

The individual retains the right to participate in the development of his service plan and the right to refuse all or part of any services and to be informed of the likely consequences of such refusal, which include referral to non-HHSC services.

Identified needs for referrals agreed to by the individual are considered as requests for information and referral. The case worker makes use of applicable existing referral policy to assist the individual with the appropriate referral located in:

Referrals for behavioral health needs identified on Form 2060-B may be made to local mental health authorities using the local phone numbers available at: https://hhs.texas.gov/services/health/mental-health-substance-abuse.

2500 Service Planning

Revision 17-1; Effective March 15, 2017

2510 Service Plan Development

Revision 17-1; Effective March 15, 2017

Program Standard: Case workers must develop service plans that accurately authorize appropriate services for individuals based on individual needs, eligibility and priority level.

After the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet need of the individual, discuss service planning with the individual and/or his family members. Consider all possible resources that may be available through Community Care for Aged and Disabled (CCAD) services or other community resources. Evaluate if the individual is interested in receiving Home-Delivered Meals, Emergency Response Services or attending Day Activity and Health Services (DAHS) or other community centers. Be sure to review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made regarding the use of those services.

To the extent of their abilities, eligible individuals must be involved in the development of their service plans. Discuss service planning with an individual or his caregivers during the initial visit to his home. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the home visit and after financial eligibility has been determined.

The discussion with the individual (and caregivers) should include the type of services that may be appropriate for purchase after unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence, allow the individual the opportunity to continue performing tasks he prefers to do himself, even though they may be difficult for him. Explain to the individual that Texas Health and Human Services Commission (HHSC) programs are not designed to replace the care that caregivers now provide or are able and willing to provide over time. At the conclusion of the initial home visit, ensure that the individual fully understands exactly what HHSC may provide, the limitations of HHSC services and the importance of the existing caregiver arrangement to the development of a service plan.

The service plan should reflect consideration of all these factors:

  • individual's existing problems that resulted in an application for CCAD services;
  • individual's physical and mental health;
  • individual's functional capacities for self care;
  • individual's need for, or availability of, self-help or adaptive devices;
  • existing caregivers and the specific amounts and types of assistance they give and can continue to give the individual;
  • individual's home environment and available community resources;
  • severity of the individual's medical and physical problems and the level of risk the problems cause;
  • other HHSC services necessary to help the individual maintain self-sufficiency, including referral to Adult Protective Services when appropriate;
  • additional services available in the individual's community (The 71st Texas Legislature passed Senate Bill 487 that requires, when appropriate to the individual's needs, the use of services provided by other state agencies. See Appendix XV, Services Available from Other State Agencies);
  • services being provided to other individuals in the household;
  • information secured from the individual's practitioner, friends or associates that may be necessary to develop a service plan suitable for the individual's needs;
  • number of service units to be authorized and the rationale for the authorization;
  • dates on which services are expected to begin; and
  • any special monitoring or case management procedures to be followed.

Document service planning information on:

  • Form 2110, Community Care Intake;
  • Form 2059-W, Summary of Individual's Need for Service Worksheet, which is entered in the Service Authorization System for Form 2059, Summary of Client's Need for Service;
  • Form 2101, Authorization for Community Care Services;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which is entered in the Service Authorization System; and
  • the case narrative.

 

2511 Caregiver Arrangements

Revision 17-1; Effective March 15, 2017

Discuss with the individual, and any family members or caregivers, that Community Care for Aged and Disabled (CCAD) services are not designed to replace the care family members and other caregivers now provide or are able and willing to provide over time. Explain that the existing caregiver arrangement is very important to the development of a service plan. If possible, confirm with the caregivers that they are able and willing to perform the tasks listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, that are marked "C" for caregiver. Be sure the individual and family members understand CCAD services are not intended to serve as a supplement to income. Decisions about service plans cannot be based upon the family's income or financial needs.

2512 Caregiver Support

Revision 17-1; Effective March 15, 2017

Caregiver support is defined as providing relief to a caregiver who provides the majority of the applicant's care or continual care for the applicant. This support is always provided by an attendant other than the applicant's regular caregiver. Caregiver support may be appropriate when the initial functional assessment results in no unmet need, but the caregiver needs relief. The paid attendant will provide some of the tasks that the caregiver has been performing in order to provide relief.

Examples: Caregiving responsibilities prevent the individual's caregiver from leaving the house to conduct personal business or do the family shopping or the caregiver needs time away from his caregiving duties on a regular basis due to his health needs or for periods of rest due to the continual care.

Discuss with the caregiver how many days per week and what tasks may be needed to provide relief. Mark the appropriate items on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, with a "P," and document on each task in the comments section that support care is needed. Indicate on Form 2101, Authorization for Community Care Services, that the service plan is for caregiver support and list the caregiver as someone not to be hired. Support care may be temporary; if so, authorize it only for the time needed.

Note: There are a number of services provided through the local Area Agencies on Aging designed to support caregivers. Service availability varies by region. For service availability in a particular area, provide the toll-free telephone number, 1-800-252-9240, to persons interested in potential services.

2513 Caregiver as the Paid Attendant

Revision 17-1; Effective March 15, 2017

If the caregiver expresses an interest in being the paid attendant, inform the caregiver and applicant that the case worker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Individuals who want a specific person to be the attendant should be encouraged to discuss this with provider staff. The case worker must explain to the potential attendant that he will be an employee of a home and community support services agency. He must be able to provide the tasks needed and work the complete specified schedule that will be developed by the provider and the applicant. His performance will be monitored and evaluated by the provider and the case worker.

The case worker must also explain to the applicant and the caregiver that the tasks listed as "C" (caregiver) under the service arrangement on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must remain as caregiver tasks if the caregiver is hired as the paid attendant. Those tasks may not be purchased tasks as long as this caregiver is the paid attendant. If circumstances change and the attendant can no longer perform or is no longer willing to perform either the purchased tasks or the caregiver tasks, then the provider will be requested to hire a new attendant for those tasks. The caregiver will be designated as someone not to be hired for those tasks on Form 2101, Authorization for Community Care Services.

In situations as described in Section 2433, Determining Unmet Need in the Service Arrangement Column, where the caregiver has recently quit employment to provide care, note the tasks the caregiver will continue to provide voluntarily and mark them as "C" in the service arrangement column of Form 2060. Other needed tasks may be purchased.

For ongoing cases, a caregiver who had been listed as working full time and quits a job to provide care for the individual may also be considered as a potential attendant. The case worker must obtain verification the caregiver quit employment within 30 days prior to the requested change. Any tasks previously identified as performed by the caregiver may not be purchased tasks.

2514 Who Cannot Be Hired as the Paid Attendant

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the individual's paid attendant. The only role HHSC plays in the hiring process is notifying the provider when a particular person must not be hired.

Based on the following chart, if a person is identified as someone who must not be hired as the paid attendant, the case worker documents this information in the Comments section on the initial and all subsequent submissions of Form 2101, Authorization for Community Care Services. The case worker enters "Do Not Hire" and the name of the individual on the form. The following chart lists the persons who must not be hired and must be specified as "Do Not Hire."

Do Not Hire: If the individual:
Abused, Neglected, Exploited, as Substantiated by Adult Protective Services has abused, neglected or exploited the individual or others.
Parent of a Minor Child is the legal or foster parent of the minor child receiving Community Attendant Services (CAS). There is no prohibition against hiring the parent of an adult child to be the paid attendant.
Spouse in Primary Home Care (PHC) or CAS is the spouse of the PHC or CAS individual.
Unwilling Household Member is not willing to help the individual with any of the tasks the individual needs.
Caregiver Support caregiver needs relief from providing continuous care and the authorization for purchased services is based on caregiver support.
Individual Designated is a particular person the applicant/individual does not want hired as the paid attendant.
Caregiver/Paid Attendant at Reassessment is no longer able or willing to provide tasks previously designated as caregiver tasks. The caregiver may not be hired for those tasks. (See Section 2664, Redetermination of Unmet Need.)

Beyond these limitations, the case worker will not specify who cannot be hired as the paid attendant.

2520 Freedom of Choice

Revision 17-1; Effective March 15, 2017

2521 Freedom of Choice in Living Arrangements

Revision 17-1; Effective March 15, 2017

The applicant has freedom of choice when it comes to his living arrangements. Case workers are, however, required to consider if the individual's needs can be met in the environment chosen by applicant.

Consider the individual's ability to understand whether the services the Texas Health and Human Services Commission (HHSC) can provide are adequate to meet his needs. If the individual has medical needs that cannot be addressed with personal care and housekeeping services, or if the environment poses a threat to health and safety, discuss these issues with the individual and the responsible person.

Explain the limitations of Community Care for Aged and Disabled (CCAD) services and determine how the individual's special needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the individual insists on remaining in his current residence, despite the fact that his needs may not be met in that environment, assess his mental capacity for making an informed choice and whether he understands the consequences of that choice. See Section 2550, Identifying Individuals at Risk, for additional information.

If he is capable of informed consent, respect his choice and develop a service plan accordingly. If he appears incapable of making an informed choice or if abuse, neglect or exploitation is suspected, make a referral to Adult Protective Services.

2522 Service Delivery in Alternate Locations

Revision 17-1; Effective March 15, 2017

It is acceptable to allow delivery of services intended for the home environment to be provided in alternate locations. Hours diverted to provide services to the individual in alternate locations may not be added back into the service plan. For example, an individual's service authorization includes an hour each day for feeding/eating. The individual will also need this help during a visit to his sister who lives 20 miles away, which will add an additional hour to the time needed to provide this assistance. The individual opts to divert an hour allocated for laundry to feeding/eating in order to make the visit. This hour cannot be added back into the service plan in order to provide the amount of time required to do the laundry.

Do not anticipate the need for additional hours based on delivery of services outside the home and build that time into the service plan. It is also unacceptable for additional hours to be approved because the extra time expenditure does not allow the attendant enough time to do some other task. Hours authorized will be based solely on services that are assumed to be provided within the home environment.

When individuals receive services outside the home, providers must document in the comments section of Form 3054, Service Delivery Record, the specific services provided and in which location. Documentation must also be available to substantiate the individual requested these services. The actual transportation, as well as transportation cost, is the responsibility of the individual.

2523 Freedom of Choice in Agency Selection

Revision 17-1; Effective March 15, 2017

Once it appears that the applicant will meet the eligibility criteria for Community Care for Aged and Disabled (CCAD) services, offer the applicant the choice of selecting an agency contracted to deliver the requested service in the applicant's area. Either the applicant or the responsible person may make the selection. The selection must be documented on an agency choice list or other document in the case record.

If the applicant requests time to consider his choice or to consult with family members or other resources, leave the applicant a return envelope or make arrangements to pick up the agency choice list when the decision is made.

If the applicant refuses to make a choice from all of the contracted agencies in the service area, an agency may be selected for the applicant as a last resort. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date.

2530 Other Resource Services

Revision 17-1; Effective March 15, 2017

When determining unmet need, also identify and examine other agencies' services that the individual now receives or is eligible to receive. This prevents service duplication and ensures all service resources have been pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the individual. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7. If possible, document information about other service resources in the Service Authorization System (SAS) "Support Assisting Client window". If that is not feasible, document using the WordPad function. See Section 7330, Narrative Documentation for SAS Wizards, for specific instructions.

All other services available to the individual must be considered and used before services are authorized by the Texas Health and Human Services Commission (HHSC).

2531 Veterans Affairs Aid and Attendance and Housebound Benefits

Revision 17-6; Effective June 28, 2017

Some individuals receive Aid and Attendance (A&A) or housebound benefits (HB) from Veterans Affairs (VA). These benefits must be considered the primary source of funds to pay for in-home services.

HHSC has an information sharing program between HHSC, the Texas Veterans Commission (TVC), and the Veterans Land Board (VLB) for the purposes of coordinating and collecting information about the use and analysis among state agencies of data received from the Public Assistance Reporting Information System (PARIS) VA match. The PARIS system is a federal-state partnership that provides states with detailed information and data to assist in maintaining program integrity and detecting improper payments.

This information sharing program helps identify HHSC recipients who may be eligible for veteran’s benefits. HHSC creates a file of active recipients in the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid programs. The file of active recipients is sent to the Defense Manpower Data Center (DMDC) on a quarterly basis for PARIS matching. DMDC returns a file of the matched recipients with veterans benefit information back to HHSC. This file is shared with the TVC and VLB to contact veterans who may be eligible for benefits or may be eligible for increased benefits and report those benefits back to HHSC.

HHSC will receive reports regarding A&A and HB that may affect the level of service currently authorized for personal attendant services (PAS).  HHSC will verify the information on any individuals currently receiving Community Attendant Services (CAS), Primary Home Care (PHC), Family Care (FC), Home and Community Services (HCS), Community Living Assistance and Support Services (CLASS), or the Texas Home Living (TxHmL) Program. Since financial eligibility for CAS is determined by HHSC, any changes to eligibility status will be processed by HHSC.

Actions Required Upon Receipt of the Report

When the report is received, the region must distribute the information to the assigned case workers to contact the individual and verify the change in VA benefits. For individuals receiving A&A or HB, the case worker must discuss and document how the individual is using the benefits. A list of some of the items/services that can be purchased using A&A or HB funds includes:

  • medical supplies;
  • medical equipment;
  • nursing services;
  • therapy;
  • skilled services;
  • medications; or
  • other medically necessary items.

If all the A&A or HB funds are being used to purchase items that help the individual remain independent and in the community, the case worker documents the information and no funds are applied to the service plan.

The individual may also use the funds to purchase:

  • PAS; or
  • home health aide services.

If the individual is using the funds to purchase PAS or home health aide services, this must be considered when developing the plan of care. For FC, PHC and CAS, this would be noted on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the individual is able to purchase all the services required, then there is no unmet need and the individual would not be eligible for PAS. If the individual can only purchase part of the required services, or if the funds are not used to purchase services, then the amount of the A&A or HB funds is applied to the purchase of attendant care per Form 2060 instructions.

If the funds are not used to purchase services that help the individual remain independent and in the community, apply the funds to the purchase of non-skilled attendant care. Calculate the number of hours of non-skilled attendant care that could be paid for with the individual's unused portion of A&A or HB. To do this, divide the unused portion of the monthly benefit by the maximum non-priority attendant care limit rate without regard to service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care limit rate. Subtract the resulting amount from the person's authorization. If the number of hours required by the individual's unmet need is more than the benefits he can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the individual's unmet need, even if this exceeds the maximum HHSC can purchase.

These procedures apply only to the purchase of PAS. Do not reduce the amount of other services because the individual receives VA benefits.

Example: An individual whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this individual's A&A benefits by the current maximum attendant care limit rate yields 46 hours per month.

46 ÷ 4.33 = 10.6 hours per week

20 − 10.6 = 9.4 hours per week

This individual may be authorized 9 1/2 hours per week.

Explain this procedure to the individual. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the individual and case worker should jointly decide which PAS tasks will be purchased and authorize only those tasks on Form 2101, Authorization for Community Care Services. Update the Service Arrangement Column of Form 2060 to match the tasks/hours authorized on Form 2101.

Reporting Requirements

Regional management will be required to report the amount of savings generated by the application of VA funds. For example, an individual requires 20 hours per week of PAS, but is now receiving A&A funds. The A&A funds can purchase five hours per week reducing the weekly service plan to 15 authorized hours per week. The cost of the five hours per week is reported as a savings for HHSC.

2532 Skilled Home Health Services

Revision 17-1; Effective March 15, 2017

If an individual is receiving or is eligible to receive Medicare/Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the individual when determining unmet need. SHH is ordered for an individual by his physician and is provided over a short period of time in conjunction with illness.

Use regional procedures to refer any applicant/individual who requests or appears in need of SHH services.

It is possible to authorize other Community Care for Aged and Disabled (CCAD) services, including personal attendant services (PAS), at the same time SHH attendant care is being utilized and both services may even be provided on the same day. If an individual is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCAD service that may be needed by the individual. If SHH provided attendant care on some but not all of the days of a week, PAS may be authorized to provide attendant care on the other days, if needed. If SHH is providing all the personal care needed by the individual but housekeeping services are needed, Family Care or Home-Delivered Meals may be suitable options to consider.

If SHH is providing only skilled nursing services by a registered nurse or licensed vocational nurse, the service would not be duplicated by any other CCAD service that might be authorized, and is not a consideration in determining unmet need. Consider how long SHH has been in use and how long it will continue as the CCAD service plan is developed with the individual. If duplication of tasks would occur by authorizing a CCAD service, denial and/or a later revision to the service plan may be necessary.

2533 Hospice Services

Revision 17-1; Effective March 15, 2017

When Medicaid recipients elect the Medicaid Hospice Program, they waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es). These waived services are limited to services also provided under Medicare. Recipients do not waive their rights to HHSC services unrelated to the treatment of the terminal illness(es). Therefore, participation of the individual in a hospice program does not affect eligibility for Community Care for Aged and Disabled (CCAD) programs.

If an individual chooses to receive hospice services and some of the individual's needs will not be adequately met by the hospice agency, assess the individual and authorize services for the individual's remaining needs on the same basis as any other individual.

For more detailed information about the Hospice program, see Section 2745, Individuals Who Need Hospice Services.

2534 Mutually Exclusive Services

Revision 17-1; Effective March 15, 2017

To determine unmet need for a particular Community Care for Aged and Disabled (CCAD) service, or determine if an individual can receive other HHSC services, ask the individual or family members if the individual is receiving another HHSC service. Check the Service Authorization System (SAS) and the Client Assignment and Registration (CARE) system for services and refer to Appendix XX, Mutually Exclusive Services. See Section 4000, Specific CCAD services.

2534.1 Services Through the Texas Home Living Waiver

Revision 17-8; Effective September 1, 2017

Due to the limited services provided through the Texas Home Living (TxHmL) waiver, some Community Care for Aged and Disabled (CCAD) services are not mutually exclusive and can be received at the same time as Texas Home Living (TxHmL).

The following services may be authorized with TxHmL:

  • CCAD Home-Delivered Meals
  • Day Activity and Health Services
  • Special Services to Persons with Disabilities

Case workers must review the services received through TxHmL before authorizing CCAD services to assure there is no duplication of tasks and there is an unmet need for the service. Individuals must meet the eligibility requirements for the specific CCAD service requested. The case worker must document there is no duplication.

2534.2 Targeted Case Management and Other HHSC Services or the STAR+PLUS Program

Revision 17-6; Effective June 28, 2017

Local Authorities (LAs) provide service coordination through Targeted Case Management (TCM) to Individuals with Intellectual and Developmental Disabilities (IDD) in the HHSC LA priority population.

