Revision 18-1; Effective June 15, 2018

 

4100 Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

 

4110 Description

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) provides a 24-hour living arrangement in a Texas Health and Human Services Commission (HHSC) contracted foster home for persons who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes. Services may include meal preparation, housekeeping, minimal help with personal care, help with activities of daily living and provision of or arrangement for transportation. The unit of service is one day.

Providers of AFC must live in the household and share a common living area with the individual. Detached living quarters do not constitute a common living area. The individual enrolled to provide AFC must be the primary caregiver. Providers may serve up to three adult individuals in an HHSC-enrolled AFC home without licensure as a personal care home.

 

4111 Four Bed Adult Foster Care Homes

Revision 17-1; Effective March 15, 2017

 

A Type C Assisted Living license is obtained if the provider wants to serve four individuals. The home cannot be approved for the fourth individual until the provider has applied for and received the Type C license. After the enrollment is complete, the provider may apply for a Type C license from the Texas Health and Human Services Commission Regulatory Services Division. The license must be renewed yearly and requires an annual fee.

 

4112 Small Group Homes

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) may also be provided in a small group home licensed by the Texas Health and Human Services Commission (HHSC) as Assisted Living Type A, Small, under the Minimum Licensing Standards for Assisted Living. The provider must submit a copy of the Assisted Living license to contract management staff before enrollment and upon renewal thereafter. The provider must report to contract management staff any problem(s) identified by Regulatory Services. HHSC regional contract managers enroll small group homes and providers must meet all applicable requirements in the Minimum Standards for AFC. Providers must serve no more than eight adult individuals in an enrolled small group home.

AFC provided in small group homes is subject to two sets of regulations: HHSC minimum standards for AFC and Licensing Standards for Assisted Living Facilities. The stricter requirements apply when requirements conflict; therefore, an enrolled AFC provider whose home is licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of individuals currently residing in the facility.

 

4113 Contract Manager and Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

 

 

4113.1 Contract Manager Responsibilities

Revision 17-1; Effective March 15, 2017

 

Texas Health and Human Services Commission regional contract managers are responsible for all requirements for adult foster care (AFC) providers and homes. The contract manager's responsibilities include:

  • recruiting adult foster homes;
  • processing AFC applications;
  • orientating and training the provider;
  • conducting fire and health inspections;
  • disenrolling adult foster homes;
  • approving private pay individuals;
  • conducting administrative reviews;
  • reassessing the provider and home; and
  • processing payments.

 

4113.2 Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

Texas Health and Human Services Commission (HHSC) case workers are responsible for all requirements for adult foster care (AFC) applicants and individuals. The case worker's responsibilities include:

  • completing the AFC applicant intake and assessment process;
  • determining financial and functional eligibility for AFC;
  • assessing appropriateness for AFC;
  • providing information to interested applicants about potential adult foster homes and arranging visits to the homes;
  • developing a service plan and completing the individual provider agreement;
  • authorizing AFC services;
  • monitoring the individual; and
  • processing changes and conducting annual reassessments of the individual.

 

4120 Eligibility

Revision 17-1; Effective March 15, 2017

 

 

 

4121 Basic Eligibility

Revision 17-1; Effective March 15, 2017

 

To be eligible for adult foster care (AFC), applicants and individuals must meet basic eligibility requirements for Community Care for Aged and Disabled services as well as specific requirements related to AFC. These requirements can be found in Section 3000, Eligibility for Services.

 

4122 Appropriate Characteristics for Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

Applicants and ongoing individuals in adult foster care (AFC) must display appropriate characteristics for AFC placement.

AFC placement is not appropriate for all individuals. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed for all applicants. If any inappropriate characteristics are identified, the applicant/individual is not appropriate for AFC and cannot be authorized for services.

A new Form 2330 must be completed at each annual review to ensure the individual's needs can be met within the foster care setting.

 

4123 Supervisory Approval

Revision 17-1; Effective March 15, 2017

 

It is the supervisor's responsibility to ensure that the applicant/individual meets the appropriate characteristics and their needs can be adequately met in adult foster care (AFC). The supervisor indicates on Form 2330, Assessment and Service Plan Approval for Adult Foster Care, whether AFC is approved or disapproved. Supervisory approval is required before AFC is authorized and also required to reauthorize.

See Section 3000, Eligibility for Services, for additional eligibility requirements.

 

4130 Adult Foster Care Intake and Assessment

Revision 17-1; Effective March 15, 2017

 

Adult Foster Care (AFC) is appropriate for individuals who, because of physical, mental or emotional limitations, are unable to continue independent functioning in their own homes and who need and desire the support and security of family living. AFC is also appropriate for individuals who do not need institutional care, but are unable to resume independent living or have no relatives who are able to provide a home.

 

4131 Response to Request for Services

Revision 17-1; Effective March 15, 2017

 

Upon receipt of an intake for adult foster care (AFC), the case worker arranges a home visit to conduct the assessment based on the intake priority. Refer to Section 2340, The Initial Interview and Application Process, for complete procedures. During the home visit, the case worker assesses the applicant for financial eligibility and functional eligibility, using Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and also completes Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to determine whether the applicant is appropriate for AFC. Form 2330 lists the appropriate and inappropriate mental and physical characteristics for AFC individuals.

AFC is not appropriate and should not be authorized for a person who:

  • requires considerable assistance with personal care due to physical or mental conditions;
  • requires long-term care in a medical or psychiatric facility;
  • is a danger to himself or others; or
  • is bedfast.

 

4132 Individual Rights and Responsibilities

Revision 17-1; Effective March 15, 2017

 

The case worker must explain the room and board requirements in adult foster care (AFC) and ensure that the applicant understands that he must pay a portion of his monthly income for room and board. Review Form 2307, Rights and Responsibilities, and Form 2307-F, AFC Rights and Responsibilities, with the applicant. Make sure the individual understands his responsibilities as a resident in an AFC home.

 

4133 Assessing Potential Adult Foster Care Homes

Revision 17-1; Effective March 15, 2017

 

If the applicant displays the appropriate characteristics and appears to meet eligibility criteria, the case worker provides information about potential adult foster care (AFC) homes. The case worker can arrange visits to appropriate AFC homes or if the applicant is capable or has family/supports available, he may make the arrangements to visit potential AFC homes. In some situations, the case worker may need to assist the applicant in making the visit(s).

The purpose of the visits to potential AFC homes is to let the applicant assess the home and let the AFC provider assess if the applicant will be appropriate in the foster home. The case worker may contact the provider and share information about the applicant, including the applicant's particular needs and problems, to ensure that the potential provider is fully aware of the responsibilities involved in caring for the particular applicant and to prevent a potential mismatch of the applicant and provider.

 

4134 Placement on the Interest List

Revision 17-1; Effective March 15, 2017

 

If an intake is received for adult foster care (AFC) but no foster homes are available to provide care, place the individual's name on the interest list and determine if other services may be appropriate to meet the individual's needs while waiting for placement in AFC. Refer to Section 2930, Community Services Interest List (CSIL), for interest list procedures. The application process for AFC begins when the individual's name is released from the interest list.

 

4135 Adult Protective Services Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

 

 

4135.1 Placement of Adult Protective Services Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

In some areas, Adult Protective Services (APS) may use adult foster care (AFC) as a resource for placement of APS individuals. Approval by the contract manager is required before an APS individual moves into a Texas Health and Human Services Commission enrolled AFC household. The purpose of the approval is to determine the:

  • appropriateness of the individual's characteristics;
  • capacity of the foster home to meet the individual's needs; and
  • compatibility of service delivery to the APS individual and the delivery of services to the certified AFC individuals.

If it is determined by the contract manager that placement in foster care is inappropriate, the APS worker and the provider will help the individual make other living arrangements.

 

4135.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 17-1; Effective March 15, 2017

 

Any time Texas Health and Human Services Commission (HHSC) staff suspect abuse, neglect or exploitation of an adult foster care (AFC) individual in a foster home, a report must be made immediately to Adult Protective Services (APS).

If reports are made to APS from outside sources, HHSC staff may not be notified of individual allegations against a service provider until after those allegations have been validated. However, APS staff may ask Community Care for Aged and Disabled (CCAD) staff to assist with the delivery of services during the course of their investigation if the alleged mistreatment poses an immediate threat to the safety of AFC residents.

The contract manager assigned to the facility handles disenrollment and corrective actions against the foster home, as appropriate. If the case worker is unable to find a suitable residence for the individual, the individual is referred to APS for assistance in moving from the foster home.

An individual who has the capacity to consent may decide not to move from the foster home, even though the allegation has been validated and the situation is likely to recur. In such an instance, the individual's AFC services will be denied and payments to the home will terminate. However, the individual may continue to reside in the home by making private pay arrangements with the provider.

If an individual who does not appear to have the capacity to consent refuses to move from a home operated by an individual identified as the perpetrator in a case of validated abuse, neglect or exploitation, make a referral to APS.

 

4136 Private Pay Individuals and Retroactive Payment Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4136.1 Private Pay Individuals in Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

Some adult foster care (AFC) providers may wish to take private pay individuals. Approval by the contract manager is required before the private pay individual is accepted in the home. The AFC provider must contact the contract manager when considering admitting a private pay individual. The contract manager will furnish Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to the AFC provider. The AFC provider must complete Form 2330 and return it to the contract manager to approve or disapprove the private pay individual. The purpose of the approval is to determine the:

  • appropriateness of the individual's characteristics,
  • capacity of the foster home to meet the individual's needs, and
  • compatibility of service delivery to the private pay individual and the delivery of services to the certified AFC individual.

If it is determined by the contract manager that placement in foster care is inappropriate, the AFC provider cannot accept the individual.

Refer any issues regarding placements to the contract manager to resolve.

 

4136.2 Retroactive Payment Procedures

Revision 17-1; Effective March 15, 2017

 

If a private pay applicant already in the foster home applies for adult foster care (AFC) and meets all eligibility requirements, AFC can be approved retroactive to the date of intake.

AFC may be authorized retroactively with supervisory approval to the latter of the date of:

  • request for services (intake date), or
  • entry into the foster home.

Supervisory approval is required in all situations. If an applicant does not meet eligibility requirements including appropriate characteristics, then AFC is not authorized and it is the individual's responsibility to arrange for payment to the foster home or relocate.

 

4140 Adult Foster Care Case Worker Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4141 Eligibility Determination

Revision 17-1; Effective March 15, 2017

 

To determine eligibility for adult foster care (AFC), the case worker must:

  • certify that the applicant meets financial and functional eligibility on Form 2064, Eligibility Worksheet;
  • determine that the applicant has an agreement with an enrolled AFC home to potentially move into the home; and
  • document on Form 2330, Assessment and Service Plan Approval for Adult Foster Care, that the applicant meets the appropriate criteria for AFC.

After eligibility is determined, the case worker submits the individual's case record to his supervisor for review and approval. Documentation in the case record must be complete to enable the supervisor to certify the individual's need for care and the appropriateness or inappropriateness of the placement arrangement.

 

4142 Supervisory Approval

Revision 17-1; Effective March 15, 2017

 

Upon receipt of the case record, the supervisor reviews:

  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to verify the individual's functional need for care;
  • Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to verify the appropriateness of the applicant; and
  • any additional documentation, including the case narrative to review the individual's care needs.

The supervisor may consult with the contract manager to evaluate the capacity of the foster care provider to meet the unique needs of the individual in the foster home setting.

The supervisor decides whether the foster home can meet the needs of the individual and if the individual is appropriate for adult foster care (AFC). If so, the supervisor approves AFC and the service plan by signing and dating Form 2330 or by giving verbal approval, which is documented by the case worker. If the service is not approved, the supervisor confers with the case worker about problems with the plan, as perceived through the record reviews. The case worker must find a more suitable arrangement or resolve the potential problems with the individual and the foster care provider to his supervisor's satisfaction. Refer the individual to Adult Protective Services (APS) if there is reason to suspect abuse, neglect or exploitation.

 

4143 Service Planning

Revision 17-1; Effective March 15, 2017

 

Upon approval for adult foster care (AFC), the supervisor and case worker discuss if the individual has any special needs that require additional monitoring in the foster home setting beyond the scheduled monitoring. If needed, a monitoring schedule is developed and documented in the case record.

The final care and monitoring plan for the individual should address his functional, medical, social and emotional needs and how they might be met in the selected foster care home. Assess whether other resources in the community should be used to meet specialized needs of the individual. Use of those resources should be documented in the care plan.

If there are health concerns regarding the individual, the regional nurse may be consulted and a recommendation may be made for the individual to have a physical/medical exam prior to moving into the AFC home.

Once the supervisor has approved the individual and potential placement in AFC, the case worker contacts the individual and the AFC provider to arrange for the initial visit and a negotiated move-in date for the individual.

 

4150 Finalizing the Care Plan – Required Initial Home Visit

Revision 17-1; Effective March 15, 2017

 

Program Standard: On or before the date the individual moves into the adult foster care (AFC) home, a meeting with the individual and the AFC provider is required to discuss the individual's care plan and to complete Form 2327, Individual/Member and Provider Agreement.

The individual's family members or responsible person may be included in the meeting and the meeting should preferably take place in the AFC home.

During the initial home visit, discuss the individual's needs and care plan as indicated on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care. Reach an agreement about how the individual's needs should be met through daily care and activities.

Discuss the individual's care plan with the individual and family members/responsible party and reach understanding with them about how the foster care provider will meet his needs. This discussion should ensure that the individual, his family/responsible party and the foster care provider are adequately prepared for a new individual in the home and that adjustments occur smoothly. Document the care plan and any special needs of the individual or special agreements between the individual and provider on Form 2327.

 

4151 Individual and Provider Agreement

Revision 17-1; Effective March 15, 2017

 

During the initial home visit, the case worker documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The case worker reviews all of the information on the agreement with the individual, family and/or responsible person and the provider. All conditions of the agreement and the following topics must be covered in the discussion:

  • a full description of the care needs of the individual, services and the schedule of care, including whether the individual requires 24-hour supervision, to be given to the individual by the adult foster care (AFC) provider;
  • the beginning and ending date of the agreement;
  • a detailed description of the rights and responsibilities of the individual and the provider;
  • an explanation of the individual's and provider's right to privacy and confidentiality;
  • the monthly dollar amount the individual agrees to pay the provider for room and board;
  • an inventory of personal effects;
  • the names, addresses and telephone numbers of the persons to be notified in an emergency, including the individual's physician, family members and/or responsible person;
  • any special habits and needs of the individual and any special arrangements or agreements between the individual and the provider;
  • any additional training needs of the provider and methods to obtain that training;
  • the rights and responsibilities of both the individual and the provider for notifying the case worker and contract manager of problems such as illnesses, hospitalizations, acts of violence, accidents, complaints about abuse, neglect or exploitation; and
  • other conditions that reflect changes in the individual's condition and might affect the appropriateness of the foster home. See Appendix VI, Minimum Standards for Adult Foster Care, for reporting requirements.

Fully discuss with the foster care provider the likelihood of problems arising after the individual moves into the home, notification procedures and suitable actions that should be taken to resolve problems. Also, discuss with the provider the impact of a new individual on members of the foster care family and other individuals in the home. Anticipate problems that might arise and how they should be handled. Outline the schedule of monitoring visits that have been planned for the individual.

The individual and the provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement.

 

4152 Personal Needs and Medical Expenses Allowance

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.3906, Adult Foster Care Personal Needs and Medical Expenses Allowance. Adult foster care clients must be allowed to keep funds for personal needs and medical expenses as specified in paragraphs (1)-(3) of this section.

(a) Clients with Medicaid coverage must be allowed to keep at least $50 a month for personal needs.
(b) Clients without Medicaid coverage must be allowed to keep at least $85 a month for personal needs and medical expenses.
(c) All clients must be allowed to keep at least one-half of any cost-of-living adjustment received on or after January 1, 1993.

Ensure that the individual keeps sufficient funds each month for personal needs and medical expenses. The $50 and $85 amounts are minimum amounts. The individual may need to keep more depending on his particular circumstances. Help the individual determine how much he spends on prescription drugs and medical bills each month. When the room and board agreement is negotiated, also consider personal expenses such as replacement of clothing and toiletries.

 

4153 Room and Board Agreement

Revision 17-1; Effective March 15, 2017

 

Ensure that the individual and provider understand that the room and board arrangement with the provider is separate from the Texas Health and Human Services Commission (HHSC) payment for services. The individual pays the provider for room and board. Help the provider and the individual negotiate the room and board agreement. The amount paid may be influenced by prevailing rates in the community. The room and board agreement and any other monetary arrangements are entered on Form 2327, Individual/Member and Provider Agreement.

If the individual is moving into the adult foster care home mid-month, prorate the amount of room and board for the month and advise the individual and provider of the prorated amount. The ongoing amount of room and board is negotiated with the individual and provider and both amounts are recorded on Form 2327.

 

4153.1 Changes in the Room and Board Agreement

Revision 17-1; Effective March 15, 2017

 

If the individual has a change in income or expenses, he or the provider may request a change in the amount of room and board payment. Changes in the room and board payment are negotiated between the individual and the provider and are documented on Form 2327-A, Room and Board Amendment to the Individual/Member and Provider Agreement.

 

4154 Leave Away from the Foster Home and Bedhold Charges

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.3904(f). The Texas Department of Human Services pays the daily rate for up to 14 days of leave for each 12-consecutive-month period when an authorized client is away from the foster home. Payment for leave in excess of 14 days per year is the responsibility of the client. Any bedhold charges are between the client and provider because they have negotiated a monthly room and board agreement. Bedhold charges, however, may not exceed the daily room and board rate.

§48.3904(g). The adult foster care provider is responsible for notifying the case worker by the next workday when a client is away from the foster home for personal leave or hospitalization.

During the initial home visit, the case worker reviews the information regarding the individual's responsibility to pay a bedhold charge when away from the home. Ensure that the individual understands that if he uses more than 14 days of leave during a 12-month period, he is responsible for paying the provider the full daily rate.

 

4155 Authorization of Adult Foster Care

Revision 17-1; Effective March 15, 2017

 

After all procedures are completed, the case worker sends the individual Form 2065-A, Notification of Community Care Services. The case worker authorizes adult foster care on Form 2101, Authorization for Community Care Services, in the Service Authorization System wizards and sends the provider a copy of Form 2101.

 

4156 Adult Foster Care and Day Activity and Health Services

Revision 17-1; Effective March 15, 2017

 

Some services cannot be authorized at the same time as Adult Foster Care (AFC). Refer to the chart in Appendix XX, Mutually Exclusive Services. Day Activity and Health Services (DAHS) may be authorized for AFC individuals under the following conditions. The AFC individual:

  • requests to attend DAHS for socialization; or
  • has a medical need that cannot be met by the AFC provider.

Documentation in the case record must clearly specify that at least one of the above conditions is met. See Section 4221, Medical Criteria, for the DAHS eligibility requirements for a medical need.

DAHS may be authorized for the maximum of 10 units per week; however, the authorization must be related to the individual's need and not authorized for the convenience of the AFC provider.

40 Texas Administrative Code §48.8907(a), Resident care and services. The adult foster care provider must:

(1) provide services to residents according to the individual service plan and the client/provider agreement;
(2) meet all requirements and conditions stated on the client/provider agreement, approval of foster care, and client service plan;
(3) ensure that an approved substitute provider is present in the home if at least one resident remains in the home when the provider plans to be absent from the home for more than three hours in a 24-hour period. Residents whose care plans specify the need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period of time.

If an individual is authorized to attend DAHS but is ill or prefers not to attend on a particular day, it is the AFC provider's responsibility to provide supervision in the AFC home for the individual.

 

4160 Monitoring

Revision 17-1; Effective March 15, 2017

 

Program Standard: Monitoring contacts are required monthly for the first three months the individual is in the foster home. Two of the monitoring contacts may be made by telephone if appropriate for the individual. At least one of the contacts must be a home visit to the individual in the foster home and the individual must be interviewed privately.

 

4161 60-Day and 90-Day Monitoring Contacts

Revision 17-1; Effective March 15, 2017

 

Monitoring contacts must be completed during the first three months after the individual is certified for adult foster care. Two of the monitoring contacts may be made by telephone. At least one of the three monitoring contacts must be made in person with the individual in the foster home. The individual must be seen alone so that he can freely discuss any problems with the provider or the home. It is the case worker's responsibility to assist in resolving any problems noted. Contact the contract manager if there are problems with the home or the provider.

 

4162 Six-Month Monitoring Contact

Revision 17-1; Effective March 15, 2017

 

After the first three months, the individual must be monitored at regularly scheduled six-month intervals, unless the case worker and supervisor have determined that the individual requires more frequent monitoring. The first six-month monitoring contact occurs three months after the 90-day monitoring contact.

Regular monitoring visits should assess the individual's needs and whether the provider is addressing and meeting those needs. Report to the contract manager if the adult foster care provider is not addressing or meeting those needs. The individual's physical and medical condition should be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness. Regional nurses should be used in this assessment/monitoring process as needed.

All monitoring contacts must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System monitoring wizard.

 

4170 Significant Changes

Revision 17-1; Effective March 15, 2017

 

It is the responsibility of the case worker and the adult foster care (AFC) provider to ensure that the AFC individual is in an appropriate setting to meet his needs. When the AFC individual has a change in functional need, health problems or changes in behavior, it is the responsibility of the AFC provider to notify the case worker.

Within 14 days or sooner, as appropriate, the case worker must follow-up with the individual and provider to determine if changes to the care arrangement are needed. The case worker may consult with the supervisor to determine how quickly a response is needed to the situation.

Give particular attention to individuals who reflect dramatic changes in functional need, medical problems or behaviors that are inappropriate for foster care. Alert family members and/or the responsible party or guardian to the situation. Discuss with them and the individual the potential for the individual to remain in the foster home. If an individual has a guardian appointed by the courts, the guardian acts on the individual's behalf. If the individual has had a decline in his medical condition or functional ability, consult the regional nurse and request that the nurse make a visit to the individual for a medical assessment.

 

4171 Changes in the Service Plan

Revision 17-1; Effective March 15, 2017

 

Document the changes in an individual's condition on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, noting changes in the individual's functional ability and appropriateness for adult foster care (AFC) placement. Discuss the changes with the supervisor, regional nurse (if needed), AFC provider and family members. Refer to Section 2550, Identifying Individuals at Risk, if the individual's health and safety are at risk and additional service planning is needed. If AFC continues to be appropriate for the individual, document the needed changes in the service plan on Form 2327, Individual/Member and Provider Agreement.

 

4172 Adult Foster Care No Longer Appropriate

Revision 17-1; Effective March 15, 2017

 

If after a review of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, the individual's needs can no longer be met or the individual is no longer appropriate for adult foster care, discuss alternative living arrangements with the individual and family/responsible party. Long-range care plans should be discussed frankly with the individual, family members and the foster care provider to ensure that all are aware of the capabilities and limitations of adult foster care services for individuals with deteriorating medical or functional conditions. Individuals who become inappropriate for foster care must be advised of other available options. Help individuals and their family members in this decision process and with transfer activities when necessary. If the provider decides that the individual is not appropriate for care in his home, the provider contacts the case worker to request that the individual be transferred to another placement. The case worker is responsible for preparing the individual for the move and transition.

 

4173 Termination of Adult Foster Care Services

Revision 17-1; Effective March 15, 2017

 

Once an individual is identified as inappropriate for foster care, the case worker must negotiate a time frame with the individual, family/responsible party and the adult foster care (AFC) provider for the individual to move. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the individual has been a threat to the health and safety of other individuals or has exhibited inappropriate behaviors so that the provider is asking the individual to move immediately, then the case worker must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the individual, refer to Adult Protective Services (APS) to assist in locating appropriate placement for the individual.

If the individual will not be transferring to another AFC setting, send the individual Form 2065-A, Notification of Community Care Services, with the negotiated move date as the end date of services. Unless the individual's service is being terminated due to threat to health and safety (see Section 2811, Effective Dates for Service Reduction and Termination), give the individual at least 12 days notice. Terminate AFC services on Form 2101, Authorization for Community Care Services.

If there is resistance to the move from the individual, family or the provider, an additional staffing with the individual, family/responsible party and provider may be required to resolve the problem. Request that the supervisor and contract manager attend the staffing, if necessary. Advise the individual and provider that AFC services will terminate on the date specified on Form 2065-A. The provider has the right to begin eviction proceedings as specified in the provider's resident rights and responsibilities. Ensure that the individual and responsible party understand the consequences of eviction. If the provider must use eviction procedures and the individual has refused to make other living arrangements, refer the individual to APS.

If the individual and provider decide that the individual will remain in the home as a private pay individual, then the contract manager must give approval. Make sure the individual and provider understand that there are no case management services or payment arrangements from the Texas Health and Human Services Commission for a private pay individual.

 

4180 Annual Reassessment

Revision 17-1; Effective March 15, 2017

 

Reassess the adult foster care (AFC) individual every 12 months as outlined in Section 2660, Reassessments and Recertification Procedures. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed annually and signed by the supervisor. Carefully review the appropriate and inappropriate characteristics on Form 2330 and be alert for changes that indicate that the individual is no longer appropriate for AFC or that his medical/functional needs can no longer be met. If the individual's condition is deteriorating, but not to the point that AFC is currently inappropriate, discuss with the individual that a move may be necessary in the future.

Reevaluate the service plan at each reassessment and update according to the individual's new/changed needs. Discuss changes in the individual's need level and in the service plan with the foster care provider and obtain supervisory approval.

Reauthorize AFC on Form 2101, Authorization for Community Care Services.

 

4200 Day Activity and Health Services

Revision 17-1; Effective March 15, 2017

 

 

 

4210 Description

Revision 17-1; Effective March 15, 2017

 

Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed and certified by the Texas Health and Human Services Commission. Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.

40 Texas Administrative Code §98.211(a) ─ The method of payment is a unit of authorized service and is defined as half a day. One unit of service constitutes three hours but less than six hours of covered services provided by the DAHS facility. Six hours or more of service constitutes two units of service. Time spent in approved transportation provided by the DAHS facility shall be counted in the unit of service.

Services must be provided according to the individual's service plan and according to the standards for participation in the Day Activity and Health Services Provider Manual.

Discuss with the individual (or, if necessary, his family or other involved individuals) the individual's condition, program plan and staff administering the plan.

Individuals must be given the opportunity to receive medical attention and help in getting health services not available from the provider.

The facility must be used only for authorized purposes.

 

4211 Nursing and Personal Care

Revision 17-1; Effective March 15, 2017

 

Services include:

  • evaluating and observing an individual's status and instituting appropriate nursing intervention, when needed, to stabilize his condition or prevent complications;
  • helping the individual order, maintain, or administer prescribed medication;
  • promoting and participating in the individual's education and counseling. Participation is based on his health needs and illness status, involving the individual and other individuals for a better understanding and implementation of immediate and long-term health goals;
  • helping with personal care tasks, including the restoration or maintenance of the individual's ability to perform personal care skills; and/or
  • assessing and evaluating the individual's health status.

 

4212 Physical Rehabilitation

Revision 17-1; Effective March 15, 2017

 

Services include:

  • restorative nursing, including the use of nursing knowledge and skills to help the individual achieve his maximum degree of functioning;
  • group and individual exercises, including range-of-motion exercises; and
  • transportation to and from a facility approved to provide therapies, if specialized services are needed on the days the individual attends the Day Activity and Health Services (DAHS) facility.

 

4213 Nutrition

Revision 17-1; Effective March 15, 2017

 

Services include:

  • one hot meal, served between 11 a.m. and 1 p.m. (the meal should supply one-third of the recommended daily allowance (RDA) for adults as recommended by the U.S. Department of Agriculture);
  • special diets required by the individual's plan of care;
  • supplementary mid-morning and mid-afternoon snacks; and
  • dietary counseling and nutrition education for the individual and family.