TCM authorizations are processed through the Service Authorization System (SAS). TCM services are identified in SAS as Service Group 14, Service Code 12A or 12C. TCM can be authorized along with Home and Community-based Services (HCS), Texas Home Living (TxHmL) or as a general revenue (GR) service.

TCM and Other HHSC Services

Other HHSC waiver services (excluding HCS and TxHmL) are mutually exclusive with TCM. An individual receiving any of the following waiver programs cannot receive TCM at the same time:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD) Waiver

If an individual on TCM is applying for one of these waivers, then the SAS Service Codes 40, 40A and 60, for assessments, pre-assessments and prescriptions, are the only service codes allowed to overlap with TCM service authorizations.

Since the waiver programs identified above provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The HHSC case worker must contact the LA to coordinate closing TCM for the waiver service to begin. Individuals receiving the STAR+PLUS program may receive TCM. These services are not mutually exclusive.

The Program for All-Inclusive Care for the Elderly (PACE) is not a waiver program but an all-inclusive program. PACE is mutually exclusive with all other services including TCM.

TCM and Other HHSC Services

Determining whether an individual who receives TCM services can receive other HHSC services, including Community Care for Aged and Disabled (CCAD) services, depends on whether he is receiving TCM services through HCS, TxHmL or as a GR service.

Once the case worker identifies an individual is receiving TCM, he or a regional designee must check the Client Assignment and REgistration (CARE) system to determine if the individual is receiving HCS or TxHmL. If the individual is receiving HCS or TxHmL, the case worker must refer to Appendix XX, Mutually Exclusive Services, to determine if the individual can receive other HHSC services, as some services are mutually exclusive and others are not.

If the individual is receiving HCS or TxHmL and the requested CCAD service is mutually exclusive, then the case worker will contact the individual to allow a choice of services and document the individual's choice. If the individual elects to continue receiving HCS or TxHmL, then the request for CCAD services is denied. If the individual elects to receive the CCAD service, then the case worker must contact the LA to coordinate closing services.

If the individual is not receiving HCS or TxHmL and is receiving TCM as a GR service, then he can receive other CCAD services.

2535 Involvement of Volunteer Resources

Revision 17-1; Effective March 15, 2017

Some services needed by aged and disabled individuals may be performed by volunteers. When developing an individual's service plan, consider whether volunteers from community resources might meet some of the individual's needs.

Volunteer help may include:

  • shopping and paying bills;
  • transportation;
  • telephone reassurance;
  • friendly visits;
  • recreation activities, such as reading aloud, games, help with sewing, knitting, art or other handwork; or
  • writing letters.

Some organizations may contribute group volunteer efforts to accomplish major tasks for functionally disabled individuals. These tasks might include:

  • clothing care and distribution;
  • yard work;
  • hauling trash;
  • cleaning windows;
  • critical home repair;
  • construction of ramps and assistive devices in the house;
  • provision of medical equipment or apparatus;
  • facilitation of support groups for caregivers; and
  • transportation for elderly and disabled shut-ins.

Before completing a plan that includes volunteers, discuss the idea fully with the individual and his family or caregiver. If an individual is served completely through planned volunteer services, the case worker may keep the case open as "case management only" as long as the individual's condition warrants regular monitoring. In the case narrative, document all volunteer resource development and use.

2536 Program of All-Inclusive Care for the Elderly

Revision 17-1; Effective March 15, 2017

The Program of All-Inclusive Care for the Elderly (PACE) is an all-inclusive program that provides all required services for an individual enrolled in the program. PACE is only available in catchment areas and information on service locations may be found in Appendix XXXIV-F, Program of All-Inclusive Care for the Elderly.

Texas Health and Human Services Commission (HHSC) intake screeners in the catchment areas must be aware of the PACE service and referral procedures for the service. Intake screeners must provide information about PACE to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. Individuals in the PACE catchment areas may request services through the local HHSC intake office or through the PACE service site. Additional information is found in Appendix XXXIV-F, Waiver Program Descriptions Program of All-Inclusive Care for the Elderly.

Since PACE is an all-inclusive program, it is mutually exclusive with all other HHSC programs and STAR+PLUS programs.

2540 Priority Status Individuals

Revision 17-1; Effective March 15, 2017

For an individual to be assigned priority status, there must be at least one purchased priority task such that both the individual's:

  • functional score for that task is 3; and
  • support score for that task is 4.

The service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must be completed for each task in which the individual scores 1, 2 or 3. The support score column must be completed for each priority task (eating, toileting, transfer and meal preparation) in which the individual scores 3 and the service is being purchased.

If the attendant does not show up during a normally scheduled service shift, the individual's health, safety or well-being may or may not be jeopardized. Always assess the potential impact on the individual's health or safety when determining the effects of an attendant not providing service.

Do not designate an individual as having priority status if the failure of the attendant to report to work would not result in any risk to the individual's health, safety or well-being. If the individual appears to be at risk (scores a 3 on a priority task with little or no caregiver support), document the reason(s) why a support score of 4 was not assigned.

In determining whether health, safety or well-being is endangered, consider the worst result that might follow from the attendant not providing service. For example, an individual may have a friend who visits daily when she can, but the friend is regularly out of town on business. Determine the consequences of the attendant not showing up on a day when the individual's friend is out of town.

Consider each individual's condition and situation. One individual may be able to miss a meal during a scheduled service shift because his caregiver will be home later to prepare the meal. Another individual may not be able to miss a scheduled meal without risk to his health because of individual nutritional needs or no caregiver to prepare the meal later. Contact the regional nurse if assistance is needed in assessing the risk that would result from an attendant not working during a scheduled shift.

Priority individuals must be advised of the importance of being available in their homes during the hours designated in the service plan. Advise the individual to contact the provider in advance if the individual knows he will not be at home during a normally scheduled shift. If information is received that a priority individual will not be home, inform the provider.

Inform a priority individual that the provider may monitor the attendant's work performance by making frequent calls or home visits. If a priority individual objects to this increased monitoring of the attendant, the individual has the option of withdrawing from priority status.

For priority cases, note in the comments section of Form 2101, Authorization for Community Care Services, this is a priority case. Use verbal referral procedures for new priority individuals.

Providers may not allow a service interruption for an individual designated as priority status unless the:

  • service interruption is caused by circumstances described in Section 4677, Suspension of Services and Interdisciplinary Team Procedures;
  • individual is not at home when the attendant is scheduled to provide services; or
  • individual requests that services not be provided on specific days.

The provider must notify the case worker within seven calendar days of a priority individual not receiving scheduled services. This notification is for the case worker's information only; no response is required. Do not approve or disapprove service interruptions for priority individuals.

Individuals can refuse priority status. If an individual refuses priority status, document in the case record the individual's decision and the reason for it.

Because the unit rate for priority individuals is higher than the rate for non-priority individuals, the maximum allowable service authorization is less for priority individuals. A priority individual receiving the maximum hours per week may not be able to receive another Community Care for Aged and Disabled service for which he may be eligible. This could exceed the total expenditures allowed by the average daily nursing facility rate (see Appendix II, Cost Limit for Purchased Services). A priority individual can exercise the option to receive less than the maximum hours in order to receive another needed service or he can decline priority status. The case worker must give the individual the choice and explain the options, including the advantages/disadvantages of each. Document the individual's decision in the case record.

2550 Identifying Individuals at Risk

Revision 17-1; Effective March 15, 2017

An individual whose unmet medical or functional need constitutes a potential hazard to his health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of his condition. The case worker may identify the unique problems of these individuals at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the case worker. Address these problems in the individual's service plan and document the information on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Form 2059, Summary of Client's Need for Service, in the Service Authorization System. Consult with the unit supervisor and the regional nurse about threats to the individual's health and safety and about unmet medical and functional need issues. Use a team approach to develop service and monitoring plans whenever necessary and feasible.

A "critical level of risk" exists when an individual has certain medical, physical and social characteristics that endanger his health and safety in his current living arrangement. Factors that contribute to critical risk are the individual's level of functional impairment, his medical condition, the quality and strength of his caregiver arrangement, and the physical and social conditions of his immediate environment.

The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in an individual or in his situation, the case worker must decide whether he should be handled as an individual at risk.

  • The individual has a score of 40 or higher on Form 2060.
  • No caregiver is available to provide needed assistance or the individual's caregiver may:
    • be unable or unwilling to provide the necessary care; or
    • exhibit abusive, neglectful behavior.
  • The individual may not have sufficient mental clarity to make an informed choice and understand the consequences of that choice (scores of 2 or 3 on Item 23, Form 2060).
  • The individual may be immobile or nonambulatory or may need total assistance with feeding, toileting or medication and exhibit inability to maintain his personal safety.
  • The individual may have complex health problems that create the need for skilled nursing assistance with personal care tasks, specialized technical skills in daily management of personal care or total assistance with several personal care tasks.
  • The individual's home may be insufficient to provide a safe environment.

Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary, and in the case narrative if more space is needed.

2551 Case Worker Actions for Individuals at Risk

Revision 17-1; Effective March 15, 2017

The case worker must discuss the individual's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The case worker and unit supervisor determine whether a risk management team meeting is necessary. If necessary, the case worker will:

  • organize and coordinate a team meeting. Include, as needed, the provider supervisor, the unit supervisor and the regional nurse. If the situation indicates possible abuse, neglect or exploitation, report this to Adult Protective Services staff at the Department of Family and Protective Services.
  • discuss with the team the specific circumstances that place the individual at risk, the options for dealing with those circumstances and the individual's capacity to consent. Determine whether a team visit to the individual's home is necessary.
  • discuss and agree on how often and by whom monitoring contacts will be made. Document the monitoring plan in the case narrative or according to regional requirements.
  • use information from team members and document the individual's circumstances or condition on Form 2084, Risk Management Team Meeting Summary. Have available team members sign the form. Keep the original in the case record and provide copies to team members.
  • coordinate the team visit to the individual's home, if necessary. (All team members may not need to attend.) Discuss with the individual, his family and caregiver:
    • specific circumstances that place the individual at risk,
    • options for dealing with those circumstances, and
    • the proposed monitoring plan and the limitations of Community Care for Aged and Disabled (CCAD) services.
  • discuss Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, with the individual, his family members and caregivers. Make certain they understand the proposed service plan and the limitations of CCAD services. If the individual has not previously signed Form 2307, Rights and Responsibilities, have him, a family member or caregiver sign the form. If no one is willing to sign the form, record the refusal on the form and file it in the case record.
  • monitor the individual according to the monitoring plan, documenting contacts in the case narrative until the circumstances or problems that caused the individual to be at critical risk are as stabilized as possible, or until the individual's circumstances or degree of risk changes. Coordinate monitoring contacts with provider staff and with the regional nurse.
  • conduct functional reassessments every 12 months, or more often if needed, depending on the individual's situation or as indicated in the monitoring plan.

If the team members disagree about whether an individual is at risk, the person who first identified the critical-risk indicators should document in the case record the:

  • individual's situation that puts him at risk;
  • notification of other appropriate parties, including the case worker's supervisor; and
  • responses to the notification.

If service plan disagreements cannot be resolved through team discussions, the unit supervisor consults with the lead regional nurse and, if necessary, the program director. Any difficulties with providers that cannot be resolved through discussion should be reported to the contract manager. If the problem cannot be resolved in the discussion process, the regional director makes the final decision.

If, during the service planning process, staff become aware the individual's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the individual and his family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the individual's response in the case narrative or on Form 2084. The individual and his family decide whether he is to remain in his present living arrangement, using the available services. The individual is free to refuse any or all services offered.

2600 Authorizing and Reassessing Services

Revision 17-1; Effective March 15, 2017

2610 Application Processing and Notification

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(d) — Eligibility for CCAD services for income-eligible applicants is determined within 30 calendar days after a signed application is received. For categorically-eligible applicants, eligibility must be determined within 30 calendar days after either the consumer's assessment or face-to-face contact with the worker, whichever occurs first. If the applicant withdraws from the program before an assessment is completed or a face-to-face interview is conducted, no further action is necessary.

2611 Processing Time Frames

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker is required to determine eligibility for Community Care for Aged and Disabled (CCAD) services for income-eligible applicants as soon as possible, but within 30 calendar days after a signed application is received. The case worker must determine eligibility for categorically eligible applicants as soon as possible, but within 30 calendar days after either the individual's assessment or face-to-face contact with the case worker, whichever occurs first.

This standard is applied to all applications, except for Community Attendant Services (CAS), using the date shown in "Date Eligibility Rules Processed" on the Service Authorization System Wizards (SASW) Form 2064, Eligibility Worksheet, as the end point of measurement. The 30-day processing deadline cannot be used to unnecessarily delay a decision if all information is available before the 30th calendar day.

Proceed with the eligibility determination process if the individual fails to cooperate but has received facility-initiated Day Activity and Health Services (DAHS) as a Medicaid individual. See the procedures in Section 4231.2, Intake Response.

2611.1 Processing Time Frames for Community Attendant Services

Revision 17-1; Effective March 15, 2017

Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. Because the MEPD process can take up to 45 days for regular referrals and 90 days if a disability determination is required, this may delay Community Care for Aged and Disabled (CCAD) certification beyond the 30-day time frame.

MEPD will notify the Texas Health and Human Services Commission (HHSC) case worker of the eligibility decision through the MEPD to HHS Communication Tool. However, if a decision is not received, the HHSC case worker must check the Texas Integrated and Eligibility Redesign System (TIERS) for an MEPD eligibility decision on or before the 25th day from the application date and perform weekly checks until the eligibility decision is received. The TIERS checks must be documented in the case record.

When the eligibility decision notification is received either through TIERS or the MEPD to HHS Communication Tool, the case worker has seven business days to:

  • complete data entry in the Service Authorization System Wizards (SASW); and
  • send the referral packet to the Home and Community Support Services Agency (HCSSA) to begin pre-initiation activities.

The seven business days are measured from the date HHSC receives the eligibility decision from MEPD or the date eligibility is verified through TIERS. The case worker must print a copy of the eligibility notice or TIERS screen and file it in the case record.

The HHSC case worker must advise MEPD only if the applicant is not approved for CAS (i.e., no practitioner’s statement or other circumstances preventing services delivery). In this circumstance, the case worker must send Form H1746-A,  MEPD Referral Cover Sheet, to MEPD within two business days of determining the individual is not eligible for CAS, advising that the applicant has not met the functional eligibility requirements. Form H1746-A is sent to MEPD at the same time Form 2065-A, Notification of Community Care Services, is sent to the individual notifying him of CAS ineligibility.

The case worker is not required to notify MEPD when CAS services are authorized.

See Section 4653, Referral to the Provider, and Section 4660, Service Authorization, for additional procedures for authorizing CAS services.

Case workers always have seven business days after confirmation of MEPD eligibility to send the referral to the provider. This applies even when verification of MEPD certification is received near the end of the 30-day period allowed for completing CCAD applications.

2612 Notification of Eligibility Decision

Revision 17-1; Effective March 15, 2017

An applicant/individual certified for one Community Care for Aged and Disabled (CCAD) service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the units per week he is eligible to receive services. If certified for Day Activity and Health Services (DAHS), the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

When notifying the applicant of eligibility, specify on Form 2065-A, Notification of Community Care Services:

  • the CCAD services for which the applicant is eligible or ineligible, and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a DAHS facility;
    • if applicable, that the Family Care or Primary Home Care applicant is eligible for priority status; and
    • the initial and ongoing copayments the Residential Care individual is to pay to the facility.

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

See Section 2662, Redetermination of Financial Eligibility, and Section 2660, Reassessments and Recertification Procedures, for time limits that apply when eligibility is redetermined.

2613 Case Record Documentation

Revision 17-1; Effective March 15, 2017

To document the eligibility decision, the case worker places in the applicant's case record a signed and dated:

  • Form 2064, Eligibility Worksheet, except if the application is denied before a financial eligibility determination is made; and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, except if the:
    • applicant requested only Day Activity and Health Services (DAHS), which does not require a Form 2060 score;
    • applicant withdrew the application before the case worker completed Form 2060;
    • application is denied for a reason other than:
      • no unmet need,
      • insufficient functional impairment, or
      • low hours for Family Care or Primary Home Care.

Note: Texas Health and Human Services Commission (HHSC) staff must send each individual the Health and Human Services Agencies’ Notice of Privacy Practices, https://hhs.texas.gov/laws-regulations/legal-information/health-insurance-portability-and-accountability-act-hipaa-and-privacy-laws/hipaa-forms, upon certification.

2620 Service Authorizations

Revision 17-1; Effective March 15, 2017

Service plans may include one or more Texas Health and Human Services Commission (HHSC) purchased service. If more than one service is authorized, be sure that the tasks are not duplicative and that the service combinations do not exceed the allowable costs specified in Appendix II, Cost Limit for Purchased Services. Example: Before authorizing 10 units of Day Activity and Health Services (DAHS) per week for an individual who will also be receiving an in-home service, determine whether or not it is feasible for the individual to participate in DAHS five full days per week.

To authorize services, enter the required information in the Service Authorization System Wizards (SASW). SASW will generate Form 2101, Authorization for Community Care Services. Based on the urgency of the individual's need, negotiate with the provider for the earliest possible date that services can begin. Remember that services can and may need to begin on the weekend if an individual is discharged from a hospital or other institution on a Friday afternoon and needs services immediately. Enter the negotiated beginning date of coverage.

Use the comments section of Form 2101 to give specific instructions to the provider about the individual's service arrangement. These include the number of days the individual requests services, specific service schedules that are required or strongly preferred by the individual, specific instructions about unique individual problems or the individual's home, or information about individuals who should not be hired as the paid attendant.

Along with Form 2101, send the provider a copy of the SASW Auto Form 2060, Needs Assessment Questionnaire and the Auto Task/Hour Guide and for all personal attendant services (PAS) individuals.

Providers are expected to follow the instructions given on Form 2101. If a provider does not do so, try to resolve the problem through discussion with the provider's supervisors. If this fails, report the problem to the supervisor and follow the procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

2630 Referrals to the Provider

Revision 17-1; Effective March 15, 2017

Refer to Section 4000, Specific CCAD Services, for specific procedures for each service for sending referrals to providers. See Appendix XIII, Content of Referral Packets, for referral-packet contents sent to providers for each service.

2631 Negotiated Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: Individuals must be referred no later than the next business day after the day the individual is visited and/or it is determined that a negotiated verbal referral is necessary. Form 2101, Authorization for Community Care Services, must be sent within five business days from the date the individual was determined eligible for a negotiated verbal referral. Use the comment section of the form to document verbal referrals, dates and other relevant information. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

Regardless of the response criteria established for the applicant at intake, the case worker must reassess the individual's need for service initiation during the assessment process. In particular, assess the continued provision of any assistance with the individual's personal care needs by individuals and/or other providers.

If it is determined that the individual's unmet needs for personal care are, or will be, such that services must begin sooner than the time usually required when using the routine written referral process, contact the provider and negotiate a start date according to the individual's need for service initiation. The need for a verbal referral will vary from individual to individual. Consult with the unit supervisor if an individual's particular circumstances are such that it is uncertain whether to use the negotiated referral process.

2632 Routine Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: For applicants who do not require negotiated referrals, authorize services by sending Form 2101, Authorization for Community Care Services, within five business days from the date the applicant is determined eligible. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

If a provider is operating at capacity, or if all budgeted service slots are filled when an eligible individual is referred for services, enter the individual's name on the appropriate interest list. Individuals must be served as indicated in Section 2230, Interest List Procedures. For services other than Day Activity and Health Services (DAHS), Community Attendant Services (CAS) and Primary Home Care (PHC), the provider must return Form 2101 by the 21st calendar day from the date of the referral. If Form 2101 or some other kind of notification is not received, contact the provider to find out the reason for the delay and the status of the referral.

If the provider is unable or fails to provide services within the negotiated time, refer the individual to another provider. If another provider cannot provide the services as needed, resolve the problem through conference with the supervisor. For special referral procedures for PHC, CAS and DAHS, see Section 4000, Specific CCAD Services.

2640 Provider Requirements for Hiring a Paid Attendant

Revision 17-1; Effective March 15, 2017

Criminal background checks are required for all facilities and service providers providing care to the aged and disabled. Except in emergency situations, providers are required to obtain a criminal history check before offering permanent employment to unlicensed employees having direct contact with individuals who are receiving:

  • Day Activity and Health Services,
  • Residential Care,
  • Primary Home Care,
  • Adult Foster Care,
  • Client-Managed Attendant Care, or
  • 24-Hour Shared Attendant Care.

A person must be barred from employment if he has been convicted of a criminal offense for which an administrative review is not available. A person may request an administrative review for some criminal offenses that may potentially bar employment.

If asked by anyone, including the individual, about the results of the criminal history check, explain that:

  • all providers must conduct criminal history checks on attendants;
  • the Texas Health and Human Services Commission (HHSC) is monitoring compliance with the law; and
  • confidentiality requirements prevent sharing information obtained as a result of a criminal history check with anyone except the employee.

2650 Changes in Service Plans

Revision 17-1; Effective March 15, 2017

2651 Disagreements about Service Plans

Revision 17-1; Effective March 15, 2017

If a disagreement arises between provider staff and Texas Health and Human Services Commission (HHSC) staff about an individual's service plan, resolve the problem through discussion and negotiation. Use an interdisciplinary meeting, if necessary. Ensure that services are not delayed unnecessarily because of these disagreements.

HHSC regional nurses make final decisions in disagreements with providers about an individual's medical need for Community Attendant Services and Day Activity and Health Services.

In all other instances, the Community Care for Aged and Disabled (CCAD) supervisor attempts to resolve the disagreement with the provider's supervisor. If supervisory staff of both providers are unable to resolve the disagreement, the CCAD program manager resolves the disagreement.

2652 Changing the Service Schedule Between Reassessments

Revision 17-1; Effective March 15, 2017

If a schedule change results in a change in hours or priority status, use the chart below to determine which specific changes must be included on Form 2101, Authorization for Community Care Services.

Type of Individual Specific Instructions
Ongoing Primary Home Care or Community Attendant Services with chronic medical conditions, and transfer individuals Specify the effective date as the beginning date of the service plan change on Form 2101, Item 4. If the change results in:

 

  • an increase in hours, the "Begin" date on Form 2101 must be at least seven days from the Form 2101 date, unless another date is negotiated; or
  • a reduction in hours, the "Begin" date on Form 2101 must be at least 12 days from the Form 2101 date. See Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services, for additional information.

    Note: For a reduction in hours, the "Begin" date on Form 2101 must match the effective date on Form 2065-A, Notification of Community Care Services.
Community Attendant Services If a change is being conducted in conjunction with an annual reassessment, enter the "Begin" date as indicated below and leave the authorization "Pending." The HHSC nurse will authorize Form 2101.

If a decrease in service is being implemented between assessment periods, the "Begin" date should be 12 days in the future to allow advance notice of the reduction in service. The "Begin" date must match the effective date on Form 2065-A.

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

Family Care and Family Care transfer case The "Begin" date should be 12 days in the future to allow advance notice of the reduction in service.

 

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

For all other changes not related to a change in hours, complete Form 2067, Case Information, for personal attendant services.

2653 Provider Flexibility

Revision 17-1; Effective March 15, 2017

Providers are, as much as possible, expected to follow instructions given on Form 2101, Authorization for Community Care Services. However, there are times when changes in tasks or schedules will be necessary in order to meet the individual's needs. In these situations, it is not necessary for the provider to notify the case worker as long as the units delivered and billed for a calendar month do not exceed 4.33 times the adjusted weekly hours identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Example – An individual who regularly receives 15 hours of service per week is sick for two days and declines services due to illness. During those two days, a total of five hours of personal care services would have been delivered had the individual been able to receive services. Because the individual may have an increased need for services following the illness, those five hours may be made up if it would be to the benefit of the individual. Because the number of hours delivered does not exceed the number of hours authorized, the provider does not need to notify the case worker.

This ongoing flexibility is intended to allow services to meet the individual's needs, considering his desires and changes in his condition. The flexibility is not intended to be for the convenience of the provider or to be applied retroactively to justify an attendant absence or interruption of services.

If a provider makes changes to tasks/schedules inappropriately or against the individual's wishes, try to resolve the problem through discussions with a provider supervisor. If this fails, report the problem to the case worker's supervisor and follow procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

2660 Reassessments and Recertification Procedures

Revision 17-1; Effective March 15, 2017

Conduct reassessments and (if applicable) referrals of individuals to Community Care for Aged and Disabled (CCAD) services within:

  • 24 months of the last financial redetermination, and
  • 12 months of the last functional assessment.

Annual reassessments are required for all CCAD services. See Section 2663.1, Annual Home Visit Required for Individuals Receiving PAS, and Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is required for the reassessment.

When the reassessment is conducted in the individual's home, the case worker must schedule the visit with the individual or his authorized representative at a time that is convenient to the individual. Schedule the appointment by telephone or in writing using Form 2068, Application, Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for some reason, inform the individual or his authorized representative in advance that the appointment will have to be rescheduled. Do not visit the individual without advance notice of the visit.

During the reassessment, the case worker must:

  • redetermine functional eligibility on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as required by the specific program;
  • redetermine unmet need, as outlined in Section 2433, Determining Unmet Need in the Service Arrangement Column;
  • present the Consumer Directed Services (CDS) option and have the individual sign Form 1581, Consumer Directed Services (CDS) Option Overview; and
  • present Form 0030, Application for Voter Registration, and offer the opportunity to register to vote

To comply with the National Voter Registration Act of 1993, the individual must be offered the opportunity to register to vote at the time of application and at each annual redetermination. Provide assistance to any individual who requests assistance in completing Form 0030, Review Form 0030 for completeness in the individual's presence. The individual may:

  • mail Form 0030; or
  • return the form to the case worker's office for appropriate mailing to the county registrar's office.

2661 Individual Unavailable for Reassessment

Revision 17-1; Effective March 15, 2017

In some situations, the case worker will use his judgment to determine how long a case should remain open when the individual is unavailable for a reassessment. As a general rule, if the individual continues to be unavailable for more than 30 days, it should be determined if the unavailability is temporary. If an individual is repeatedly unavailable after an appointment has been scheduled, refer to the procedures in Section 2830, Refusal to Comply with Service Delivery Provisions. If the individual is unavailable because of temporary nursing home admission, use the time limits and procedures in Section 2822, Service Suspension by Case Workers.

2661.1 Delay in Home Visits Due to Individual Illness

Revision 17-1; Effective March 15, 2017

While it is important that required home visits are performed on a timely basis, due to the increase in serious transmittable diseases in the general population, there may be circumstances that could place staff at risk for contracting contagious illnesses.

In order to ensure the health and welfare of staff members who could come in contact with individuals reporting a contagious illness, case workers may delay home visits under the following circumstances.

If a case worker contacts an applicant/individual to schedule a home visit (initial, reassessment or monitoring visit) and the individual states he has a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker 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 worker must contact the individual at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

2662 Redetermination of Financial Eligibility

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must redetermine financial eligibility within 24 months of the previous determination of financial eligibility.

The financial reassessment must be completed by the last day of the 24th calendar month from the previous financial redetermination. To redetermine financial eligibility for income-eligible individuals, use the policies and procedures in Section 3000, Eligibility for Services. The case worker must:

  • compare income and resources reported this year with what was previously reported;
  • discuss with the individual any discrepancies between the two; and
  • verify the existence and amounts of new income or resources if these additional assets bring the individual within proximity to eligibility limits.

Case workers must be diligent in ensuring that individuals receiving personal attendant services (PAS) are served by Title XIX PAS whenever possible. If the financial situation of an ongoing Family Care (FC) individual has changed in a way that might make him eligible for Community Attendant Services (CAS), a referral should be made to Medicaid for the Elderly and People with Disabilities (MEPD).

Example: An FC individual was denied CAS eligibility at the time of application because of resources that exceeded the $2,000 eligibility limit. However, the individual now reports a total of $1,200 in resources and all other CAS eligibility criteria (for example, a need for a personal care task) are met. A referral to MEPD must be made.

2662.1 Financial Reassessments for Community Attendant Services

Revision 17-1; Effective March 15, 2017

Texas Health and Human Services Commission (HHSC) Medicaid for the Elderly and People with Disabilities (MEPD) redetermines financial eligibility annually for individuals receiving Community Attendant Services (CAS).

In order for individuals to maintain financial eligibility, redetermination packets must be returned to HHSC in a timely manner. Individuals may not recognize the envelope as being an official HHSC document and therefore do not open the envelope. As a result, redetermination packets are not returned and financial eligibility is denied.

Due to changes in the wording on the envelopes, HHSC staff must provide individuals with an explanation of the changes. Previously, the envelopes contained the following wording, “ Important Insurance Information.” The envelopes now state the following:

Picture of Time Sensitive Stamp

HHSC staff must take examples of the envelopes to face-to-face contact visits so individuals can become familiar with the new appearance of the envelopes. HHSC staff can make copies of the envelope examples (see Appendix XXXIX, Examples of HHSC Envelopes) to provide to individuals at face-to-face contact visits. HHSC staff must discuss with individuals at face-to-face contact visits the importance of returning Form H1200-EZ, Application for Assistance – Aged and Disabled, to HHSC within the required time frame provided in the redetermination packet.

HHSC has also implemented Form H1200-SR, Streamlined Redetermination for MEPD. Form H1200-SR is generated from the Texas Integrated Eligibility Redesign System (TIERS). HHSC may determine an individual appropriate for a streamlined redetermination if the individual has had a minimum of one annual redetermination using Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-A, Medical Assistance Only (MAO) Recertification. The individual will receive Form H1200-SR instead of Form H1200, Form H1200-A or Form H1200-EZ. The cover sheet to Form H1200-SR provides specific directions for the individual to follow to determine if the form needs to be completed and returned to HHSC.

HHSC staff must discuss with the individual the importance of thoroughly reviewing Form H1200-SR to determine if changes need to be reported to HHSC. If the individual has any questions regarding the information on Form H1200-SR, he should contact HHSC by mail or fax using the address or fax number on the application or by calling 211.

In addition to receiving one of the forms mentioned above from HHSC, the individual may also receive Form H1010, Texas Works Application for Assistance – Your Texas Benefits. Individuals may only return Form H1010 thinking this form will suffice for all services the individual is receiving. HHSC staff must inform these individuals that Form H1200, Form H1200-A, Form H1200-EZ or Form H1200-SR (if changes need to be reported) and Form H1010 must both be completed and returned to HHSC. HHSC staff must make individuals aware they can track the status of their application using the “"HHSC Your Texas Benefit"s” website at www.yourtexasbenefits.com, or by calling 211.

For some ongoing CAS cases, the functional information was not retained in TIERS due to automation issues. When MEPD completes an annual review for an individual on CAS and there is no functional information available in TIERS, the MEPD specialist will send an MEPD to HHS Communication Tool to the CCAD case worker requesting functional information on the individual if the MEPD specialist is unable to verify the information in the Service Authorization System (SAS).

If requested by the MEPD specialist, the CCAD case worker must send a copy of the Service Authorization screenshot in SAS to MEPD showing the individual is currently active on CAS. Form H1746-A, MEPD Referral Cover Sheet, must be used as a cover sheet when faxing this information to the Document Processing Center (DPC). Any time an MEPD specialist requests Form H1746-A from the CCAD case worker to clarify information on an individual receiving CAS, the CCAD case worker must send Form H1746-A to MEPD with the requested information.

If an individual on CAS has not returned his recertification packet to MEPD, the MEPD specialist may contact the individual, or the authorized representative/responsible person listed in the Texas Integrated Eligibility Redesign System (TIERS), by phone approximately 30 days after the recertification packet was sent to the individual to remind him to return the packet to MEPD. The MEPD specialist may contact the HHSC case worker for assistance with contacting the individual or authorized representative/responsible person. Both the individual and the authorized representative/responsible person will receive the recertification packet to help reduce the number of CAS denials for failure to return recertification packets.

2663 Reassessment of Functional Need

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker reassesses the individual's need within 12 months of the previous assessment. The functional assessment must be completed by the last day of the 12th calendar month from the previous functional assessment.

To reassess functional need, use the policies and procedures in Section 2430, Functional Assessment, and in the instructions for Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

  • For services requiring a functional needs Form 2060 score for eligibility, the case worker must complete or update the score in Part A of Form 2060 at each annual reassessment.
  • For individuals who receive Day Activity and Health Services (DAHS) or Consumer Managed Personal Attendant Services (CMPAS) as the only service, a Form 2060 score is not required.
  • For Family Care (FC), Community Attendant Services (CAS) and Primary Home Care (PHC), the case worker must review Part B and Part C of Form 2060 at least annually during the interview with the individual.

2663.1 Annual Home Visit Required for Individuals Receiving PAS

Revision 17-6; Effective June 28, 2017

Program Standard: A home visit must be conducted with all individuals receiving Community Attendant Services (CAS) for all annual reassessments and 90 day monitoring contacts. A home visit must be conducted with all individuals receiving Primary Home Care (PHC) and Family Care (FC) at least once every 24 months at the same time the financial redetermination is conducted.

During the home visit, the case worker provides oversight of the individual's health and safety. The case worker must evaluate the individual's ability to cope with the activities of everyday living in the home environment and identify when changes to the service plan or the addition of other services provided by the Texas Health and Human Services Commission (HHSC) may be of benefit.

For CAS, it is recommended the case worker complete the annual functional reassessment during the last 90-day monitor for the year prior to the annual being due. If the annual functional reassessment is not completed during the last 90-day monitoring visit prior to the annual being due, then an additional home visit is required to complete the reassessment. An exception to having to make a home visit is when Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, has been completed within the last 60 days due to an interim change, the case worker may conduct the annual reassessment by telephone.

For all CCAD services, if an individual requests a change at the annual reassessment, the change must be worked within five days or by the annual reassessment due date, whichever is earlier.

For CAS, Form 2101, Authorization for Community Care Services, will continue to be sent within five business days of the home visit due to the nurse approval requirements for the program.

All annual reassessments must be recorded on Form 2314, Satisfaction and Service Monitoring, and in the Service Authorization System Wizards (SASW). It must include the individual as the primary contact and the location as a home visit.

2663.2 Determining When a Home Visit is Necessary for Other Services

Revision 17-1; Effective March 15, 2017

For services other than Community Attendant Services, determine if the reassessment should be done in a face-to-face home visit or by telephone interview, based on the service received and the individual's circumstances. See Section 4000, Specific CCAD Services, for home visit requirements for each specific service.

Individual circumstances that may include the need for a face-to-face reassessment include but are not limited to:

  • a service other than Emergency Response Services or Home-Delivered Meals is being added to the service plan;
  • individuals with no telephone or who cannot communicate by telephone because of cognitive or physical impairments and/or lack a knowledgeable source to contact;
  • Community Care for Aged and Disabled (CCAD) individuals who are receiving services from Adult Protective Services (APS) or have a history of self-neglect;
  • individuals who have experienced multiple changes in a short time frame, such as major changes in health, living arrangements or caregiver arrangements, and the case worker is unable to obtain an accurate assessment that reflects all of the changes by telephone;
  • case transfers to case workers or newly hired case workers, unless the losing and gaining case workers discuss and agree on the individual's condition;
  • individuals with weak, unreliable or no caregiver support systems;
  • individuals who have a history of refusal to comply with service provisions;
  • individuals whose health and safety are at risk; or
  • individuals who choose to live in a home with dilapidated, unsanitary or hazardous living conditions.

Case worker circumstances may warrant that a home visit be made, such as case worker trainees assigned to a caseload.

2664 Redetermination of Unmet Need

Revision 17-1; Effective March 15, 2017

The unmet need policy applies to ongoing cases as well as to applications. At each reassessment, the case worker must evaluate whether the Community Care for Aged and Disabled (CCAD) services already being purchased are meeting needs that would go unmet if no services were purchased. During the annual functional assessment or for each request for a change in service plan or hours, review each task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

In the Service Arrangement column, determine if needs are being met through other sources or if the individual continues to have a need for the task to be purchased. If there are no tasks to be purchased, the individual no longer has an unmet need and is no longer eligible. If unmet need exists, continue with the development of an appropriate service plan.

In situations in which the individual's caregiver also serves as the paid attendant, carefully review the tasks marked "C" on the Service Arrangement Column on the previous Form 2060. These are the tasks that the caregiver agreed to perform voluntarily at the last assessment. These tasks may not be purchased. If the caregiver states that he/she is no longer able or no longer willing to provide the tasks, then advise the caregiver that the provider will be notified to hire a new paid attendant for those tasks. Document any changes in caregivers or caregiver tasks on Form 2060 and Form 2059-W, Summary of Individual's Need for Service Worksheet. The information on Form 2059-W is entered in the Service Authorization System Wizards (SASW) for Form 2059, Summary of Client's Need for Service.

In reassessment decisions, apply policy about duplicate services.