 

4214 Transportation

Revision 17-1; Effective March 15, 2017

 

If needed, the Day Activity and Health Services (DAHS) facility ensures transportation to and from the facility.

 

4215 Other Supportive Services

Revision 17-1; Effective March 15, 2017

 

Services include:

  • cultural enrichment or educational activities;
  • social activities, on-site or in the community; and
  • recreational therapy in a program planned to meet the individual's social needs and interests.

 

4220 Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §98.201, Eligibility Requirements for Participation

Community Care for Aged and Disabled (CCAD) policy prohibits the provision of CCAD services to individuals who live in an institution. An institution is defined as a skilled nursing facility or an intermediate care facility, including an intermediate care facility for persons who have an intellectual disability.

An individual who needs less than one unit (three hours of service) per week is not eligible for DAHS. One unit of DAHS service equals at least three hours but less than six hours per week. Authorization for DAHS cannot exceed more than 10 units per week.

 

4221 Financial Eligibility Criteria

Revision 17-1; Effective March 15, 2017

 

Medicaid recipients are financially eligible for Title XIX Day Activity and Health Services (DAHS). Applicants who are not Medicaid recipients but who are categorically eligible or within the Community Care for Aged and Disabled (CCAD) income and resource limits are financially eligible for Title XX DAHS. Applicants are not eligible if they are receiving another CCAD service that duplicates DAHS. See Section 3000, Eligibility for Services, for the policies concerning income and resources.

 

4222 Medical Eligibility Criteria

Revision 17-1; Effective March 15, 2017

 

For an individual to be eligible for Day Activity and Health Services (DAHS):

  • DAHS must be prescribed by a physician who has certified that the individual has a need for DAHS because of an identified chronic medical condition.
  • The individual must be able to benefit therapeutically from DAHS, as determined by a health assessment of the individual’s medical needs. The health assessment will inform of the functional need or needs, as defined by 40 Texas Administrative Code §98.206, which will be addressed and of the therapeutic benefit the individual will receive from personal care, habilitative or restorative activities by participation in DAHS.
  • Form 3055, Physician’s Orders (DAHS), and Form 3050, DAHS Health Assessment/Individual Service Plan, must be utilized for new enrollments, for transfers to a different DAHS facility, and if the individual’s condition changes.

If a physician has accepted Medicaid payments for the diagnosis and treatment of the individual's illness that makes him eligible for DAHS, that physician cannot bill the individual for completing Form 3055.

 

4223 Unmet Need Criteria

Revision 17-1; Effective March 15, 2017

 

Applicants must have an unmet need for services and are not eligible for Day Activity and Health Services (DAHS) if they are receiving another CCAD service that duplicates DAHS. DAHS may be received with some other services as long as there is not a duplication of services.

 

4223.1 DAHS in Conjunction with Other Services

Revision 18-1; Effective June 15, 2018

 

Day Activity and Health Services (DAHS) may be received in conjunction with some other services, including the following:

  • Individuals who receive personal care and supervision through Adult Foster Care (AFC) services may receive 10 units per week of DAHS to benefit medically from the other services provided by the DAHS program. Documentation of the medical benefit must be included in the case record. See Section 4156, Adult Foster Care and Day Activity and Health Services, for additional information.
  • A Consumer Managed Personal Attendant Services (CMPAS) individual may receive up to 10 units of DAHS per week.
  • Residential Care (RC) individuals may receive DAHS only if the services provided by the DAHS facility are medical services that cannot be provided by the RC facility. An RC individual may receive no more than one unit per day of DAHS, which is the time needed for the DAHS facility to provide medical services.
  • An individual in the following waiver programs can access DAHS if the individual meets the DAHS eligibility criteria:
    • Home and Community-based Services (HCS), if age 18 or older;
    • Community Living Assistance and Support Services (CLASS), if age 18 or older;
    • Deaf Blind with Multiple Disabilities (DBMD); and
    • Texas Home Living (TxHmL).

See Appendix XX, Mutually Exclusive Services, for complete information regarding which Long-term Services and Supports may be received in conjunction with others. Staff must also ensure that individuals with active Medicaid coverage are not certified for Title XX DAHS.

 

4224 DAHS Licensure Age Requirements

Revision 17-1; Effective March 15, 2017

 

Day Activity and Health Services (DAHS) facilities licensed as adult day care centers are unable to serve individuals under age 18. An individual under age 18 requesting DAHS must be advised that even if eligibility criteria for DAHS are met, he may not be able to access the service unless a facility is licensed to serve children and has a separate facility not accessible to adults. The case worker should refer the applicant to alternative services, such as:

  • after school and/or summer programs offered by independent school districts;
  • Texas Workforce Commission providers that offer day care services;
  • local day care centers;
  • faith-based local organizations; or
  • other organizations that provide assistance to children with specific physical or medical conditions.

 

4230 DAHS Approval

Revision 17-1; Effective March 15, 2017

 

Determination and redetermination of eligibility for Day Activity and Health Services (DAHS) involves the cooperative efforts of the regional nurse, the case worker, the facility nurse and the individual's physician.

 

4231 Intake

Revision 17-1; Effective March 15, 2017

 

Intake into Day Activity and Health Services (DAHS) begins when the case worker receives a request for services. Requests for DAHS services may be made by:

  • the individual,
  • his physician,
  • his authorized representative, or
  • an interested party.

A DAHS facility may also request services for an individual who is already attending the DAHS facility if the applicant is:

  • Medicaid eligible, and
  • not a DAHS individual.

 

4231.1 Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

The Texas Administrative Code stipulates that facility-initiated referrals for Day Activity and Health Services (DAHS) apply only to Title XIX services:

40 Texas Administrative Code §98.204(a)(1)(2), DAHS Facility-Initiated Referrals

Only Medicaid recipients are eligible for facility-initiated referrals. The facility may admit and serve the Medicaid recipient before approval by the Texas Health and Human Services Commission (HHSC) is obtained if it is willing to risk the loss of revenue if the applicant is determined ineligible. The individual cannot be someone who is currently receiving DAHS at any facility that has a DAHS contract. Individuals have freedom of choice in the selection of qualified providers. It is critical that the case worker and/or regional nurse coordinate transfers from one DAHS facility to another to prevent duplication of services or gaps in coverage.

For the facility-initiated referral, the facility must:

  • have verbal or written physician orders;
  • verbally notify the HHSC case worker or intake unit to request services for the applicant; and
  • follow up the notification in writing within seven days by sending Form 2067, Case Information, to the case worker.

The date of the verbal notification is the date of request for Community Care for Aged and Disabled Services.

 

4231.2 Intake Response

Revision 17-1; Effective March 15, 2017

 

Within 14 calendar days of receipt of the intake, the case worker must contact the applicant either by telephone or face-to-face contact to complete the application for Day Activity and Health Services (DAHS). Time frames for responding to other requests for services (intakes) are based on the priority of the intake. See Section 2320, Case Worker Response, for priorities and time frames. A home visit is required only at the applicant's request.

Prior to the contact, the case worker checks the Texas Integrated Eligibility Redesign System (TIERS) to determine if the applicant is Medicaid eligible or categorically eligible. The case worker also checks the Service Authorization System (SAS) to determine the applicant is not a current DAHS individual.

If the applicant is not Medicaid eligible, determine if the applicant will meet the criteria for Title XX Services and if Title XX Services are available. See Section 2230, Interest List Procedures.

If the applicant is not Medicaid eligible and the intake is a facility-initiated referral, notify the facility by telephone and follow up with Form 2067, Case Information, letting the facility know the applicant is not Medicaid eligible and is not eligible for the facility-initiated referral.

If the applicant is already a DAHS individual at another facility, notify the facility by telephone and follow up with Form 2067, letting the facility know the applicant is already an individual, is not eligible for the facility-initiated referral and must follow the transfer procedures as outlined in Section 4262, DAHS Transfers.

 

4231.3 Initial Interview

Revision 17-1; Effective March 15, 2017

 

The case worker contacts the applicant either by telephone or face-to-face to complete the assessment interview. During the interview, the case worker discusses services available through Day Activity and Health Services (DAHS) and determines if the applicant appears to have a medical diagnosis and a functional disability related to the medical diagnosis, an unmet need for services or is receiving other services that duplicate DAHS.

During the assessment, the case worker:

  • completes Form 2307, Rights and Responsibilities, and if the contact is by telephone, mails Form 2307 to the individual for signature;
  • completes Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered into the Service Authorization System;
  • assesses the number of units (one unit equals at least three hours but less than six hours) the applicant prefers and needs per week;
  • assesses the applicant for any other needed services; and
  • obtains an Application for Assistance form (see Section 2333, Applications), if the applicant is not Medicaid or categorically eligible.

The date of assessment begins the 30-day time frame for the case worker to complete the application process.

 

4231.4 Response to Individuals Who Are No Longer Attending DAHS

Revision 17-1; Effective March 15, 2017

 

If the applicant has stopped attending Day Activity and Health Services (DAHS) before the application process is complete, the applicant does not have to complete an application or Form 2307, Rights and Responsibilities, if he was Medicaid-eligible when DAHS was received. Attempt to contact the individual by telephone, mail or home visit to:

  • determine if he is receiving DAHS at another facility or receiving other Community Care for Aged and Disabled (CCAD) services that may duplicate DAHS;
  • verify his attendance at the facility; and
  • complete Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered into the Service Authorization System.

If unable to locate the individual or if the individual refuses to provide any information, verify through automation records the individual's effective date of Medicaid coverage and whether the individual is receiving other CCAD services that may duplicate DAHS. See Section 2433, Determining Unmet Need in the Service Arrangement Column, to determine CCAD services that duplicate each other. Complete and send to the facility:

  • Form 2101, Authorization for Community Care Services, if the individual is eligible; or
  • Form 2065-A, Notification of Community Care Services, if the individual is ineligible.

Send Form 2065-A to the applicant.

See Section 4233, Initial Eligibility Determination and Referral.

Note: Coordinate with the local Area Agency on Aging to ensure there is no service duplication.

 

4232 Facility Choice

Revision 17-1; Effective March 15, 2017

 

If the individual is to be referred to a Day Activity and Health Services (DAHS) facility, describe the facility to the individual and the type of service available. When possible, the individual should visit the facility before services begin. Based on federal requirements for services that are funded under Medicaid, the individual maintains freedom of choice among the DAHS facilities that serve the individual's area. If the individual meets all DAHS eligibility requirements, he has freedom of choice to choose a DAHS facility, regardless of any relationship to the provider.

40 Texas Administrative Code §98.202(a)(3). A Day Activity and Health Services (DAHS) facility must serve eligible clients, unless a facility is at licensed capacity.

Individuals must be referred to DAHS facilities based on the following priorities:

  • individual's choice;
  • physician's choice, if stated;
  • rotation of eligible providers.

Contact the facility selected by the individual to determine if the facility has openings. If the facility is operating at capacity, contact the individual and arrange another placement that is satisfactory to him.

The facility staff maintain an interest list for Title XIX and private-pay individuals since Medicaid regulations prohibit the Texas Health and Human Services Commission (HHSC) from maintaining an interest list for any Title XIX service. HHSC regional staff maintain the Title XX interest list. See procedures in Section 2930, Community Services Interest List (CSIL).

 

4233 Initial Eligibility Determination and Referral

Revision 17-3; Effective May 15, 2017

 

If the case worker determines the applicant meets the initial eligibility criteria of being financially eligible and having an unmet need for Day Activity and Health Services (DAHS) (no duplication of Community Care for Aged and Disabled (CCAD) services), the case worker, within five business days of the assessment, completes a referral Form 2101, Authorization for Community Care Services, and sends the referral packet to the facility.

The referral packet includes:

  • Form 2101; and
  • Form 2059, Summary of Client's Need for Service.

See Appendix XIII, Content of Referral Packets.

If the referral is facility-initiated, the case worker indicates in the comments section of Form 2101 that the applicant is being referred for facility-initiated DAHS. If the applicant no longer attends the DAHS facility, enter the date the applicant stopped as the "end" date on Form 2101 and note in the comments section the applicant is no longer attending DAHS.

If the case worker determines the applicant is not eligible for DAHS, the case worker sends the applicant Form 2065-A, Notification of Community Care Services. If the referral was facility-initiated, the case worker sends a copy of Form 2065-A to the DAHS facility and notifies the facility by telephone of:

  • the denial for the facility-initiated referral; and
  • whether the applicant qualifies for Title XX DAHS.

 

4234 Facility Response for Facility-Initiated Referrals

Revision 17-3; Effective May 15, 2017

 

40 Texas Administrative Code §98.204(c)-(d), DAHS Facility-Initiated Referrals

For facility-initiated referrals, the Day Activity and Health Services (DAHS) facility must submit a full prior approval packet to the Texas Health and Human Services Commission (HHSC) regional nurse within 30 calendar days after the date of the initial physician's orders (verbal or written) by submitting:

  • Referral Form 2101, Authorization for Community Care Services;
  • Form 3050, DAHS Health Assessment/Individual Service Plan; and
  • Form 3055, Physician's Orders (DAHS).

 

4234.1 Regional Nurse Responsibilities for Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

The Day Activity and Health Services (DAHS) facility must request written prior approval for the applicant from the regional nurse within 30 days after the date of the physician orders. If the DAHS facility submits the prior approval packet to the Texas Health and Human Services Commission (HHSC) regional nurse within 30 calendar days of the initial physician's orders and the applicant meets all eligibility requirements, the HHSC regional nurse authorizes services. Within five business days of receipt of the prior approval packet, the HHSC regional nurse sends the Authorization Form 2101, Authorization for Community Care Services, to the facility and the case worker. The effective date is the date of the physician's orders on Form 3055, Physician's Orders (DAHS).

Example: The facility receives Form 3055 on April 5 with a physician's signature date of April 1. The facility receives Form 2101 and the referral packet from the case worker on April 20. The facility submits the prior approval packet to the regional nurse on April 22 and the nurse receives the packet on April 24. This is within 30 calendar days of the physician's orders and the applicant meets all eligibility requirements, so the regional nurse authorizes services effective for April 1.

If the DAHS facility fails to submit the prior approval packet or additional documentation within the required time frames, or if the additional documentation is not adequate, or if the applicant is determined ineligible by the HHSC case worker, the regional nurse cancels the DAHS facility-initiated prior approval and the DAHS facility is not reimbursed for services. If the applicant meets all eligibility requirements, the HHSC regional nurse authorizes services by sending Form 2101 to the facility and the case worker. The nurse may send Form 2101 to the case worker by secure electronic mail (email) as determined by regional procedures. If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into the Service Authorization System (SAS) and print a copy of the Authorization Form 2101 from SAS and a copy of the email for the case record.

The effective date is the earliest of the following dates on the prior approval packet:

  • Postage meter date (if not cancelled by the U.S. Postal Service)
  • U.S. Postal Service date
  • HHSC stamp-in date

The facility is not reimbursed for any services delivered prior to the authorization date.

Example: The facility obtains verbal physician's orders and requests services through HHSC on April 1. The facility sends Form 3055 to the physician for his completion and signature. The HHSC case worker completes the assessment on April 13 and sends the facility Form 2101 and the referral packet. The facility has not received Form 3055 back from the physician. On May 2, the facility receives Form 3055 and mails the prior approval packet to the HHSC regional nurse. The regional nurse receives the packet on May 4, which is more than 30 days from the physician's verbal orders. The regional nurse establishes eligibility and authorizes services effective May 2, which is the U.S. Postal Service date on the envelope mailed from the facility.

 

Critical Omissions for Facility-Initiated Referrals

If there are critical omissions, the HHSC regional nurse sends Form 3070, Day Activity and Health Services Notification of Critical Omissions, within five business days of receipt of the prior approval packet to the facility with a copy to the case worker. The corrections from the facility must be submitted to the regional nurse within 14 days. If the corrections are received within the time frame and the applicant meets eligibility requirements, the regional nurse authorizes services effective the date of the physician's orders on Form 3055. If the facility fails to meet this time frame, the date of prior approval can be no earlier than the postmark or HHSC-stamped date on the corrected documentation. See Section 4236, Critical Omissions, for additional information.

 

4234.2 Case Worker Responsibilities for Facility-Initiated Referrals

Revision 17-1; Effective March 15, 2017

 

It is the case worker's responsibility to determine the applicant's eligibility within 30 calendar days from the assessment date and to track if Form 2101, Authorization for Community Care Services, has been completed by the Texas Health and Human Services Commission (HHSC) regional nurse. If, on the 30th day the case worker has not received Form 2101 or received notice of critical omissions, the case worker contacts the regional nurse to inquire if the required information has been received. The case worker must document the contact and the regional nurse's response. The case worker will take one of the following actions:

  • If the regional nurse has received the prior approval packet and services will be authorized, the regional nurse advises the case worker of the anticipated authorization date and sends Form 2101 to the facility and the case worker.
  • If the regional nurse has sent the prior approval packet back to the facility for critical omissions, the case worker allows another 30 calendar days for the facility to send corrections and receive approval. If Form 2101 has not been received at the end of the 30 days, the case worker contacts the regional nurse for the status and anticipated dates of approval or denial.
  • If the regional nurse has not received the prior approval packet or the critical omissions corrections, the case worker must deny the application and notify the applicant, the facility and the regional nurse of the denial, using Form 2065-A, Notification of Community Care Services. The facility will not be reimbursed for the services delivered.

The applicant may reapply for services, but new physician's orders and a new assessment must be completed.

 

4235 Facility Response to Case Worker Referrals

Revision 17-3; Effective May 15, 2017

 

For Texas Health and Human Services Commission (HHSC) case worker initiated referrals, the Day Activity and Health Services (DAHS) facility must respond within 14 days of receipt of the referral Form 2101, Authorization for Community Care Services, from the case worker.

40 Texas Administrative Code §98.203(d)-(f), Written Referrals for Services

Within 14 days of the receipt of the referral Form 2101, the DAHS facility sends the prior approval packet to the HHSC regional nurse. The prior approval packet consists of:

  • Referral Form 2101;
  • Form 3050, DAHS Health Assessment/Individual Service Plan; and
  • Form 3055, Physician's Orders (DAHS).

If the DAHS nurse notifies the case worker that the health assessment or the physician's orders will be delayed beyond 14 days, evaluate the cause of the delay. Consult the individual to determine whether he should be referred to another provider of his choice. If the case worker decides to make a new referral, verbally notify the original provider and HHSC regional nurse of the new referral. Send Form 2067, Case Information, to the original provider to confirm the withdrawal.

 

4235.1 Regional Nurse Responsibilities for Case Worker Referrals

Revision 17-3; Effective May 15, 2017

 

When the regional nurse receives the required forms from the facility, the regional nurse reviews Form 2101, Authorization for Community Care Services, Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 3055, Physician's Orders  (DAHS), to determine if the individual meets the Day Activity and Health Services (DAHS) medical eligibility criteria found in Section 4222, Medical Eligibility Criteria. If there are critical omissions/errors in the required documentation, the regional nurse follows procedures in Section 4236, Critical Omissions.

The regional nurse must keep the envelope in which the prior approval material is mailed. If more than one prior approval packet is included in the envelope, the regional nurse or his designee must indicate on the outside of the envelope the names of the prior approval packets that are included in the envelope.

Within five business days of the receipt of the prior approval request, the regional nurse generates and sends the authorization, Form 2101, to the facility and the case worker for notification of approval or denial of the applicant. The regional nurse grants approval if the:

  • individual meets the eligibility criteria specified; and
  • documentation from the facility contains no critical omissions or errors.

The region has the option of allowing the regional nurse to send notification of the authorization to the case worker by secure electronic mail (email), rather than sending the paper copy. Each region may determine which method best suits its needs. The regional nurse will continue to send a paper copy to the provider.

If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into the Service Authorization System (SAS) and print a copy of the Authorization Form 2101 from SAS, and a copy of the email for the case record.

 

4235.2 Effective Dates for Initial Cases

Revision 17-1; Effective March 15, 2017

 

The regional nurse establishes the beginning date of Day Activity and Health Services (DAHS) coverage based on whether the individual is referred by the case worker or by the facility as a facility-initiated referral, and if there are critical omissions/errors in the required documentation.

For case worker referrals, the regional nurse establishes the Begin Date of coverage on Form 2101, Authorization for Community Care Services, as the date it is expected to be mailed to the facility. If this date is not feasible, the regional nurse negotiates the Begin Date of coverage on Form 2101 with the case worker and the facility, according to the individual's needs and the individual's unique circumstances.

The regional nurse establishes the beginning date of coverage on Form 2101 for a facility-initiated referral using the date of the physician orders. If there are corrections for critical omissions/errors in the required documentation, the regional nurse follows procedures in Section 4236, Critical Omissions, and establishes the effective date as the:

  • date of the physician orders, if corrections are received within 14 days of the date the regional nurse sends Form 3070, Day Activity and Health Services Notification of Critical Omissions; or
  • date the corrections are received, if the corrections are not received within 14 days.

 

4235.3 Case Worker Responsibilities for Case Worker Referrals

Revision 17-1; Effective March 15, 2017

 

Within two business days of receipt of Form 2101, Authorization for Community Care Services, from the regional nurse, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual notifying the individual of eligibility or ineligibility.

If the individual was a facility-initiated referral, a copy of Form 2065-A is also sent to the facility. The effective date on Form 2065-A must match the effective date on Form 2101 from the regional nurse.

 

4236 Critical Omissions

Revision 17-1; Effective March 15, 2017

 

For a list of critical omissions, please refer to 40 Texas Administrative Code (TAC) §98.204(e), DAHS Facility-Initiated Referrals.

If the required documentation contains errors and/or omissions, the HHSC regional nurse:

  • completes Form 3070, Day Activity and Health Services Notification of Critical Omissions; and
  • sends it to the facility along with the rejected prior approval packet.

Corrections of critical omissions or errors in DAHS facility documentation must be postmarked or date stamped as received by HHSC within 14 days after the regional nurse mails HHSC Notification of Critical Omissions/Errors in Required Documentation form to the facility. If the facility fails to meet this time frame, the case worker will contact the individual within three workdays after being notified by the regional nurse and refer the individual to another DAHS facility, if the individual or the individual’s family/representative prefers this option.

The regional nurse uses the earliest of the following dates to establish the date that prior approval material and corrections of critical omissions or errors are received from the facility:

  • postage meter date (if not canceled by the U.S. Postal Service);
  • U.S. Postal Service date; or
  • HHSC stamp-in date.

The facility has 14 days to correct critical omissions/errors. If the facility returns the packet before the 14th day but all identified omissions/errors have not been corrected, the facility has the remainder of the 14 days to resubmit additional corrections. The regional nurse verbally notifies the facility that:

  • the corrected packet does not address all errors noted on Form 3070, and
  • additional corrections must be submitted on or before the 14th day to avoid a gap in payment.

The regional nurse documents this verbal notification (date, name of contact, etc.) in the case record.

 

4240 Facility Initiation of Services

Revision 17-1; Effective March 15, 2017

 

The facility must complete and return HHSC’s authorization for community services form to the case worker within 14 days from the begin date on HHSC’s authorization for community care services form. The Day Activity and Health Services (DAHS) facility must indicate the date services were initiated, the schedule for delivering services, and the total units authorized for the individual.

The 14-day period (for the facility to return Form 2101, Authorization for Community Care Services) encourages the facility to start services promptly. The 14-day period does not apply if an individual is already attending a DAHS facility when the facility refers him to the case worker (for example, a facility-initiated referral). For facility-initiated referrals, the facility returns Form 2101 as soon as possible after receiving it from the case worker.

 

4250 Monitoring

Revision 17-1; Effective March 15, 2017

 

Monitor the services based on the priority assigned to the individual's case. For priority levels, see:

Timelines for Day Activity and Health Services (DAHS)-only cases are measured differently than other situations because there is no Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, date from which to count. Measure DAHS-only timelines from the:

  • initial contact date (for initial certifications); or
  • the previous date on Form 2314, Satisfaction and Service Monitoring, (for recertifications).

The regional nurse also monitors DAHS through utilization review.

 

4260 Changes

Revision 17-1; Effective March 15, 2017

 

The Day Activity and Health Services (DAHS) facility must inform the case worker of changes in the individual's status, condition and when the individual is suspended from attending DAHS.

 

4261 Service Plan Changes Reported by the Facility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.208(b), Notifications

Approve changes in the plan of care which may affect eligibility or units of service. Within 14 calendar days of receipt of Form 2067, Case Information:

  • contact the individual to confirm he is in agreement with the proposed change;
  • review the request for change which may affect eligibility or units of service; and
  • respond to the written request.

If the case worker and individual agree with the facility's request, complete and send Form 2101, Authorization for Community Care Services. If the case worker and individual agree to terminate or reduce services, follow adverse action procedures in:

If the case worker or individual disagree with the request, send Form 2067 to the facility to explain the reason for not making the change.

 

4261.1 Individual Absences

Revision 17-1; Effective March 15, 2017

 

If a Day Activity and Health Services (DAHS) participant is absent from the facility for 15 consecutive days, the DAHS facility must verbally notify the Texas Health and Human Services Commission (HHSC) of the suspension no later than the first workday after services are suspended and then send Form 2067, Case Information, within seven workdays after the incident was reported verbally.

If an individual is absent from a regularly scheduled program, the DAHS facility must contact the individual or someone knowledgeable about his condition the same day that the absence occurs. If the DAHS facility is unable to contact the individual or someone knowledgeable about his condition, the DAHS staff must document this in the individual's record. DAHS facilities are not required to notify the case worker of daily absences from the facility.

 

4262 DAHS Transfers

Revision 17-1; Effective March 15, 2017

 

Only the individual may initiate a Day Activity and Health Services (DAHS) facility transfer; the change cannot be requested by facility staff.

When an individual decides to transfer to a new DAHS facility (including a facility in a different region), the individual must contact the HHSC case worker before making the move. The individual may make the request to the case worker orally or in writing. If a request for a DAHS transfer is received from anyone other than the individual, the case worker must contact the individual to ensure he desires the change. Services at the new facility may begin no earlier than one day after the individual receives services from the previous facility.

Within 14 days of the request from a current individual to transfer to another facility, follow these procedures:

  • Negotiate with both facilities the date the current facility will stop providing services and the date the new facility will start services, ensuring there is no gap or overlap in services.
  • Update Form 2101, Authorization for Community Care Services, by entering:
    • the nine-digit vendor number;
    • the effective date of the transfer; and
    • a statement in the comments section that this is an individual transfer.
  • Send Form 2101 to the gaining DAHS facility to begin services.
  • Send Form 2101 to the losing facility to terminate services.

It is critical for the case worker to coordinate individual transfers from one facility to another to ensure that no duplication of service or gaps in dates of coverage exist. Facility-initiated referrals are for applicants only and may not be used for individuals currently receiving DAHS services.

 

4263 Suspensions

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.207, Suspension of Day Activity and Health Services

For procedures on how to respond to suspension of services, see Section 2820, Service Suspension.

 

4264 Ensuring Health and Safety at DAHS Facilities

Revision 17-1; Effective March 15, 2017

 

If an individual attending a Day Activity and Health Services (DAHS) facility exhibits reckless behavior that may result in imminent danger to the health and safety of other DAHS individuals and/or DAHS staff, the DAHS facility must take immediate action to protect the individuals and staff in the facility. This may require removing the individual from the facility or away from other individuals and/or contacting the local authorities (police, sheriff's department or mental health authorities) to ensure safety. The facility may make a referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) Adult Protective Services (APS). The facility must immediately suspend services to the individual.

The DAHS facility must verbally inform the HHSC case worker by the following HHSC workday of the reason for the immediate suspension and follow up with written notification to HHSC within seven HHSC workdays of verbal notification, in accordance with 40 Texas Administrative Code (TAC) §98.207(b). Upon notification, the case worker must follow the procedures outlined in Section 2731, Threats to Health or Safety, including notifying management of the incident and conferring to ensure all appropriate actions are taken to maintain a safe environment in the facility.

An interdisciplinary team meeting must be arranged at the earliest opportunity to determine if the issue can be resolved and services continued. If the threat to health and safety was serious enough, services may be terminated immediately. See additional guidelines in Section 2811, Effective Dates.

If the individual reapplies for services at a later date, the policy outlined in 40 TAC §48.3902 applies and the individual must provide information or authorize collateral contacts to verify he is no longer a threat. See additional policy in Section 2732, Reinstatement of Services Terminated for Threats to Health or Safety.

 

4270 Reassessment

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §98.201, Eligibility Requirements for Participation

After the regional nurse gives initial prior approval for Day Activity and Health Services (DAHS), the authorization is transferred to the case worker. Review ongoing DAHS for these individuals according to Section 4271, Renewal of Prior Approval. The DAHS facility does not obtain new physician's orders for individuals receiving ongoing DAHS.

Review the DAHS individual's eligibility at least every 12 months. Timelines for DAHS-only cases are measured differently than other case situations because there is no Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, date from which to count. Measure DAHS-only reassessment timelines from the:

  • initial contact date (for initial certifications); or
  • the previous date on Form 2314, Satisfaction and Service Monitoring, (for recertifications).

When reassessing a DAHS individual's eligibility, examine the individual's past history of attendance and reauthorize only the number of units which the individual is likely to use. Explore the reasons for underutilization by discussing the situation with the individual, facility staff and the individual's family.

If underutilization has been sporadic due to temporary factors such as acute illness or hospitalization, no change in service authorization may be needed. However, if underutilization has occurred consistently during the previous six months, discuss changing the service plan with the individual and family. The case worker may need to decrease the number of units authorized per week.

A review of the service plan may be appropriate during the 12-month period if a change in units of service is required.

If the case worker determines that the individual continues to be eligible for DAHS, and if the number of units changes, submit Form 2101, Authorization for Community Care Services, to the facility. If the facility does not agree with the service plan change, the facility representative must contact the case worker before the effective date of the change, if possible, to resolve the disagreement.

Follow procedures in Section 4271 and Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services, to complete Form 2101.

If the case worker determines that the individual no longer qualifies for DAHS, send the individual Form 2065-A, Notification of Community Care Services, to terminate services. Update Form 2101 to terminate services. Follow procedures in:

  • Section 2811, Effective Dates for Service Reduction and Termination;
  • Form 2101 instructions; and
  • Appendix IX, Notification/Effective Date of Decision.

Send Form 2101 to the facility.

 

4271 Renewal of Prior Approval

Revision 17-1; Effective March 15, 2017

 

Although the coverage period is open-ended in the Service Authorization System, the case worker must conduct a reassessment/redetermination of the individual and send the facility Form 2101, Authorization for Community Care Services, confirming eligibility status if the number of units changes or if services are terminated. Use the following procedures for renewal of prior approval, including late renewals.

If the case worker . . . Then . . .
reassesses/redetermines the individual eligible for services and there are no changes to the service plan,

verbally notify the individual that services will continue at the same level.

Do not send any forms to the Day Activity and Health Services facility if there are no changes.

reassesses/redetermines the individual eligible for services and there are changes to the service plan (units),
  • send the individual Form 2065-A, Notification of Community Care Services, to notify him of the change in the service plan; and
  • send the facility an updated and signed Form 2101 to notify it of the change.

The effective date for a decrease is 12 days following the Form 2065-A date. The effective date for an increase is seven days following the Form 2101 date.

reassesses/redetermines the individual ineligible for services,
  • send the individual Form 2065-A to notify him of the termination; and
  • send the facility an updated and signed Form 2101 as notification of the termination.

See Appendix IX, Notification/Effective Date of Decision, to determine the effective date.

 

4300 Emergency Response Services

Revision 17-1; Effective March 15, 2017

 

 

 

4310 Introduction

Revision 17-1; Effective March 15, 2017

 

Emergency response services (ERS) are provided through an electronic monitoring system. This system is for use by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps ensure that the appropriate person or service agency responds to an alarm call from an individual.

ERS can be delivered to individuals with a landline telephone or in some areas may be available to individuals with cellular phone service or Voice Over Internet Protocol (VOIP). The provider agency choice list designates which ERS providers in the contracted service area are able to accommodate applicants who elect to receive ERS without a landline telephone. The rates for the service are the same regardless of the ERS delivery mechanism (e.g., cellular, landline, VOIP).

 

4311 Program Definitions

Revision 17-1; Effective March 15, 2017

 

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

Alarm call — A signal transmitted from the equipment to the provider's response center indicating that the individual needs immediate assistance.

Call button — An electronic device that, when pressed, triggers an alarm to the response center to alert the provider that an individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment or kept within the individual's reach.

Installer — A volunteer, a subcontractor or an employee of a provider who connects, maintains or repairs the equipment.

Monitor — A volunteer, subcontractor or an employee of a provider who monitors Emergency Response Services (ERS) and ensures that an alarm call is responded to immediately.

Responder — A person designated by an individual to respond to an emergency call activated by the individual. A responder may be a relative, neighbor or a volunteer.

Response center — The site where a provider's ERS monitoring system is located.

Subcontractor — An organization or individual who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.

 

4312 Eligibility and Referral Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

4312.1 Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2928. To be eligible for emergency response services, a client must:

(1) meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility; and

(2) meet the requirements:

(A) live alone, be alone routinely for eight or more hours each day, or live with an incapacitated individual who could not call for help or otherwise assist the client in an emergency;
(B) be mentally alert enough to operate the equipment properly, in the judgment of the DHS case worker;
(C) have a telephone with a private line, if the system requires a private line to function properly;
(D) be willing to sign a release statement that allows the responder to make a forced entry into the client's home if he is asked to respond to an activated alarm call and has no other means of entering the home to respond; and
(E) live in a place other than a skilled institution, assisted living facility, foster care setting, or any other setting where 24-hour supervision is available.

The eight hours mentioned in requirement (1) of the rule does not have to be continuous, provided the individual is alone at least eight hours in each 24-hour period. Even if the individual has an attendant, consider the individual alone.

If the provider is unable to complete installation, inform the individual that installation of ERS equipment is pending for the reasons stated by the provider. If the individual is unable or unwilling to make the needed modifications, explore other community resources to determine if these could be used to complete the needed modifications. If none are available, services may then be denied using termination code "other." Document the reason in the case record.

See Section 3000, Eligibility for Services, for additional eligibility requirements.

40 TAC §48.3903(d). The client is not eligible for emergency response services if:

(1) he abuses the service by activating:

(A) four false alarms which result in a response by fire department, police/sheriff, or ambulance personnel within a six-month period; or

(B) twenty false alarms of any kind within a six-month period;

(2) he is admitted to a skilled institution, personal care home, foster care setting, or any other setting where 24 hour supervision is available;

(3) in the case worker's judgment, he is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to:

(A) he damages the equipment,

(B) he disconnects the equipment and has received two warnings that are documented in the case record,

(C) he refuses to participate in the monthly systems checks; or

(4) he is away from the home or is unable to participate in the service delivery for a period of three consecutive months or more.

 

4312.2 Referral Process

Revision 18-1; Effective June 15, 2018

 

A provider must accept all HHSC referrals.  A case worker makes a routine referral on Form 2101, Authorization for Community Care Services, or makes a negotiated referral by phone and Form 2101.  

The case worker gives eligible applicants an explanation of the service. He explains that applicants/individuals are required to:

  • participate in the service delivery requirements; and
  • the case worker reviews Form 2307-B, ERS Eligibility Criteria and Responsibilities, with the individual, which includes a statement allowing the responder to enter the participant's home, by force if necessary, to assist the participant.

The case worker follows procedures as outlined in Section 3000, Eligibility for Services.

 

4313 Case Management Duties Related to Emergency Response Services (ERS)

Revision 17-1; Effective March 15, 2017

 

If the applicant/individual appears to be in need of ERS and wants to receive ERS, the case worker determines if the applicant/individual meets the general criteria for participating in ERS.

If eligible for ERS, the case worker shares the regional list of all ERS providers and encourages the applicant to choose the most economical alternative for service provision. The applicant/individual selects a provider from the list of providers. If the applicant/individual has no preference, the case worker refers the applicant to the provider with the lowest rate. If more than one provider has the same lowest rate, the case worker makes the referral by rotation of providers. If the individual is currently receiving services from a provider that does not have the lowest rate, but is not satisfied with that provider, the case worker should encourage the individual to choose another provider. The individual should not be encouraged to choose another provider just because it has a lower rate.

The case worker may assist the individual or the provider in identifying potential responders, and in periodically updating the information the provider maintains in its files on responders and other emergency numbers. The case worker must not be an emergency responder for the individual.

HHSC rules require the ERS provider to notify the case worker no later than the next HHSC workday of alarms, other individual emergencies or changes in the individual's behavior or condition that preclude ERS.

At least annually, the case worker must review the list of responders provided to the provider to ensure the list is current. During the course of the services, the case worker and the provider have the joint responsibility of keeping each other informed of changes or problems.

Report to the contract manager any provider tendency or pattern of designation of emergency personnel as respondents. Advise the individual that he is responsible for any charges assessed by emergency personnel if they are summoned to the individual's home for a non-medical emergency.

 

4320 Service Delivery Requirements

Revision 17-1; Effective March 15, 2017

 

 

 

4321 Service Initiation

Revision 17-1; Effective March 15, 2017

 

The service initiation process is located in 40 Texas Administrative Code (TAC) §52.403, Service Initiation.

When the provider receives a copy of Form 2101, Authorization for Community Care Services, and Form 2065-A, Notification of Community Care Services, he:

  • contacts the participant to make an appointment to install the emergency response home unit equipment; and
  • prepares a participant file, which includes applicable provider agency forms. Example: Individual information, home entry release statement, ownership of equipment statement and complaint procedure form.

If there is a negotiated service initiation date, the provider will receive confirmation from the case worker of the negotiated service initiation date by which services must begin.

The case worker evaluates whether an alternative service or other resources are available to meet the individual's needs. The case worker instructs the provider to retain the authorization and initiate services as soon as possible, or requests the return of the written referral packet.

 

4322 Securing Responders

Revision 17-1; Effective March 15, 2017

 

Responders must follow the rules as specified in 40 Texas Administrative Code §52.303, Responders.

 

4323 Equipment Installation

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §52.405, Equipment Installation.

(a) During an initial home visit, an installer must:

(1) install and make an initial test of the equipment;

(2) ensure that the equipment has an alternate power source in the event of a power failure;

(3) install within limits set forth in manufacturers' installation instructions; and

(4) if necessary:

(A) purchase a telephone extension cord;

(B) connect and run a telephone extension cord not to exceed 50 feet between the wall jack and the equipment; and

(C) safely tack the telephone extension cord against the wall or floorboard to prevent a hazard to an individual.

(b) An installer is not required to:

(1) adapt the physical environment in an individual's home to make it compatible with the equipment;

(2) arrange or pay for relocation of the telephone; or

(3) purchase or install electrical extension cords. An installer must not use an electrical extension cord when installing equipment.

(c) A provider must document a failure to install the equipment, including:

(1) the reason for the delay;

(2) the date the provider anticipates it will install the equipment or the specific reason the provider cannot anticipate a date; and

(3) a description of the provider's ongoing efforts to install the equipment, if applicable.

During the visit to the applicant's home, the installer connects the equipment and obtains the information needed to complete the applicable provider forms.

If the installer is unable to complete installation, the provider will document the reason for the delay, the date he anticipates he will install the equipment and a description of ongoing efforts to install the equipment, if applicable.

After installing the equipment, the installer demonstrates the equipment and allows the individual to activate an alarm call to become familiarized with the equipment. The installer explains the following service delivery requirements for which the individual is responsible:

  • participating in the monthly systems checks;
  • contacting the provider if he moves or has his telephone number changed; and
  • contacting the provider if he becomes aware of changes related to his responder(s).

The installer provides the individual with a written copy and an explanation of the complaint procedures.

 

4324 Provider Follow-Up Procedures

Revision 17-1; Effective March 15, 2017

 

The provider notifies the case worker of service initiation as outlined in Section 4321, Service Initiation.

The provider maintains ongoing communication with the case workers and the regional contract manager. He discusses individual-specific issues with the case worker, and contract management issues (overall service delivery, policies and procedures) with the regional contract manager.

 

4325 Selection of Providers and Provider Changes

Revision 17-5; Effective June 13, 2017

 

HHSC will encourage the individual to choose the most economical alternative for service provision.

The individual must contact his case worker to request a provider change. The case worker determines:

  • the individual's reason for dissatisfaction;
  • whether the individual's satisfaction can be met without changing providers;
  • if the provider will agree to the transfer; and
  • if the request was received within six months of service authorization.

The case worker attempts to resolve any problems the individual may have with the current provider before processing a transfer. If the case worker determines the individual's dissatisfaction is based on the individual's failure to comply with the service plan, the case worker may convene an interdisciplinary team (IDT) meeting to discuss the issues. If it is not necessary to terminate services due to the failure to comply with the service plan, the case worker may authorize a transfer if it is necessary to meet the individual's satisfaction or if the individual insists on changing providers.

The case worker asks the individual to select another provider and processes the transfer coordinating the date the current provider will end services and the date the new provider will begin services. As stated in Section 4340, Suspension and Termination of Services, and Texas Administrative Code §52.421, an Emergency Response Services (ERS) provider may receive payment for the month of service regardless of the number of days services were provided in the month services were terminated.  During a transfer of ERS services, the case worker must make every effort to coordinate the last day of service of the first provider to end on the last day of the month, and the begin date of transfer service of the second provider to start on the first day of the following month. Coordination by the case worker of transfer ERS end and begin dates reduces the need for administrative payment of services to a second ERS provider for the same calendar month.

 

4330 Service Delivery

Revision 17-1; Effective March 15, 2017

 

 

 

4331 Alarm Calls

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §52.409, Alarm Calls.

Activated alarms received at the response center are responded to immediately. The monitor keeps track of an incident from the time the alarm is activated to the time the participant receives assistance. Each activated alarm call must be considered an emergency, not an accident.

The monitor immediately contacts the responder(s) and/or proper authorities if the individual activates an alarm. If the monitor contacts the individual before a responder, he must talk to the individual to verify that an emergency exists.

Monitors contact a responder whenever an alarm call is activated and the monitor is unable to reach the individual.

 

4332 Systems Checks

Revision 17-1; Effective March 15, 2017

 

 40 Texas Administrative Code §52.407, System Checks.

(a) Purpose. The purpose of a system check is to ensure:

(1) that an individual can successfully make an alarm call; and

(2)that the equipment is working properly.

(b) Conducting a system check.

(1) A provider must conduct a system check at least once during each calendar month.

(2) The system check must be conducted during normal working hours or as negotiated with the individual.

(3) A provider must document a completed system check. The documentation must include the date and time of the completed system check and confirm that the individual was contacted.

The test involves contacting the individual and instructing him to press the call button to activate the alarm call. If two individuals live in the same residence, the monitor conducts a monthly systems check for each individual.

The following procedures apply when the monitor is unable to reach the individual to conduct a monthly systems check.

Calendar Procedures
For three consecutive months
  1. Try to reach the individual at least three times on three different days during the month.
  2. After three attempts, contact a responder and try to find out why the individual is unable to participate in the test.
  3. If a provider is unable to complete a system check during a calendar month, the provider must notify the case worker in writing as outlined in Chapter 52, Contracting to Provide Emergency Response Services.

Note: If within three consecutive months a monthly systems check is not successful, the provider may continue to receive payments if the provider continues to attempt to conduct system checks and convene an IDT meeting.

Note: In each of the three months, the provider is eligible for payment if all the requirements are met. The provider is not eligible for partial payment for partial completion of procedures.

The provider documents the reasons why the individual is unable to participate in the monthly systems check. The provider will contact the responder if he does not have a documented reason why the system checks have not been completed. The provider must ask the responder to find out why the individual is unable to complete the system check. The information may be documented in the individual's case folder or the monthly log of systems checks. Written notification is provided to the case worker as outlined in Chapter 52, Contracting to Provide Emergency Response Services.

An IDT is convened and the case worker evaluates the situation and determines if the individual continues to be appropriate for the service. The case worker completes and returns Form 2067, Case Information, if continuing services for the individual; if terminating services, he completes Form 2101, Authorization for Community Care Services.

The case worker may allow the authorization for ERS to remain effective if the individual continues to be eligible for the services, but is unable to participate in the monthly systems check.

The case worker ensures that the individual's authorization does not exceed three consecutive billing months during which the individual is unable to participate in the monthly systems check.

 

4333 Equipment Malfunction

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §52.411, Equipment Maintenance.

(a) Equipment failure. A provider must:

(1) contact an individual by the end of the next working day after learning of an equipment failure; and

(2) replace the equipment:

(A) by the end of the next working day after learning of an equipment failure if the individual is available; or

(B) by the end of the third working day after learning of an equipment failure if the individual is not available within one working day.

(b) Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.

(c) Documentation. A provider must document and maintain a record of each equipment failure and low battery signal. The documentation must include:

(1) the date the provider became aware of the equipment failure or low battery signal;

(2) the equipment or subscriber number;

(3) a description of the problem; and

(4) the date the equipment is repaired or replaced.

The provider must ensure the equipment is functioning properly and that each participant receives services during the entire authorization period.

The following persons may report equipment malfunctions to the provider:

  • individual,
  • individual's family members,
  • individual's responders,
  • case workers, and
  • monitors.

As equipment malfunctions are reported, the provider sends the installer to the individual's home to repair or replace the equipment.

The provider keeps a record of each equipment malfunction in the provider's files.

§52.411(b), Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.

The provider must respond to "low battery" signals received from individual's equipment. Provider staff should contact the individual by telephone after receiving a "low battery" signal to determine if the "low battery" could be caused by an accident, such as the unit having been unplugged. If the "low battery" signals continue, the provider must send a staff member to check, and repair or replace, the individual's ERS equipment within five days after the receipt of the fifth "low battery" signal.

 

4340 Suspension and Termination of Services

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code (TAC) §52.417, Required Notification,  §52.419, Suspension, and §52.421, Termination.

An interdisciplinary team (IDT) meeting may need to be called if monthly system checks are unsuccessful or an individual or someone in their home engages in illegal discrimination against a provider staff or HHSC employee. The case worker uses Form 2067, Case Information, to notify the provider that services should continue and Form 2101, Authorization for Community Care Services, to terminate services.

The case worker reports to the provider any changes involving the individual (Example: hospitalization, change of residence or visits with relatives.)

A provider may leave ERS equipment in a participant's home and continue service delivery when the individual has temporarily entered an institution. The provider must suspend services once the individual has been in the institution for more than 120 consecutive days. The provider is eligible for payment if the system checks are conducted during the 120-day period.

The provider requests termination of services when the individual is no longer mentally alert enough to operate the equipment properly. Situations include, but are not limited to, when the individual:

  • damages the equipment,
  • disconnects the equipment and has received two warnings that are documented in the case record, or
  • refuses to participate in the monthly systems checks.

The provider documents staff's inability to test the home unit in the individual's case file.
The provider requests the installer to remove the equipment from the individual's home after the case worker authorizes that services be terminated.
A provider may leave ERS equipment in an individual's home and continue services until the end of the month the service authorization expires. The provider receives payment for the month the service authorization ends, as long as:

  • monitoring continues until the equipment is picked up, and
  • the equipment is tested during the same calendar month or at the time of pickup.

If HHSC terminates ERS, a provider may be paid for the last month of service regardless of how many days of service were provided in that month, if the provider has complied with ERS requirements.

The individual is not liable for payment for lost or damaged equipment.

 

4341 Interdisciplinary Team (IDT) Meeting

Revision 17-1; Effective March 15, 2017

 

Interdisciplinary teams must follow the rules as specified in 40 Texas Administrative Code §52.413, Interdisciplinary Team.

The provider will convene an IDT meeting when the need arises. A meeting should be called for situations in which the provider is unable to resolve issues with the individual. The case worker must participate in the IDT to assist in resolving issues. The IDT could result in continuation or discontinuation of services. If applicable, policy relating to failure to comply with the service plan must be considered.

 

4350 Rates and Contracts

Revision 17-1; Effective March 15, 2017

 

The Health and Human Services Commission (HHSC) determines a unit rate ceiling for ERS. Rates can be accessed at: http://legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs/ers/index.shtml. The provider must maintain financial records and documentation of claims as outlined in 40 Texas Administrative Code §52.501, Record Keeping, in addition to the records required to be maintained for the participants.

 

4351 Advertising and Solicitation

Revision 17-1; Effective March 15, 2017

 

HHSC may investigate complaints of solicitation or coercion of individuals. Validated complaints may lead to adverse actions or termination of contracts. The ERS provider is in violation of the ERS contract if the provider employs a person:

  • who is paid money each time he recruits a new Medicaid recipient; or
  • whose sole responsibility is recruitment, regardless of how he is compensated.

The ERS provider may have an employee who is responsible for recruitment in addition to other assignments, as long as he is paid a regular salary and does not receive bonuses or anything that could be construed as a bonus for recruitment of Medicaid recipients.

 

4352 Disclosure of Previous Employment and Certification

Revision 17-1; Effective March 15, 2017

 

If a former or current HHSC employee or former or current council member or their relatives are an officer, director, owner or employee, the commissioner of HHSC or designee must approve the contract or contract renewal.

 

4353 Participant Records

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §52.501, Record Keeping.

 

4360 Reassessment

Revision 17-1; Effective March 15, 2017

 

Reassess for eligibility within 12 months of the last functional assessment for services. Call or make a home visit to re-determine the individual's eligibility for ERS. During the home visit, ask the individual to explain how to initiate an alarm call. Evaluate whether the individual continues to be sufficiently mentally alert to operate the equipment. (See Section 4312.1, Eligibility.)

If the individual continues to be eligible and there are no changes, do not send anything to the provider. If services are terminated, coordinate the effective date of termination to match on Form 2065-A, Notification of Community Care Services, and Form 2101, Authorization for Community Care Services, to allow the individual 12 days prior notice.

 

4400 Family Care Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4410 Primary Home Care Program

Revision 17-1; Effective March 15, 2017

 

The Primary Home Care Program (PHCP) is the personal attendant services (PAS) umbrella program under Chapter 47 of the Texas Administrative Code (TAC), which includes the following services:

  • Primary Home Care (PHC);
  • Community Attendant Services (CAS); and
  • Family Care (FC).

FC provides in-home PAS to individuals eligible under Title XX of the Federal Social Security Act (relating to block grants to states for social services). Providers delivering PAS must meet all the requirements in Texas Administrative Code §47.11, Contracting Requirements.

With the exception of this section and Section 4610, Primary Home Care Program, all non-Chapter 47 rule references within the Community Care for Aged and Disabled Handbook to "Primary Home Care" or "PHC" refer to the service, not the umbrella program.

For information on the Title XIX PHCP programs, see Section 4600, Primary Home Care and Community Attendant Services.

 

4411 Family Care Services Description

Revision 17-1; Effective March 15, 2017

 

Family Care (FC) provides assistance with activities of daily living to eligible individuals who have functional limitations caused by age, disabilities or medical problems. Services are limited to 50 hours per week (42 hours per week for a priority individual). Services include help with personal care, household tasks, meal preparation and escort.

FC is a non-skilled, non-technical service delivered by an attendant employed by the provider. The attendant must be age 18 or older. Providers must comply with the requirements in the contract with the Texas Health and Human Services Commission and in the Contracting to Provide Primary Home Care Services Handbook.

 

4412 Allowable Tasks

Revision 18-1; Effective June 15, 2018

 

Personal attendant services (PAS) that may be delivered under Family Care (FC) include the tasks defined in 40 Texas Administrative Code §47.41, Allowable Tasks.

For information on Escort Services, refer to 40 TAC §48.2919(a) and (b), Time Allocation for Escort Services.

Refer to the examples given in Section 4621, Allowable Tasks, for more information on calculating time for escort.  Escort may include accompanying the individual on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist/barber or social events. The time used to provide the escort task must not exceed the total time purchased for attendant care. No additional time for escort is allocated to the individual's service plan. The individual may elect to receive escort in place of assistance with household or personal care on a day that best meets his/her needs. This service does not include the direct transportation of the individual by the attendant.

Because shopping is an authorized task, it may entail the provider paying mileage to the attendant to perform the task. The individual cannot be charged for transportation costs incurred in performance of this task by either the attendant or the provider.

To facilitate safe individual ambulation or movement, arranging furniture may be provided (Example: Individuals who use wheelchairs, walkers or crutches or for blind individuals). The provider supervisor addresses this activity during orientation for an attendant who provides services to this type of individual.

Refer to Page 3 & 4 of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for further definition of activities that may be provided within each task.

 

4413 Excluded Services

Revision 17-1; Effective March 15, 2017

 

Family Care (FC) does not include services that must be provided by a person with professional or technical training. Examples include but are not limited to the following:

  • insertion and irrigation of catheters;
  • irrigation of body cavities;
  • application of sterile dressings involving prescription medications and aseptic techniques;
  • tube feedings;
  • injections;
  • administration of medication; and
  • any other skilled or technical services identified by the department.

Services that maintain an entire family or household are also excluded unless the entire household receives FC services. Examples:

  • cleaning floor and furniture in areas that the individual does not occupy or use;
  • preparing meals for the entire family or household;
  • laundering clothing or bedding that the individual does not use; and
  • shopping for groceries or household items the individual does not need for health and maintenance.

An attendant may shop for items the individual needs and that the rest of the household also uses.

 

4420 Eligibility

Revision 17-8; Effective September 1, 2017

 

To be eligible for family care, the applicant/individual must:

  • meet the income and resource guidelines established by the department in 40 Texas Administrative Code §§48.2902, 48.2903, 48.2922, and 48.2923  (relating to Income and Income Eligibles, Determination of Countable Income, Resource Limits, and Countable Resources);
  • meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the individual’s ability to perform activities of daily living. This yields a score, which is a measure of the individual’s level of functional need. The department sets the minimum required score for an individual to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility; and
  • be ineligible to receive attendant care services funded through Medicaid.

The applicant/individual must require at least six hours of family care per week to be eligible, unless the applicant/individual:

  • requires family care to provide respite to the caregiver;
  • lives in the same household as another individual receiving family care, community attendant services, or primary home care;
  • receives one or more of the following services (through the department or other resources):
    • congregate or home-delivered meals;
    • assistance with activities of daily living from a home health aide;
    • day activity and health services; or
    • special services to persons with disabilities in adult day care;
  • receives aids-and-attendance benefits from the Veterans Adminstration; or
  • is determined, based upon the functional assessment, to be at high risk of institutionalization without family care.

For eligibility policy not contained in this section, see:

 

4421 Residence

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(b). To receive services, the applicant/client must reside in a place other than:

(1) a hospital;
(2) a skilled nursing facility;
(3) an intermediate care facility;
(4) an assisted living facility;
(5) a foster care setting;
(6) a jail or prison;
(7) a state school;
(8) a state hospital; or
(9) any other setting where sources outside the primary home care program are available to provide personal care.

Family Care (FC) cannot be authorized if the individual lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

  • If three or fewer persons live in the home, the proprietor can be the personal attendant services (PAS) attendant for the individual(s) who resides there. The individual may not receive both PAS and Adult Foster Care.
  • If the home provides only room and board to four or more persons living in the home, it does not require licensure as a personal care home. PAS services can be authorized for individuals in this setting, but the proprietor, his agent or employee cannot be the attendant for individuals who reside in the home. The case worker must specify this on Form 2101, Authorization for Community Care Services.

FC can be provided to a private pay applicant/individual living in a residential care facility (whether or not contracted with HHSC) under the following conditions. The case worker:

  • applies the unmet need policy on a task-by-task basis, not duplicating services. Facilities provide varying degrees of assistance, and tasks purchased should not be tasks provided by the facility.
  • must closely monitor the case to determine if the individual is receiving additional services from the facility. Service plans must be adjusted to avoid duplication of services/tasks.