2670 Notifications at Reassessment

Revision 17-10; Effective October 6, 2017

40 Texas Administrative Code §48.3902 – To continue receiving services, the client must meet the CCAD eligibility requirements at the time of recertification of financial eligibility and reassessment of needs.

Program Standard: Notify the individual in writing, using Form 2065-A, Notification of Community Care Services, of changes in the individual's service plan, to include: addition of service(s), increase in hours, decrease in copayment, or loss of priority status based on the individual's request.

Form 2065-A must be sent within two workdays of the decision if the change involves:

  • denial of priority status if the applicant requests it;
  • an increase in units;
  • a decrease in the copayment; or
  • adding a new service.

For Community Attendant Services (CAS) case actions initiated by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, the Community Care for Aged and Disabled (CCAD) case worker is only required to check the notice forwarded by MEPD for accuracy and file it in the case record. The case worker's only liability for any MEPD-issued Form 2065-A is to report the error to the MEPD specialist via Form 2067, Case Information.

Program Standard: Notify the individual in writing of any reduction, termination in services, loss of priority status or increase in copayment at least 12 days before the effective date of the decision.

If an individual loses eligibility, Form 2065-A must be sent with 12 days advance notice. Exception: Advance notice is not required if the individual loses Medicaid eligibility such as Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF).

Program Standard: Notify the applicant/individual or his authorized representative of his rights and responsibilities and of HHSC service limitations.

The case worker gives Form 2307, Rights and Responsibilities, to the Adult Foster Care (AFC) individual/responsible person before AFC is authorized or reauthorized. The form is given to the CCAD individual/responsible person at the initial face-to-face visit. (For individuals receiving only Day Activity and Health Services (DAHS) or Home-Delivered Meals (HDM), the initial Form 2307 may be reviewed over the telephone.)

The case worker also gives Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, when the applicant/individual requests attendant care and when the individual moves into a new home. At least annually, the case worker discusses all parts of Form 2307 with the individual/responsible person to ensure that he understands the form's content.

2680 Recertification

Revision 17-1; Effective March 15, 2017

The following forms must be sent upon completion of the reassessment:

  • Form 2101, Authorization for Community Care Services, for all Day Activity and Health Services, Primary Home Care, Home-Delivered Meals, Family Care and Residential Care cases in which there is a change in the service plan;
  • Form 2101 for all Community Attendant Services (CAS), whether or not there is a change in the service plan;
  • Form 2065-A, Notification of Community Care Services, for all cases in which there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another. If functional eligibility is being denied for a CAS case, the Medicaid for the Elderly and People with Disabilities (MEPD) case specialist also receives a copy of this notification.

Additionally, for Adult Foster Care (AFC), send:

  • Form 2327, Individual/Member and Provider Agreement, updated as needed;
  • Form 2330, Assessment and Service Plan Approval for Adult Foster Care, whether or not there is a change; and
  • Form 2307-F, AFC Rights and Responsibilities, only if the individual has moved to another home.

If a case is closed after Form 2101 has been updated by the system and Form 2065-A, notifying the individual of termination of services, has not been sent, send Form 2065-A as soon as it is determined the case must be closed. Allow 12 days prior notice before the effective date of termination. See Section 2811, Effective Dates for Service Reduction and Termination. Advise the individual that approved services have ended. Include the date and the reason in the comments section of Form 2065-A.

2700 Service Monitoring, Changes and Transfers

Revision 17-1; Effective March 15, 2017

2710 Monitoring Visits and Contacts

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must monitor the individual's situation, the service(s) the individual receives and the adequacy of the service plan, in accordance with the requirements of the specific service he receives. Monitoring of the service plan includes checking for the appropriate priority level, ensuring the individual has the appropriate Community Care for Aged and Disabled services and ensuring the hours/units authorized meet the individual's needs.

2710.1 Monitoring Initiation of Services

Revision 17-1; Effective March 15, 2017

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care for Aged and Disabled (CCAD) cases. Monitoring visits to ensure service initiation are required for two groups of individuals:

  • those with priority status (three-day and 30-day); and
  • those who are using the Consumer Directed Services (CDS) option for service delivery (30-day only). See Section 6332.3, Monitoring CDS Service Initiation.

For these two groups, the case worker must:

  • contact the provider if they determine that services have not been initiated;
  • determine the reason for the delay;
  • determine when services will begin;
  • monitor the progress of service initiation; and
  • complete a service satisfaction monitoring contact within 30 days of the first monitoring contact.

Case workers should be aware of service initiation issues and complete optional three-day or 30-day contacts if it is deemed appropriate based on the:

  • individual's medical condition to ensure his health and safety;
  • dependability of the individual's family/friends resource system;
  • impact of environmental circumstances (for example, unsafe or unsanitary conditions that could become a barrier to service delivery); or
  • provider's ability to deliver services within the specified timelines.

Although not required, case workers should verify service initiation by:

  • contacting the individual by telephone or home visit;
  • contacting the provider contracted to deliver services;
  • reviewing notifications of service initiations from providers, including Form 2067, Case Information, or Form 2101, Authorization for Community Care Services;
  • considering other reliable verbal or written information received that verifies service initiation; or
  • providing the individual with notice to contact the case worker if services are not initiated within a designated time frame.

2710.2 Monitoring Ongoing Services

Revision 17-6; Effective June 28, 2017

In addition to the initial three-day or 30-day monitoring contact, the minimum requirements for additional individual contacts are as follows:

  • Monitor services for all individuals every six months. For all individuals except those receiving Community Attendant Services (CAS), contact the individual by the last day of the sixth month from the previous monitoring contact.
  • Federal regulations require the 90-day monitoring for CAS individuals to be conducted by a face-to-face home visit. For CAS cases, the 90-day monitoring meets the requirement of the six-month monitor. See Section 2711, Monitoring Community Attendant Services Individuals.
  • For a priority individual other than CAS and if required by the region, make a face-to-face visit within six months of the last contact monitoring date. Example: If the last monitoring contact was made on March 15, the next contact is due on or before Sept. 14. See Section 2663.2, Determining When a Home Visit is Necessary for Other Services, for possible circumstances that may require a home visit.
  • For an Adult Foster Care individual, the case worker must also make any visits required in Section 4100, Adult Foster Care.

The case worker must also contact the individual or make a home visit as individual circumstances warrant. Individuals with weak or informal support systems may need to be seen more frequently. Staff must make home visits as necessary to ensure the individual's safety and well-being are not compromised.

Some individuals may need additional monitoring or problems may arise that require additional contacts. The case worker must develop a monitoring plan that takes into account:

  • functional needs,
  • the capabilities of family/friends resource systems, and
  • the impact of environmental circumstances.

Inform the individual in advance if a visit is required by telephone or in writing, using Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is indication of abuse, neglect or fraud.

2710.3 Service Plan Changes at the Monitoring Contact

Revision 17-1; Effective March 15, 2017

Reduce hours or terminate services at annual reassessment or any other time the individual:

  • requests a reduction or termination;
  • gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
  • is performing all or some activities of daily living due to long-term improvement in functional condition.

The case worker uses his judgment to determine if the individual's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. See Section 2721.6, Long-term Versus Short-term Changes in the Individual's Condition, for additional details in making that determination.

The individual and provider may agree to change the number of personal attendant service (PAS) hours to be provided based on the individual's needs without prior approval from the case worker. The amount of service provided should be sufficient to meet the individual's needs depending on the loss or gain in the individual's functional ability to perform activities of daily living.

Case worker approval or denial is required for all requests to increase PAS service hours previously authorized or to add or delete priority status.

2710.4 Monitoring Documentation Requirements

Revision 17-1; Effective March 15, 2017

The primary purpose of each monitoring contact, whether it is a home visit or a telephone call, is to determine the adequacy of the current service plan and actual service delivery.

Form 2314, Satisfaction and Service Monitoring, must be used for all required monitoring contacts, including three-day, 30-day, 60-day, 90-day, six month and annual contacts. Case workers are not required to use Form 2314 for other contacts.

Assess the quality of services the individual receives and whether the services continue to meet the needs of the individual by determining at the monitoring visits whether:

  • services are delivered according to the service plan and agreed to by the individual and the provider;
  • the attendant comes and leaves as negotiated by the individual, attendant and provider;
  • the individual is satisfied with each of the services being delivered; or
  • there is a need to change the priority status, increase hours or change other services.

Ask enough questions at each contact so the individual's current responses, together with the written case record, form a reasonable basis upon which each applicable question can be answered. See Appendix XVI, Monitoring Questions, for examples of specific questions that may be appropriate.

At every contact, document each of the following:

  • Eligibility — Does the individual continue to meet all eligibility requirements for the authorized services?
  • Condition/Status — Has there been any change in the individual's condition or situation that affects service delivery or adequacy of the service plan, such as priority status or the need for more hours or other services?
  • Quality of Services — Have services been delivered according to the agreed upon service plan? Does the attendant perform the required tasks and arrive and leave as scheduled? Is the individual satisfied with the services that have been delivered?
  • Adequacy of Service Plan — Does the service plan need to be changed?

Form 2314 may be used to document other contacts with the individual, including requests for changes in the service plan or complaints regarding service delivery. All contacts with the individual or regarding the individual must be documented in the case record. Form 2058, Case Activity Record, may be used, or other case narratives as determined by the region.

All requests for changes in services, whether received from the individual or the provider, must be documented and clearly show the date the request is received. Documentation may be on Form 2067, Case Information, or recorded in the case record narrative. If the individual requests a change during the monitoring contact, then the request, as well as the action to be taken, must be documented on Form 2314.

All monitoring contacts, whether by telephone or face-to-face, must be entered in the SAS Monitoring Wizard. The copy of the Service Authorization System (SAS) automated Form 2314 must be filed in the case record.

See Section 7300, Service Authorization System (SAS) Wizards and Use Requirements.

2710.5 Actions Required After Monitoring

Revision 17-9; Effective September 15, 2017

Case workers report and discuss with the provider any problems or deficiencies in service provision and strive to resolve the problems. See Section 2736.1, Reporting Service Delivery Issues, for detailed instructions for handling service delivery issues.

2711 Monitoring Community Attendant Services Individuals

Revision 17-1; Effective March 15, 2017

Individuals receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of §1929(b) of the Social Security Act. The act requires the case worker to monitor the home and community care provided under the State plan and specified in the “ICCP” (Individual Community Care Plan). This monitoring must involve visiting each individual’s home or community setting where care is being provided not less often than once every 90 days.

An HHSC case worker must meet this requirement by conducting a face-to-face  visit with the individual receiving CAS in the individual’s home or community setting where CAS services or State Plan services included in the individual’s Individual Service Plan (ISP) are being provided. This face-to-face visit must occur not less often than once every 90 days. The 90 day visit will be for the purpose of monitoring the individual’s satisfaction of services.  

The Texas Health and Human Services Commission (HHSC) is required to make every reasonable attempt to complete the CAS monitoring, as the Social Security Act requires. In order to meet the reasonable attempt requirement, case workers must adhere to the following guidelines:

  • The 90-day monitoring must be completed at least every 90 days with the individual or primary caregiver in the location where services are delivered.
  • All attempts to contact the individual must be documented in the case record to support the efforts to meet the federal requirement. A 90-day monitoring contact may not be made with an employee of the provider serving the individual.
  • If the 90-day monitoring visit becomes delinquent, it must still be completed at the earliest possible opportunity. The case record must contain ongoing documentation of attempts to contact the individual until the monitoring is actually completed.
  • In cases where the individual is in a nursing facility, hospital or out of the service area, the 90-day monitor must be conducted within 14 calendar days of learning the individual has returned to the home. Documentation of the individual's inaccessibility must be contained in the case record.

Federal law specifically requires visits every 90 days, not every three months. This 90-day deadline will usually be one or two days short of three calendar months. Example: If a CAS case is monitored March 15, the next monitoring visit must be on or before June 13 (the 90th day after March 15). See Appendix XVIII, Time Calculation.

For CAS cases, the case worker sets the initial 90-day home visit schedule from the date within 90 days of the initial start of care (SOC), as determined by the regional nurse and documented on Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO). The case worker is not required to conduct a 90-day monitor home visit prior to the SOC date determined by the regional nurse. Once the initial SOC has been determined, the case worker sets subsequent 90-day monitors using the Deadline Calculation Chart within Appendix XVIII to calculate when the next 90-day monitoring visit is due. It is recommended that case workers conduct the annual reassessment simultaneously with the 90-day monitor due prior to the first annual reassessment to align future 90-day monitors due at the annual reassessment.

All 90-day monitors must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System (SAS) Monitoring Wizard. Use the coding for entry into the SAS Monitoring Wizard. See Section 7300, Service Authorization System (SAS) Wizards and Use Requirements, or the SAS Help File for assistance in completing the SAS monitoring visit.

Inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of any changes that may affect the eligibility of a CAS individual.

2712 Six-Month Monitoring Contacts

Revision 17-1; Effective March 15, 2017

When a six-month monitoring contact is required but a home visit is not required by the region, the contact may be completed by telephone. If the individual does not have a telephone or cannot communicate by telephone, and a caregiver or relative can tell the case worker about the individual's condition, service needs and the adequacy of service delivery, the contact may be with a caregiver or responsible relative. If contact cannot be made by telephone with the individual, caregiver or responsible relative, a face-to-face visit is required. The first attempted contact should be at least seven days before the contact due date. All attempts to contact the individual must be documented in the case record.

Before a face-to-face or telephone contact is made with someone other than the individual, make at least two attempted contacts with the individual. Document all attempts in the case record. For a priority status individual, two attempted contacts are defined as:

  • at least one attempted face-to-face contact with the individual, his caregiver or his authorized representative if circumstances require a home visit; and
  • another attempted face-to-face contact with the individual or his authorized representative if the region requires a home visit or a telephone contact with the individual, caregiver or his authorized representative.

During each six-month monitoring contact, ask about the:

  • current condition and situation of the individual; and
  • appropriate delivery of services.

Determine if any changes are needed in the service plan. The case worker may have to make a face-to-face contact if the:

  • telephone contact indicates a significant change and the case worker cannot adequately assess the situation without a home visit (see Section 2721, Functional Changes);
  • contact indicates a need to add a service or increase hours (see Section 2663.2, Determining When a Home Visit is Necessary for Other Services); or
  • individual indicates dissatisfaction with services and the case worker cannot adequately assess the situation without a home visit.

A face-to-face contact is not required if the individual requests a decrease in hours, unless eligibility could be affected.

2720 Interim Changes

Revision 17-1; Effective March 15, 2017

2721 Service Plan Changes

Revision 17-1; Effective March 15, 2017

Changes to the service plan may be necessitated by changes in the individual's functional abilities or personal circumstances, including:

  • hospitalizations;
  • severe acute illnesses or accidents, or recoveries from major illness or accidents;
  • loss of or changes in caregivers; and
  • moves or changes in living arrangements.

2721.1 Individual Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Discuss with the individual the importance of reporting changes and explain the consequences of failing to do so. If the individual receives Primary Home Care (PHC), Community Attendant Services (CAS), Family Care (FC) or Home-Delivered Meals (HDM), explain the need to notify the provider if the individual will not:

  • be home when services are scheduled, or
  • need services when scheduled. This is particularly important for personal attendant services individuals with priority status.

2721.2 Provider Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Attendants are also responsible for reporting to supervisors any changes in the individual's status or environment that threaten the individual's health or safety or that may affect his service plan. The provider supervisor reports these changes to the case worker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, skin problems, bruises, mental instability that endangers the individual or others, onset of incontinence, unusual complaints of pain, unusual behaviors, or unusual changes in food intake.

The attendant also reports changes that may affect social resource systems, family relationships and assistance programs Examples include changes or problems in housing, household make-up, loss or change in caregiver arrangements or loss of benefits. If necessary, refer the individual to Adult Protective Services.

If a provider fails to report changes that affect an individual's service plan, the problem must be discussed with provider staff. If the problem continues, document the instances and discuss them with the Community Care for Aged and Disabled (CCAD) supervisor, who notifies the contract manager and program manager.

2721.3 Determining if a Home Visit is Necessary

Revision 17-1; Effective March 15, 2017

The case worker will use his judgment to decide if he has enough information to respond to the reported change without visiting the individual. If in doubt, a home visit should be made. Consider the following when making that determination:

  • Is the case worker already very familiar with the individual's situation?
  • Does the information available about the change and its impact seem clear and appear reliable?
  • Is the reported change relatively simple or more complex? Examples: Several changes at once or sudden and severe deterioration.
  • Is there disagreement between what others say the individual now needs and what the individual is saying he needs?

Make a home visit and complete a functional reassessment if the individual needs or requests a new service and his current Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, score is below the minimum score for that service.

Reduce hours or terminate services at annual reassessment, or any time before the annual review, when the individual:

  • requests a reduction or termination,
  • gains a resource resulting in few unmet needs and the need to reduce service hours, or
  • performs all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.

2721.4 Revising the Service Plan

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must revise the service plan, which is priority level, need for more/less hours or tasks, within 14 calendar days of learning of a change in the individual's status/condition, or must document why no changes to the service plan are needed. If the case worker becomes aware of the need for a service plan change as a result of conducting an annual reassessment, the change must be completed as part of that reassessment. If the individual is released for another CCAD service, the case worker will refer to Section 2611, Processing Time Frames.

Contact the individual and determine whether a new assessment, a revised service plan or a revised monitoring plan is needed, based on the individual's new condition or situation. Assess the needs of the individual and develop or revise the individual's service plan, including:

  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (update if not being completely recreated);
  • personal assistance services tasks;
  • priority level; and
  • number of hours/units of service the individual is authorized to receive per week.

2721.5 Long-term Versus Short-term Changes in the Individual's Condition

Revision 17-1; Effective March 15, 2017

The case worker uses his judgment to determine if the change in the individual's condition is expected to last through the current authorization period or beyond before reducing or terminating services. Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition.

If it is determined the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week. Send the provider Form 2067, Case Information, to inform the provider that fewer service hours may be provided if the individual agrees to the reduction. In this situation, the case worker would not update the Service Authorization System (SAS) record or send Form 2065-A, Notification of Community Care Services, to the individual for a reduction of hours.

If a change in the individual's condition impedes his functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Case worker approval or denial is required for all requests to increase personal attendant services hours previously authorized or to add or delete priority status. The amount of service provided must be sufficient to meet the individual's needs.

2721.6 Authorizing and Documenting Changes

Revision 17-1; Effective March 15, 2017

All requests for changes in services, whether received from the individual or the provider, must be documented in the case record. Documentation may be on Form 2067, Case Information, or recorded in the case record narrative. Form 2058, Case Activity Record, may be used as well as other case narratives. Form 2314, Satisfaction and Service Monitoring, may also be used, but is not required for changes.