If the individual begins receiving Residential Care (RC) through HHSC, FC is terminated effective no later than the date RC services are started.

 

4430 Case Worker Procedures for Determining Eligibility

Revision 17-1; Effective March 15, 2017

 

See Section 2200, Intake Procedures, for intake, screening criteria and interest list procedures.

Upon receipt of a Family Care intake or release from the interest list, the case worker makes a home visit within the required time frames to begin the application process.

Conduct a home visit to determine whether the individual meets eligibility criteria as outlined in Section 4420, Eligibility. The applicant must provide information to determine financial eligibility as outlined in Section 3000, Eligibility for Services, and must be screened for eligibility for Community Attendant Services (CAS).

Give Form 2307, Rights and Responsibilities, and Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, to all applicants. Explain that the case worker must approve increases in the number of hours of services he receives. Also inform the individual that he may select another provider if he is dissatisfied with the services or with the attendant providing the services.

 

4431 Family Care Financial Eligibility

Revision 17-1; Effective March 15, 2017

 

To be eligible for family care, the applicant/individual must:

  • meet the income and resource guidelines established by the department in 40 Texas Administrative Code §§48.2902, 48.2903, 48.2922, and 48.2923 (relating to Income and Income Eligibles, Determination of Countable Income, Resource Limits, and Countable Resources);
  • be ineligible to receive attendant care services funded through Medicaid.

The case worker must determine that an applicant for Family Care is not eligible for services through Primary Home Care (PHC) or Community Attendant Services (CAS). See Section 2340, The Initial Interview and Application Process, for information on the determination of financial eligibility and screening for eligibility for CAS.

See Section 3000, Eligibility for Services, and Appendix XII, Examples of Methods to Verify Income and Resources, for specific information on determining financial eligibility.

 

4432 Family Care Functional Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §48.2911, Family Care

(a) To be eligible for family care, the applicant/client must:
(2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

40 TAC §48.2907, Need

(a)The client needs assessment questionnaire is used to determine an individual's functional need for CCAD services.
(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.

Applicants and individuals must score at least 24 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to be eligible for Family Care.

See Section 2400, Assessment Process, Section 2500, Service Planning, and Section 2600, Authorizing and Reassessing Services, for case worker procedures for full determination of functional eligibility and unmet need determination.

 

4433 Time Frames

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.

The case worker must complete all eligibility determination within 30 calendar days from the assessment date and send the applicant Form 2065-A, Notification of Community Care Services, within two business days of the eligibility decision.

 

4440 Referral Process

Revision 17-3; Effective May 15, 2017

 

Send the selected provider a referral packet consisting of:

  • Form 2059, Summary of Client's Need for Service;
  • Auto Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (generated by the Service Authorization System); and
  • Form 2101, Authorization for Community Care Services.

Follow the procedures in Section 2630, Referrals to the Provider.

All referrals to the provider, both initial and ongoing, must include the tasks being authorized, the total number of authorized hours and the number of days the applicant/individual requests services to be delivered. If the individual has special needs that require a specific schedule, document the requested schedule and the reason on Form 2101. Example: An individual may need a specific eating schedule due to a diabetic condition or a person with sleep problems may require that service delivery not begin until the afternoon.

Case workers must document in the comments section of Form 2101 the number of days the individual is to receive services based on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Example: "The individual requests a 5-day plan," or "The individual requests a 7-day plan."

Case workers must also document if there are any persons designated not to hire as outlined in Section 2514, Who Cannot Be Hired as the Paid Attendant.

 

4440.1 Types of Referrals

Revision 17-1; Effective March 15, 2017

 

 There are two methods of referral:

  • For expedited referrals, the case worker makes the referral by oral notice and on Form 2101, Authorization for Community Care Services.
  • For routine referrals, the case worker makes the referral on Form 2101.

Routine Referrals

Within five business days of the eligibility decision, the case worker mails the referral packet to the provider to authorize service delivery.

Expedited Referrals

In some instances, the individual's need for services, based on the case worker's judgment, is such that delivery of services must be facilitated. When weighing whether an expedited referral is warranted, consider:

  • What was the individual's assigned intake priority? In most situations, cases which required an expedited response to a request for services also require an expedited referral.
  • Is the applicant being authorized as having priority status? If so, that may indicate a need for an expedited referral.
  • Could a delay in starting services constitute a threat to the individual's health, safety or well-being? If so, an expedited referral is needed.

The expedited referral process includes:

  • upon making the eligibility decision, the case worker makes a verbal referral to the selected provider and negotiates a start of care date which must be less than 14 calendar days; and
  • following up the verbal referral by sending a referral packet to the provider, including Form 2101, Authorization for Community Care Services, noting the time, date and staff person contacted, and the negotiated start date in the comments section.

 

4441 Provider Responsibilities after Receipt of Referral

Revision 17-1; Effective March 15, 2017

 

Upon receipt of the referral packet, the provider must conduct pre-initiation activities, develop a service plan and assign an attendant to perform services for the individual in accordance with 40 Texas Administrative Code §47.45. These activities must be completed within 14 days after one of the following dates, whichever is later:

  • the referral date on Form 2101, Authorization for Community Care Services; or
  • the date the provider receives Form 2101, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness.

For expedited referrals, the provider must document the date, time and the name of the case worker who gives the verbal authorization. Provider staff contact the case worker if the packet is not in their office by the seventh day after the verbal referral.

The provider can request a corrected authorization if the information (for example, hours or dates of coverage) conflicts with what was given over the telephone. In these situations, correct and initial Form 2101 and mail a copy of it to the provider.

Within 14 days after initiating services, the provider must send notice of service initiation to the case worker. The provider may, but is not required, to use Form 2101 to notify the case worker of service initiation.

 

4441.1 Delay of Service Initiation

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §47.61, Service Initiation.

(c) Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond its control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider's control;

(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and

(3) a description of the provider's ongoing efforts to initiate services.

(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

 

4441.2 Initial Service Delivery Plan Variances

Revision 17-1; Effective March 15, 2017

 

Providers must follow the rules as specified in 40 Texas Administrative Code §47.45(b), Service delivery plan variances.

 

 

4442 Resolution of Service Plan Disagreement

Revision 17-1; Effective March 15, 2017

 

If a disagreement exists about the appropriateness of a referral or about service delivery issues involving the individual, the case worker and the provider staff attempt to resolve the disagreement. If the disagreement is not resolved at this level, supervisory staff of the two agencies attempt to resolve it. If supervisory staff of both agencies are unable to resolve a disagreement, the regional director or designee resolves it. Do not delay service initiation because of a disagreement. The regional nurse may always be consulted regarding health and safety issues or the appropriateness of the service plan.

 

4443 Change of Providers

Revision 17-3; Effective May 15, 2017

 

Monitor the individual after services are initiated and periodically thereafter to check on the adequacy of the service plan, the quality of service delivery and the individual's condition. Report to the unit supervisor any apparent deficiencies in the provider's delivery of Family Care (FC) services.

When an FC individual plans to change providers, the individual must first contact his case worker, who will:

  • coordinate the transfer to prevent a gap in coverage; and
  • attempt to resolve any problems the individual may be having with his current provider before processing the transfer.

Within 14 calendar days of notification that an ongoing FC individual is requesting a transfer to another provider, the case worker contacts the individual and the provider to determine:

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

The case worker considers the following to identify the individual's reason for dissatisfaction:

  • Timeliness of services
    • Are services being provided during the hours of the days the individual wants the services?
    • Is a special attendant sent when a priority individual's special attendant is not able to work for the individual?
    • Are services not being provided to a non-priority individual for more than 14 consecutive days or to a priority individual as scheduled, except if the reason for the break is based on:
      • the individual not being home when the attendant was scheduled to work;
      • the individual's request that services not be provided on a specific day(s); or
      • a reason for suspension of services, as listed in Section 4446, Suspension of Services and Interdisciplinary Team (IDT) Procedures?

        If a non-priority individual refuses to be without services for any length of time, the individual may transfer to another provider that may provide services when the individual prefers to receive them.

    • When the individual is unavailable to receive services at the scheduled time, are services being delivered at an alternate time? For example, the individual has been discharged from a three-day hospital stay.
    • Are services being provided as scheduled? Is it due to any of the following reasons?
      • The individual is often away from his residence when his service is scheduled and repeatedly fails to notify the agency that he will be gone, even if the case worker and provider have counseled him about this problem and its implications.
      • The individual or someone in the individual's home regularly will not permit the provider to perform one or more of the tasks in the service plan.
      • The individual refuses to accept services because of dissatisfaction with all attendants the provider sends.
      • The individual or someone in the individual's home regularly behaves in a way that is so offensive to staff employed by the provider that the provider refuses to serve the individual, and the individual knowingly and passively condones the person's behavior, and the staff are unable to provide services. Examples of offensive behavior include sexual harassment, sexual misconduct and racial discrimination.
    • Does the attendant have a pattern of being late or not showing up for work?
  • Accessibility of services
    • Is the individual able to speak with the provider when he wants to request a change in his service plan?
    • Is the provider readily responsive to the individual's request for change in the service plan?
    • Is the provider reluctant to speak with the individual because the individual has a history of harassing the provider or attendant?
    • Does the individual want to receive a task that is not purchased by the Texas Health and Human Services Commission?
  • Quality of services
    • Is the attendant performing the tasks the individual wants?
    • Is the attendant able to perform the tasks the individual wants?
    • Is the attendant following the individual's instructions in performing tasks?
    • Are the individual's expectations of the attendant realistic?
  • Individual's rights and responsibilities
    • Did the provider consider the individual's wishes when developing the service plan?
    • Does the provider respect the individual's right to privacy by informing the individual in advance when the attendant or the agency supervisor plan to visit the individual?
    • Does the individual feel that the provider communicates with him as an adult?
    • Does the individual feel that he can express his opinions or dissatisfactions without fear of losing his attendant or services?
    • Does the provider inform the non-priority individual, in advance, of the attendant's inability to work a particular day?

If the case worker determines that the individual's dissatisfaction is based on the individual's failure to comply with the service plan, the case worker contacts the individual or the party involved and attempts to resolve the problem in a way that is satisfactory to all parties involved. The case worker discusses the problem with the supervisor. An interdisciplinary team meeting may be conducted at the individual's home to try to resolve the situation. The case worker may terminate the individual's services if the individual refuses more than three times to comply with service delivery provisions by repeatedly and directly, or knowingly and passively, condoning the behavior of someone in his home.

By the 14th day, authorize the transfer if:

  • it is determined that the individual's satisfaction cannot be met without changing providers and services do not have to be terminated based on failure to comply with the service plan; or
  • the individual insists on transferring to another provider and it is determined that services do not have to be terminated based on failure to comply with the service plan.

Within 14 calendar days of receiving a request from the individual or the individual's representative to change providers, the case worker:

  • asks the individual or the individual's representative to select a new provider and document the individual's choice of the new provider in the case record by:
    • coordinating with both providers the date the current provider will stop providing services and the date the new provider will start services;
    • updating any pertinent information on Form 2059, Summary of Client's Need for Service;
    • updating Form 2101, Authorization for Community Care Services, by entering the new nine-digit contract number in Item 2; and
    • documenting in the comments section that the individual is changing providers;
  • sends the new provider the updated Form 2101 and Form 2059; and
  • sends the current provider a copy of the updated Form 2101 that includes the effective date the individual changes providers.

 

4443.1 Service Interruptions

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §47.63(a), Service interruptions.

A service interruption occurs anytime service delivery is discontinued for 14 days or more for a reason that is not covered in Section 4446, Suspension of Services and Interdisciplinary Team (IDT) Procedures. The provider should make every effort to ensure that interruptions in service last less than 14 days, particularly if a break in service would jeopardize the individual's health or safety. When an interruption of services is unavoidable, the provider must document all service interruptions by the:

  • 30th day after the beginning of the service interruption for priority individuals and

30th day that exceeds 14 days after the service interruption for non-priority individuals.

 

4444 Reporting Significant Changes

Revision 17-1; Effective March 15, 2017

 

The provider notifies the case worker or the case worker's office (by telephone or in person) about a change in the individual's condition or circumstances that may require a service plan change or service termination.

The provider must notify the case worker by the first Texas Health and Human Services Commission workday after provider staff notice the change and must follow up in writing, using Form 2067, Case Information, within seven days after verbal notification.

Any of the following changes in the individual's condition or circumstances may require a change in his service plan. (These are examples only; this list is not intended to be all inclusive.)

  • The individual's health improves or deteriorates.
  • The individual no longer needs services.
  • The individual is discharged from a hospital.
  • Problems exist with family relationships.
  • The individual is evicted or otherwise loses his housing.
  • The individual relocates.
  • The individual is referred for home health services.
  • Changes occur in the individual's household composition.

If the case worker receives a request for a change, respond to it within 14 days from the date the request is received. Review the individual's service plan to decide whether the change is necessary. If the case worker decides the change is not necessary, document the decision on Form 2067 and send it to the provider, keeping a copy in the case record.

Depending on the individual's new condition or situation, a new assessment or

Revision of the service plan (such as a change in priority status or a need for more hours) may be necessary. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, according to Section 2720, Changes Reported in the Individual's Condition or Status during the Certification Period. Consult with the supervisor about the requested change, if necessary. If the report meets the criteria for Adult Protective Services (APS), refer the individual to that service. See Section 2220, Response to Requests for Service.

 

4445 Service Plan Changes

Revision 17-1; Effective March 15, 2017

 

If a service plan change is authorized, mail two copies of Form 2101, Authorization for Community Care Services, and one copy of Form 2059, Summary of Client's Need for Service, to the provider. If a service plan change increases hours or adds priority status, the beginning date of coverage is seven days from the Form 2101 date.

For a service reduction/termination, the provider must abide by the case worker's 12-day prior notice provided to the individual before implementing the change. The case worker must advise the provider using the comments section on Form 2101, if applicable, not to implement an adverse action until after the 12-day notice. The individual may appeal the decision and choose to continue to receive services pending the outcome of the appeal. These time frames apply only to those cases in which the provider has a current authorization for the individual.

When the individual requires an immediate change to the service plan, approve the change by telephone or in person. Respond by the next Texas Health and Human Services Commission (HHSC) workday when any of the following situations occur:

  • The individual has a major illness and no available caregiver.
  • The individual loses his caregiver suddenly, has no other available caregiver, and
    • is totally bedridden or unable to transfer from bed to chair without assistance;
    • cannot manage toileting tasks without personal assistance; or
    • needs meal preparation or feeding to ensure that he receives daily nourishment.

If necessary, verbally authorize a service plan change, initial the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and send two copies of Form 2101 to the provider within two workdays of the verbal request.

See Appendix XVIII, Time Calculation, for assistance in determining the change effective date.

 

4446 Suspension of Services and Interdisciplinary Team (IDT) Procedures

Revision 17-1; Effective March 15, 2017

 

 The provider agency must suspend services if:

  • the individual permanently leaves the state or moves to a county in which the provider agency does not contract with the Texas Health and Human Services Commission (HHSC) to provide services under the Primary Home Care Program (see Section 4677.1, Individual Temporarily Leaving Service Area);  
  • the individual moves to a location where services cannot be provided under the Primary Home Care Program;
  • the individual dies;

Note: When notified of an active SSI/Medicaid individual's death, complete and send Form SSA-1610-U2, Public Assistance Agency Information Request, to report the death of the individual to the Social Security Administration. Keep a copy of Form SSA-1610-U2 and file in the case record.

  • the individual is admitted to an institution. An institution is defined as a:
    • hospital;
    • nursing facility;
    • state school;
    • state hospital; or
    • intermediate care facility serving individuals with an intellectual disability or related conditions;
  • the individual requests that services or specific tasks end;
  • HHSC denies the individual’s Medicaid eligibility (not applicable to family care services); or
  • the individual or someone in the individual’s home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person. If this occurs, the provider agency must make an immediate referral to:
    • the Texas Department of Protective and Regulatory Services or other appropriate protective services agency;
    • local law enforcement, if appropriate; and
    • the individual’s case worker.

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.

The provider agency may also suspend services if:

  • the individual or someone in the individual’s home engages in discrimination against a provider agency or HHSC employee in violation of applicable law; or
  • the individual refuses services for more than 30 consecutive days.

The provider agency must notify the case worker by fax of any suspension by the next working day. The faxed notice of a suspension must include:

  • the date of service suspension;
  • the reason(s) for the suspension;
  • the duration of the suspension, if known; and
  • an explanation of the provider agency's attempts to resolve the problem that caused the suspension, including the reasons why the problem was not resolved.  

The provider agency must convene an interdisciplinary team (IDT) meeting to resume services.

The provider agency must resume services after suspension:

  • upon the individual’s return home, or the date the provider agency becomes aware of the individual’s return home, if applicable;
  • on the date specified in writing by the case worker;
  • as a result of a recommendation by the IDT; or
  • upon the provider agency's receipt of notification from the case worker that the provider agency must resume services pending the outcome of the appeal.

The provider agency must notify the case worker in writing of the date services resume and must send the notice within seven days of that date.

 

4447 Reassessment

Revision 17-7; Effective July 1, 2017

 

At each annual functional reassessment of Family Care individuals, the case worker must review the screening exception criteria to see if the individual’s circumstances have changed. For example, if an individual was placed on Family Care due to no personal care tasks, but at the annual reassessment he now requires a personal care task, then the case worker must refer the individual to Primary Home Care (PHC) or Community Attendant Services (CAS).

Financial eligibility must be redetermined for Family Care within 24 months of the last eligibility determination. If Medicaid for the Elderly and People with Disabilities (MEPD) previously determined the individual was ineligible for CAS due to resources, the case worker must review the individual’s financial status in accordance with Section 3422, Exceptions to Verification Requirements. If it appears the individual would now meet CAS requirements, the case worker must assist the individual in completing a new Form H1200-EZ, Application for Assistance – Aged and Disabled, and obtain verifications of income and resources to send to MEPD.

If the individual or provider reports interim changes between annual reassessments, the case worker will apply the screening exception criteria at the next annual review.

For Family Care 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.

 

4448 Complaints

Revision 17-9; Effective September 15, 2017

 

An individual has the right to voice grievances or complaints concerning the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation. The individual has a right to report service delivery issues to the Health and Human Services Office of Ombudsman at 1-877-787-8999. If the case worker is aware of the issue, the case worker must work to resolve the individual's issues. See policy outlined in Section 2736.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

 

4500 Meals Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4510 Description

Revision 17-1; Effective March 15, 2017

 

Home-Delivered Meals (HDM) provides hot, nutritious meals that are typically served in the individual's home. Meals may be delivered to alternate locations, provided the location is within the provider's normal service delivery area.

Example: An individual receives dialysis treatments on Mondays, Wednesdays and Fridays. Because the treatment center is within the provider's normal service delivery area, HDMs can be delivered to that location on the days the individual receives treatments.

When it is necessary for the individual to receive meals in an alternate location out of the service area on a regular basis, shelf-stable or frozen meals may be delivered to the individual's home for use in the other location. The case worker must check with the contract manager to ensure that the provider's contract allows delivery of shelf-stable/frozen meals.

Meals delivered by contracted providers are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics or food service management.

40 Texas Administrative Code (TAC) §55.15, Menus.

(a) A dietary consultant must approve each menu with a list of allowable substitutions as meeting one-third of the recommended daily dietary allowance. The approval must be dated before the date the meal is served. A provider agency may not deviate from the approved menu and its allowable substitutions, unless the provider agency is providing a therapeutic medical diet.
(b) Planned menus must provide foods with a variety of flavor, consistency, texture and temperature.
(c) A provider agency must maintain approved menus that meet the terms of the contract.

40 TAC §55.19, Modified Diets.

(a) A provider agency must keep documentation from the client's physician of the client's need for a therapeutic medical diet, according to the terms of the contract.
(b) A provider agency must determine the extent to which the provider agency can provide therapeutic medical meals.

In addition to healthy meals, monthly nutrition education is provided to HDM individuals.

40 TAC §55.11, Nutrition Education. A provider agency must provide nutrition education on a monthly basis, either verbally or in writing, to clients. An annual written plan for nutrition education must be developed, identifying subject matter, method of presentation, materials used, and source of the information presented. This plan must be maintained according to the terms of the contract.

 

4520 Eligibility

Revision 17-1; Effective March 15, 2017

 

Individuals who apply for or receive Title XX meals are not subject to an income and resource eligibility determination.

40 Texas Administrative Code §48.2912. To be eligible for home-delivered meals, applicants and clients must meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

An individual must score at least 20 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to be functionally eligible for Home-Delivered Meals.

 

4521 Home-Delivered Meals Interest List Procedures

Revision 17-1; Effective March 15, 2017

 

If all service authorization slots are filled at the time an individual requests home-delivered meals, consult the individual to decide whether his needs can be met through other services. If no other service is available or suitable, add the individual's name to the Home-Delivered Meals Interest List(s) by entering the information in the Community Services Interest List (CSIL) system. Individuals who request placement on an interest list must be Texas residents. Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for service become available. See Section 2230, Interest List Procedures, for additional information.

If the individual is receiving meals through some other service, the case worker must explore if the meals are through a temporary service. There are several organizations within communities that offer temporary delivery of meals until another source is available. Meals received through the Area Agency on Aging (AAA) through Title III are limited and only meant to provide temporary assistance to individuals. Meals provided through other local organizations may also be temporary.

If an individual calls to request home-delivered meals through Title XX and is currently receiving meals, the intake person records the source of the current meals. The individual must not be screened out due to receiving meals from another source. The intake person completes the intake and either refers to a case worker for assessment, if the region has open enrollment, or places the individual's name on the interest list. If an ongoing individual requests Title XX meals, the same policy applies. The applicant/individual may continue to receive temporary meals while on the interest list for Title XX home-delivered meals.

When the case worker receives the request for services or an individual's name is released from the interest list, the case worker must determine if the source of current meals is ongoing or temporary. If the applicant/individual states the meals are ongoing, the case worker must verify with the source and document that the meals are ongoing. The applicant/individual has a right to choose between Title XX home-delivered meals and the other source. The case worker must document the applicant's/individual's decision and follow procedures for approving or denying the request for services.

If the source is a temporary service, the applicant must be authorized for Title XX meals if all other eligibility requirements are met. Service initiation through Title XX meals must be coordinated with the termination of the temporary service and documented in the case record.

 

4530 Casework Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

 

4531 Service Initiation

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §55.25, Service Initiation.

To refer individuals to providers for Home-Delivered Meals (HDM), complete Form 2101, Authorization for Community Care Services, and send the referral packet to the selected provider (see Appendix XIII, Content of Referral Packets). The provider must initiate services within 10 days from the date of referral and return Form 2101 to the case worker within 21 calendar days.

Inform the provider of any special circumstances that would be relevant to the individual's service provision. Whenever necessary for the individual's health, specify on Form 2101 that the provider must deliver meals that have been prepared without added salt as seasoning or flavoring. Ensure that the individual understands when the home-delivered meals will be delivered, his responsibility for receiving the meals and that he is not responsible for contributing or paying for them.

Reassess the individual's eligibility for services annually, within 12 months of the previous functional assessment.

Note: To ensure there is no service duplication of home-delivered meals, coordinate services with the local Area Agency on Aging.

 

4532 Individual Health and Safety

Revision 17-1; Effective March 15, 2017

 

 A provider agency must have written procedures in place to ensure it investigates and reports to the appropriate persons or entities any significant changes in the individual’s physical or mental condition or environment. These procedures must require the following:

  • The provider agency notifies an individual’s case worker, orally or by fax, within one working day after becoming aware of significant changes in the individual’s physical or mental condition or environment.
  • If the provider agency notifies the case worker orally, the provider agency must send written notification to the case worker within five working days of the initial verbal notification.

A provider agency must inform the individual about safety, health, or fire hazards identified in the individual’s home when the provider agency discovers these hazards. The provider agency must retain documentation of such communications in its files, according to the terms of the contract.

A provider agency must notify the Texas Health and Human Services Commission (HHSC) personnel, orally or by fax, within one working day after an incident that may prevent the provider agency from delivering meals to one or more individuals.

A reportable incident includes:

  • weather-related emergency;
  • fire; or
  • other natural disaster.

The provider agency must report an incident to:

  • the contract manager;
  • the individual’s case worker or supervisor.

If the provider agency notifies the case worker orally, the provider agency must send written notification to the contract manager or case worker, or both, within five working days of the initial notification.

If the individual delivering the meal reports to the provider any individual illnesses, potential threats to safety or observable changes in the individual's condition, the provider must notify the case worker about the report within 24 hours. The provider must also notify the case worker within 24 hours whenever the meal is found uneaten or untouched.

 

4532.1 Waivers for Alternate Meal Delivery Methods

Revision 17-1; Effective March 15, 2017

 

Home Delivered Meals (HDM) providers are generally expected to deliver five hot meals a week to each individual. Occasional exceptions to allow the use of "…frozen, chilled or shelf-stable meals for emergency or inclement weather situations, emergency situations and for situations approved by the contract manager on a case-by-case basis…", may be granted under Texas Administrative Code, Title 40, §55.21, concerning Frozen, Chilled or Shelf-Stable Meals.

HDM providers must submit a waiver request to the Texas Health and Human Services Commission (HHSC) contract manager if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the provider's contracted service area. Any waivers granted will be effective for a period not to exceed one fiscal year. The provider must not implement the waiver of the requirement for delivery of a hot meal five days a week prior to HHSC approval of the waiver request.

In order to be able to adequately inform individuals of the service delivery plan, case workers are expected to work closely enough with the contract manager to be aware of the delivery provisions of each HDM provider. Any inquiries by providers regarding the waiver must be referred to the contract manager.

 

4533 Suspension of Services

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §55.33, Suspension of Services.


The provider must notify the case worker on the day Home-Delivered Meals is suspended without the case worker's authorization. The provider must suspend services in any of the following situations when the:

  • individual moves out of the geographical area served by the provider;
  • individual enters an institution;
  • individual requests that services be suspended or terminated;
  • individual dies; or
  • case worker directs the provider to suspend services.

Unless the interruption is the result of one of the above situations, the provider must obtain the case worker's approval for service interruptions of more than two consecutive days.

When the individual requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the case worker.

 

4534 Termination of Services

Revision 17-1; Effective March 15, 2017

 

The case worker must send the provider authorization for community care services for Title XX services, indicating the date services are to be terminated.

Send a copy of Form 2065-A, Notification of Community Care Services, to the provider as notification of the termination and of the date the service will end. For detailed information regarding service termination, see Section 2800, Procedures for Denying or Reducing Services.

 

4600 Primary Home Care and Community Attendant Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4610 Primary Home Care (PHC) and Community Attendant Services (CAS) Contracting

Revision 17-1; Effective March 15, 2017

 

PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under §1929(b)(2)(B) of the Social Security Act, respectively. Both programs require that recipients have a need for assistance with personal care tasks. Providers delivering PAS must meet all of the requirements in 40 Texas Administrative Code §47.11, Contracting Requirements.

For information on the Title XX PHCP program, see Section 4400, Family Care Services.

 

4620 Personal Attendant Services Description

Revision 17-1; Effective March 15, 2017

 

Primary Home Care and Community Attendant Services provide non-technical attendant services to eligible individuals who have a medical condition resulting in a functional limitation in performing personal care. Attendants help individuals with activities of daily living, such as bathing, grooming, meal preparation and housekeeping. Attendants are trained and supervised by non-medical personnel.

 

4621 Allowable Tasks

Revision 18-1; Effective June 15, 2018

 

Primary Home Care (PHC) and Community Attendant Services (CAS) provide in-home assistance to eligible Medicaid individuals who have medically-related health problems that cause them to be functionally impaired in performing personal care. Personal attendant services (PAS), which may be delivered under CAS and PHC, include the tasks defined in 40 Texas Administrative Code §47.41. PHC and CAS include the following tasks:

(1) personal care tasks related to the care of the individual's physical well-being, including:
(A) bathing, which is:
(i) drawing water in sink, basin, or tub;
(ii) hauling or heating water;
(iii) laying out supplies;
(iv) assisting in or out of tub or shower;
(v) sponge bathing and drying;
(vi) bed bathing and drying;
(vii) tub bathing and drying; and
(viii) providing standby assistance for safety;
(B) dressing, which is:
(i) dressing the individual;
(ii) undressing the individual; and
(iii) laying out clothes;
(C) meal preparation, which is:
(i) cooking a full meal;
(ii) warming up prepared food;
(iii) planning meals;
(iv) helping prepare meals; and
(v) cutting individual's food for eating;
(D) feeding/eating, which is:
(i) spoon-feeding;
(ii) bottle-feeding;
(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and
(iv) providing standby assistance or encouragement;
(E) exercise, which is walking with the individual;
(F) grooming, shaving, or oral care, which is:
(i) shaving;
(ii) brushing teeth;
(iii)shaving underarms and legs, when requested;
(iv)caring for nails; and
(v)laying out supplies;
(G) routine hair or skin care, which is:
(i) washing hair;
(ii) drying hair;
(iii) assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair;
(iv) combing or brushing hair;
(v) applying nonprescription lotion to skin;
(vi) washing hands and face;
(vii) applying makeup; and
(viii) laying out supplies;
(H) assistance with self-administered medications, which is assistance with medication as defined in §97.2(11) (relating to Definitions);
(I) toileting, which is:
(i) changing diapers;
(ii) changing colostomy bag or emptying catheter bag;
(iii) assisting on or off bedpan;
(iv) assisting with the use of a urinal;
(v) assisting with feminine hygiene needs;
(vi) assisting with clothing during toileting;
(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;
(viii) changing external catheter;
(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and
(x) providing standby assistance; and
(J) transfer, which is:
(i) non-ambulatory movement from one stationary position to another, not including carrying;
(ii) adjusting or changing the individual's position in a bed or chair (positioning);
(iii) assisting in rising from a sitting to a standing position;
(K) ambulation, which is:
(i) assisting in positioning for use of a walking apparatus;
(ii) assisting with putting on and removing leg braces and prostheses for ambulation;
(iii) assisting with ambulation or using steps;
(iv) assisting with wheelchair ambulation; and
(v) providing standby assistance;
(2) home management tasks that support the individual 's health and safety, including:
(A) cleaning, which is:
(i) cleaning up after the individual's personal care tasks;
(ii) emptying and cleaning the individual's bedside commode;
(iii) cleaning the individual's bathroom;
(iv) changing the individual's bed linens and making the individual's bed;
(v) cleaning floor of living areas used by individual;
(vi) dusting areas used by individual;
(vii) carrying out the trash and setting out garbage for pick up;
(viii) cleaning stovetop and counters;
(ix) washing the individual 's dishes; and
(x) cleaning refrigerator and stove;
(B) laundry, which is:
(i) doing hand wash;
(ii) gathering and sorting;
(iii) loading and unloading machines in residence;
(iv) using Laundromat machines;
(v) hanging clothes to dry; and
(vi) folding and putting away clothes;
(C) shopping, which is:
(i) preparing a shopping list;
(ii) going to the store and purchasing or picking up items;
(iii) picking up medication; and
(iv) storing the individual's purchased items.
(3) escorting, which includes:
(A) accompanying the individual outside the home to support the individual in living in the community;
(B) arranging for transportation, not including direct individual transportation;
(C) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and
(D) waiting in the doctor's office or clinic with an individual if necessary due to individual's condition or distance from home.

The case worker must document a specific need for escort. If escort for medical trips occurs at least once a month, time may be allocated. To determine the weekly time allocation, divide the time by 4.33 to arrive at a weekly figure. If escort occurs more than once a week, the case worker must include additional documentation explaining why the individual needs escort this frequently. See Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for additional information.

Since escort is always determined and entered on a weekly basis, use the following examples for escort services:

Example 1: Individual has a doctor’s appointment every week for one hour with her chiropractor and needs another hour transportation time to get to and from the doctor’s office. The individual needs two hours total escort weekly. The case worker applies 120 minutes weekly for escort. 

Example 2: Individual has one appointment a month with her radiologist. The individual needs four hours total for her once monthly appointment. The case worker uses the following formula: 4 hours x 60 minutes = 240 minutes. 240 minutes/4.33 = 55.43 minutes per week which will round up to 60 minutes per week.  

Monthly minutes must be divided by 4.33 (weeks per month) to get a weekly amount of minutes needed. 

Example 3: Every month, the individual sees his cardiologist two hours, general practitioner three hours, chiropractor three hours and psychologist two hours. These are all standing appointments the individual sees monthly. 2 hours + 3 hours + 3 hours + 2 hours = 10 hours monthly. 10 hours x 60 minutes = 600 minutes. 600 minutes/4.33 = 138.57 minutes per week which will round up to 140 minutes per week.  The case worker enters 140 minutes per week.  

While the Service Authorization System Online (SASO) will automatically round up in five minute increments, services are allotted and delivered in 30 minute increments so the individual will actually receive 150 minutes or 2 ½ hours a week.

Example 4: The individual sees a therapist every other Friday (bi-weekly) for 2 1/2 hours including travel time. 2 1/2 hours x 60 minutes = 150 minutes. 150 minutes x 2.17 Fridays per month = 325.50 minutes total per month. 325.50 minutes per month /4.33 weeks per month = 75.17 minutes per week which will round up to 80 minutes. The case worker enters 80 minutes per week. 

Bi-weekly amounts must be multiplied by 2.17 to get a monthly amount, which can then be dived by 4.33 to get a weekly amount.

Example 5: The individual has a large need for escort as they have been in a car accident. The individual sees a chiropractor three times a week for one hour each time, a physical therapist three times a week for an hour each time, a psychiatrist bi-weekly for two hours, a pain management specialist bi-weekly for two hours, a general practitioner two hours per month and a cardiologist once a month for three hours.  
In this example, you will not need to do anything for the chiropractor and physical therapist as their times are already in the weekly amounts. The conversions needed will apply to the bi-weekly and monthly visits, which will need to be converted to weekly amounts and then all added together.    
    Weekly: 6 hours x 60 minutes = 360 minutes 
Bi-weekly: 4 hours x 60 minutes x 2.17 = 520.80/4.33 = 120.28 (per week)
    Monthly: 5 hours x 60 minutes = 300 minutes/4.33 = 69.28 (per week)
360 + 120.28 +69.28 = 549.56 minutes per week, which will round to 550 minutes per week.  

Escort may also include accompanying the individual on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist, barber or social events. No additional time for escort for non-medical trips is allocated to the individual's service plan on Form 2060. The individual may elect to receive escort in place of assistance with household or personal care on a day that best meets his needs. The time used to provide the escort task must not exceed the total time purchased for attendant care.

This service does not include the direct transportation of the individual by the attendant. Transportation is available through the Medical Transportation Program (MTP). Contact the MTP manager in the case worker's region about referral of an individual to this program.

A provider contracted to deliver PHC or CAS must do so according to the requirements in the contract with the department and in the Contracting to Provide Primary Home Care Services Handbook.

 

4622 Excluded Tasks

Revision 17-1; Effective March 15, 2017

 

Services that must be provided by a person with professional or technical training may not be purchased through Title XIX personal attendant services. These excluded services include, but are not limited to:

  • insertion and irrigation of catheters;
  • irrigation of body cavities;
  • application of sterile dressings involving prescription medications and aseptic techniques;
  • tube feedings;
  • injections;
  • administration of medication; or
  • any other skilled services identified by the Texas Health and Human Services Commission nurse.

Services that maintain an entire family or household, unless the entire household receives the service, are also excluded. Examples include:

  • cleaning the floor and furniture in areas that the individual does not occupy or use;
  • preparing meals for the entire family or household;
  • laundering clothing or bedding that the individual does not use (for example, laundering clothing and bedding for the entire household rather than laundering only the individual's clothing and bed linens); or
  • shopping for groceries or household items the individual does not need for health and maintenance. Note: An attendant may shop for items the individual needs and the rest of the household also uses.

 

4623 Personal Attendants

Revision 17-1; Effective March 15, 2017

 

The individual's or provider's choice of attendants is not limited unless the:

  • case worker has specified that a particular attendant should not be employed by the provider (see Section 2514, Who Cannot Be Hired as the Paid Attendant); or
  • supervisor, case worker or Texas Health and Human Services Commission nurse has determined that the attendant is not providing adequate care.

Per 40 Texas Administrative Code §97.404, personal attendant services tasks may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency to perform the tasks assigned by the supervisor. Additionally, tasks may be performed by an unlicensed person who is:

  • under 18 years of age and a high school graduate; or
  • enrolled in a vocational educational program and has demonstrated competency to perform the tasks assigned by the supervisor.

The attendant cannot be a legal or foster parent of a minor child who receives the service, or the individual's spouse. For additional information regarding personal attendants, see Section 2514.

 

4624 Priority Status Determination

Revision 17-1; Effective March 15, 2017

 

Priority status is determined by evaluating the effect that going without certain critical purchased tasks would have on an individual.

An individual with priority status may receive no more than 42 hours of service per week. An individual without priority status may receive no more than 50 hours of service per week.

The community care case worker establishes a priority status for each individual based on the functional assessment. An individual is considered to have priority status if the following criteria are met:

  • The individual is completely unable to perform one or more of the following activities without hands-on assistance from another person:
    1. transferring himself into or out of bed or a chair or on off a toilet;
    2. feeding himself;
    3. getting to or using the toilet;
    4. preparing a meal; or
    5. taking self-administered prescribed medications.
  • During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the attendant.
  • The community care case worker determines that there is a high likelihood the individual's health, safety, or well-being would be jeopardized if services were not provided on a single given shift.

Each eligible individual may receive up to 50 hours of personal attendant services per week (42 hours per week for an individual with priority status). For additional information regarding the determination of priority status, see Section 2540, Priority Status Individuals.

 

4630 Eligibility

Revision 17-1; Effective March 15, 2017

 

For eligibility policy not contained in this section, see:

 

4631 Residence

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(b). To receive services, the applicant/client must reside in a place other than:

(1) a hospital;
(2) a skilled nursing facility;
(3) an intermediate care facility;
(4) an assisted living facility;
(5) a foster care setting;
(6) a jail or prison;
(7) a state school;
(8) a state hospital; or
(9) any other setting where sources outside the primary home care program are available to provide personal care.

Title XIX personal attendant services (PAS) cannot be authorized if the individual lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

  • If three or fewer persons live in the home, the proprietor can be the PAS attendant for the individual(s) who resides there. The individual may not receive both PAS and Adult Foster Care.
  • If the home provides only room and board to four or more persons living in the home, it does not require licensure as a personal care home. PAS services can be authorized for individuals in this setting, but the proprietor, his agent or employee cannot be the attendant for individuals who reside in the home. The case worker must specify this on Form 2101, Authorization for Community Care Services.

Title XIX PAS services can be provided to a private pay applicant/individual living in a residential care facility (whether or not contracted with HHSC) under the following conditions. The case worker:

  • applies the unmet need policy on a task-by-task basis, not duplicating services. Facilities provide varying degrees of assistance and tasks purchased should not be a task provided by the facility.
  • must closely monitor the case to determine if the individual is receiving additional services from the facility. Service plans must be adjusted to avoid duplication of services/tasks.

If the individual begins receiving Residential Care (RC) through HHSC, the Title XIX PAS service is terminated effective no later than the date RC services begin.

 

4632 Financial Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(1) be eligible for Medicaid in a community setting or be eligible under the provisions of the Social Security Act, §1929(b)(2)(B)

Before referring the individual to Primary Home Care (PHC), verify Medicaid eligibility for the month that financial/functional eligibility is determined.

To receive PHC services, applicants/individuals must be receiving benefits that include full Medicaid eligibility. Case workers must consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if an applicant or individual is receiving full Medicaid benefits. Note: Residence outside an institution is also an eligibility criterion so institutional type programs will not be eligible for PHC. See Section 7110, TIERS Inquiries, and Appendix XIV, SAVERR/TIERS Type Program Chart, for a description of all TIERS type programs.

Individuals obtain financial eligibility for Community Attendant Services (CAS) by applying to Medicaid for the Elderly and People with Disabilities. CAS eligibility can be confirmed by checking TIERS.

See Section 2347, Texas Medicaid Estate Recovery Program (MERP), when processing CAS applications.

 

4633 Functional Eligibility

Revision 17-8; Effective September 1, 2017

 

40 Texas Administrative Code (TAC) §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

Title XIX personal attendant services (PAS) eligibility only requires that an individual have a need for assistance with personal care. However, the provider is not allowed to provide services unless at least one personal task is authorized, scheduled and delivered by the provider.

Example: An applicant requests Primary Home Care (PHC) and scores 30 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. However, the only personal care task the individual needs is meals service, which is being provided via congregate meals. Therefore, PHC services cannot be approved.

Applicants and individuals must score at least 24 on Form 2060, and require at least six hours of service per week. An individual requiring fewer than six hours of service per week may be eligible if the individual:

  • requires primary home care or community attendant services to provide respite care to the caregiver;
  • lives in the same household as another individual receiving primary home care, community attendant services, or family care;
  • receives one or more of the following services (through the department or other resources):
    • congregate or home-delivered meals;
    • assistance with activities of daily living from a home health aide;
    • day activity and health services; or
    • special services to persons with disabilities in adult day care;
  • receives aid-and-attendance benefits from the Veterans Affairs; or
  • is determined, based upon the functional assessment, to be at high risk of institutionalization without primary home care or community attendant care services.

See Section 4651, Assessing the Individual's Needs, for casework procedures involved in establishing functional need.

 

4634 Practitioner's Statement of Medical Need

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/individual must:

(3) have a medical need for assistance with personal care.
(A) The individual's medical condition must be the cause of the individual's functional impairment in performing personal care tasks.
(B) Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnosis. The diagnoses do not disqualify an individual for eligibility as long as the individual's functional impairment is related to a coexisting medical condition;
(4) have a signed and dated practitioner's statement that includes a statement that the individual has a current medical need for assistance with personal care tasks and other activities of daily living.

The need for Primary Home Care (PHC) and Community Attendant Services (CAS) must be documented by a practitioner's statement of medical need. As part of the determination of eligibility for Title XIX personal attendant services (PAS), case workers must verify that applicants have a medically related health problem that causes a functional limitation in performing personal care.

See Section 4661, Receipt of the Practitioner's Statement of Medical Need, for procedures to determine medical need.

 

4640 Retroactive Payments

Revision 17-1; Effective March 15, 2017

 

State law requires that home and community support services agencies that provide personal attendant services (PAS) be licensed by the Texas Health and Human Services Commission (HHSC). It is possible for a Medicaid-eligible person to begin receiving services before HHSC receives a referral for Primary Home Care (PHC). The information below states the procedures case workers, HHSC nurses and providers must use when processing an application for retroactive payment.

 

4641 Provider's Role

Revision 17-1; Effective March 15, 2017

 

A provider who delivers attendant care services to a non-Medicaid individual on a private pay basis risks losing revenue unless an agreement exists for the individual to pay the provider if he is not determined eligible. A provider may bill non-Medicaid individuals for services delivered before the time the individual is eligible for retroactive payment by the Texas Health and Human Services Commission (HHSC). However, federal requirements do not allow providers to bill Medicaid recipients for Medicaid reimbursable services.

 

40 Texas Administrative Code (TAC) §47.85(c)(1) ─ The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS' 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.

 

The three month prior period applies to non-Medicaid individuals who apply for Primary Home Care (PHC) services using retroactive payment procedures. The three month prior period does not apply to Medicaid recipients who request PHC services using retroactive payment procedures. For Medicaid recipients, HHSC can reimburse a provider for a retroactive payment period beyond three months as long as the services are Medicaid reimbursable and the individual was Medicaid eligible when the services were received. Medicaid recipients do not complete a written application (Form H1200, Application for Assistance – Your Texas Benefits) for retroactive or ongoing PHC services.

A request for retroactive payment can be made by the individual, provider or interested party by contacting Community Care for Aged and Disabled (CCAD) intake staff. CCAD staff who receive requests for retroactive payment use current intake procedures for a routine request for in-home care services. The beginning date of services cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.

40 TAC §47.85(e)  Pre-initiation activities. The provider agency must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).

(f) Intake referral. On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local DHS office by telephone and make an intake referral by providing DHS information on the person to start the eligibility process.
(g) Service initiation. The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

Within seven days after the date the provider processes the intake referral, the provider must submit the written request for retroactive payment to the case worker. The written request must include the:

  • copy of the service plan;
  • copy of Form 3052;
  • retroactive payment information, including the:
    • name of the provider;
    • contact information for the individual;
    • date services were started;
    • tasks provided to the individual including both tasks allowed and not allowed by the PHC program;
    • actual service hours that were provided per week, including hours allotted to allowed tasks and tasks not allowed by the PHC program; and
    • cost per hour of service charged to the individual.

If the provider billed the individual for tasks that are not Medicaid reimbursable, the provider must inform the case worker so he will know how many hours to deduct from the payment made by HHSC to the provider.

 

4642 Case Worker's Role

Revision 17-1; Effective March 15, 2017

 

The case worker must respond to the request for services according to the time frames in Section 2320, Case Worker Response, and make the home visit to assess the applicant for ongoing services.

The case worker is not responsible for determining functional need during the retroactive period. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed to determine ongoing functional eligibility but does not affect eligibility for retroactive payments. Also, the case worker does not apply the unmet need policy to the retroactive period. See Section 2433, Determining Unmet Need in the Service Arrangement Column.

 

4643 Applicant Approved for Retroactive Payment and Continued Services

Revision 17-1; Effective March 15, 2017

 

If the applicant is Medicaid eligible or was Medicaid eligible at service initiation, the Texas Health and Human Services Commission (HHSC) will only reimburse the provider for tasks/hours/costs within the scope of the Primary Home Care (PHC) program. If the applicant is eligible for the retroactive payment period and for continued PHC services, the case worker must verify that the service plan developed by the provider contains the following information:

  • individual is receiving at least one personal care task. If there are no personal care tasks, the provider will not be reimbursed for services;
  • total amount of weekly service hours;
  • the total amount of weekly services hours are within the maximum weekly hours (50 allowed in the PHC program);
  • tasks provided are the type covered under the PHC program; and
  • cost per hour of service is equal to the non-priority rate in the PHC program. Note: Provider agencies will not determine priority status nor will they be reimbursed at the higher priority status rate for the retroactive payment period.

Determine the amount of reimbursement the applicant is eligible to receive from the provider by multiplying the cost per hour of service found in the service plan developed by the provider times the total amount of hours of approved service provided to the applicant. Include this amount on Form 2065-A, Notification of Community Care Services, to advise the applicant and the provider of the dollar amount of retroactive payment the applicant should receive from the provider.

Note: Because the individual is receiving services up to the time of the service initiation date for continued PHC services, the case worker may not know the last day services were provided during the retroactive period. The reimbursement amount may vary from the actual amount due to the applicant depending on whether the applicant paid in full, or has not paid the provider for the most recent service provided during the retroactive period.

The provider will not be reimbursed for a retroactive payment period if:

  • the applicant did not receive any personal care tasks from the provider;
  • none of the tasks provided by the provider were within the scope of the program (Example: the individual received transportation, direct administration of medications or protective supervision assistance); or
  • the applicant is determined ineligible for retroactive payment by HHSC.

The provider will not be reimbursed for amounts higher than the HHSC limits when the:

  • service plan includes more than the maximum weekly hours allowed in PHC; or
  • cost per hour of service is more than the non-priority rate.

The case worker must deduct time for any task(s) that cannot be purchased as part of PHC service from the total hours of services provided by the provider in order to determine how many hours (at the non-priority status rate) HHSC will reimburse the provider. If more than 50 hours per week were provided, the time for the non-allowable tasks should be deducted first and then the additional hours deducted to be within the 50 hour per week limit.

Send the provider a copy of the same Form 2065-A sent to the applicant to advise the provider of the amount to reimburse the applicant. Multiply the total service hours the applicant received by the cost per hour of services reported in the provider's service plan. Note: The dollar amounts used in the examples are fictitious. The current PHC rates may be verified at http://legacy-hhsc.hhsc.state.tx.us/rad/long-term-svcs/index.shtml.

 

Example 1:

A provider documents in the service plan that an applicant received 52 hours of service at $12.00 an hour for one week of the retroactive period. Of the total 52 service hours reported to date, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

52 hours minus 3 hours— — (deduct 3 hours since transportation is not an allowable task in PHC) = 49 hours

49 hours x $9.61 — — (the non-priority participating rate in PHC) = $470.89

$470.89 is the amount HHSC will pay the provider.

Document 49 hours in Item 18, Units, on Form 2101, Authorization for Community Care Services, and send it to the provider.

49 hours x $12.00 an hour (estimated private-pay rate) = $588.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $588.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for three hours of services determined by the case worker not to be Medicaid-reimbursable tasks.

 

Example 2:

A provider documents in the service plan that an applicant received 55 hours of service at $10.00 an hour for one week of the retroactive period. All of the 55 service hours were performed on Medicaid-reimbursable tasks. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 5 hours — — (deduct five hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours x $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send to the provider.

50 hours x $10.00 an hour = $500.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $500.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the applicant.

 

Example 3:

A provider documents in the service plan that an applicant received 55 hours of service at $12.00 an hour for one week of the retroactive period. Of the total of 55 service hours provided, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 3 hours for transportation — (a non-Medicaid reimbursable task) = 52 hours

52 hours minus 2 hours — (deduct two hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours × $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send it to the provider. Send the usual initial PHC packet to the provider for the continued service period.

50 hours x $12.00 an hour = $600.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the applicant.

Document $600.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for the three hours for transportation since this is not a Medicaid-reimbursable task.

If a provider provides service to an individual during a retroactive period where all tasks/hours/costs are all within the scope of the PHC program, then the dollar amount due the individual and the provider will be the same.

Example: A provider documents in the service plan that the individual received 30 hours of allowable household and at least one personal care task per week and charged the individual $9.61 an hour non-priority participating PHC rate to provide the attendant care. Calculate 30 hours x $9.61 = $288.30. This is the amount HHSC pays the provider and is the same amount refunded by the provider to the applicant. In this example, advise both the provider and the applicant the same amount, using Form 2065-A.

Send the provider Form 2101 for the retroactive payment period with an end date the day before the beginning of the continued PHC services. Send a second Form 2101 authorizing ongoing services with the complete initial PHC packet.

 

4644 Applicant Approved for Retroactive Payment and Denied Continued Services by the Case Worker

Revision 17-1; Effective March 15, 2017

 

If the applicant is eligible for the retroactive period but is not financially or functionally eligible for continued Primary Home Care (PHC) services, the case worker must call the provider and notify the provider of the last day of the retroactive period and the ineligibility for ongoing services. Document the telephone call in the comments section of Form 2101, Authorization for Community Care Services, for the retroactive period.

The case worker must verify the following conditions are present in the service plan developed by the provider:

  • applicant is receiving at least one personal care task;
  • total amount of weekly service hours are within the maximum weekly hours (50 allowed in the PHC program); and
  • the tasks provided are covered within the PHC program.

The provider will not be reimbursed if no personal care task(s) were provided. The amount of reimbursement will be reduced if the:

  • service plan includes more than the 50 weekly maximum hours allowed in PHC;
  • tasks provided are not the type of tasks covered by the PHC program; or
  • cost per hour of service the provider billed the applicant is more than the Texas Health and Human Services Commission non-priority rate.

Within two business days of the decision of ongoing ineligibility, the case worker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, which includes the:

  • effective date of denial of continued services, and
  • amount the provider should reimburse the applicant.

The case worker must complete and send Form 2101 to the provider for the retroactive payment period. Use the Form 2101 instructions to complete the items for the retroactive period with the following exceptions:

  • Item 4 — "Begin" date is obtained from the applicant's service plan which was developed by the provider. The begin date cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.
  • Item 5 — "End" date is the date the case worker determines the applicant ineligible for continued PHC services. The "End" date on Form 2101 must match the:
    • effective date of denial on Form 2065-A; and
    • verbal termination date for the retroactive period.
  • Item 18 — Enter the amount of service hours minus any disallowed tasks/cost/hours for services that are not Medicaid reimbursable.
  • Item 31 — Last name of Doctor of Medicine/Doctor of Osteopathic Medicine (MD/DO) = RETRO PAS
  • Item 33 — MD/DO License Number
  • Item 34 — Date of Orders

 

4645 Special Procedures for Community Attendant Services (CAS)

Revision 17-1; Effective March 15, 2017

 

Providers must be aware of the risk of losing revenue if attendant care services are delivered to a non-Medicaid individual. If the applicant is determined ineligible, retroactive payment will not be made by the Texas Health and Human Services Commission (HHSC).

The case worker proceeds with the referral to Medicaid for the Elderly and People with Disabilities (MEPD) upon receipt of Form H1200, Application for Assistance – Your Texas Benefits, following the CAS referral procedures.

When the eligibility decision is received from MEPD and the applicant is determined eligible, the case worker sends the HHSC nurse a copy of the pre-assessment packet from the provider and Form 3052, Practitioner's Statement of Medical Need, along with a "pending" Form 2101, Authorization for Community Care Services, for the retroactive period. The case worker enters "“Retroactive Payment Applicant"” in the comments section on Form 2101. The HHSC nurse may authorize services effective the start date of service delivery as long as it is within the three months prior to the medical effective date established by MEPD, and other conditions are met. The HHSC nurse also completes a second Form 2101 for ongoing services if the applicant is eligible for ongoing CAS. See Section 4662.1, Authorization for Routine Referrals, for procedures for ongoing authorization. The HHSC nurse sends a copy of Form 2101 for the retroactive period and a copy of Form 2101 for ongoing services to the provider and the case worker.

Within two business days of receipt of Form 2101, the case worker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, for the retroactive period which includes the:

  • effective dates of the retroactive period;
  • total weekly hours of service approved; and
  • amount to be reimbursed to the applicant.

The case worker sends a second Form 2065-A to the applicant advising of ongoing services, including the effective date and the total weekly hours.

 

4646 CAS Applicant Determined Ineligible by MEPD Staff

Revision 17-1; Effective March 15, 2017

 

If the Community Attendant Services (CAS) applicant is determined ineligible by Medicaid for the Elderly and People with Disabilities (MEPD) staff, the case worker must:

  • immediately notify the provider that the applicant is not Medicaid eligible, advising of the date of Medicaid denial; and
  • send the applicant and provider Form 2065-A, Notification of Community Care Services, advising the denial for retroactive payment and continued services.

Note: The provider will not be reimbursed for retroactive services by the Texas Health and Human Services Commission and the provider does not have to reimburse the applicant for privately paid services.

 

4647 Notifications

Revision 17-1; Effective March 15, 2017

 

For all decisions on retroactive payments, both the applicant and the provider must be sent Form 2065-A, Notification of Community Care Services. The applicant must also be notified of eligibility or ineligibility for ongoing services on Form 2065-A. The provider is sent Form 2101, Authorization for Community Care Services, authorizing the retroactive services and Form 2101 for ongoing services, if the applicant is eligible.

 

4647.1 Notifications to Providers

Revision 17-1; Effective March 15, 2017

 

For all decisions on retroactive payments, send the provider a copy of Form 2065-A, Notification of Community Care Services. For any service authorizations, send the provider Form 2101, Authorization for Community Care Services. If, during the retroactive determination process for Primary Home Care the applicant is determined ineligible for continued services, the case worker must call the provider immediately to advise of the applicant's ineligibility. The case worker documents the telephone call in the comments section of Form 2101, authorizing the retroactive period.