Make all necessary changes in the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. To authorize changes in priority level and/or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the individual if the:

  • Primary Home Care, Community Attendant Services, Family Care hours increase or decrease;
  • individual gains or loses priority status;
  • number of home delivered meals per week changes; or
  • authorized units of Day Activity and Health Services change.

Document the outcome of the request for the change in the case record. If it is determined that no revision is needed in the service plan, document the decision and the reasons in the case record. If the provider or regional nurse requested the change, use Form 2067.

2722 Individual Moves and Case Transfers

Revision 17-1; Effective March 15, 2017

At times, an individual's move requires transferring the individual's case to a new case worker within the same region or a different region.

When an individual moves to an area served by a different case worker within the same region or outside the region, the case remains open and the existing service plan stays in effect until a new plan is implemented. Every effort should be made to minimize gaps in coverage for the individual. Although the old plan remains in effect until amended, actual services may in some cases have to be temporarily suspended. For example, the new area/region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility. The case worker who is notified of the move should initiate the action for the transfer.

2722.1 Procedures If the Losing Case Worker Initiates Action

Revision 17-8; Effective September 1, 2017

If the current case worker (losing case worker) is contacted by the individual (or individual's representatives) and the individual has not already moved, it is that case worker's responsibility to:

  • contact the office in the new location and get the name, address and telephone number of the gaining case worker to give to the individual.
  • contact the gaining case worker by telephone and discuss the case. Provide the gaining case worker with the individual number so the case worker can access the Service Authorization System (SAS) for current individual information.
  • have the gaining case worker fax a provider choice list, if the current provider does not provide services in the new area. If the same provider will be serving the individual in the new location, the losing case worker keeps Form 2101, Authorization for Community Care Services, open and the gaining case worker makes any needed changes. If moving to another region, the provider number will be different even if the individual is staying with the same agency.
  • provide the individual with the case worker and provider information. Have the individual select a new provider and relay that information to the gaining case worker with a projected date of transfer.
  • forward the case record to the gaining case worker within three workdays of confirming the move.
  • send Form H1746-A, MEPD Referral Cover Sheet, if applicable, advising of the transfer and the new address so that the MEPD case can also be updated. Advise staff for any other services the individual is receiving that the individual has moved (for example, Supplemental Nutrition Assistance Program).

2722.2 Procedures If the Gaining Case Worker Initiates Action

Revision 17-3; Effective May 15, 2017

It is the gaining case worker's responsibility to:

  • update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case. Include the negotiated start date and the losing provider's end date.
  • mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency.
  • advise the losing case worker that Form 2101 has been updated. He must print a copy of Form 2101 and send it to the losing provider.
  • update any current Community Care Interest List entries for the individual for the new area.
  • send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) individuals to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist advising that the individual has moved to the service area and has a continued need for service. The old and new addresses should be provided, so the CAS case can be requested from the current MEPD worker.
  • contact the individual within 14 days to assess the individual's new living arrangements and need for service plan changes. If needed, schedule a home visit. (See Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary.)

2722.3 Additional Procedures

Revision 17-1; Effective March 15, 2017

The regional nurse does not need to give prior approval unless a reassessment is being conducted at the same time the transfer is being done, and then a copy of Form 2101, Authorization for Community Care Services, needs to be forwarded to the regional nurse with the transfer agency information.

The provider does not have to obtain new physician's orders for prior approval from the regional nurse for a transferring case.

2723 Freedom of Choice

Revision 17-3; Effective May 15, 2017

In areas where there is more than one provider for a specific service, allow the individual the freedom to choose/change providers without restriction.

When an individual requests to change providers, the case worker must first determine the individual's reason for dissatisfaction and whether the individual's satisfaction can be met without the provider change. The case worker completes the following steps within fourteen days of the individual's request:

  1. Ask the individual or his representative to select a new provider, and document the choice.
  2. Contact the gaining provider before the transfer occurs to determine when services can begin.
  3. Update the information on Form 2059, Summary of Client's Need for Service.
  4. Update Form 2101, Authorization for Community Care Services, by entering:
    • the nine-digit vendor provider number; and
    • a statement in the comments section that this is an individual-requested change of providers and the effective date of the change.
  5. Send the new provider Form 2110, Form 2059 and Form 2101.
  6. For non-Community Attendant Services (CAS) cases, send the current (losing) provider a copy of Form 2101 that reflects the effective date of the transfer.
  7. On CAS cases where the change is being made in conjunction with an annual reassessment, the regional nurse will:
    • update Form 2101 upon receipt; and
    • send the updated form that shows the effective date of the transfer to the new provider.

The case worker will send the current (losing) provider a copy of the updated form that reflects the effective date of the transfer.

In situations in which the individual has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC case worker must determine how much information to share with the new provider regarding the previous actions. See Section 2840.1, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for Individuals Denied SSI

Revision 17-1; Effective March 15, 2017

In almost all instances, receipt of Supplemental Security Income (SSI) entitles an individual to Medicaid. In most instances, loss of SSI eligibility also means loss of Medicaid benefits. There are several exceptions to this, however, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCAD individual receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the individual to apply to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for an eligibility determination. Send a referral to the MEPD specialist if the individual is interested.

2725 Certificates of Insurance Coverage

Revision 17-1; Effective March 15, 2017

Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health insurers, including Medicaid, furnish certificates of creditable coverage whenever an individual ceases coverage under a plan or policy. The purpose of the certificate is to provide evidence that the individual had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the individual may obtain.

This legislation will affect community care individuals who are Medicaid recipients. Information regarding certificates of coverage is provided to CCAD applicants and individuals on Page 2 of Form 2065-A, Notification of Community Care Services.

Texas Medicaid & Healthcare Partnership (TMHP) is the contractor that produces these certificates for denied Medicaid individuals. If an individual has questions about the certificate or needs a replacement certificate, he should write or call TMHP.

2730 Special Procedures for Helping Individuals Enter or Leave a Nursing Facility, Institution, or Hospice

Revision 17-1; Effective March 15, 2017

2731 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

Some individuals living in their own homes may need counseling about the available options for receiving long-term care, including nursing facility placement. Caregivers of individuals who have heavy care needs may experience severe stress or be unable to continue the duty for weeks and months without reprieve. Individuals may be at risk if they remain in their current environments. Assess these situations from the standpoints of both the individual's safety and the caregiver's ability to withstand the stress of constant care. Offer them the opportunity to consider nursing facility care.

If an individual wants to enter a nursing facility, help him make his plans. If the individual is not a Medicaid recipient, refer him to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as quickly as possible.

If an individual lacks family or a responsible person to help him with all the final activities involved in moving into a nursing facility, help him by involving his friends and other volunteers.

Nursing Facility Care for Individuals Under Age 22

State Law (Chapter 242, Health and Safety Code) requires that the Community Resource Coordination Group (CRCG) be notified no later than the third day after the date a Community Care for the Aged and Disabled child under age 22 with a developmental disability is initially placed in an institution.

The name and telephone number of the CRCG contact person may be obtained by calling the CRCG State Office at 512-206-4564. A CRCG list is also available via the Internet at:

https://crcg.hhs.texas.gov/faq.html.

If notice is received of an initial placement of a child in an institution, contact the person making the placement to ensure that family members of the family are aware of:

  • service and support that could provide alternative to placement of the child in the institution, and
  • available placement options.

2732 Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

2732.1 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

A batch process is in place that closes the service authorization records for Community Care individuals who have entered a nursing facility. When Form 3618, Resident Transaction Notice, is submitted by the nursing facility, all Service Authorization System (SAS) authorization records, except Service Code 20-Emergency Response Services, are closed by an automated batch process that occurs five times a week.

The batch process uses the date in Item 11 (Date of Above Transaction) on Form 3618 as the end date of the service authorization. A daily report is generated and posted to the Claims Management Project Documents website.

Regional Claims Management System (CMS) coordinators must access the reports and notify case workers when they have individuals whose service authorization records are closed by the batch process. Case workers must monitor these cases for 30 days until it is determined whether the individual's nursing facility stay will be long term. If the individual will be remaining in the facility, the case worker closes the remaining Service Code 20 record, if applicable.

2732.2 Individuals Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

For individuals being discharged from a nursing facility who are to begin receiving Community Care services, Provider Claims Services has established a hotline number to call to close the nursing facility authorization. The hotline number is 512-438-2200. Select Option 1.

The case worker should call the hotline directly to request the nursing facility record in the Service Authorization System (SAS) be closed so Community Care services can be authorized. The case worker will no longer contact the regional Claims Management Services (CMS) coordinator for this action. The case worker must confirm the individual has been discharged from the facility and Community Care services are negotiated to begin on or after the date of discharge.

When calling the hotline, the case worker must identify himself as a Texas Health and Human Services Commission (HHSC) employee and report that the individual has discharged from the nursing facility and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SAS, including the Service Code 60. The case worker documents the contact in the case record.

2732.3 Individuals Denied a Determination of Medical Necessity

Revision 17-1; Effective March 15, 2017

When a Medicaid nursing facility resident is denied a determination of medical necessity, Texas Medicaid & Healthcare Partnership (TMHP) sends a denial letter to the individual and the individual's physician. The facility and the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are notified via TMHP's weekly status report.

If the individual requests CCAD services, respond to this request by following the usual intake procedures, including interviewing and assessing needs. If the individual is determined eligible to receive CCAD services but prefers to receive services outside the intake unit's geographical area, the intake unit staff refers the case to the appropriate case worker or region. When CCAD staff receive an out-of-town referral or inquiry, they help with alternate placement activities.

2732.4 Promoting Independence Initiative

Revision 17-1; Effective March 15, 2017

Promoting Independence (PI) Initiative, enacted by House Bill 1867 of the 79th Session of the Texas Legislature, is intended to ensure a system of services and supports that fosters independence and productivity, and provides meaningful opportunities for the elderly and people with disabilities to live in their home communities.

Money Follows the Person (MFP) is available for persons requiring waiver services. It allows Medicaid funds that are being used to pay for the individual's care in a nursing facility to be transferred to pay for Medicaid waiver services in the community. Individuals identified as using MFP-funded services do not use regional interest list allocations.

MFP does not apply to non-waiver community care services.

For additional information, see the appropriate program handbook for the desired community care or waiver service.

2733 Individuals Receiving Services through Local Authorities

Revision 17-1; Effective March 15, 2017

Local Authorities (LAs) specialize in working with persons who have intellectual developmental disabilities (IDDs), intellectual disabilities (IDs) or persons with mental illness, especially those who are in crisis situations. Close coordination with LA is vital to ensure the safety and well-being of the individual and others. Contact the local LA agency to determine what procedures to follow to obtain permission from the individual to discuss his case with LA staff.

The liaison case workers at the LA community center are responsible for helping individuals with IDD/ID with the process of admission to or discharge from state supported living centers or intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID). Refer to the appropriate liaison worker any persons requesting or requiring entry into these facilities. Liaison case workers also have primary case management responsibility for individuals with IDD/ID who return to the community from state supported living centers. Contact liaison workers for specific information about their responsibilities and about the availability of LA resources for individuals with IDD/ID.

Persons discharged from state hospitals are referred to the appropriate LA community center or outreach program for follow-up. LA case management services are available to them if they meet eligibility and priority criteria. Contact the liaison worker for specific eligibility information. These individuals may also apply personally for CCAD services.

If there is no LA case worker assigned to the individual's case, contact the local LA agency to discuss the individual's condition. Refer the individual to them for services, assistance and/or case management, if appropriate. Include the LA case worker in the development of the individual's CCAD service plan and clearly define the case worker's roles and responsibilities in managing the case. Encourage the LA case worker to offer support counseling and training to the:

  • individual;
  • the individual's caregiver; and
  • provider of services.

Keep the LA case worker informed of changes in:

  • the individual's environment (such as hospitalizations, residence, household composition);
  • the individual's physical/mental condition;
  • medications or lack of medication; and
  • the service plan.

Document in the case record contacts with LA staff, including any agreements reached.

Refer to Appendix XV, Services Available from Other State Agencies, for a list of the services that may be available through the LA agency.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2734 TDC Individuals Leaving TDC

Revision 17-1; Effective March 15, 2017

Texas Department of Corrections (TDC) staff are responsible for discharge planning for elderly or disabled persons being released from TDC. TDC tries to make a referral at least 30 days before the inmate is to be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the individual in the community and provides or arranges for other services he may need. Follow the usual case management procedures to certify the individual eligible for services, to refer his case for service, and to monitor or evaluate any services authorized.

2735 Individuals Who Need Hospice Services

Revision 17-1; Effective March 15, 2017

Medicare and Medicaid hospice services are available to terminally ill Medicare/Medicaid eligibles who file an election statement with a particular hospice. Hospice applicants must be certified as terminally ill (six months or less to live) by a physician. For dually eligible individuals who elect hospice care, coverage is concurrent for the Medicare and Medicaid programs. Hospice care is also available on a private-pay basis.

Hospice staff contact the case worker by telephone concerning the start and cancel dates for hospice care. Hospice staff will no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. Individuals may elect or cancel hospice care at any time.

Individuals electing hospice may be eligible for services through HHSC as long as there is no duplication in the services delivered. A Medicaid recipient, age 21 and older, who elects Medicaid hospice, waives his rights to other programs with Medicaid services related to the treatment of the terminal illness. The Medicaid recipient does not waive his rights to services offered by HHSC that are unrelated to the treatment of the terminal illness. Individuals under 21 years of age who elect hospice do not waive rights to Medicaid services related or unrelated to the terminal illness.

HHSC case workers must follow up with the individual receiving services to determine what hospice will provide and adjust the individual’s service plan to assure no duplication of services. Case workers must respond to a notification of hospice election within the time frames of a change request.

The unmet need policy in Section 2433, Determining Unmet Need in the Service Arrangement Column, does apply to hospice individuals. Coordinate any CCAD service plan with the hospice provider to prevent duplication and to assure adequate services to the individual. If an individual's need for help with a particular task is adequately met by the hospice provider, do not authorize purchased services for that task.

If the need for help will not be met by the hospice provider, or if the need will be only partly met, authorize services on the same basis used for any other individual.

Case workers may receive a request to initiate a CCAD service for an individual who is already receiving that service from a hospice. In this case, it must be determined whether the hospice will continue to provide the needed care. Authorize the CCAD service if the hospice service will end on a particular date, or if the hospice provider will provide the service only until the CCAD service can begin. Coordinate service initiation and ending dates with the hospice provider in order to prevent a break in services. When a CCAD individual enters a nursing home under hospice, terminate CCAD services effective the date the individual entered the facility. If the individual receives hospice care at home, making reduction or termination of CCAD services necessary, give the individual the usual 12-day advance notice before the effective date of the reduction or termination.

If an HHSC individual with Medicaid for the Elderly and People with Disabilities (MEPD) eligibility determination (Community Attendant Medicaid Hospice Program Services) enters a nursing facility under Medicaid hospice, the HHSC case worker notifies the MEPD staff of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In relevant situations, consider hospice services as a resource available to CCAD applicants and individuals. Monitor CCAD individuals on an ongoing basis to determine whether they need or are receiving hospice services.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2736 Complaints, Grievances or Suggestions

Revision 17-1; Effective March 15, 2017

The applicant or individual has the right to lodge a complaint, voice a grievance or recommend changes in policy or service without restraint, interference, coercion, discrimination or reprisal. Staff must:

  • acknowledge the complaint, grievance or recommendation within 14 days of the date the Texas Health and Human Services Commission (HHSC) receives it; and
  • resolve it within 60 days of that date.

2736.1 Reporting Service Delivery Issues

Revision 17-9; Effective September 15, 2017

Program provider service delivery issues may be reported to the Health and Human Services (HHS) Office of the Ombudsman. These reports may be generated by:

  • the individual/individual's representative;
  • Texas Health and Human Services Commission (HHSC) staff, including issues discovered by the case worker, 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 effect on the individual.

This list is not all inclusive.

Complaints of a regulatory nature about nursing facilities, home and community support service agencies, intermediate care facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, and Home and Community-based Services and Texas Home Living providers should be reported to Consumer Rights and Services at 1-800-458-9858 or crscomplaints@hhsc.state.tx.us to generate an investigation by Regulatory Services.

Within five working days of receiving a report or becoming aware of service delivery issues, the case worker must respond to the individual and the provider either by phone or face-to-face contact to discuss the issues. The case worker must inform the provider of the service delivery issues and discuss resolutions. The case worker convenes an interdisciplinary team (IDT) meeting, if appropriate. The case worker coordinates with the individual and provider to implement actions required to resolve the issues. The case worker must document the receipt of the report and contacts with the individual and the provider in the case record. The case worker 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 issue 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 worker must:

  • report the service delivery issues to the HHS Office of the Ombudsman at 1-877-787-8999;
  • inform the individual of his right to call the HHS Office of the Ombudsman to register a complaint regarding the provider, including a Consumer Directed Services agency (CDSA); and
  • inform the individual of his right to choose another provider.

The case worker must make the report to the HHS Office of the Ombudsman 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 worker must report as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case worker must also contact Adult Protective Services (APS) or Child Protective Services (CPS) within 24 hours if there is an immediate or imminent threat to the health and safety of the individual. The case worker must continue to work with the individual and provider to resolve the issues within the 10-working-day time frame.

The case worker must identify the specific service the provider is delivering when calling to report a complaint. For example, the case worker identifies the provider as a "Primary Home Care provider" when making a referral that involves Primary Home Care service delivery issues. The case worker 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 issues.

2740 Fraud Detection and Documentation

Revision 17-1; Effective March 15, 2017

2741 Provider Fraud

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

  • Intentional misstatement or concealment by the provider created a false impression.
  • HHSC paid the provider based on the false impression, when the payment would not have been made if the truth had been known.

Examples of provider fraud include (list is not all-inclusive):

  • billing for services which were not provided,
  • provision of services which are not medically necessary,
  • filing false claims,
  • continuing inappropriate billing after provider education visits,
  • billing for services provided by inappropriate persons,
  • practicing without a proper license or obtaining a license under false pretenses,
  • using improper billing practices, and
  • violating the contract or provider agreement.

2742 Responding to Allegations of Provider Fraud

Revision 17-1; Effective March 15, 2017

When an allegation of provider fraud is received, staff should follow these procedures:

  • During the first contact, staff receiving the complaint should obtain facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct,
    • what the suspected violation was,
    • when the conduct occurred (dates or time periods),
    • where the conduct occurred,
    • how the fraudulent action was performed, and
    • the names of witnesses and how they can be contacted.
  • Staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
  • Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

2743 Individual Fraud

Revision 17-1; Effective March 15, 2017

Individuals receiving Long Term Care Services are perceived honest and entitled to the same protection under the law as all other individuals. However, when there is indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

  • Intentional misstatement or concealment by the individual or authorized representative created a false impression.
  • The Texas Health and Human Services Commission or contracted provider delivered services based on the false impression, when the services would not have been provided if the truth had been known.