 

4647.2 Notifications to Applicants

Revision 17-1; Effective March 15, 2017

 

Applicants must be notified of all decisions on Form 2065-A, Notification of Community Care Services, within two business days of the date of the decision. If the applicant is determined eligible for retroactive and continued services, send two Form 2065-As. Form 2065-A for the retroactive period must contain the effective dates, type and amount of service authorized and the amount of reimbursement the applicant should receive for the services the provider delivered during the retroactive period. The second Form 2065-A advises the applicant of the eligibility for ongoing services, including the effective date, type and amount of service authorized.

If the applicant is denied for retroactive and continued services, document in the comments section of Form 2065-A that the applicant is ineligible for continued Primary Home Care or Community Attendant Services and is not eligible for retroactive payments from the provider for the months of the retroactive period (list the actual months). Retroactive payment applicants who appeal because payment was denied by the Texas Health and Human Services Commission are not entitled to payment for continued services pending outcome of the appeal.

 

4648 Reimbursement

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §47.85(i), Charges to persons who receive services.

(1) The provider agency may charge a person for services for which the provider agency intends to request retroactive payment, unless the person is Medicaid eligible.
(2) The provider agency must reimburse the entire amount of all payments made by the person to the provider agency for eligible services, even if those payments exceed the amount DHS will reimburse for the services, if DHS determines that the person is eligible for the Primary Home Care Program.

If the Texas Health and Human Services Commission determines the applicant is eligible for Primary Home Care or Community Attendant Services, the provider must reimburse the entire amount of all payments made to the provider for eligible services during the three months preceding eligibility, regardless of whether or not those payments exceeded the amount the provider will be reimbursed for those services.

If an applicant has a question or does not agree with the amount of reimbursement from the provider, it is up to the applicant, caregiver, authorized representative or applicant's family to advise the case worker of any discrepancies between the:

  • amount of money the case worker advised that the applicant would receive; and
  • actual amount received from the provider.

Final resolution of any disagreements between the provider, individual and/or case worker over the amount of reimbursement due the individual is resolved by the case worker's supervisor. The supervisor may consult appropriate regional support staff in an effort to reach a final decision involving reimbursement disagreements. Note: The provider must reimburse the individual within seven days of receiving payment from HHSC.

 

4650 Service Planning

Revision 17-1; Effective March 15, 2017

 

The case worker is responsible for all aspects of service planning for Primary Home Care (PHC), including:

  • determining the applicant's eligibility for services, as described in Section 4630, Eligibility;
  • developing a service plan based on the applicant's unmet need for service, as described in Section 2433, Determining Unmet Need in the Service Arrangement Column;
  • authorizing services and referral to a provider, as described in Section 4660, Service Authorization; and
  • providing ongoing case management for the individual.

The case worker follows the procedures for initial intakes in Section 2300, Responding to Requests for Service. The initial home visit and functional assessment are completed in accordance with Section 2400, Assessment Process. Note on the worksheet of Form 2059, Summary of Client's Need for Service, the applicant's reported medical diagnosis and functional limitations. If the individual reports only a diagnosis of mental health, intellectual disability (ID) or intellectual and developmental disability (IDD), discuss that he may not meet the medical eligibility criterion for PHC. Advise the applicant that the provider will contact his medical practitioner for additional medical information. In developing the service plan, ensure that the applicant needs at least one personal care task.

 

4651 Assessing the Individual's Needs

Revision 17-1; Effective March 15, 2017

 

In a face-to-face interview with the individual, conduct a functional assessment of the applicant, as described in Section 2430, Functional Assessment. The case worker may consult the Texas Health and Human Services Commission (HHSC) nurse about any issues that:

  • may impact individual health and safety; or
  • bring medical and functional eligibility into question.

If, during the process of developing the service plan, it is determined that a particular person should not be employed as the individual's attendant, the case worker documents this information on Form 2101, Authorization for Community Care Services. See Section 2514, Who Cannot Be Hired as the Paid Attendant, for additional information.

Review the service plan and explain the services to the individual. Let him know the number of hours and number of days services are to be delivered and the tasks he is authorized to receive. Inform the individual that to continue to qualify for services, he must need at least one personal care task. If the individual does not need a personal care task, Title XIX personal attendant services (PAS) cannot be authorized. The individual must also need at least six hours of services per week, unless he meets one of the criteria listed in Section 4633, Functional Eligibility. Assess the individual for Family Care Services if the criteria for Title XIX PAS are not met.

Give Form 2307, Rights and Responsibilities, and Form 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, to all applicants. Explain that the case worker must approve changes in the service plan. Also, inform the individual that he may select another provider if he is dissatisfied with the services or attendant providing the services.

If the Primary Home Care applicant meets all eligibility criteria, send a referral packet to the provider within five business days from the face-to-face interview. This referral will prompt the provider to begin pre-initiation activities.

If the Community Attendant Services applicant meets all functional eligibility criteria, send the Application for Assistance form to Medicaid for the Elderly and People with Disabilities for the financial determination.

 

4651.1 Service Delivery Outside the Home

Revision 17-1; Effective March 15, 2017

 

Services may be authorized to be delivered in locations other than the individual's home.

For service delivery outside the individual’s home but within a provider agency’s contracted service delivery area:

  • The provider agency may develop a service plan that includes services regularly delivered at a location other than the individual’s home. The service plan must not exceed the weekly hours authorized on Form 2101, Authorization for Community Care Services.
  • The provider agency may deliver services outside the individual’s home when the service plan does not include the regular delivery of such services.

The provider agency:

  • may deliver services outside the individual’s home only if the individual requests such services;
  • is not required to pay for expenses incurred as a result of an attendant delivering services outside the individual’s home;
  • must make a reasonable effort to deliver services at a location other than the individual’s home when requested by the individual;
  • maintains written justification if the individual’s request was not granted; and
  • documents in the individual’s record:
    • each instance when the individual requested services at a location other than the home;
    • whether the individual’s request was granted;
    • what services were provided; and
    • where the services were delivered.

Texas Administrative Code §47.63, Service Delivery, provides the rules for Home and Community Support Services (HCSS) agencies to deliver services outside the home. The provider may develop a service plan that includes services regularly delivered at a location other than the individual's home or may deliver services at an alternate location at the individual's request. See Section 2522, Service Delivery in Alternate Locations, for additional case worker procedures.

Case workers should pay particular attention to this policy if they have disabled individuals who are working or attending school and need assistance in the workplace/school. The Social Security Administration has several programs to assist disabled persons with employment at www.socialsecurity.gov/pubs/10095.html.

Additionally, persons enrolled in the Medicaid Buy-In program will be working and may require service delivery in alternate locations.

While services may be delivered outside the home, only allowable tasks may be authorized and the provider is not required to pay for expenses incurred by attendants delivering services outside the home. Hours authorized are based solely on services that could be delivered in the home.

The case worker must send Form 2067, Case Information, to the provider with information about the individual's request for services in an alternate location and work with the individual and provider to arrange the services that will meet the individual's needs within the scope of the program.

 

4652 Types of Referrals

Revision 17-1; Effective March 15, 2017

 

 There are two methods of referral:

  • For expedited referrals, the case worker makes the referral by oral notice and on Form 2101, Authorization for Community Care Services.
  • For routine referrals, the case worker makes the referral on Form 2101.

See Appendix IV, Workflow and Time Frames, for procedures for the different types of referrals.

 

4652.1 Routine Referrals for Primary Home Care

Revision 18-1; Effective June 15, 2018

 

Routine Primary Home Care (PHC) referrals start with the case worker sending a referral, Form 2101, Authorization for Community Care Services, and referral packet to the provider. The referral Form 2101 notifies the provider that pre-initiation activities must commence.

For routine PHC referrals, the case worker, within five business days from the home visit:

  • enters the assessment information in the Service Authorization System (SAS); and
  • sends the provider a referral packet including:
    • Form 2059, Summary of Client's Need for Service;
    • Auto Form 2060, Needs Assessment Questionnaire (generated by SAS); and
    • Referral Form 2101.

The provider will begin pre-initiation activities upon receipt of the referral packet.

Individuals who apply for PHC that are mandatory STAR+PLUS individuals will be referred to the enrollment broker, as described in Section 2221, Requests for Services in STAR+PLUS Areas.

 

4652.2 Expedited Referrals for Primary Home Care

Revision 18-1; Effective June 15, 2018

 

In some instances, the individual's need for services, based on the case worker's judgment, is such that delivery of services must be facilitated. When weighing whether an expedited referral is warranted, the case worker should consider the following:

  • What was the individual's assigned intake priority? In most situations, cases that require an expedited response to a request for services also require an expedited referral.
  • Is the applicant being authorized as having priority status? If so, that may indicate a need for an expedited referral.
  • Could a delay in starting services constitute a threat to the individual's health, safety or well-being? If so, an expedited referral may be needed.

The expedited referral process includes the case worker:

  • making an oral request by the next business day from the home visit that immediately begins pre-initiation activities and negotiating a date for the completion of pre-initiation activities, which must be less than 14 days;
  • following up the oral request by sending a referral packet, including Form 2101, Authorization for Community Care Services, to the provider, noting the negotiated completion date in the comments section;
  • negotiating a start of care date with the provider upon notification of a completed practitioner's statement, which must be in less than 14 calendar days; and
  • authorizing services in the Service Authorization System no later than the fifth business day after a start date has been negotiated.

The provider may only call the case worker to provide information from Form 3052, Practitioner's Statement of Medical Need, and negotiate a start-of-care date in the case of an expedited referral. The start of care for the expedited referral must be earlier than the 14-day time frame for a routine referral and cannot be before the date the practitioner signed Form 3052. The provider must send the case worker Form 3052 within seven days.

 

4652.3 Initial Referrals for Community Attendant Services

Revision 17-3; Effective May 15, 2017

 

For Community Attendant Services (CAS) applicants, the referral process begins after the eligibility decision is received from the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. See Section 2342, Screening for Primary Home Care and Community Attendant Services, for additional requirements.

The case worker, within seven business days of receiving the eligibility determination:

  • enters the assessment information in the Service Authorization System (SAS); and
  • sends the provider a referral packet including:
    • Form 2059, Summary of Client's Need for Service;
    • Auto Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (generated by SAS); and
    • Referral Form 2101, Authorization for Community Care Services.

The case worker does not send a copy of the referral Form 2101 to the HHSC nurse on initial CAS cases. The case worker sends the referral packet to the provider and it is the provider's responsibility to send the required documents to the HHSC nurse. The provider is required to send Form 3052, Practitioner's Statement of Medical Need, to HHSC, but is not required by the Texas Administrative Code rules to send Form 2101. Providers have been requested to send Form 2101 with Form 3052 as a courtesy to assist with individual identification. However, under no circumstances will HHSC staff request submittal of Form 2101.

It is the case worker's responsibility to track the CAS referral. If the authorization Form 2101 is not received from the HHSC nurse within 30 calendar days from sending the referral Form 2101 to the provider, the case worker must check with the HHSC nurse to see if the referral was received from the provider. If not, the case worker must contact the provider and request Form 3052 be sent to the HHSC nurse. The case worker must document the contacts in the case record.

See Appendix IV, Workflow and Time Frames, for the chart for initial referrals for CAS.

 

4652.4 CAS Applicants Requiring Immediate Service Delivery

Revision 17-1; Effective March 15, 2017

 

While a Community Attendant Services (CAS) applicant's financial eligibility is pending, the case worker may refer the individual to Family Care (FC). Unless new intakes are being placed on the interest list by the region, a referral to FC is mandatory if the individual:

  • had an intake priority of immediate or expedited; or
  • has a health condition requiring immediate service delivery in order to ensure his health and safety.

 

4653 Referral to the Provider

Revision 17-3; Effective May 15, 2017

 

The referral packet sent to the provider must contain adequate information for the provider to develop the service plan with the individual based on the case worker's assessment. The case worker sends the selected provider a referral packet consisting of:

  • Form 2059, Summary of Client's Need for Service;
  • Auto Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (generated by the Service Authorization System); and
  • Form 2101, Authorization for Community Care Services (referral).

Follow the procedures in Section 2620, Service Authorizations, and Section 2630, Referrals to the Provider.

All Form 2101 referrals to the provider, both initial and ongoing, must include the tasks being authorized, the total number of authorized hours and the number of days the applicant/individual requests services to be delivered. If the individual has special needs that require a specific schedule, document the requested schedule and the reason on Form 2101. Example: An individual may need a specific eating schedule due to a diabetic condition or a person with sleep problems may require that service delivery not begin until the afternoon.

Case workers must document in the comments section of Form 2101 the number of days the individual is to receive services based on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Example: "The individual requests a 5-day plan," or "The individual requests a 7-day plan."

Case workers must also document in the comments section of Form 2101 if there are any persons designated not to hire as outlined in Section 2514, Who Cannot Be Hired as the Paid Attendant.

 

4654 Pre-Initiation Activities

Revision 17-1; Effective March 15, 2017

 

The receipt of the referral packet, including Form 2101, Authorization for Community Care Services, prompts the provider to begin pre-initiation activities.

40 Texas Administrative Code (TAC) §47.45(c)(1-2) specifies that providers must complete pre-initiation activities:

  • for routine referrals, within 14 days of the later of:
    • the referral date; or
    • date the provider receives Form 2101; or
  • for expedited referrals, by the date negotiated between the case worker and provider.

Pre-initiation activities include the following:

The supervisor must develop a service delivery plan on a single document that records the following:

  • the tasks which the individual is authorized to receive;
  • the total weekly hours of service HHSC authorizes the individual to receive;
  • the service schedule, which must include as necessary, based on an individual's needs, certain time periods for the delivery of specified tasks.

The provider must obtain a complete practitioner's statement and submit for HHSC's review, as described in TAC §47.47 (relating to Medical Need Determination). This does not apply to Family Care services. For routine referrals, the provider must:

  • send a copy of the practitioner's statement to HHSC by facsimile or secured email; or
  • mail a copy of the practitioner's statement to HHSC.

For expedited referrals:

  • HHSC may send the authorization for community services form pending receipt of the practitioner's statement if the provider notifies HHSC that the provider has received a complete practitioner's statement that documents the individual's medical condition is the cause of the individual's functional impairment.
  • Upon notification of a completed practitioner's statement, HHSC and the provider will negotiate a start-of-care date.
  • The provider must send the complete practitioner's statement to HHSC within seven working days of service initiation.
  • If a complete practitioner's statement is not sent to HHSC within seven business days of service initiation, the provider is not entitled to payment from HHSC until the date HHSC receives the completed practitioner's statement. In this circumstance, HHSC will change the service initiation date to the date HHSC receives the completed practitioner's statement.
  • The signature date of the practitioner must be on or before the negotiated start-of-care date.

 

4654.1 Delays in Pre-Initiation Activities

Revision 17-1; Effective March 15, 2017

 

The provider must complete the pre-initiation activities within the required time frames as described in Section 4654, Pre-Initiation Activities, or document the reason(s) for a delay.

  •  A provider may delay meeting the due dates only for reasons beyond its control, such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.
  • The provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:
    • the reason for the delay, which must be beyond the provider's control;
    • either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and
    • a description of the provider's ongoing efforts to complete pre-initiation activities.
  • The provider must notify the case worker of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case worker may refer the individual to another provider.

 

4655 Initial Service Delivery Plan Changes

Revision 17-1; Effective March 15, 2017

 

The provider must notify the case worker of a variance in the service delivery plan when the initial service delivery plan developed by the provider:

  • has more hours than authorized on the authorization for community care services form; or
  • has no personal care services, except for Family Care services.

If the provider does not agree with the service plan on Form 2101, Authorization for Community Care Services, after completing pre-initiation activities, the provider must send a notice to the case worker explaining why changes are needed in the initial service plan.

Upon receipt of the written notification, the case worker must contact the individual within two business days to review the service plan and resolve the reported request for a change in tasks or hours. If the individual consents to the initial service plan developed by the case worker, the case worker sends the provider Form 2067, Case Information, advising that the individual is in agreement with the developed service plan. If the individual states that a change is needed, review and update Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and include the changes on Form 2101 to the provider. Services must be authorized within five days of receipt of the practitioner's statement. If a notification is received after services are authorized, process as an interim change. See Section 4673, Interim Service Plan Changes.

If the individual refuses all personal care tasks on the service plan, advise the individual that he will not be eligible for Primary Home Care or Community Attendant Services. Transfer the individual to Family Care or place on the Family Care Interest List. See Section 2720, Interim Changes, for additional guidelines for service plan changes.

 

4660 Service Authorization

Revision 17-1; Effective March 15, 2017

 

 

 

 

4661 Receipt of the Practitioner's Statement of Medical Need

Revision 17-1; Effective March 15, 2017

 

Before services can be authorized, the provider must submit Form 3052, Practitioner's Statement of Medical Need, to the case worker (for Primary Home Care (PHC)) or to the Texas Health and Human Services Commission (HHSC) nurse (for Community Attendant Services (CAS)). A copy of the form must be retained in the case record.

 

4661.1 Review of the Practitioner's Statement

Revision 17-1; Effective March 15, 2017

 

Once the practitioner's statement is received from the provider, the case worker (for Primary Home Care (PHC)) or Texas Health and Human Services Commission (HHSC) nurse (for Community Attendant Services (CAS)) will review the practitioner's statement to ensure that everything needed for authorization is in place.

The case worker (for PHC) or the HHSC nurse (for CAS) must ensure that:

  • the practitioner has completed the Statement of Medical Need and certified the individual has a medical need resulting in a functional limitation;
  • at least one functional limitation related to a diagnosis has been checked;
  • the form has been completed and there is no missing information;
  • the practitioner has signed the form;
  • the practitioner's license number has been entered; and
  • the practitioner's contact information is included.

The practitioner's name and license number must be entered in the Service Authorization System.

The case worker or HHSC nurse will accept the practitioner's certification that the individual has an acceptable medical diagnosis when the "Statement of Medical Need" on Form 3052, Practitioner's Statement of Medical Need, is completed. The practitioner must also check at least one functional limitation related to the diagnosis(es) and the case worker or HHSC nurse accepts that the practitioner has checked an appropriate functional limitation.

Persons with only a diagnosis(es) of mental illness and/or intellectual disability (ID)/intellectual and developmental disability (IDD) are not considered to have established medical need based solely on those diagnoses. However, they may establish medical need through a related diagnosis that results in a functional limitation.

In this situation, the practitioner will not sign the "Statement of Medical Need" on Form 3052 and the provider will notify the case worker that a signed Form 3052 will not be sent. When the case worker does the initial assessment and the applicant/family is stating that the only diagnosis is mental illness or ID/IDD, the case worker may consult with the HHSC nurse before making the referral for PHC or CAS. If it is clear at the time of the initial assessment there is no other medical diagnosis or if a signed Form 3052 cannot be obtained, the applicant may be placed on the Family Care interest list, or if funds are available and there is no interest list, may be assessed for Family Care services.

 

4661.2 Required Corrections

Revision 18-1; Effective June 15, 2018

 

Some problems related to the practitioner's statement will require correction. The case worker or Texas Health and Human Services Commission (HHSC) nurse must review the practitioner's statement within two business days after receipt to determine if all information is correct or if it will require correction. If correction is required, action must be taken that same day. Depending on the type of error, HHSC will either return the practitioner's statement to the provider for correction or obtain the information via a telephone call, requesting faxed confirmation when necessary.

Obtain the information via a telephone call when:

  • functional limitation is not checked;
  • practitioner's signature is not on Form 3052, Practitioner's Statement of Medical Need; 
  • provider/financial management services agency (FSMA) did not complete Part II that the practitioner who signed the order is not excluded from participation in Medicare or Medicaid;
  • Form 3052 does not include the credential of the medical practitioner who signed the form (MD for Doctor of Medicine, APN for Advanced Practice Nurse, DO for Doctor of Osteopathic Medicine, PA for Physician Assistant);
  • Form 3052 does not include the license number or the individual National Provider Identifier (NPI) number of the practitioner who signed it;
  • the provider must fax an updated copy of Form 3052 to the case worker or HHSC nurse because the practitioner's signature date is missing or illegible; or
  • the provider must fax an updated copy of Form 3052 to the case worker or HHSC nurse when the provider's stamped date is used instead of the practitioner's date on Form 3052, which does not include the provider name, abbreviated name or initials; or
  • the case worker or HHSC nurse requires additional information to authorize services.

The provider is given five business days to complete all corrections. If appropriate, expedited procedures may be used to refer the individual to another provider.

Form 3052 will not need to be corrected for missing medical diagnosis and ICD-10 codes if the functional limitation has been checked. 

 

4661.3 Closing Initial Referrals for Delays in Securing a Signed Practitioner’s Statement

Revision 17-1; Effective March 15, 2017

 

When contacts from the program provider and case worker have proven unsuccessful in obtaining a signed practitioner’s statement, the case worker may close the initial referral for services within 90 calendar days from the date of the initial Form 2101, Authorization for Community Care Services.

In cases in which the individual or provider agency indicates to the case worker that an appointment has been made with an alternative physician for the purpose of obtaining the practitioner’s statement, the case worker shall continue to monitor the initial referral for up to 90 additional days. The case worker closes the referral by sending Form 2065-A, Notification of Community Care Services, to the applicant if the physician’s statement has not been obtained following the second 90-day extension period.

The case worker will place the individual on the Family Care interest list, and must advise Medicaid for the Elderly and People with Disabilities (MEPD) that the applicant was not approved for CAS. In this circumstance, the case worker must send Form H1746-A, MEPD Referral Cover Sheet, stating the applicant has not met the functional eligibility requirements.

 

4662 Authorization of Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4662.1 Authorization for Routine Referrals

Revision 17-1; Effective March 15, 2017

 

For Primary Home Care (PHC), within five business days of receipt of the completed practitioner's statement, the case worker must enter the information into the Service Authorization System (SAS) and send authorization Form 2101, Authorization for Community Care Services, to the provider. The "Begin Date" (Item 4) on Form 2101 is the same as the "Mail Date" (Item 1). Form 3052, Practitioner's Statement of Medical Need, must be date stamped on the date of receipt. The case worker files Form 3052 in the individual's record. Services cannot begin until the provider receives Form 2101 authorizing services. The provider has seven days to initiate services after receipt of Form 2101. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual within two business days of the "Begin Date" on Form 2101.

For Community Attendant Services (CAS), within five business days of receipt of the completed practitioner's statement and Form 2101, the Texas Health and Human Services Commission (HHSC) nurse must enter the information into SAS and send authorization Form 2101 to the provider and send a copy to the case worker, or notify the case worker by electronic mail. If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number, type of case action (initial, annual reauthorization, etc.) and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into SAS and print a copy of Form 2101 from SAS and a copy of the email for the case record.

The "Begin Date" (Item 4) on Form 2101 is same as the "Mail Date" (Item 1). Form 3052 must be date stamped on the date of receipt. The HHSC nurse sends Form 3052 by mail, fax or electronic scan to the HHSC case worker for retention in the individual's case record. The case worker must file the form in the case record and retain the form according to established form retention schedules. Services cannot begin until the provider receives Form 2101 authorizing services. The provider has seven days to initiate services after receipt of Form 2101.

The case worker sends Form 2065-A to the individual within two business days of receipt of Form 2101 from the HHSC nurse. Form 2101 must be date stamped when it is received in the case worker's office.

 

4662.2 Authorization for Expedited Referrals

Revision 17-1; Effective March 15, 2017

 

When the provider orally notifies the case worker that the practitioner's statement has been received, the case worker must ask for the functional limitations, the practitioner's name and license number, and the signature date. The case worker and provider negotiate a begin date for services. The case worker enters the information in the Service Authorization System (SAS) and generates Form 2101, Authorization for Community Care Services, within five calendar days, entering the negotiated date as the begin date. In "Comments," the case worker enters the information on the oral notification, including the provider representative and date of negotiation. Form 2101 must be sent to the provider within five calendar days of the negotiation. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual within two business days.

Each region must ensure there is always a case worker available to negotiate a start of care date on expedited referrals.

The provider must send the completed practitioner's statement to the Texas Health and Human Services Commission (HHSC) within seven business days of service initiation. If a completed practitioner's statement is not sent to HHSC within seven business days of service initiation, the provider is not entitled to payment from HHSC until the date HHSC receives the completed practitioner's statement. In this circumstance, the case worker changes the service initiation date in SAS to the date HHSC receives the completed practitioner's statement and sends the provider a corrected Form 2101.

 

4663 Effective Dates

Revision 17-1; Effective March 15, 2017

 

The case worker (for Primary Home Care) or Texas Health and Human Services Commission nurse (for Community Attendant Services) establishes the beginning date of coverage for initial cases on Form 2101, Authorization for Community Care Services, Item 4, as the date the form is expected to be mailed to the provider. If this date is not feasible, the beginning date of coverage is negotiated according to the individual's needs and the unique circumstances of the case.

See Section 4664, Time-Limited Services, for additional information.

 

4664 Time-Limited Services

Revision 18-1; Effective June 15, 2018

 

If the practitioner believes the individual may not need services ongoing, they may choose to put an end date on Form 3052, Practitioner's Statement of Medical Need. Since time-limited services are not often requested, there are special procedures for handling the request.

  1. The initial assessment and referral processes remain the same.
  2. When the provider receives Form 3052, indicating a need for time-limited services, the provider sends a copy of the form to the Texas Health and Human Services Commission (HHSC).
  3. The case worker (for Primary Home Care (PHC)) or HHSC nurse (for Community Attendant Services (CAS)) completes the authorization for services and enters an end date on Form 2101, Authorization for Community Care Services. Explain the reason for an end date in the comments section. Example: "Individual needs services because of a broken arm; full recovery expected in three months," or “practitioner has specified time limited services ending on XXXXX.”
  4. The case worker enters a monitor date into the Service Authorization System (SAS) scheduler and plans to monitor the individual at least 30 days before the end date on Form 2101.
  5. At the scheduled time, the case worker contacts the individual to see if his needs have been met or if he requests continued PHC or CAS services.
  6. If the individual's needs have been met, the case worker closes the case by sending the individual Form 2065-A, Notification of Community Care Services, with a 12-day prior notice and enters a date and termination code of "14-No Medical Need" on Form 2101. The effective date of termination on Form 2065-A is the same as the end date on Form 2101.
  7. If the individual wishes to continue PHC or CAS services, the case worker must send Form 2065-A at least 12 days prior to, but not more than 30 days prior to, the Form 2101 end date informing the individual that if a new Form 3052 is not received before the end date of Form 2101, services will be terminated. The case worker must complete a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and a new Form 2101. The case worker must also advise the provider that a new Form 3052 is required.
  8. If the practitioner refuses to sign Form 3052, the case worker screens the applicant for Family Care (FC) services. If eligible, the case worker refers the applicant for FC services or places the applicant on the FC interest list.
  9. If the practitioner signs Form 3052, the case is authorized and the individual remains eligible for service. The case worker must send a new Form 2065-A to inform the individual of the new certification.    

If an individual on CAS has time-limited benefits, the regional nurse will add the end date. The case worker must never change or delete the end date added by the regional nurse when adding an effective date for a plan change:  

For example, an individual is certified January 2 for CAS with time-limited services ending December 31. The regional nurse will add the end date of 12/31/XX. During the authorized period, the individual requests a change in July that will be effective August 1. When working the change, the case worker must not change or delete the date added by the regional nurse to add an effective date for the change. The case worker will document in the comments of Form 2101 the normal information regarding the change, including “Increase in hours effective 08/01/XX.” The case worker will also still include in the comments, along with the change information, that the individual has time-limited benefits ending on 12/31/XX. This will give the provider the information regarding the change, including the effective date of the change, but will leave the end date intact.

Also use this process when an individual’s time-limited benefits end after the annual certification. Using the same dates above, the case worker sees the individual for their annual reassessment on October 5 and processes the case October 10, leaving the end date in the authorization of 12/31/XX. Along with the regular annual reassessment comments, the case worker will add the comment that “the individual has time-limited benefits ending on 12/31/XX.” The case worker will still follow the same procedure in the list above starting with number 4 to set the scheduler 30 days before the end date to monitor the individual’s time limited case. 

 

4665 Service Initiation and Delivery

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §47.61, Service Initiation.

 

4665.1 Delays in Service Initiation

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §47.61(c), Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond the provider's control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider's control;
(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and
(3) a description of the provider's ongoing efforts to initiate services.
(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

Evaluate the cause of the delay and take whatever action is necessary to ensure the individual receives services at the earliest possible date.

Example: The provider may state the individual's physician is on vacation but is expected to return by a specific date and a practitioner's statement will be obtained as soon as the physician returns. If the delay will not adversely affect the individual, the case worker may decide to take no further action. If the delay is problematic for the individual, the case worker may discuss with the individual the need to obtain a practitioner's statement from another practitioner. Appropriate action may necessitate making a new referral to a different provider.

Each situation is evaluated on a case-by-case basis. The provider may contact the case worker's supervisor if the case worker has a pattern of transferring individuals to other providers even though they have indicated that it is due to reasons beyond their control. The case worker may also contact the contract manager if the provider frequently submits Form 2067, Case Information, to the case worker about a delay in initiating services.

 

4665.2 Service Delivery Requirements

Revision 17-1; Effective March 15, 2017

 

  The provider agency must ensure:

  • services are delivered according to the service plan described in Texas Administrative Code §47.45  (relating to Pre-Initiation Activities);
  • (all authorized and scheduled services are provided to an individual, except in the case of a service interruption; and
  • an individual does not receive, during a calendar month, more than five times the weekly authorized hours on Form 2101,  Authorization for Community Care Services.

 

4670 Ongoing Case Management

Revision 17-1; Effective March 15, 2017

 

 

 

 

4671 Ongoing Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

Monitor the individual according to Section 2710, Monitoring Visits and Contacts, to review the continued adequacy of the service plan, the quality of service delivery and the individual's condition.

The case worker:

  • reassesses the individual's functional need within 12 months of the previous functional assessment date on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, (see Section 2663, Reassessment of Functional Need); and
  • reverifies financial eligibility status within 24 months of the previous eligibility date on the Service Authorization System (see Section 2662, Redetermination of Financial Eligibility).

In addition to providing ongoing case management services to the individual, the case worker also reports to, and discusses with, the unit supervisor, the contract manager and the provider any apparent deficiencies noted in the provider's delivery of Primary Home Care or Community Attendant Services.

 

4672 Transferring Individuals from Family Care to Title XIX Personal Attendant Services

Revision 17-1; Effective March 15, 2017

 

When the case worker transfers an individual from Family Care (FC) to Primary Home Care (PHC) or Community Attendant Services (CAS), send a referral packet to the receiving provider. The provider will begin pre-initiation activities, as well as coordinate the end date for FC and begin date for PHC/CAS, with the case worker or Texas Health and Human Services Commission nurse.

The FC authorization must be closed in the Service Authorization System before the PHC/CAS authorization can be opened. Send the individual Form 2065-A, Notification of Community Care Services, within two business days of authorizing services as notification of the program change and (if applicable) of the change in providers.

 

4673 Interim Service Plan Changes

Revision 17-1; Effective March 15, 2017

 

The individual may request a change in tasks or hours. See Section 2720, Changes Reported in the Individual's Condition or Status during the Certification Period.

The provider may also notify the case worker of any ongoing change in the individual's condition or circumstances that may require a service plan change or service termination. Any of the following changes in the individual's condition or circumstances may require a change in the service plan. (These are examples only.)

  • Individual's health improves or deteriorates;
  • Individual no longer needs services;
  • Individual is discharged from a hospital;
  • Problems exist with family relationships;
  • Individual is evicted or otherwise loses housing;
  • Individual relocates;
  • Individual is referred for home health services; and/or
  • Changes occur in the individual's household composition.

 

4673.1 Temporary Service Plan Variances

Revision 17-1; Effective March 15, 2017

 

The provider may temporarily vary the service delivery plan at the individual's request as long as the variance in tasks can be provided within the total approved hours. The case worker will not be advised of the temporary variance unless the circumstance lasts for more than 60 days.

The provider must provide services according to the existing service delivery plan, until the provider receives a new Form 2101, Authorization for Community Care Services, except the provider may temporarily change the service delivery plan if:

  • the individual requests and requires temporary assistance with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and
  • the change in tasks does not increase the total approved hours of service or continue for more than 60 days.

The provider must request and obtain a new Form 2101 when a temporary variance in tasks and/or hours on the service delivery plan is to continue for more than 60 days or would result in more hours of services provided than have been approved.

If the temporary variance lasts for more than 60 days, the provider must notify the case worker and request a new Form 2101 for the change. The case worker must follow normal procedures for responding to reported changes as outlined in Section 2720, Interim Changes. If the provider does not request a new authorization, then the service plan delivery must go back to the original authorization of tasks and hours.

 

4673.2 Ongoing Service Plan Changes

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §47.67(a), Increase in hours or terminations.

If the case worker receives a request for a change, he must respond to it within 14 calendar days from the date the request is received. Contact the individual and review the individual's service plan to decide whether the change is necessary. If the case worker decides the change is not necessary, document the reasons on Form 2067, Case Information, and send it to the provider. Keep a copy of Form 2067 in the case record.

Depending on the individual's new condition or situation, a new assessment or revision of the service plan (such as the need for more hours or a different priority level) may be necessary. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, according to Section 2720, Interim Changes. Consult with the supervisor about the requested change, if necessary. If the change in circumstances meets the criteria for Adult Protective Services, refer the individual to that service. See Section 2220, Response to Requests for Service.

For Community Attendant Services interim changes and provider transfers during the service plan year, the case worker can authorize changes without authorization from the HHSC regional nurse. The case worker enters the "Begin Date" on Form 2101 based on the case action (increase or decrease). The effective date on Form 2065-A, Notification of Community Services, must match the "Begin Date" on Form 2101.

 

4673.3 Increase in Hours

Revision 17-1; Effective March 15, 2017

 

For expedited or routine service plan changes resulting in an increase in hours, set the begin date on the authorization form. Within two business days of the case decision, the case worker sends the:

  • negotiated date of increase as the begin date on Form 2101, Authorization for Community Care Services; or
  • routine date of increase as the begin date on Form 2101, which must be seven days later than the date the form is expected to be mailed. There may be times when unique or extenuating circumstances make it more appropriate to make the increase later than seven days. In these circumstances, the begin date of coverage is negotiated between the case worker and the provider according to the individual's unique needs. The increase should not be delayed solely because the delay is more convenient for the provider.

Send Form 2101 to the provider.

 

4673.4 Immediate Increase in Hours

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §47.67(c), Immediate increase in hours of service.

Upon notification from the provider that the individual requires an immediate increase in hours, the case worker or the designated case worker immediately contacts the individual to verify the need for the immediate increase. Review the tasks and hours on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, making the necessary

Revisions to the service plan. Contact the provider and negotiate an effective date for the increase. The request for an immediate increase must be responded to within the same day of the request. Within three business days, send a revised Form 2101, Authorization for Community Care Services, documenting the reason for the increase, the additional tasks and/or hours, the effective date and the provider representative contacted to negotiate the effective date. See Section 2721, Service Plan Changes, for additional information.

The following are examples of situations that require immediate response:

  • The individual is experiencing a major illness and has no available caregiver.
  • The individual suddenly loses his caregiver and has no other available caregiver and
    • is totally bedridden or unable to transfer from bed to chair without assistance; or
    • cannot manage toileting tasks without personal assistance; or
    • needs meal preparation or feeding to ensure that he receives daily nourishment.

Each region must ensure there is always a case worker available to negotiate an immediate increase in hours.

 

4673.5 Termination or Reduction of Hours

Revision 17-1; Effective March 15, 2017

 

Reduce hours or terminate services 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.

Use personal judgment to determine if the individual's long term improvement is expected to last through the current authorization period or beyond before services are reduced or terminated. If the case worker determines the individual's condition has temporarily improved because the individual is performing the task(s) previously done by the attendant, the individual and provider may agree to a temporary variance. To continue to qualify for Title XIX personal attendant services, the individual must need at least one personal care task.

For changes made in conjunction with an annual reassessment of Community Attendant Services cases, the Texas Health and Human Services Commission (HHSC) nurse must authorize the change.

For decreases, the change is effective 12 days from the date in Item 1 on Form 2101, Authorization for Community Care Services, unless waived by the individual. The effective date of decrease on Form 2065-A, Notification of Community Care Services, must match the effective date of decrease entered in Item 4 of Form 2101.

If services are terminated, follow the individual notification procedures in Section 2810, Notice of Ineligibility or Service Reduction. Coordinate the effective date of denial of services with the provider and HHSC nurse (if appropriate) to allow enough time for the individual to appeal.

 

4673.6 Temporary Loss of Eligibility and Reinstatement Procedures

Revision 17-1; Effective March 15, 2017

 

When an individual loses Medicaid or financial eligibility as determined by Medicaid for the Elderly and People with Disabilities (MEPD), the case worker must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The case worker must contact the individual to discuss the situation and, if feasible, assist the individual with reinstatement of eligibility. If eligibility is reinstated without a gap in eligibility dates, no further action is needed. See Section 3441, Loss of Categorical Status or Financial Eligibility, Section 3441.1, Procedures Pending Reinstatement, and Section 3441.2, Reinstatement Procedures After Denial, for case worker procedures.

If the individual's Medicaid or financial eligibility is later reinstated after a gap in eligibility, the individual may not be automatically placed back on Primary Home Care (PHC) or Community Attendant Services (CAS), if the service has been terminated.

If HHSC notifies the provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

If the case worker has sent Form 2101, Authorization for Community Care Services, terminating services, then the case worker must send a referral Form 2101 for PHC or CAS to the provider for pre-initiation activities, including a new Form 3052, Practitioner's Statement of Medical Need. Expedited procedures may be used in this situation, if appropriate. All policies regarding new referrals apply, including those for CAS and the authorization of services by the HHSC regional nurse. If the individual was placed on another service, the transfer between services must be negotiated for end dates and begin dates and the individual must be notified on Form 2065-A, Notification of Community Care Services.

 

4673.7 Implementation of Service Delivery Plan Changes

Revision 17-1; Effective March 15, 2017

 

The provider must implement the service delivery plan change on the following date, whichever is later:

  • the authorization begin date on Form 2101, Authorization for Community Care Services; or
  • five days after the date the provider receives Form 2101, unless the provider fails to stamp the receipt date on the form, in which case the authorization begin date on the form will be used to determine timeliness.

If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document by the next working day any failure to implement a service delivery plan change on the effective date of the change. The documentation must include:

  • the reason for the failure to timely implement the service delivery plan change; and
  • the new implementation date.

 

4674 Service Interruptions

Revision 17-1; Effective March 15, 2017

 

A service interruption occurs anytime service delivery is discontinued for 14 days or more. The provider should make every effort to ensure that interruptions in service last less than 14 days, particularly if a break in service would jeopardize the individual's health or safety. When an interruption of services is unavoidable, the provider must document in the individual's file all service interruptions by:

  • the 30th day after the beginning of the service interruption for priority individuals; and
  • the 30th day that exceeds 14 days after the service interruption for non-priority individuals.

The provider is not required to advise the case worker that service interruptions have occurred. If the individual contacts the case worker or if the case worker learns of the interruption during a monitoring contact, the case worker takes the following actions:

  • The case worker contacts the individual to determine if the service interruption is jeopardizing the individual's health and safety or is having an adverse impact on the individual.
  • If there is no adverse impact and the individual is willing to wait for services, the case worker documents this information in the case narrative.
  • If there is an adverse impact, the case worker:
    • contacts the provider to determine the status of resuming services;
    • contacts the individual and discusses the individual's right to change providers if the provider cannot provide a resumption date; and
    • follows procedures in Section 4676, Change of Providers, if the individual elects to change providers.

 

4675 Interdisciplinary Team

Revision 17-1; Effective March 15, 2017

 

The interdisciplinary team (IDT) is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:

  • the individual or the individual's representative, or both;
  • a provider representative; and
  • an  HHSC representative, who may be the:
    • case worker (or designee);
    • case worker’s supervisor (or designee);
    • contract manager (or designee); or
    • HHSC regional nurse (or designee).

A Texas Health and Human Services Commission representative must attend all IDT meetings requested by the provider.

Additionally, the case worker may choose to conduct an IDT meeting to resolve problems before the individual elects to transfer from one provider to another. If the individual remains dissatisfied or continues to request to change providers, he may do so. The individual must always have the freedom of choice in selecting a provider and should not be required to go through the IDT process for this purpose. See Section 4676, Change of Providers, for additional information.

See Section 4677, Suspension of Services and Interdisciplinary Team Procedures, for a detailed description of the IDT's role in service suspensions.

 

4675.1 Individual Reports of Service Delivery Issues

Revision 17-9; Effective September 15, 2017

 

An individual has the right to voice grievances or complaints concerning the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation. The individual has a right to report service delivery issues to the Health and Human Services Office of the Ombudsman at 1-877-787-8999. If the case worker is aware of the issue, the case worker must work to resolve the individual's issues. See policy outlined in Section 2746.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

 

4676 Change of Providers

Revision 17-3; Effective May 15, 2017

 

When the individual plans to change providers, the individual must first contact the case worker who:

  • coordinates the transfer to prevent a gap in coverage; and
  • attempts to resolve any problems the individual may have with the current provider before he processes the transfer.

Within 14 calendar days after notification of a request to transfer providers, the case worker contacts the individual and the provider to determine:

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

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

The case worker may determine that an interdisciplinary team (IDT) meeting is appropriate to discuss the issues and find a resolution to the service delivery issues. (See Section 4675, Interdisciplinary Team, for additional information.) The case worker may terminate the individual's services if the individual refuses more than three times to comply with service delivery provisions by repeatedly and directly, or knowingly and passively, condoning the behavior of someone in his home.

Within three business days of the IDT decision, the case worker authorizes the transfer if:

  • he determines that the individual's satisfaction cannot be met without the individual changing providers and services do not have to be terminated based on failure to comply with the service plan; or
  • the individual insists on transferring to another provider and the case worker determines that services do not have to be terminated based on failure to comply with the service plan.

Within those three business days, the case worker also:

  • asks the individual or the individual's representative to select a new provider and documents the individual's choice in the case record by:
    • coordinating with both providers the date the current provider will stop providing services and the date the new provider will begin services;
    • updating any pertinent information on Form 2059, Summary of Client's Need for Service;
    • updating Form 2101, Authorization for Community Care Services, for ongoing cases by entering the new nine-digit contract number in Item 2; and
    • documenting in the comments section that the individual is changing providers;
  • sends the new provider the updated Form 2101 and Form 2059; and
  • sends the current provider a copy of the updated Form 2101 that includes the effective date the individual changes to the new provider.

 

4677 Suspension of Services and Interdisciplinary Team Procedures

Revision 17-1; Effective March 15, 2017

 

A provider must suspend services if:

  • an individual temporarily or permanently leaves the provider agency’s contracted service delivery area during a time when the individual would routinely receive services and the individual does not request the provision of services outside the provider agency’s contracted service delivery area;
  • the provider declines the request of the individual for the provision of services outside of the provider agency’s contracted service delivery area and the individual leaves the service delivery area;
  • the individual moves to a location where services cannot be provided under the PHC Program;
  • the individual dies;
  • the individual is admitted to an institution, which is a:
    • hospital;
    • nursing facility;
    • state supported living center;
    • state hospital;
    • intermediate care facility serving individuals with an intellectual disability or related conditions; or
    • correctional facility.
  • the individual requests that services end;
  • the Health and Human Services Commission denies the individual's Medicaid eligibility (not applicable to Family Care services); or
  • the individual or someone in the individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person in which case the provider agency must make an immediate referral to:
    • the Texas Department of Family and Protective Services or other appropriate protective services agency;
    • local law enforcement, if appropriate; and
    • the individual's case worker.

The provider agency may suspend services if:

  • the individual or someone in the individual's home engages in discrimination against a provider or HHSC employee in violation of applicable law; or
  • the individual refuses services for more than 30 consecutive days.

The provider agency must notify the case worker of any suspension by the first working day after the provider suspends services. The notice must include:

  • the date of service suspension;
  • the reason(s) for the suspension;
  • the duration of the suspension, if known; and
  • a written explanation of the circumstances surrounding the suspension.

Refer to 40 Texas Administrative Code §47.71(d), Interdisciplinary Team (IDT) meeting, and §47.71(e), Resuming services after suspension.

The provider must suspend services if the individual:

  • is not available to receive services;
  • requests that services end;
  • loses Medicaid coverage; or
  • someone in the individual's home exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the attendant or another person.

The provider may suspend services if the:

  • individual or someone in the individual's home engages in discrimination against a provider or Texas Health and Human Services Commission (HHSC) employee in violation of applicable law; or
  • individual refuses services for more than 30 consecutive days.

In situations of reckless behavior, discrimination or refusal, the provider must convene an IDT meeting within three business days of the date the provider suspends services or identifies an issue that prevents the provider from carrying out a requirement of the program. The IDT meeting may be conducted by telephone or in person.

The IDT must consist of:

  • the individual or individual's representative, or both;
  • a provider representative; and
  • an HHSC representative, which may be the:
    • case worker (or designee);
    • contract manager (or designee); or
    • HHSC nurse (or designee).

If the provider is unable to convene an IDT meeting with all the members present, the provider convenes with available members and sends documentation of the IDT meeting within five days to the regional director for the HHSC region in which the individual resides. Participation by HHSC staff is mandatory; staff must be aware of the requirements for participation in the IDT meeting. Based on a HHSC review of the IDT documentation, further action by the provider may be required.

During the IDT meeting, the team must:

  • evaluate the issue;
  • identify any solutions to resolve the issue; and
  • make recommendations to the provider.

The case worker takes the appropriate action following the IDT meeting, either terminating services or authorizing resuming services. See Section 2820, Service Suspension by Providers. The provider must implement the recommendations of the IDT in accordance with §47.71(e) of the Texas Administrative Code.

 

4677.1 Individual Temporarily Leaving Service Area

Revision 17-1; Effective March 15, 2017

 

An individual receiving services may continue to receive services while he is temporarily staying at a location outside of the provider’s contracted service delivery area, but within the state of Texas. This will help prevent a disruption in services and protect an individual’s health and welfare while the individual is traveling or staying at a location other than his location of residence.

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

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

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

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

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

Out of Area Service Limitations

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

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

 

4678 Annual Reassessments

Revision 17-1; Effective March 15, 2017

 

For Primary Home Care (PHC) individuals, the case worker must make a home visit and face-to-face interview to conduct an annual functional reassessment and completion/review of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, every 24 months. 

A home visit is not required for a PHC individual if verification of financial eligibility status is not due at the next reassessment. The case worker retains the ability to make a home visit if individual case circumstances require a home visit be made, as indicated in case examples listed Section 2663.2, Determining When a Home Visit is Necessary for Other Services.

For Community Attendant Services individuals, the case worker must make an annual home visit and face-to-face interview to conduct a functional reassessment. If the need for a change in tasks and/or hours is identified at the annual reassessment, Form 2101, Authorization for Community Care Services, will be sent as follows.

 

4678.1 Primary Home Care Annual Reassessments

Revision 17-1; Effective March 15, 2017

 

For Primary Home Care cases at reassessment with no changes, the service authorization is open ended and nothing is sent to the provider. If there are changes in the service plan, within five business days of the annual contact, the case worker must send the provider Form 2101, Authorization for Community Care Services, and appropriate forms as noted in Appendix XIII, Content of Referral Packets. See Appendix IX, Notification/Effective Date of Decision, for effective dates.

 

4678.2 Community Attendant Services Annual Reassessments

Revision 17-7; Effective July 1, 2017

 

For the Community Attendant Services (CAS) program, there is a requirement that the individual be reassessed not less often than every 12 months. The reassessment includes the case worker's functional assessment, the review by the provider, and the authorization determination by the HHSC regional nurse. The reauthorization must be completed by the end of the 12th month from the previous authorization (either the initial authorization or the annual reassessment). For example, the case worker completes the annual functional assessment by October 31. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is due by the end of the 12th month from the previous Form 2060. The case worker sends the referral Form 2101, Authorization for Community Care Services, to the provider. The HHSC regional nurse's last annual reauthorization was on November 20 in the previous year and this year will be due by November 30.

See Appendix IV, Workflow and Time Frames, for a CAS reassessment. See Section 6333.4, Annual Recertification, for procedures for CAS annual reassessments in the Consumer Directed Services (CDS) Option.

 

Case Worker Procedures

The case worker must make the annual home visit and complete the functional assessment early enough for the reauthorization process to be completed within the 12-month time frame. It is recommended the case worker complete the annual functional reassessment during the fourth 90-day monitor for the year. If the annual reassessment is not completed during the fourth 90-day monitoring visit, then an additional home visit is required to complete the reassessment. The only exception is if Form 2060 has been completed within the last 60 days due to an interim change. Then, the case worker may conduct the annual reassessment by telephone. Within five business days from the home visit, the case worker sends the Referral Form 2101 to the provider and:

  • documents "Annual Reassessment" in the comments section on Form 2101.
  • if there are changes in the service plan, the case worker enters the appropriate "Begin Date" on Form 2101. The case worker enters the information in the Service Authorization System Wizards (SASW) and sends Form 2065-A, Notification of Community Care Services, to advise the individual of the changes in the service plan.
  • if there are no changes in the service plan, the case worker indicates "No Changes" on the Form 2101 and leaves the "Begin Date" blank.

For CAS or Primary Home Care 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.

 

HHSC Regional Nurse Procedures for Annual Reassessments

For ongoing CAS cases, the HHSC regional nurse must review and authorize CAS services annually in SASW. The authorization in SASW is required with or without any changes in the service plan. The annual reauthorization is due by the end of the 12th month from the last annual authorization.

Within 14 calendar days of receipt of the referral Form 2101 from the case worker, the provider must send Form 2101 to the HHSC regional nurse with a signed statement of the agreement or disagreement with the service plan.

 

Provider Agreement

If the provider is in agreement, within five business days of receipt of Form 2101 from the provider, the HHSC regional nurse completes the authorization of CAS as follows:

  • If there are no changes to the service plan, the HHSC regional nurse enters the "Begin Date," which is the same as the "Mail Date," and sends the provider and the case worker a copy of the authorization Form 2101.
  • If there are changes in the service plan, the HHSC regional nurse reviews the plan and authorizes the service based on the "Begin Date" the case worker entered. The HHSC regional nurse enters the "Mail Date" and sends the provider a copy of the authorization Form 2101.
  • The HHSC regional nurse notifies the case worker by either sending a paper copy of Form 2101 or notification of the authorization by electronic mail. If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number, type of case action (initial, annual reauthorization, etc.) and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must print a copy of the email for the case record and go into the SAS to print a copy of Form 2101 for the case record.

 

Provider Disagreement

If the provider disagrees with the service plan, within five business days, the HHSC regional nurse:

  • negotiates with the provider and the case worker to arrive at an agreement on the service plan and the effective date of the change. If the negotiation results in a decrease in services for the individual, the effective date must allow time for the individual to receive 12 days notice on Form 2065-A from the case worker;
  • makes any necessary changes to Form 2101, noting the negotiated change in the comments;
  • completes the authorization in the Authorization Wizard;
  • sends Form 2067, Case Information, notifying the provider and the case worker of the outcome of the negotiation; and
  • sends a copy of the authorization Form 2101.

The case worker sends another Form 2065-A to the individual, noting the negotiated service plan change(s) and the new effective date.

 

Tracking Receipt of Form 2101 from the Provider

The case worker is responsible for tracking the receipt of Form 2101 from the provider. If the authorization Form 2101 is not received from the HHSC regional nurse within 14 calendar days of the referral Form 2101 being sent to the provider, the case worker checks in SAS to see if services have been authorized by the regional nurse. If services have been authorized, the case worker prints the authorization Form 2101 and files it in the case folder. If services have not been authorized, the case worker contacts the regional nurse requesting services be authorized.

The regional nurse enters the authorization in SAS within five business days of receipt of the email from the case worker or Form 2101 from the provider, whichever is earlier. The regional nurse sends the provider a copy of the authorization Form 2101 and sends a copy to the case worker, or emails the case worker advising the authorization has been completed.

 

4700 Residential Care Services

Revision 17-1; Effective March 15, 2017

 

 

 

 

4710 Description

Revision 17-1; Effective March 15, 2017

 

Residential Care (RC) services include RC and Emergency Care (EC).

 

Residential Care

  • Contracted facilities serve eligible adults who require round-the-clock access to services. In RC services, the individual must contribute to the cost of care, including a room and board payment and a copayment, if applicable.
  • For details about eligibility for RC, see Section 4721, Residential Care Eligibility.
  • For special casework procedures for RC, see Section 4730, Special Casework Procedures for Residential Care.

 

Emergency Care

  • EC is available to eligible individuals for as many as 30 days while the case worker seeks permanent care arrangements. EC may be provided in Adult Foster Care (AFC) homes and in RC facilities. If an individual is not placed in a permanent care arrangement within the initial 30-day period, he is eligible to receive services for one 30-day extension (for a total of as many as 60 days).
  • For details about eligibility for EC, see Section 4722, Emergency Care Eligibility.
  • For special casework procedures for EC, see Section 4770, Ongoing Casework Procedures.

 

4711 Required Services

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §46.41(b), Required services.

An individual in a Residential Care (RC) facility has access to services on an as-needed basis. The frequency of a task is therefore not designated.

 

4720 Eligibility for Service

Revision 17-1; Effective March 15, 2017

 

 

 

 

4721 Residential Care Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2920, Residential Care

(a) Eligibility for residential care is based on the following criteria:

(1) the applicant must be income eligible or Medicaid eligible (not in an institution);

(2) the applicant must meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility;

(3) the applicant's needs may not exceed the facility's capability under its licensed authority; and

(4) the applicant must have financial resources at or below the level established by the department.

(b) The client must contribute to the total cost of care that he receives, including payment for room and board. The room and board amount is calculated from the client's gross income. The client is responsible for paying this amount directly to the provider agency. The client may be required to pay a copayment based on the amount of income remaining after all allowances are deducted.

Applicants/individuals must score at least 18 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and have adequate income to pay the required room and board payment to become/remain eligible for Residential Care (RC). For other eligibility requirements, see:

 

4722 Emergency Care Eligibility

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §48.2921(a), Eligibility for emergency care criteria.

 

4730 Special Casework Procedures for Residential Care

Revision 17-1; Effective March 15, 2017

 

 

 

 

4731 Assessment

Revision 17-1; Effective March 15, 2017

 

If an individual is requesting Residential Care (RC) services, determine if services are open and space in an RC facility is available. If services are not open at that time, place the individual on the interest list. If funding and RC spaces are available or if the individual is released from the interest list, proceed with the eligibility determination and assessment.

Advise the individual of spaces available in the RC facilities in his area, and recommend that the individual visit the facilities. If the individual selects a facility and wants to move to the facility, continue with eligibility determination.

To assess if an applicant qualifies for RC, interview the applicant to determine:

  • if he meets the Community Care for Aged and Disabled (CCAD) income and resource limits;
  • if he has adequate income to pay the required room and board payment;
  • the extent of the applicant's functional disability by scoring his response to Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • the applicant's appropriateness using the guidelines for appropriate and inappropriate mental and physical characteristics in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics; and
  • if his needs can be met adequately at an RC facility.

The Texas Health and Human Services Commission (HHSC) Licensing Standards for Assisted Living Facilities, in 40 Texas Administrative Code (TAC) §92.41(e)(1), specify that "A facility must not admit or retain: (A) residents whose needs cannot be met by the assisted living facility, or the necessary services secured by the resident. ..."