Examples of individual fraud include (list is not all-inclusive):

  • knowingly providing false information regarding an applicant's financial, medical or functional status in order to be determined eligible for assistance;
  • withholding or concealing information pertaining to the applicant's financial, medical or functional status which may cause the applicant to be ineligible for services;
  • receiving services which the individual knows to be medically unnecessary; and/or
  • knowingly receiving services from individuals who do not have a proper license or who obtained a license under false pretenses.

2744 Responding to Allegations of Individual Fraud

Revision 17-1; Effective March 15, 2017

When potential individual fraud is discovered, staff should follow these procedures:

  1. Record all pertinent facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct,
    • what the suspected violation was,
    • when the conduct occurred (dates or time periods),
    • where the conduct occurred,
    • how the fraudulent action was performed, and
    • the names of individuals with knowledge of the situation and how they can be contacted.
  2. If fraud is alleged by a third party, staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
  3. Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

Restitution must not be requested in cases where fraud is being pursued. Restitution is securing payment from an individual when fraud is not indicated. Once restitution is requested, you cannot refer the case for fraud.

2745 Reporting Suspected Fraud in the Consumer Directed Services Option

Revision 17-1; Effective March 15, 2017

Following are established procedures for reporting suspected fraud in the Consumer Directed Services (CDS) option to the Office of Inspector General (OIG). This applies when there is suspected fraud committed by the individual receiving services, the CDS employer or the CDS employee. This does not apply to provider fraud.

When the HHSC case worker suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, or is made aware of suspected fraud from an entity other than the Financial Management Services Agency (FMSA), the case worker must report the suspected fraud to the OIG. The case worker can submit the referral using the OIG website, https://oig.hhsc.state.tx.us/wafrep/, or by calling 1-800-436-6184. The case worker must inform the OIG the individual is using the CDS option.

If the case worker does not receive a referral number after submitting the information on the OIG website, it means the referral may not have transmitted successfully. The case worker must call 1-800-436-6184 to confirm the OIG received the referral and ask for the referral tracking number. The case worker must document the suspected fraud and referral information on Form 2058, Case Activity Record.

Once the case worker submits the fraud referral to the OIG, the case worker must inform the FMSA about the suspected fraud and that a referral was made to the OIG using Form 2067, Case Information. The case worker must also send a secure email to CDS Operations staff, cds@hhsc.state.tx.us, at state office containing the following information for tracking purposes:

  • Name of the FMSA;
  • Name of the person(s) suspected of committing fraud (include as much identifying information as possible, such as Social Security number, Medicaid number, date of birth, address and phone number);
  • Brief summary of the fraud allegation, including dates and estimated cost as a result of the violation;
  • Date the fraud allegation was reported to the OIG and the OIG referral tracking number;
  • Program or service impacted; and 
  • Contact information for the HHSC case worker who submitted the referral and the HHSC office where the case worker is located.

When an FMSA suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, the FMSA will make a referral to the OIG. The FMSA will inform HHSC CDS Operations staff at state office that the FMSA submitted a fraud referral to the OIG for tracking purposes.

The FMSA will also inform the HHSC case worker that a fraud referral was submitted to the OIG using Form 2067. The case worker must file Form 2067 received from the FMSA in the individual’s case file. No further action is needed by the case worker regarding the fraud referral once the FMSA notifies HHSC the referral was made to the OIG.

2750 Fraud Referral

Revision 17-1; Effective March 15, 2017

2751 Development of the Fraud Referral Packet

Revision 17-1; Effective March 15, 2017

Consult the unit supervisor for guidance in determining the appropriateness of the referral and the information being provided. If it is decided that a referral is to be submitted, complete the online reporting document, Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, available at https://oig.hhsc.state.tx.us/Fraud_Report_Home.aspx. The online reporting system will prompt the user to enter:

  • the name of the person providing information;
  • additional contact person information, if available;
  • the name of the person completing the form, if different from the person providing the information;
  • law enforcement information, if available (indicate if law enforcement was notified);
  • witness information, if available;
  • the name of the person or facility being reported; and
  • detailed information about the waste, abuse or fraud concern, including:
    • provider identification. Include the name, provider type and specialty, business address, residence address and provider numbers.
    • identification of the alleged illegal act. Include specific data regarding potential witnesses, addresses, work and home telephone numbers. Also include names, mail codes and telephone numbers of all staff who can provide information.
    • identification of policy, regulation or procedural violations. Cite the appropriate numerical reference and manual title, the department rule or policy clearance letter. The reference should include the specific chapter, subchapter, page number and effective date of the manual or publication.
    • source. Indicate who or what initiated the allegation.
    • other pertinent documentation related to the case.

Once all of the information has been entered, the system will allow users to print the information to be included in the referral packet.

2752 Expedited Referrals

Revision 17-1; Effective March 15, 2017

If staff have reason to believe that the conduct of the suspected provider, individual or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the unit supervisor must first be consulted. An expedited referral should be made when a delay would:

  • probably result in the loss, destruction or altering of valuable evidence;
  • probably result in harm to an individual;
  • probably result in significant monetary loss to the Texas Health and Human Services Commission (HHSC) that would probably not be recoverable; or
  • hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit at 512-436-6184 before the referral packet is produced. The HHSC representative will instruct staff as to what portions of the required information should be completed and sent.

2753 Referral of Potential Fraud

Revision 17-1; Effective March 15, 2017

If the unit supervisor determines that the criteria for fraud exists, a fraud referral to the Texas Health and Human Services Commission (HHSC) Medicaid Program Integrity Unit is initiated (even if the potential fraud does not affect Title XIX funds). Mail the referral packet to:

Office of Inspector General
Mail Code 1361
P.O. Box 13247
Austin, TX 78708-5200

HHSC is responsible for ensuring that all pertinent information is obtained and may subsequently request additional information. Providing requested material to the HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. Continue to maintain the case as usual. HHSC staff should preserve a professional working relationship with the provider, individual or authorized representative while the fraud referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.

2800 Notifications, Suspensions, Denials and Terminations

Revision 17-1; Effective March 15, 2017

2810 Individual Notification Procedures

Revision 17-1; Effective March 15, 2017

Program Standard: Notify the individual in writing using Form 2065-A, Notification of Community Care Services, of all eligibility/ineligibility decisions or any changes in the individual's service plan, to include: addition of service(s), increase or decrease in hours, increase or decrease in copayment, or loss of priority status based on the individual's request within two business days of the decision.

When notifying the applicant of eligibility, specify on Form 2065-A:

  • the Community Care for Aged and Disabled (CCAD) services for which the applicant is eligible or ineligible; and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a Day Activity and Health Services (DAHS) facility;
    • if applicable, that the Family Care, Primary Home Care or Community Attendant Services applicant is eligible for priority status;
    • the initial and ongoing room and board payments for Residential Care and Adult Foster Care; and
    • the initial and ongoing copayments the Residential Care individual is to pay to the facility.

An applicant/individual certified for one CCAD service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the hours per week or meals per week he is eligible to receive. If certified for DAHS, the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

For ongoing individuals, on Form 2065-A, record the:

  • action taken and the effective date; and
  • name of the CCAD service(s) on which the action is based.

If the notification is an adverse action, the notice must also state the:

  • reason for the adverse action; and
  • Case Worker CCAD Handbook reference on which the adverse action is based.

See the Form 2065-A Attachment for handbook and rule references.

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

2811 Effective Dates

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker notifies the applicant or individual in writing of any action that denies, suspends, reduces or terminates services. The HHSC case worker sends the notice of adverse action to the individual 12 calendar days before the effective date of the action, except in situations in which services have been suspended due to threats to health and safety. In those situations, the HHSC case worker sends the written notice of adverse action without advance notice if the crisis cannot be resolved.

An applicant or individual has the right to appeal any decision that denies, reduces or terminates his services and request a fair hearing in accordance with Title I, Texas Administrative Code (TAC) §357.

For information about calculating effective dates of reduction or termination of services, see Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation.

In general, the effective date of the reduction in services is 12 calendar days after the Form 2065-A, Notification of Community Care Services, date. The effective date of an increase in hours is seven calendar days after the Form 2101, Authorization for Community Care Services, date. For an adverse action, if the day after the effective date is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. (See Appendix XVIII.)

The date at the top of Form 2065-A is the date the HHSC case worker completes the form. Since offices have different mail pickup times, staff are not required to consider the mail date when completing the form. Staff must ensure applicants and individuals are notified within the required time frames.

Services will be reduced or terminated at annual reassessment, or any other time the case worker becomes aware before the annual review, when the individual:

  • requests a reduction or termination;
  • gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
  • is performing all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.

An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits. The effective date of the action depends on the situation, as shown in the following table:

If . . . Then . . .
Termination or reduction is because client lost his eligibility as an income eligible, failed to qualify as an income-eligible after a verbal referral, failed to meet the client needs assessment score or medical criteria for the service, repeatedly (more than three times), directly or knowingly and passively condoned the behavior of someone in his home and thus, refused to follow the service delivery provisions, experienced a change in his need for the specific service, or failed to pay fees for services, The action is effective 12 days from the date of the notice unless the action is appealed. In the event of appeal, services continue until the hearings officer gives a decision. The cost of providing services during this period is subject to recovery by the department from the client. Services to clients in Residential Care facilities are terminated five days after the hearings officer gives his decision.
Termination is because client lacks TANF, SSI, Medicaid, or Supplemental Nutrition Assistance Program eligibility, Services continue only to the end of the month that the client is determined ineligible, even if the action is appealed.
Termination is because client lacks physician's orders for the service, Services continue only through the date the previous orders end, even if the action is appealed.
Termination or reduction is because of budgetary constraints or changes in federal law or state regulations, and services are reduced or terminated for an entire categorical client group, Services continue only through the date of termination of a categorical client group, even if appealed.
Termination is because the client or someone in his home threatens the health or safety of others, or because the client threatens his own health or safety. Services may be terminated immediately under the following conditions:
  • a client receiving Residential Care, Adult Foster Care, DAHS, or special services to persons with disabilities threatens his own health or safety or that of others, or
  • someone in the client's home or an individual receiving Emergency Response Services, Home-Delivered Meals, waiver services, Family Care, Primary Home Care, or special services to persons with disabilities threatens the Texas Health and Human Services Commission (HHSC)  staff or provider's health or safety.

2812 Changes in the Individual's Need for Services

Revision 17-1; Effective March 15, 2017

Case workers determine if the individual's long-term improvement is expected to last through the current authorization period or beyond, before reducing or terminating services.

If it is determined that the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week.

Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition. If the individual feels he temporarily needs fewer hours, send the provider Form 2067, Case Information, informing the provider that fewer service hours may be provided if the individual agrees to the reduction. If the individual is experiencing temporary functional improvement, the case worker would not change the task/hour guide or authorization, or send Form 2065-A, Notification of Community Care Services, to the individual for reduction of hours.

The individual and provider may agree to change the delivery schedule for personal attendant services (PAS) hours based on the individual's needs without prior approval from the case worker.

Case worker approval or denial is required for all requests to increase PAS hours previously authorized or to add or delete priority status. In these situations, terminate or reduce services 12 calendar days after the Form 2065-A completion date.

2813 Situations in Which the 12-Day Adverse Action Period May Be Reduced

Revision 17-1; Effective March 15, 2017

There may be situations when an individual wants to waive or shorten the 12-day notice period before services are reduced or terminated. Some examples of applicable situations include the following:

  • A Family Care individual is being removed from an interest list for Title XX Day Activity and Health Services (DAHS) and wants to withdraw or have services reduced in less than 12 days in order to attend DAHS immediately; or
  • Community Care for Aged and Disabled individuals who prefer to receive 1915(c) waiver services may also wish to have the change take place in less than 12 calendar days.

If the individual indicates a desire to waive or reduce the 12-day advance notice, be very cautious and remember that an individual may change his mind. In most instances, the provider can be verbally notified to stop service and still maintain the formal effective date 12 calendar days in the future.

If the individual still wants to waive or shorten the 12-day advance notice, complete Form 2065-A, Notification of Community Care Services, with the effective date being the date the individual wants services to end or be reduced. Explain in the comments section that the individual is voluntarily waiving or reducing his right to the 12-day advance notice. The individual must:

  • sign this statement; and
  • be given the original and one copy of the notice.

2814 Transfers Between Primary Home Care, Community Attendant Services and Family Care

Revision 17-1; Effective March 15, 2017

Send Form 2065-A, Notification of Community Care Services, when an individual is transferred from Primary Home Care (PHC) or Community Attendant Services (CAS) to Family Care (FC) or FC to PHC or CAS. Do not send another form to terminate the previous service. Specify on the form the:

  • name and amount of the previous service,
  • name and amount of the new service,
  • effective date of the transfer, and
  • reason for the transfer.

Indicate in the comments section that the individual should not notice any difference in the amount or type of services received because of this transfer.

Example:
The service you were receiving, Primary Home Care, 16 hours a week, will change to Family Care, 16 hours a week, effective June 1, 2010.

Comments: Primary Home Care will terminate because you lost financial eligibility for that program. You should not notice any difference in the amount or type of services you will receive because of this transfer.

Although Form 2065-A must be sent when an individual transfers between PHC, CAS and FC, the effective date is either the negotiated date or the date following the Medicaid end date.

See Section 4600, Primary Home Care and Community Attendant Services, for additional transfer procedures.

Refer to Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation, for other exceptions to the 12-day notice requirement. The effective date of the transfer does have to be at least 12 days following the date of notification if the number of hours is decreased.

 

2820 Service Suspensions

Revision 17-1; Effective March 15, 2017

Services may be suspended by the provider or by the case worker.

2821 Service Suspension by Providers

Revision 17-1; Effective March 15, 2017

Providers may suspend services to individuals before the service approval period ends. See Section 4000, Specific CCAD Services, for information about suspension of each specific service.

On the day of suspension or by the first Texas Health and Human Services Commission workday following suspension, the provider must contact the case worker to explain the reason for suspending services. The Emergency Response Services provider must submit written notification (Form 2067, Case Information, optional) within five workdays of the oral notification or suspension of services.

If an individual meets the criteria for Adult Protective Services, refer him accordingly. Refer other individuals to other appropriate service resources as needed.

The case worker documents in the case record the incident that caused the suspension and the date of the incident. The results of any related interdisciplinary team meetings must be included in the documentation. After evaluating suspensions to determine whether services should be terminated and the case closed, the case worker takes the appropriate action. In some situations, the problems that caused the suspension can be resolved. If they are resolved:

  • send Form 2067 to the provider documenting the problem resolution; and
  • reach an agreement with the provider about the date on which services will be reinstated.

2822 Service Suspension by Case Workers

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

(c) A client is not eligible for CCAD services when:

(1) he dies;
(2) he is admitted to an institution;
(3) his physician requests service termination (Medicaid services only); or
(4) he requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case, or he refuses to comply with his service plan.

2822.1 Hospital and Nursing Facility Stays

Revision 17-1; Effective March 15, 2017

Unless the case worker has definite information that a nursing home or hospital stay will be longer than 30 days, suspend Community Care for Aged and Disabled services. Send Form 2067, Case Information, to the provider to suspend services effective the date of nursing home or hospital entry. It is not necessary to send updates to the provider.

The case worker must closely monitor the situation. If the individual has not returned home by the 30th day, the case worker must check with the individual to see if a discharge date has been planned. If the individual has a discharge date planned within the next 30 days, leave the case open and monitor on the planned discharge date.

If information is received that the nursing facility or hospital stay will be longer than 30 days, terminate services, using the date of admission as the effective date of termination. Exception: The effective date of termination for Residential Care or Special Services to Persons with Disabilities (SSPD) 24-hour shared attendant program should be the 30th day after admission to the nursing facility or 60 days after admission to a hospital.

In many instances, determining the length of stay will be a judgment call. Consult with the individual, family and others associated with the individual. Be cautious about terminating Title XX services, especially if the region has an interest list for those services.

Emergency Response Services (ERS) may remain open until the decision is made to terminate all services because the nursing facility stay has become permanent. See Section 4300, Emergency Response Services, for suspension of ERS by the ERS provider.

The following situations should always be considered short-term and services should be suspended for up to 30 days, rather than terminated:

  • admission to a swing bed facility (by regulation, swing bed nursing home stays are limited to 30 days); and
  • admission to a hospital for mental illness treatment.

Services may be suspended indefinitely if the individual is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

2830 Refusal to Comply with Service Delivery Provisions

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §48.3903 Denial, Reduction, and Termination of Benefits

Examples of refusal to comply with the service delivery provisions include, but are not limited to, the following:

  • The individual is often away from his residence when service is scheduled and he repeatedly fails to notify the provider that he will be gone, even though he has been counseled about this problem and its implications.
  • The individual or someone in the individual's home regularly will not permit the in-home provider to perform one or more of the tasks in the service plan or the individual receives personal attendant services and refuses to allow the provider to perform the authorized tasks.
  • Despite several provider efforts to find and place an acceptable attendant in the home, the individual refuses to accept in-home services because of dissatisfaction with a particular attendant.
  • The individual or someone in the individual's home regularly behaves in a way that is so offensive to staff that they refuse to serve him, and the individual knowingly and passively condones the person's behavior, and staff are unable to provide services. (Examples of offensive behavior include sexual harassment, sexual misconduct and racial discrimination.)

If the provider notifies the Texas Health and Human Services Commission about a service delivery compliance problem, contact the individual or the responsible party. Attempt to resolve the problem in a way that is satisfactory to the individual and the parties involved. A joint staffing may be conducted at the individual's home to try to resolve the situation.

2830.1 Individuals Who Refuse to Comply with Electronic Visit Verification Requirements

Revision 17-1; Effective March 15, 2017

Individuals requesting or receiving attendant services from a Home and Community Support Services Agency (HCSSA) are required to participate in Electronic Visit Verification (EVV) by allowing the attendant to use their home landline to report the start of work and the end of work. If an individual does not have a home landline, or if the individual will not allow the attendant to use the home landline, the individual must agree to an alternate device installation in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services.

It is the case worker’s responsibility to review the information on the rights and responsibilities form and adequately explain the EVV requirements to the applicant or individual receiving services. It is important to communicate that an individual’s failure to cooperate with EVV requirements can result in the suspension or termination of services. The case worker must explain the following points:

  • EVV is a telephone and computer-based system that electronically verifies service visits occur and documents the precise time service provision begins and ends. The purpose of EVV is to verify that individuals are receiving the services authorized for their support and for which the state is being billed.
  • EVV will not change the services the individual receives.
  • EVV is mandatory for all HCSSAs and individuals receiving services from an attendant, unless the individual receives services through the CDS option.
  • The attendant will need the individual’s permission to use the home landline toll-free number at the start and at the end of work. Under no circumstances should the individual call the toll-free number on behalf of the attendant. If the individual is asked to do this, they should report it to the provider agency.
  • If the individual does not have a home landline or does not want the attendant to use his telephone, an alternative device can be placed in the home, which is used only to verify the attendant’s start and end of work. This device must remain in the home at all times. If the individual notices the removal of the device, they should report it to the provider agency.
  • If the individual notices any other possible EVV violation such as an instance in which the attendant leaves the home without providing services after calling the toll-free number upon arrival , they should report it to the provider agency.
  • 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.

For individuals using the CDS option, the case worker must explain that the individual receiving services, or a designated representative (DR), is the employer of record and can choose to use the EVV system or use paper time sheets. The three choices are:

  • Full Participation-Phone and Computer: The CDS employee(s) use the telephone portion of EVV, and the employer of record uses the computer portion of the system to perform visit maintenance.
  • Partial Participation-Phone Only: 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 they end 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 sheets approved by the CDS employer.
  • 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 require the employer of record to complete Form 1722, Employer’s Selection for Electronic Visit Verification (EVV), to indicate his choice.

If an individual is refusing to cooperate with EVV requirements, it is considered as a refusal to comply with service delivery provisions and policies in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, are applicable. Some individuals whose provider is required to participate in EVV are not allowing the attendant to use their home phone and are also refusing to allow a Fixed Visit Verification (FVV) device to be placed in their home.

Providers are required to participate in EVV for services delivered by an attendant. Individuals who refuse to allow the attendant to record hours worked through EVV, either through the use of their home phone or a FVV device, are non-compliant with their service delivery plan. These individuals are essentially not allowing the provider to carry out services in accordance with provider requirements.

2831 Suspensions Due to Refusal to Comply with Service Delivery Provisions

Revision 17-10; Effective October 6, 2017

The provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. After the IDT meeting, the case worker must send the individual a letter within five working days stating services can be terminated if he does not comply with service delivery provisions and stating specifically what the individual must do to continue services.

If the situation is not resolved and the individual continues to refuse to comply, the case worker convenes a second IDT and sends the individual a second notice stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues not to be resolved and a third situation arises, the case worker convenes a third IDT and must send a third and final letter to the individual stating continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues, the case worker may terminate services by sending Form 2065-A, Notification of Community Care Services. See Section 2810, Individual Notification Procedures. Denials based on refusal to comply with service delivery provisions must be approved by the supervisor. Document the conference and approval in the case narrative.

There is no time period during which the instances of refusing to comply must occur.

2832 Documentation of Compliance Issues

Revision 17-1; Effective March 15, 2017

Documentation in the case narrative is required in all situations involving the individual's refusal to comply with service delivery provisions. Opinions or evaluative conclusions are not appropriate documentation to substantiate a denial of services. Documentation should stress a factual statement of actions constituting noncompliance.

Determine and document whether the individual is aware of and able to understand the consequences of his or other's actions. If the individual is not aware of his behavior or the behavior of someone in his home, discuss the issues with him.

Determine if the person seems to be abusing, neglecting or exploiting the individual, and refer the individual to Adult Protective Services (APS), if necessary. Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian, to resolve the problem if the individual is abused, neglected or exploited.

Document the date and content of each discussion with the:

  • individual;
  • interested family member;
  • provider; and
  • unit supervisor.

2833 Reauthorization of Services After Termination for Refusal to Comply

Revision 17-1; Effective March 15, 2017

If an individual's services have been terminated because of his refusal to comply with service delivery provisions that involve a provider, confer with the unit supervisor prior to referral to another. It may be necessary to discuss the individual's particular compliance issues before reauthorizing services. The unit supervisor must approve the referral. Note the approval in the comments section of Form 2101, Authorization for Community Care Services.

Follow these steps when an applicant who had been authorized services in the past, but whose services were terminated due to his failure to comply with service delivery provisions, reapplies:

  1. Before contacting the applicant, review with the supervisor circumstances of the previous denial and the steps to be taken with the applicant. Document the review in the case record.
  2. Review with the individual/responsible party:
    • the reason for the previous termination,
    • the responsibility of the individual/responsible representative to notify the provider and Texas Health and Human Services Commission (HHSC) about problems related to the service delivery provisions and the importance of good communication, and
    • each task to be authorized, emphasizing the only tasks to be performed by the attendant are those authorized by HHSC.
  3. Authorize services if the individual agrees to follow the service delivery provisions.
  4. Record the conversation with the individual in the case record narrative.
  5. Contact the individual or provider weekly for one month to assess the individual's compliance with service delivery provisions. If the individual continues to have problems complying with service delivery provisions, contact the individual and emphasize the need for him to comply.
  6. If the provider complains about the individual refusing to follow his service delivery provisions, contact the individual monthly after the first month of service. Discontinue monthly contacts when complaints cease.
  7. Terminate services if the individual refuses more than three times to comply with service delivery provisions.

2840 Threats to Health or Safety

Revision 17-1; Effective March 15, 2017

Occasionally, an individual or someone in his home might exhibit behavior that constitutes a threat to the health or safety of another person. Examples include, but are not limited to:

  • exhibiting weapons;
  • making direct spoken threats of physical harm, force or death;
  • physically attacking a person with or without a weapon;
  • threatening use of force by self or someone else;
  • using or selling illegal drugs; and
  • displaying dirty needles or the smell of toxic fumes from the manufacture and/or sale of illegal drugs in the individual's home environment.

If, during the initial contact or any other contact by the case worker or provider staff, an individual or someone in his home exhibits threatening behavior or makes comments that are threatening, hostile or of a nature that would cause concern for the individual, provider or Texas Health and Human Services Commission (HHSC) employee, the case worker must immediately notify management. Regional management must review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's safety may be at risk, the case worker must follow current policy regarding notification to the Department of Family and Protective Services Adult Protective Services (APS). If the case worker believes there is a potential threat to others, regional management should determine the best method for notifying the provider and addressing the individual's needs without placing staff members at risk.

If an individual threatens his own health or safety by threatening or attempting suicide or self-injury and is at immediate risk, place a 911 call to report the emergency. A referral to APS must also be made. If the applicant or individual seems to be abused, neglected or exploited by the person who threatens the health or safety of others, refer the individual to APS.

In most cases where there is a potential for danger, services should be suspended immediately.

The case worker must send Form 2065-A, Notification of Community Care Services, by the next working day after receiving notice from the provider that services have been suspended for failure to comply or threats to health and safety. The notice must reference 40 Texas Administrative Code §48.3903, state the last day services are delivered, and include a clear statement in the comments explaining why services have been suspended.

Within three working days after the case worker becomes aware of the suspension, the case worker must arrange an interdisciplinary team (IDT) meeting to try to resolve the issue with the provider and the individual. Depending on the severity of the reason for the suspension, some IDT meetings may be conducted by telephone or some may require a face-to-face contact.

The case worker may conduct the IDT meeting by telephone or a face-to-face contact for all suspension reasons listed in this section. Case workers are required to discuss the specific case with their supervisors to determine the best approach for conducting the IDT. Case workers must document the rationale for conducting the IDT by telephone.

During the IDT meeting, the case worker, provider staff, the individual and the individual’s representative, if any, must evaluate the issue and discuss the program requirements for continued services. The IDT should identify any solutions to resolve the issue, including the individual’s understanding of the issue and what must be done to resolve the issue. The case worker must document the requirements for continued services. See Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, and Section 2832, Documentation of Compliance Issues, for additional guidelines.

If the issue leading to suspension is resolved during the IDT, the provider must, within two business days after the IDT meeting, either implement the recommendations of the IDT or discharge the individual and refer the individual to the case worker for referral to another provider. The case worker must notify the individual orally or in writing of the reinstatement of services. If services continue, assess if the individual meets the guidelines for an individual at risk and if so, follow procedures outlined in Section 2550, Identifying Individuals at Risk. If the issue is not resolved and services cannot be continued, the case worker begins the termination process.

2840.1 Monitoring or Annual Home Visit Delay Due to Unsafe Environmental Circumstances

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) case worker is required to make every reasonable attempt to complete the Community Attendant Services (CAS), Primary Home Care (PHC) and Family Care (FC) service monitoring or annual reassessment visit. All attempts to contact the individual must be documented in the case record to support the efforts to meet the requirements. In some situations, the case worker is unable to make the face-to-face home visit due to a dangerous environmental situation beyond the case worker or individual’s control. These situations may include but are not limited to:

  • current police activity (i.e., a car chase, weapons drawn, drug raids);
  • gathering of people on the streets demonstrating threatening or intimidating behavior directed at the case worker; and
  • illegal activities in close proximity (e.g., next door to the individual’s home) occurring at the time the case worker attempts the home visit.

When such situations occur and the case worker feels threatened, he or she can make the home visit at another time. The case worker must immediately notify regional management of his inability to conduct the home visit. The case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain ongoing documentation of attempts to complete the visit and the reason for the delay until the monitoring visit has been completed.

If, during the home visit an individual or someone in his home exhibits threatening behavior or makes comments that are threatening or hostile, the case worker can end the service monitor or annual reassessment and reschedule for a later time. The case worker must immediately notify regional management of his or her inability to conduct the home visit. The case worker will refer to Section 2840, Threats to Health or Safety, to suspend or terminate services. If the threatening behavior is resolved, the case worker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case record must contain documentation of all attempts to complete the visit, along with any reasons for delays until the monitoring visit has been completed.

2840.2 Chronic Contagion/Infestation Conditions

Revision 17-1; Effective March 15, 2017

While the chronic contagious medical condition or infestation of the individual’s home may not pose an immediate danger to the health and safety of the individual, provider agency staff or case worker, either situation may adversely affect the health of all such persons involved in supporting the individual’s services and may pose a risk of exposing other individuals to the contagious medical condition or environmental infestation. Examples of unresolved chronic adverse medical or environmental related condition(s) may include the presence of bed bugs, fleas, ticks, lice or scabies.
 
The case worker must assess the individual’s ability to comply with the request to eradicate contagions or infestations and should exhaust all efforts in arranging for assistance to eradicate contagions or infestations, based upon the assessment of the individual’s capabilities. The case worker should identify available local resources which may provide the needed assistance in meeting the individual’s specific needs in relation to resolving the risks associated with the spread of the contagion or environmental infestation to others.

As stated in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, the provider or case worker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. Efforts to identify local resources and natural supports to assist the individual if any such resources and supports exist, should be well documented as part of the IDT meeting. Any specific actions and responsibilities required of the individual and other persons and an agreed-upon time frame for completion of the eradication should be documented. Information from a pest control professional must be the basis in the establishment of a timeline expectation for eradication, as each situation will be unique. The specific actions and responsibilities required of the individual or other persons, such as family members or friends, who have agreed to provide support as part of the eradication plan should be documented as service provision requirements.

If the eradiation plan is not followed and the situation is unresolved, the case worker refers to Section 2830, Refusal to Comply with Service Delivery Provisions, and Section 2831 for guidance in instances in which the individual is non-compliant with service delivery provisions.

The case worker follows policy in 40 Texas Administrative Code §48.3903, (f) Denial, Reduction or Terminations of Benefits, to provide adequate notice of possible termination of services if the individual fails to cooperate with service delivery provisions.

2840.3 Active Tuberculosis (TB) Diagnosis

Revision 17-1; Effective March 15, 2017

An applicant or individual with a TB diagnosis cannot have services denied or terminated as a consequence of his disease.

Under state law, physicians must report all cases of TB to the Texas Department of State Health Services (DSHS). Upon receiving the physician's report, DSHS assigns a representative to monitor the case through "directly observed therapy." This process involves observation of the individual taking his medication; it may also involve health-related training and the provision of additional care of the individual.

For cases with active TB, a team meeting should be set up to include the regional nurse, case worker, provider and the local DSHS representative handling the case. These individuals will ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct the Texas Health and Human Services Commission to suspend the case while the TB remains active; if so, it will provide care for the individual during this period. Most individuals become negative for TB within a few weeks of drug therapy.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2840.4 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 17-1; Effective March 15, 2017

When services have been suspended due to health and safety reasons, HHSC staff are required to convene an interdisciplinary team (IDT) meeting to resolve the issues. If the issues cannot be resolved, the provider may report it will no longer serve the individual due to health and safety concerns.

In some situations, HHSC may terminate the individual’s services due to health and safety issues. In other situations, HHSC may initiate services with a new provider. If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions.

The HHSC case worker 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.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.

2841 Reinstatement of Services Terminated for Threats to Health or Safety

Revision 17-6; Effective June 28, 2017

An applicant whose services were terminated in the past due to his or someone in his home being a threat to the health or safety of the client, department staff, or provider agency staff may be authorized services if the applicant signs Form H0003, Agreement to Release Your Facts, authorizing release of information, and:

(1) The applicant/person in home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that he is no longer a threat to himself or others; or
(2)The applicant/person in home allows a collateral contact with his physician, psychiatrist, or psychologist and the contact indicates that the applicant is no longer a threat to himself or others; or
(3)The person in the home who posed the threat no longer poses the threat.

Complete the eligibility determination in the Service Authorization System Wizards within 30 calendar days after the date the signed application is received by the department. (See Section 2344, Individual Rights and Responsibilities.)

2841.1 Sharing Information on Previous Actions for Reinstatement

Revision 17-1; Effective March 15, 2017

If an individual who has been previously terminated from services due to health and safety reasons reapplies for services and meets the requirements in Section 2841, Reinstatement of Services Terminated for Threats to Health and Safety, information may need to be shared with a newly selected provider.

If the HHSC case worker makes a referral to a new provider, he must determine how much information to share with the new provider regarding the previous actions that resulted in termination of services. The case worker must share sufficient information with the new provider to avoid putting the provider at risk and allow the provider to adequately plan for safely delivering services to the individual. This includes 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.

Case workers must use good judgment in determining what information to share and, if in doubt, consult with their supervisors for guidance.

2900 Appeals and Fair Hearings

Revision 17-1; Effective March 15, 2017

2910 Individual’s Right to Appeal and Request a Fair Hearing

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903

(a) An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits.
(b) A client is entitled to be notified 10 days before any reduction or termination of his services, or to have the notification mailed 12 days before the date of reduction or termination. If a client threatens his own health or safety or that of others, purchased services may be terminated without advance notice.

Inform the applicant/individual in writing by sending Form 2065-A, Notification of Community Care Services, about his right to request a fair hearing if services are denied, reduced or terminated. An individual may appeal his dissatisfaction concerning

  • ineligibility for services;
  • the tasks within a service;
  • the amount (number of units) of service the individual will receive;
  • the amount of the copayment for Residential Care; or
  • the denial or termination of the priority status.

An individual also may appeal when the individual requests a new service, or requests an increase in the number of tasks or units of service, and the request is not acted on within required time limits.

To request a hearing, an individual may return Form 2065-A with a check mark in the appropriate box, or the individual may make an oral or written request for a fair hearing.

An individual must request a fair hearing within 90 days from the date of the action he wants to appeal. To continue receiving benefits until the hearings officer gives a decision, the individual must request the fair hearing before the effective date shown on Page 1 of Form 2065-A. In situations where services were terminated because of threats to the health or safety of another person, the individual is not entitled to continued services even if appealed before the effective date shown on Page 1 of Form 2065-A. (See Section 2811, Effective Dates, and Appendix IX, Notification/Effective Date of Decision, for guidance on effective date of termination in which the individual is not entitled to continued benefits.)

When a fair hearing is requested after the 90 day time period, HHSC staff may not prevent an applicant or individual from filing an appeal because they believe the appeal was not requested within the required number of days. If a fair hearing request is received after 90 days from the date of the notice, the case worker must follow current procedures to file the appeal. The hearings office will make the decision regarding the individual’s right to appeal.

The hearings officer is the final authority regarding the timeliness of appeal requests and accepts appeals filed after the time limit in order to determine whether there was good cause for the delay in filing.

2911 Notice to the Provider for Continuing Services

Revision 17-1; Effective March 15, 2017

If the individual appeals before the effective date on Page 1 of Form 2065-A, Notification of Community Care Services, the case worker must continue services at the current level pending the hearings officer’s decision, unless denial is based on threats to health and safety. (See Section 2840, Threats to Health and Safety). Within three business days after receipt of the request for a fair hearing, the case worker must complete a new Form 2101, Authorization for Community Care Services, in the Service Authorization System (SAS) reinstating services at the current level. The case worker sends Form 2101 to the provider notifying them to provide services at the current level until the hearings officer’s decision is rendered. The “Begin Date” of services is the day after the termination date or reduction date on the previous Form 2101. The case worker also sends Form 2067, Case Information, informing the provider to reinstate services pending the hearings officer’s decision.

Example 1: At the annual reassessment, the case worker determines the Primary Home Care personal attendant services (PAS) hours must be reduced from 20 hours per week to 15 hours per week. The case worker sends Form 2065-A to the individual and Form 2101 to the Home and Community Support Services Agency (HCSSA) as notification of the reduction in hours. The individual appeals before the effective date of the case action. The case worker authorizes PAS at 20 hours per week until the hearings officer’s decision is rendered.

When all services are terminated, such as at the annual reassessment when the individual does not meet eligibility criteria, case workers must continue services at the current level when the individual files an appeal before the effective date.

Example 2: At the annual reassessment, a Family Care individual is terminated due to scoring 21 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The case worker sends Form 2065-A to the individual and Form 2101 to the provider as notification of the termination of services. The individual appeals before the effective date of the case action. The case worker authorizes services at the same level as the previous Form 2101 authorization.

When the individual submits a clear, written statement requesting services stop during the appeal process, the case worker sends Form 2067 to the provider with an effective date to stop service delivery. The case worker does not send the individual another Form 2065-A.

HHSC does not continue services during the appeal process if Medicaid eligibility has been terminated, unless Medicaid eligibility is reinstated during the appeal period. Refer to Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 2932, Coordination of Fair Hearings with MEPD Utilizing OES CRU, for procedures related to Medicaid terminations and continuation of services.