An individual is, therefore, inappropriate for placement if his needs exceed the facility's capability under its licensed authority. In general, an RC facility may provide services to an individual whose needs correspond with those listed in the Appropriate Characteristics column of the mental and physical characteristics in Appendix VIII. The facility may not be capable of providing services to an individual whose needs correspond with those listed in the Inappropriate Characteristics column. Because each individual's case must be reviewed according to the setting in which care is to be provided, the appropriate and inappropriate characteristics are only examples.

An assessment of an individual who is being considered for RC should include review of his personal abilities to perform activities of daily living, as measured by Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and other functional areas, such as the need:

  • for the routine daily care offered in a group-care setting;
  • for a structured environment and the ability to tolerate it;
  • and ability to interact with groups and to socialize daily;
  • for a home or for one different from his current living environment; and
  • for and ability to tolerate daily monitoring or supervision for behavior control or both.

By carefully assessing individuals in relation to the environment of RC facilities, the case worker will be able to develop care plans that make maximum use of the facilities' benefits.

Share findings with facility staff to determine whether the individual is a suitable candidate for RC and to facilitate a smooth transition.

Discuss money management with the individual during the assessment. If the individual expresses an interest in money management, inform the facility on Form 2067, Case Information, or in the comments section of Form 2101, Authorization for Community Care Services. According to 40 TAC §46.61, Trust Fund Management, the facility must provide assistance to the individual in managing his finances only if the individual requests help in writing. The facility is not permitted to assist an individual in writing checks without first establishing a trust fund account for him.

 

4732 Freedom of Choice

Revision 17-1; Effective March 15, 2017

 

The applicant maintains the freedom of choice among the facilities that serve the applicant's area.

The applicant can:

  • select the facility, or
  • choose to take the next facility on the rotation list.

The applicant must indicate his choice of available facilities before beginning the assessment process. If an applicant already has a facility in mind that does not have space available, he may elect to remain on the interest list until a space is available in that facility.

 

4733 Referral

Revision 17-3; Effective May 15, 2017

 

Once the applicant has met all eligibility requirements, selected a facility and has been determined appropriate for placement in Residential Care (RC), negotiate a move-in date with the individual and the facility.

Refer to 40 Texas Administrative Code §46.39, Service Initiation.

To refer the applicant to the facility:

  • complete Form 2059, Summary of Client's Need for Service, and Form 2101, Authorization for Community Care Services; and
  • send these forms to the facility administrator.

If the applicant needs assistance managing his money, inform the facility:

  • on Form 2067, Case Information, or
  • in the comments section of Form 2101.

 

4733.1 Delay of Entry into the Facility

Revision 17-1; Effective March 15, 2017

 

If the individual changes his mind, or for some other reason does not move into the facility on the negotiated date, advise the individual that he has three days from the negotiated date to enter the facility.

Inform the individual that if he does not move into the facility within three days from the negotiated date, the facility may give the bed space to another individual, the referral for services may be withdrawn, and his request for services will be denied. If there are extenuating circumstances and the facility is willing to re-negotiate a move-in date, the date may be changed.

 

4733.2 Termination

Revision 17-1; Effective March 15, 2017

 

If the individual does not move in and the move-in date is not re-negotiated, begin termination procedures. Inform the individual that his request for services will be denied and that if he wants to reconsider Residential Care (RC) placement at a later date, his name will be placed on the interest list with a new request date.

Send the individual Form 2065-A, Notification of Community Care Services, citing "Failure to follow the service plan" as the denial reason, and send the facility Form 2101, Authorization for Community Care Services, to close the referral.

 

4734 Inappropriate for Residential Care

Revision 17-1; Effective March 15, 2017

 

If an individual has been hospitalized, or has temporarily gone to a nursing facility or other institution, reassess the individual upon return to the Residential Care (RC) facility. Complete the reassessment using the list of appropriate characteristics in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics, to ensure that the individual's needs do not exceed the facility's licensed capability to provide service to the individual. Other circumstances may also require that the individual be assessed for appropriateness. If the individual no longer meets the appropriate characteristics, work closely with the facility to explore all available resources in making arrangements for the individual's move. Other resources to consider in making arrangements may include, but are not limited to:

  • other agencies involved with the individual,
  • the individual's family,
  • area ambulance service, or
  • the local sheriff's department.

 

4735 Duplication of Services

Revision 17-1; Effective March 15, 2017

 

A Residential Care (RC) individual may receive Day Activity and Health Services (DAHS) only if the services provided by the DAHS facility are medical services that cannot be provided by the RC facility. Documentation in the case record must clearly specify that at least one medical service is being provided at the DAHS facility that cannot be provided at the RC facility. For example, an individual's needs are being met at the RC facility except for a daily insulin injection. The individual goes to DAHS each morning for the DAHS nurse to administer the injection.

The number of units authorized to an RC individual must be limited to the time needed by the DAHS facility to provide the medical services. Because most RC individuals are not high medical need individuals, the authorized services are limited to one unit (three but less than six hours) per day.

 

4736 Transfers

Revision 17-1; Effective March 15, 2017

 

Once the individual is in a facility, he has the right to move from one contracted Residential Care (RC) facility to another. If the individual decides to move to another facility, contact the new facility to share information regarding the individual's needs and to ensure that his needs can be met in the new facility. If the individual is appropriate for the facility, negotiate a date of transfer, and update Form 2101, Authorization for Community Care Services, to reflect the change in facility. Send a copy of this form to the new facility and the former facility, noting in the comments section that the individual's transfer has been completed.

 

4740 Individual Contribution to the Cost of Care

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2920(b). The client must contribute to the total cost of the care that he receives, including payment for room and board. The room and board amount is calculated from the client's gross income. The client is responsible for paying this amount directly to the provider agency. The client may be required to pay a copayment based on the amount of income remaining after all allowances are deducted.

(1) The client keeps a monthly allowance for his personal and medical expenses. The Medicaid client keeps $123, a qualified Medicare beneficiary (non-Medicaid) keeps $182; and the non-Medicaid non-QMB client keeps $211 and the part B Medicare premium fee.
(2) In addition to the monthly allowance, a client with earned income keeps all of the earned income up to a maximum of $65 per month.
Do not confuse the $65 earnings allowance in this section with the $65 plus 1/2 remainder amount used in the eligibility budget.
(3) In no case may the client's contribution, when added to the department's payment, exceed the rate established for residential care.

§48.3903(e). The client is not eligible for residential care if he is required to contribute to the cost of his care, but refuses to do so.

 

4740.1 Room and Board Payments

Revision 17-1; Effective March 15, 2017

 

Individuals entering Residential Care (RC) are required to pay for room and board. The room and board payment is determined by a specific daily rate based on the type of residential setting. After deducting the room and board payment, the individual's copayment will be calculated based on personal needs allowance and any other approved deductions. The case worker must complete Form 1032, Residential Care Copayment Worksheet. Form 1032 is an automated calculation worksheet for determining room and board and copayment amounts. A copy of the worksheet must be filed in the case record.

 

4740.2 Copayments

Revision 17-1; Effective March 15, 2017

 

Residential Care (RC) includes a copayment system in which the individual is expected to contribute to the cost of care. (Emergency Care (EC) individuals do not contribute any copayment.) Under the copayment system, each individual is allowed certain monthly deductions for personal expenses and contributes the remainder of his income to the cost of care.

Withholding tax can be deducted from unearned income. Both withholding tax and Federal Insurance Contributions Act (FICA) tax can be deducted from earned income provided the deduction is mandatory. Other forms of mandatory deductions may be deducted if the case worker is able to obtain documentation from the employer to confirm that the individual does not have control of the expense being deducted. This includes mandatory repayments to the Social Security Administration (SSA) or other governmental agencies.

The copayment system takes into consideration the costs of non-Medicaid individuals who must pay for their own medical expenses. Medicaid individuals also keep a small allowance for medical expenses that are not covered by their Medicaid/Medicare insurance. If an individual chooses to receive RC services, inform him about the mandatory contribution to the cost of care, and implications for his income and eligibility.

See Form 1032, Residential Care Copayment Worksheet, and Instructions, for step-by-step instructions on how to calculate the individual's total contribution to the cost of care.

 

4741 Individuals on Services Before September 1, 2003

Revision 17-1; Effective March 15, 2017

 

Beginning Sept. 1, 2003, individuals in Residential Care (RC) are required to pay room and board. Individuals authorized for RC before that date were converted to the new payment system by dividing the current copayment into a room and board payment and a copayment.

For individuals authorized for RC before Sept. 1, 2003 with inadequate income to pay room and board, a special payment system was implemented using non-Title XX funds. Individuals in this category were automatically enrolled for the room and board payment with new service codes of 19O for the apartment setting or 19N for the non-apartment setting. The amount authorized is the difference between the individual's income and the room and board amount owed to the provider. Individuals receiving the special room and board payment continue to be eligible for the payment as long as they remain in RC without a break in service. However, these individuals must pursue all possible sources of income and report new income to the case worker. The new income is applied to the room and board fee.

State payment of room and board is available only for this group of individuals and does not apply to new applicants or individuals. Anyone authorized for RC after Sept. 1, 2003, must have adequate income to pay the room and board fee to be eligible for the program.

 

4742 Case Worker Calculation Procedures

Revision 17-1; Effective March 15, 2017

 

While the amount of the individual's room and board is a set amount, the copayment amount varies depending on his income and whether he is a Medicaid, Qualified Medicare Beneficiary (QMB) or Specified Low Income Medicare Beneficiary (SLMB) recipient. If a non-Medicaid, non-QMB or non-SLMB individual receives Social Security or Railroad Retirement benefits, his Medicare premium is deducted from the gross amount of the benefit before the allowances are deducted. No other deduction is allowed. If the individual has earned income, consider only the amount of net income over $65 per month. The net earned income is what the individual actually takes home after all the deductions for taxes, Social Security, etc. (See Form 1032, Residential Care Copayment Worksheet, and Instructions, for instructions on calculating copayments.)

Determine the amount that the individual must contribute and enter the amount in Items 20 and 21 of Form 2101, Authorization for Community Care Services. Item 20 reflects the amount of copayment due for the first month of service. Item 21 reflects the ongoing copayment amount. Whenever cost-of-living changes increase benefits, review the affected individuals' cases and increase the copayment amounts accordingly. Increases are effective the first day of the month following the end of the 12-day notification period.

Inform the individual, in writing, about the fees he must contribute and advise him that if fees are not paid he will no longer be eligible for Residential Care (RC). Send a copy of Form 2065-A, Notification of Community Care Services, to the individual and the RC provider whenever there are changes in the fees the individual must contribute.

The individual's contribution to the cost of care must never exceed the daily RC rate established by the department.

 

4743 Waiver of Copayment

Revision 17-1; Effective March 15, 2017

 

An individual's copayment (not the room and board payment) may be reduced or waived because of unusual financial obligations such as high medical expenses or a need to purchase mobility aids. Consult with the supervisor to determine who in the region has the authority to waive the copayment for a Residential Care (RC) individual.

Evaluate the individual's circumstances to determine whether his copayment should be reduced or waived. Regional staff may not allow a blanket reduction or waiver for all individuals served in an RC facility. Determine a specific period in which the reduction or waiver is applied.

If the copayment is reduced or waived, document the basis for the reduction or waiver in the individual's case folder and forward a copy of the documentation to the provider. Complete Items 20 and 21 on Form 2101, Authorization for Community Care Services, to reflect waived or reduced copayments and enter a statement in the comments section. Review the waiver or reduction before the waiver expires to determine whether it needs to be continued, and document any continuation of the waiver.

 

4744 Adjusting Payments

Revision 17-1; Effective March 15, 2017

 

Whenever there is a change in the individual's income or an increase in the room and board rates, the case worker is responsible for calculating the change in the individual's copayment amount.

Notify the individual about a copayment increase or room and board rate change by using Form 2065-A, Notification of Community Care Services. The individual must be given at least 12 days after the Form 2065-A date to appeal the increase. If the individual does not appeal, the increase is effective the first day of the following month.

The same day the individual is notified, send the facility a copy of Form 2065-A with the new amounts. For increases in copayment, send the facility Form 2101, Authorization for Community Care Services, showing the new copayment amount. This gives the facility time to prepare to collect the new amounts. If the individual appeals the increase during the 12-day notification period, send the facility another Form 2101 authorizing the original amount until the fair hearing is completed.

Room and board rates are set amounts based on the living arrangement and will not change unless there is an across-the-board rate change. Only individuals designated on Sept. 1, 2003, for receiving a room and board payment will have adjustments based on changes in their income. See Section 4741, Individuals on Services Before September 1, 2003, for additional details.

Copayments are based on the individual's income and will change at least yearly with the Retirement, Survivors and Disability Insurance (RSDI) or Supplemental Security Income (SSI) benefit cost-of-living increase. Case workers will be notified yearly of the increased amounts and procedures for adjusting the copayments.

 

4745 Collection of the Individual's Contribution to the Cost of Care

Revision 17-1; Effective March 15, 2017

 

The facility must collect the individual's room and board payment and copayment and must keep receipts for all copayments collected. The facility must deduct the copayment amount (entered on Form 2101, Authorization of Community Care Services, and in the Service Authorization System) from reimbursement claims submitted to the department.

The facility collects the room and board payment and copayment monthly from the individual by a set due date determined by the facility. If full payment is not made by the due date, the facility sends a notice to the individual and notifies the case worker using Form 2067, Case Information, by the first working day after the due date. When the due date falls on a holiday or a weekend, the facility collects the room and board payment by the first workday following the holiday or weekend.

When Form 2067 is received from the facility stating that the individual has failed to pay the required payments, refer to Section 4774.1, Termination Due to Failure to Pay the Required Contribution to the Cost of Care, for procedures.

The facility must:

  • keep receipts for each room and board payment collected;
  • keep receipts for each copayment collected; and
  • deduct all copayments from reimbursement claims submitted to the Texas Health and Human Services Commission (HHSC).

The individual must pay his entire room and board payment. The individual must also pay the entire copayment or request that the case worker ask for a waiver, if financially unable to pay. See Section 4743, Waiver of Copayment, for procedures.

 

4750 Personal Leave

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2920(c). The client is eligible for 14 days of personal leave from the residential Care facility each calendar year. If the client does not pay the bedhold charge for days of personal leave that exceed the limits, he may lose his space in the facility.

Inform the individual that he is allowed up to 14 days per year of personal leave from the facility. Vacations and visits with family or friends are examples of personal leave. The individual must pay the copayment and room and board charges for personal days. The facility may not bill the Texas Health and Human Services Commission (HHSC) for more than 14 days of personal leave taken by an individual each calendar year.

If an individual exceeds the allowable limit of 14 days of personal leave, the individual is responsible for paying all charges for services, according to any existing contract or agreement between the individual and the facility.

Individuals who use excessive additional days of personal leave (as many as 30 days per year) but continue to pay bed hold charges should be assessed to determine their need for Residential Care (RC). Determine whether the institutional placement is still necessary, appropriate and in the individual's best interest.

Excessive use of personal leave may indicate that family members or friends are able and willing to have the individual live with them, and this potential option should be explored. Discuss excessive use of personal leave with the individual to ensure that he understands the limitations and requirements of the RC service.

 

4760 Hospital, Nursing Home or Institutional Facility Stays

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2920(d). To reserve his space in the facility during hospital, nursing home, or institutional stays, the client must pay his copayment or the facility's bedhold charge, whichever is lower. If the copayment amount is less than the bedhold charge, the department pays the difference. Nursing home and institutional stays are limited to 30 days. There is no limit to the length of hospital stays.

For the individual to reserve his space in the facility during a hospital, nursing facility or institutional stay, the facility receives a bedhold charge payment. The bedhold charge is a set rate established by the Texas Health and Human Services Commission (HHSC). As part of the bedhold charge, the individual is responsible for paying an amount equal to his room and board charge. HHSC then pays the difference up to the bedhold charge. The amount HHSC pays is called the bedhold rate.

The individual does not pay his copayment while out of the facility for a hospital, nursing facility or institutional stay. If the copayment has been paid for the month and the individual goes into a hospital, nursing home or institution, the facility must refund the copayment for the days the individual is out of the facility.

After a hospital or nursing home stay, review the individual's condition to determine whether the facility can continue to meet his needs according to Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics. Refer to Section 4734, Inappropriate for Residential Care, for additional procedures if the individual is no longer appropriate for Residential Care (RC).

 

4770 Ongoing Casework Procedures

Revision 17-1; Effective March 15, 2017

 

 

 

 

4771 Facility Reporting and Notification Requirements

Revision 17-1; Effective March 15, 2017

 

Refer to 40 Texas Administrative Code §46.45, Required Notifications.

If you receive a notice from the facility regarding a significant change, you have to determine within 14 calendar days of receiving the notice whether the change is necessary. See Section 2811, Effective Dates, if the nature of the change requires a termination of services.

 

4772 Monitoring

Revision 17-1; Effective March 15, 2017

 

Monitor the individual's situation every six months. For monitoring procedures, see Section 2710, Monitoring Visits and Contacts. Assess the individual's satisfaction with the facility and services delivered and the appropriateness of the service plan. If the individual has any complaints regarding the facility or service delivery, report the situation to the facility directly or send Form 2067, Case Information. Work with the individual and the facility to resolve the problem.

Report chronic problems to the unit supervisor, who may forward the information to the program manager and the contract manager.

 

4773 Annual Reassessment

Revision 17-1; Effective March 15, 2017

 

The case worker must reassess the individual annually for functional eligibility and redetermine financial eligibility within 24 months of the previous determination of financial eligibility. See Section 2663, Reassessment of Functional Need, and Section 2662, Redetermination of Financial Eligibility, for additional information about reassessments. Update any information on Form 2059, Summary of Client's Need for Services, and any changes to services on Form 2101, Authorization for Community Care Services, and send to the Residential Care (RC) facility.

If the individual no longer meets eligibility requirements or is no longer appropriate for placement in RC, see Section 4774, Termination of Services, and Section 4734, Inappropriate for Residential Care, for procedures to assist the individual in relocation and termination.

 

4774 Termination of Services

Revision 17-1; Effective March 15, 2017

 

The Residential Care (RC) individual is not eligible for services if the individual:

  • dies;
  • is admitted to an institution for more than 30 days;
  • requests service termination;
  • refuses to comply with his service plan;
  • jeopardizes his or others' health or safety;
  • loses Medicaid or becomes financially ineligible for services; or
  • is able to contribute to the cost of his care, but refuses to do so.

Do not terminate services if there is an adverse change in the individual's health, but his needs can continue to be met by the facility.

When terminating services, follow procedures in Section 2800, Procedures for Denying or Reducing Services. Send the individual Form 2065-A, Notification of Community Care Services, 12 days before the effective date of denial, except in situations threatening the health or safety of the individual or other individuals. Terminate services immediately in situations threatening health/safety as outlined in Section 2840, Threats to Health and Safety, and Section 2811, Effective Dates for Service Reduction and Termination.

The individual has the right to appeal any adverse action within 90 days of the date of Form 2065-A. The individual may continue to receive services pending the outcome of the appeal hearing if the individual:

  • is provided with 12 days advance notice, as specified in Section 2800 and Appendix IX, Notification/Effective Date of Decision; and
  • notifies the case worker within those 12 days that he wants to appeal the decision.

If the individual does not appeal the service termination, the termination is final. If the individual appeals the service termination notice, follow the Texas Health and Human Services Commission (HHSC) appeal procedures in Section 2830, Appeal Procedures.

 

4774.1 Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 17-1; Effective March 15, 2017

 

If the individual fails to pay the required contribution to the cost of care (room and board and/or copayment) by the facility's due date, the facility must notify the individual/representative and the case worker in writing that payment was not received no later than the first working day after the due date. The facility may notify the case worker orally by the next workday, and follow up in writing within five calendar days of when the individual or the individual's representative fails to pay the required payments.

Upon receipt of the notice, the case worker will:

  • coordinate with the facility to convene a meeting of the interdisciplinary team (IDT) within five working days of receipt of the notification. The IDT must include the individual, a facility representative, the case worker and the individual's authorized representative(s), if applicable;
  • explore with the individual and IDT if there are new circumstances preventing the individual from making the required payment. Circumstances to consider are:
    • the individual has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
    • the individual meets any of the criteria for waiving the copayment amount, such as increased medical bills (See Section 4743, Waiver of Copayment);
    • circumstances indicate that the individual is being exploited by another person; and
    • other situations exist in which the individual and facility can work out an agreement for the individual to pay the required payments;
  • make every effort to resolve the problem with the individual and the facility;
  • advise the individual of the consequences that will result from refusal to make the required payments to the RC facility, including:
    • termination of eligibility,
    • eviction, and
    • being placed at the end of the interest list if he reapplies for services in the future; and
  • ask the individual to read and sign Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the individual continues to refuse to pay the required payments. The form states that he refuses to pay the required payments and understands the consequences of not meeting this eligibility requirement. If the individual refuses to sign, document the refusal on the form and have a witness sign. Leave the individual a copy of the form and retain the original copy with the signature in the individual's case record. Advise the individual that he will receive a notice to terminate services. Also advise the individual that he will not be allowed to move to another RC facility while he has an outstanding balance at the current facility, and the current facility may evict the individual for refusal to pay. Coordinate the notice of termination with the facility.

After the IDT meeting, make any appropriate referrals to adjust countable income, request a waiver of copayment or refer to Adult Protective Services (APS), if exploitation is suspected.

If the situation cannot be resolved and the individual is refusing to pay for any reason, the case worker sends Form 2065-A, Notification of Community Care Services, giving the individual a 30-day notice that services will be terminated unless the individual pays the required payments. In the comments section of the form, advise the individual that services will end and the facility may evict the individual if payment is not made by the 30th day. Send the facility a copy of Form 2065-A.

The facility may initiate the eviction proceedings by giving the individual an eviction notice in writing.

If the individual does not appeal, terminate services 30 days from the Form 2065-A notice. The facility will receive payment from HHSC during the 30-day period. If the individual has not made other living arrangements at the end of the 30 days, make a referral to APS. Provided the facility is in compliance with the provisions of its license and contract regarding the eviction of individuals, the facility may evict the individual on the date provided on the written eviction notice.

 

4774.2 Services During the Appeal

Revision 17-1; Effective March 15, 2017

 

The individual may appeal the decision to terminate services. If the individual makes the appeal request on or before the date of the action to terminate services, the individual's case will remain open until a hearing decision is made. However, the facility has the right to continue with eviction proceedings and may evict the individual with appropriate notice to the individual, even if the hearing decision has not been made. No services will be provided.

 

4774.3 Requests to Transfer to Another Residential Care Facility

Revision 17-1; Effective March 15, 2017

 

The individual may not transfer to another Residential Care (RC) facility as long as the outstanding payment has not been made to the previous facility. The case worker must maintain clear documentation in the case record regarding the individual's refusal to pay and the subsequent actions.

If the individual contacts another facility or the case worker requests placement in a new facility, the gaining case worker must contact the current case worker to determine if the individual is current on all required payments. If the individual has outstanding payments to a facility, the case worker will not approve ongoing RC services at a new facility and the request to transfer will not be processed. The individual may receive other services, if determined eligible, but will remain ineligible for RC services until all outstanding payments are made.

 

4780 Special Casework Procedures for Emergency Care

Revision 17-1; Effective March 15, 2017

 

 

 

 

4781 Case Worker Assessment

Revision 17-1; Effective March 15, 2017

 

Respond to a request for Emergency Care (EC) on the same day the report is received. If an individual is in an emergency situation because he needs a home and no other care arrangement is available, determine whether he meets the remaining eligibility criteria for EC. If he does, complete the eligibility determination process within one workday after he enters the facility.

An individual who moves into a Residential Care (RC) facility or an Adult Foster Care (AFC) home for EC must meet eligibility requirements for EC and meet the mental and physical characteristics specified in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics. If necessary, consult the regional nurse.

 

4782 Immediate Placement

Revision 17-1; Effective March 15, 2017

 

To expedite the individual's move into the facility, make the referral by telephone. If space is available, help him and his caregivers arrange for transportation to the Adult Foster Care (AFC) home or the Residential Care (RC) facility. If the case worker determines that the individual does not meet the eligibility criteria and the appropriate characteristic criteria for Emergency Care (EC), help him make other arrangements. An ineligible individual must leave the EC facility within five days of the date he entered.

The provider is entitled to payment for EC services for up to five days after individual entry, regardless of the applicant's eligibility status.

If the provider determines that the individual's needs exceed the facility's capability under its licensed authority, the provider may request an additional review by the supervisor in consultation with the regional nurse. Regional staff are responsible for developing review procedures. The case worker is responsible for making the final decision on the individual's appropriateness for RC services.

 

4783 Length of Stay

Revision 17-1; Effective March 15, 2017

 

Residential Care (RC) is provided for up to 30 days while you seek a permanent care arrangement within the initial 30-day period. Obtain your supervisor's approval to extend Emergency Care (EC) beyond 30 days. Obtain this approval before the first 30-day period expires. Note: An extension must not exceed 30 days.

 

4800 Reserved for Future Use

Revision 17-1; Effective March 15, 2017

 

 

 

 

4900 Special Services to Persons with Disabilities (SSPD)

Revision 17-1; Effective March 15, 2017

 

 

 

 

4910 SSPD Program Description

Revision 17-1; Effective March 15, 2017

 

Special Services to Persons with Disabilities (SSPD) helps individuals with disabilities achieve habilitative or rehabilitative goals according to their service plans.

40 Texas Administrative Code (TAC) §58.73. The client's service plan is a document that contains the services, tasks, and frequency of services a particular client will receive. These services must be part of the provider agency's service array outline in the plan of operation.

40 TAC §58.75. The provider agency must develop the service plan.

Services included in the service plan consist of counseling, personal care and help with the development of skills needed for independent living in the community. Support services may include transportation and information and referral.

Services vary depending on the regional contract. The Community Care for Aged and Disabled (CCAD) supervisor can provide specific information about regional contracts. SSPD must not be authorized with any other CCAD service, with the exception of Emergency Response Services.

 

4920 SSPD Eligibility

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §48.2914. To be eligible for special services to persons with disabilities, clients must meet the functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility. Applicants may be admitted to the attendant services program only if their needs do not exceed the program's available services.

To be financially eligible for Special Services to Persons with Disabilities (SSPD), the applicant/individual must:

  • be at least 18 years of age;
  • have Medicaid or meet financial eligibility criteria for individuals in an institution; and
  • have a functional assessment score of at least nine.

If the applicant/individual appears to need personal attendant services (PAS), use the guidelines in Appendix III-A, Appropriate/Inappropriate Client Characteristics Special Services to Persons with Disabilities — Attendant Services Program, for appropriate/inappropriate individual characteristics to decide whether the individual's needs can be met adequately by the SSPD PAS program. If services are inappropriate, follow adverse action procedures in Section 2810, Notice of Ineligibility or Service Reduction.

 

4930 Service Referral, Initiation and Delivery

Revision 17-1; Effective March 15, 2017

 

Special Services to Persons with Disabilities (SSPD) is currently available only in Regions 03, 04, 06 and 07. Refer interested individuals in these locations by completing and sending to the provider Form 2101, Authorization for Community Care Services. Conduct reauthorizations annually according to the same procedure. When necessary, follow procedures in Section 2550, Identifying Individuals at Risk.

40 Texas Administrative Code (TAC) §58.77. The provider agency must develop the service plan before services are initiated.

40 TAC §58.79. The provider agency must initiate services:

(1) within 14 days after the referral date (Item 1) on the DHS Authorization for Community Care Services form; or
(2) as required by the procedures developed in the DHS region where services are delivered.

40 TAC §58.13. The provider agency may deliver services in the following settings:

(1) 24-Hour Shared Attendant Care;
(2) an adult day care facility; or
(3) other settings approved by the contract manager.