2912 Special Procedures for Denials of Community Attendant Services (CAS) Individuals

Revision 17-1; Effective March 15, 2017

Denials of CAS individuals must be coordinated with both the HHSC regional nurse and with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. If the HHSC case worker denies the individual based on functional need, Form H1746-A, MEPD Referral Cover Sheet, must be sent to advise MEPD of the denial.

If the individual appeals the denial, another Form H1746-A must be sent to MEPD advising that services will be reinstated pending the fair hearings officer’s decision. MEPD must also be notified on Form H1746-A when a decision is rendered.

If the change that prompted the request for an appeal on a Community Attendant Services decision occurred in the course of an annual reassessment, use Form 2067, Case Information, to notify the provider and the HHSC regional nurse. The HHSC regional nurse submits Form 2101, Authorization for Community Care Services, to reinstate services.

2913 Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings

Revision 17-1; Effective March 15, 2017

HHSC case workers must notify the utilization review (UR) nurse and UR regional manager when an applicant or individual has requested a fair hearing as a result of UR findings for concurrent reviews.

Case workers must follow normal time frames and procedures for implementing UR findings following receipt of a UR tool indicating a case action is required. When the action is completed for an addition/increase in services or termination/decrease in services, the case worker must send a notice to the applicant or individual notifying him of the case action. The applicant or individual has the option to appeal the case action indicated on the notice. Case workers must follow current policies and procedures regarding continuation of services pending an appeal.

If the applicant or individual requests a fair hearing, the case worker must inform the UR nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR findings. The case worker will complete Form H4800, HHSC Fair Hearing Request Summary, and send the form to the Hearing Division and supervisor within three days of the request for a hearing.

On Form H4800, the case worker will list the UR nurse, Agency Representative, UR regional manager, and Agency Representative Supervisor. The case worker may be listed. The case worker must confirm the correct UR nurse and UR regional manager to list on the form. The case worker includes the UR nurse whose name is located in Section A of the UR tool. The case worker identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The designated data entry representative (DER) will be responsible for uploading the case worker’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The evidence packet submitted by the case worker will include the applicable notification form. If available, the case worker includes the signed notification form returned by the applicant or individual. The case worker does not include any other documentation in the evidence packet.

The UR nurse and UR regional manager will develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or individual. The evidence packet will include a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for each fair hearing evidence packet. The DER and UR representative must upload the fair hearing evidence packets in TIERS no later than 10 calendar days prior to the fair hearing date. The case worker and UR nurse must forward a copy of the fair hearing evidence packets to the applicant or individual no later than 10 calendar days prior to the fair hearing date.

The UR nurse, UR regional manager (optional) and case worker will participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony regarding the case action.

2913.1 Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered

Revision 17-1; Effective March 15, 2017

When a case record is selected for concurrent review and a fair hearing is pending, the case worker must inform the Utilization Review (UR) nurse that a fair hearing is pending. The case worker does not submit the case record for concurrent review. UR will then replace the case with another randomly selected case record for concurrent review.

When a case record is selected for concurrent review and a fair hearing decision has been rendered during the current plan year, the case worker must inform the UR nurse of the fair hearing decision details by providing the UR nurse with a copy of the final order submitted by the hearings officer. The case worker must provide specific information to the UR nurse about the service(s) appealed and the actions the case worker took to implement the hearings officer’s decision. The case worker submits the case record for concurrent review following current procedures. The case worker will follow current policy and procedures for implementing UR findings.

2914 Withdrawal of an Appeal

Revision 17-1; Effective March 15, 2017

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. HHSC staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts HHSC staff regarding the withdrawal, HHSC staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to HHSC staff, HHSC staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on an HHSC decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify HHSC by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and a written notice will be sent to participants informing them of the fair hearing cancellation.

2920 Request for Increase in Services During an Appeal

Revision 17-1; Effective March 15, 2017

When services are reduced or terminated, such as at the annual reassessment, and the individual files an appeal before the effective date of the reduction or termination, the case worker must continue services at the current level until the hearings officer’s decision is rendered. If the individual requests increased services pending the hearings officer’s decision, the case worker cannot process the request. Within 14 calendar days of the request, the case worker must send the individual Form 2065-A, Notification of Community Care Services, explaining the request for increased services is denied pending the hearings officer’s decision and may be reviewed for authorization once the hearings officer’s decision is rendered, if the individual is determined eligible.

2930 Fair Hearing Procedures

Revision 17-1; Effective March 15, 2017

All fair hearings are processed through the Fair and Fraud Hearings section of the Appeals Division of the Texas Health and Human Services Commission (HHSC). The appeals division receives appeal requests from applicants and individuals contesting actions taken regarding benefits and services of various programs. These include the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program), Temporary Assistance for Needy Families, all Medicaid-funded services, and other agency programs that are required by state or federal law, or rules, to provide the right to a fair hearing. Hearings officers conduct hearings, consider evidence and issue decisions in accordance with rules, regulations and state and federal law.

See the HHSC Fair and Fraud Hearings Handbook for specific information regarding the HHSC rules and requirements governing the fair hearings process.

2931 Processing Fair Hearing Requests Using TIERS

Revision 17-1; Effective March 15, 2017

When a request for a fair hearing is received from an applicant or individual orally or in writing, the Texas Health and Human Services Commission (HHSC) must refer the request to the hearings officer within five calendar days from the date of the request. Information is not mailed to the hearings officer, but is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by the designated data entry representative.

Upon receipt of the fair hearing request, the case worker completes Form H4800,  Fair Hearing Request Summary.

The case worker sends Form H4800 to the Hearing Division and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the TIERS system. See the Form H4800 Instructions for specific directions for completion and transmittal.

Designated Data Entry Representative Procedures

Within two calendar days of receipt of Form H4800, the data entry representative enters the information into the Fair Hearings and Appeals system in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry representative will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the case worker and supervisor.

HHSC Fair Hearings and Appeals Procedures

The TIERS system will generate a hearing packet which includes Form H4803, Notice of Hearing, and Form H4800. The case worker and supervisor will receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the hearing. It is the supervisor's responsibility to ensure that the case worker or a designated representative participates in the hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

If Form H4800 has already been submitted into TIERS and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for a fair hearing, the case worker completes Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submits it to the data entry representative.

The data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending information, the data entry representative completes the following activities according to the situation:

  • When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the data entry representative sends Form H4800-A directly to the hearings officer’s email address. The case worker must enter the appeal ID number in the subject line.
  • When the data entry representative submits supporting documentation for an appeal, he uploads the information directly into TIERS and sends the hearings officer an email with Form H4800-A attached. The case worker must enter the appeal ID number in the subject line. The email must also inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The case worker and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

2932 Coordination of Fair Hearings with MEPD Utilizing OES CRU

Revision 17-1; Effective March 15, 2017

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

  • represents HHSC OES in fair hearings;
  • completes and implements all MEPD case actions based on fair hearing decisions; and
  • coordinates actions required with regional MEPD staff and HHSC staff.

The case worker must coordinate all appeals with CRU in which MEPD staff determine financial eligibility. The case worker must remember CRU replaces the local MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and CRU administrative assistant.

Applicants/individuals may appeal a decision orally, in person or in writing. The case worker is responsible for completing Form H4800, Fair Hearing Request Summary, to 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. HHSC staff must determine if the appealed action is:

  • a waiver/service denial (excludes denials based on MEPD denials); or
  • an MEPD financial denial (denials based on an MEPD denial action).

If the appealed action is related to Community Care for Aged and Disabled (CCAD) criteria other than an MEPD financial denial action, the case worker completes Form H4800 and enters his name as the "Agency Representative." In the "Additional Witnesses” field, HHSC staff enter "CRU Supervisor" (enter the actual name), and "CRU Administrative Assistant" (enter the actual name). The CRU supervisor and administrative assistant names must be entered by using the "MOR Search" function. This will ensure that all the correct information is populated in TIERS and both the CRU supervisor and the administrative assistant receive the notice of the appeal.

If the appealed action is an MEPD financial denial, the case worker completes Form H4800 and enters "CRU Supervisor" (enter the actual name) as the "Agency Representative." This information must be entered through the "MOR Search" function for CRU to receive the hearing information. List the HHSC case worker, supervisor and titles in the "Additional Witnesses” section. The name of the local MEPD specialist is not entered by staff on Form H4800 for MEPD financial appeals. HHSC staff must include the title, such as HHSC case worker or HHSC supervisor. Enter the HHSC staff email address. Enter the CRU administrative assistant (enter the actual name) in "Additional Witnesses” using the "MOR Search" function.

When Form H4800 is sent to the Hearing Division, the case worker sends an email notification regarding the request for an appeal to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, oesfairhear@hhsc.state.tx.us. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, HHSC staff must also include a copy of the HHSC notification form sent to the applicant or individual. The email must include the:

  • applicant's/individual's name;
  • Medicaid number (if available);
  • type of service (CCAD Community Attendant Services); and
  • specific information requesting the MEPD 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. The case worker must notify CRU to keep the MEPD case open pending the fair hearing decision.

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

When a hearing decision based on program criteria is rendered by the hearings officer, the case worker (staff name entered as "Agency Representative") will be notified via email of the decision by the hearings officer. Based on the hearing decision, the case worker determines the appropriate action according to program specific time frames. The case worker may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor and administrative assistant for the coordination. The case worker reports the implementation of the hearing decision through TIERS on Form H4807, Action Taken on Hearing Decision, according to current procedures.

The local MEPD specialist will continue to notify the case worker if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU will notify HHSC staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, the case worker determines the appropriate action for the service. The email sent by CRU will include:

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

The case worker must not put an applicant/individual back on a specific interest list while an MEPD denial is in the appeal process. The case worker must take appropriate action to certify or deny the case, or resume services once the MEPD hearing decision is rendered. The individual may choose to be added back to the interest list once the case worker denies the service.

2933 Submitting the Appeals Evidence Packet

Revision 17-1; Effective March 15, 2017

When an applicant or individual requests a fair hearing, the burden of proof to uphold the Texas Health and Human Services Commission (HHSC) decision rests with HHSC. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency decision.

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case worker and his/her supervisor receive a copy of Form H4800 and the letter identifying the hearings officer assigned, and the time and location of the hearing. Staff or the designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

Each entity involved in the fair hearing is responsible for preparing its packet and forwarding the packet to both the:

  • hearings officer identified on Form H4800; and
  • appellant.

All documentation must be neatly and logically organized, and all pages numbered. Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

Provide the names, titles, addresses and telephone numbers of all persons or designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send additional staff (e.g., the regional nurse, regional attorney, etc.); however, it is mandatory that the following staff attend:

  • Texas Medicaid & Healthcare Partnership (TMHP), for medical necessity/level of care (MN/LOC) denials;
  • Medicaid for the Elderly and People with Disabilities (MEPD) or Centralized Representation Unit (CRU), for financial denials;
  • case worker or designee, for all case decisions; and/or
  • Utilization Review nurse to the appeal action, if applicable.

All related documentation necessary to support the agency's decision must be sent by the data entry representative (DER) to the fair hearings officer as soon as possible, but no later than 10 calendar days before the hearing. Examples of additional information and who is responsible for submitting that information to the state fair hearings officer and appellant include, but are not exclusively limited to:

  • the case worker or designee:
    • Texas Administrative Code or policy handbook references related to the case action;
    • summary of events;
    • a copy of any individual service plans, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or other official documentation forms including form instructions;
    • other documentation supportive of the decision, such as records of telephone calls, visit summaries, etc.;
    • any relevant Utilization Review findings; and
    • a signed copy of the denial notification form (if available, use the signed form returned by the applicant/individual when the appeal was filed);
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed denial form returned by the member, if available (if unavailable, send unsigned copy);
  • TMHP:
    • a copy of the MN/LOC assessment; and
    • other documentation supporting the decision.

Uploading the Appeals Evidence Packet into TIERS

All evidence packets must be scanned into the TIERS Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation (also referred to as the "appeals packet") to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A. The DER must upload the fair hearing evidence packet in TIERS no later than 10 calendar days prior to the fair hearing date.

The case worker must provide the information to the DER no later than 12 calendar days prior to the fair hearing date, to allow enough time for the evidence packet to be submitted timely. The case worker must:

  • go to the multi-function HHSC WorkCenter and scan in the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

No later than 10 calendar days prior to the fair hearing date, the case worker must forward a copy of the fair hearing evidence packet to the applicant or individual requesting the fair hearing.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal (without launching TIERS) and select the "Appeals" tab;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select "Hearing Evidence Packets Upload" and enter the appeal identification;
  • select "Document Type: Agency Evidence Packet" (items entered in any other selection will not be included in the evidence packet);
  • select "Validate";
  • check the details to ensure the right person has been selected;
  • browse for the document; and
  • select "Upload."

Users who make mistakes that cannot be reversed may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

2934 Presentation of Evidence at the Fair Hearing

Revision 17-1; Effective March 15, 2017

Staff listed on Form H4800, Fair Hearing Request Summary, will receive Form H4803, Notice of Hearing, notifying participants when the hearing will be held. HHSC staff must adequately prepare both the fair hearing packet and presentation of evidence at the fair hearing. The burden of proof to uphold the agency's decision rests with the agency. The hearings officer is a neutral party and is restricted by law from presenting the agency's case.

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Joe Smith. Pages 1-10 contain information relating to the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Community Care for Aged and Disabled Handbook, which relate directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form 2065-A, Notification of Community Care Services, which was mailed to the applicant on March 2, 2010."

The hearings officer usually can only consider the specific information offered in evidence when making the hearing decision. For example, the case worker may clearly explain how the applicant must score 24 points on Form 2060 to be eligible for Primary Home Care. However, if documentation backing up that explanation (Handbook policy, Form 2060 Instructions and appropriate appendices) is not contained in the packet, the explanation will not be considered.

Oral testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if he received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record in order to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

2935 Action Taken after the Hearing Decision

Revision 17-1; Effective March 15, 2017

2935.1 Action Taken on the Hearing Decision for Reductions

Revision 17-1; Effective March 15, 2017

After the hearing is held, the Texas Health and Human Services Commission (HHSC) hearings officer will send a decision letter, Form H4807, Action Taken on Hearing Decision, to the appellant and send copies to the case worker and the supervisor. If the HHSC decision is sustained, then the case worker takes the appropriate action. If services continued during the appeal period, then the case worker completes a new Form 2101, Authorization for Community Care Services, and sends it to the provider with the reduced service amounts. The action must be completed within 10 calendar days after the hearings officer’s decision. It is not necessary to send the individual another Form 2065-A, Notification of Community Care Services, since the individual has already been notified of the change.

If the hearings officer reverses the decision, the hearings officer also sends HHSC Form H4807 and specifies the corrective action to be taken and a 10-day time frame for the completion of the action. The case worker continues authorization at the higher level of services. The case worker sends the individual Form 2065-A showing the new level of services. A new Form 2101 is not required, since the provider is already delivering services at the higher level. The case worker actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Form H4807 is no longer completed and mailed back to the hearings officer. All communication will be through TIERS.

2935.2 Action Taken after the Hearing Decision of Terminations

Revision 17-1; Effective March 15, 2017

Once the hearings officer’s decision is rendered and if the individual is determined eligible to continue receiving services, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual to notify him that the hearings officer’s decision overturned the termination and his eligibility is continued. The case worker includes the following statement in the comments: “The hearings officer has overturned the termination decision and you have been determined eligible for continued services effective (the begin date).” The case worker sends the provider an updated Form 2101, Authorization of Community Care Services, reinstating services.

If the hearings officer sustains the termination decision and services were not continued, then no further case worker action is required on the case. If the hearings officer sustains the termination decision and services were continued, the case worker must terminate services in Service Authorization System and send the provider Form 2101 ending services within 10 calendar days after the hearings officer decision, or in accordance with instructions provided by the hearings officer. The case worker does not send another Form 2065-A to the individual to provide notification that the individual is not eligible based on the hearings officer’s decision. The case worker orally notifies the individual of the termination of services and the effective date and documents the contact in the case record.

2935.3 Fair Hearings Officer Orders a New Assessment

Revision 17-1; Effective March 15, 2017

If the hearings officer’s final decision orders completion of a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the hearing is closed as a result of this ruling. The case worker must notify the individual of the results of the new assessment on Form 2065-A, Notification of Community Care Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, the case worker must indicate in Section 8, Summary of Agency Action of Form H4800, HHSC Action Taken on Hearing Decision, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision. If the individual requests an appeal of the new assessment, HHSC continues services until the second fair hearing decision is implemented.

2935.4 Reporting the Action Through TIERS

Revision 17-1; Effective March 15, 2017

The case worker completes Form H4807, Action Taken on Hearing Decision, recording case actions taken and sends it to the supervisor and the designated data entry representative. The case worker must send Form H4807 within the time frames to allow at least two days for the data entry representative to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, the case worker must complete Section B on Form H4807 and send to the supervisor and data entry representative providing the reason for the delay. Acceptable reasons are listed on the form and the begin delay date and end delay date must be included. See the form instructions for detailed information on completing Form H4807.

2936 Fair Hearing Exception Process

Revision 17-1; Effective March 15, 2017

When a fair hearing decision is rendered, staff must implement the decision of the fair hearings officer within the applicable time frames, including the restoration of any benefits or services.

Staff who disagree with the result of a fair hearing must follow regional procedures in referring the issue to the regional director. Staff use Form 1590, Request for a Fair Hearing Exception, to initiate a fair hearing exception request. The form documents the region's request for a review of a fair hearing decision.

If he agrees with the region's request, the regional director forwards Form 1590 to the Community Services Policy (CSP) unit manager. The CSP unit manager must receive the form by the fifth calendar day following the date on the hearing decision. A copy of the form is kept in regional files, not in the case record.

Upon reviewing the region's exception request, the CSP unit manager will decide whether to forward the exception request for consideration by HHSC. If the CSP unit manager (or designee):

  • concurs with the regional assertion that policy was misapplied, the form is forwarded to the Fair and Fraud Hearings Section.
  • determines a clear error of law or fact was made by the hearings officer, he requests that HHSC review the case action and, if they are in agreement, issues a revised hearing decision.
  • does not concur with the regional request, the request will not be forwarded to HHSC.

If the CSP unit manager forwards the exception request for consideration by HHSC, then the HHSC case worker or designee must mail Form 1015 or Form 1015-S, Fair Hearing Exception Letter, and a copy of the exception request to the applicant or individual. The case worker or designee must place the letter and exception request in the outgoing mail by the close of the next business day following receipt of the notification from the CSP unit manager. A copy of the letter and exception request must be placed in the case record.

The region will be notified of the decision whether the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames.