Revision 13-2; Effective September 6, 2013

The following words and terms, when used in this manual, have the following meanings unless the context clearly indicates otherwise.

# A C D E F H I L M N P R S T U

§1915(c) Medicaid Waiver — The provision of the Social Security Act that authorizes the secretary of Health and Human Services to grant waivers of certain Medicaid statutory requirements so that a state may furnish home and community-based services to Medicaid beneficiaries who need a level of institutional care that is provided in a hospital, nursing facility or intermediate care facility for persons with intellectual disability (ICF/ID).

# A C D E F H I L M N P R S T U

Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of an individual. Types of abuse include:

  • physical abuse (a physical act by an individual that may cause physical injury to another individual).
  • psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual).
  • sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of an individual by another).
  • verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate an individual).

Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.

Agency Option — A service delivery option in which the provider agency is the employer of record of the direct service provider of a specific CLASS program service.

Applicant — A person who has requested CLASS program services for whom eligibility for CLASS is in the process of being determined.

Appeal — The formal process by which an applicant, individual, or the applicant or individual's parent, guardian or legally authorized representative (LAR) requests a review of an adverse action.

 

# A C D E F H I L M N P R S T U

 

Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based" id="Community">Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based services and supports to people with developmental disabilities other than intellectual disability as an alternative to residing in an intermediate care facility.

Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.

Case Manager — An employee of the Case Management Agency (CMA) who serves as the focal point for service planning and delivery. Responsibilities include needs assessment and reassessment, development of the service plan, identifying appropriate community resources, monitoring the appropriateness and quality of services, providing crisis intervention and advocacy, safeguarding individual rights, and keeping records.

 

Case Management Services — Services that assist the individual in:

 

  • assessing the individual's needs;
  • enrolling into the CLASS program;
  • developing the Individual's Plan of Care (IPC);
  • coordinating the provision of CLASS program services;
  • monitoring the effectiveness of the CLASS program services and the individual's progress toward achieving the outcomes identified;
  • revising the IPC, as appropriate;
  • accessing non-CLASS program services;
  • crisis resolution; and
  • advocating for the individual's needs.

Case Management Agency (CMA) — Contracted agency that provides case management services to the individual.

Catchment Area — A geographic area composed of multiple Texas counties.

Consumer Directed Services (CDS) Option — A service delivery option in which an individual/LAR employs and retains service providers and directs the delivery of program services.

Consumer Directed Service Agency (CDSA) — The name of the entity that provided financial management services to the individual/LAR who serve as the employer of their service providers. The entity is now called Financial Management Services Agency (FMSA).

Continued Family Service (CFS) Agency — Agency that provides services to an individual age 18 or older who resides with a support family, which allows the individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADL. The individual must be receiving support family services immediately before receiving continued family services. A CFS agency must maintain licensure as a Child-Placing Agency through the Texas Department of Family and Protective Services (DFPS).

Consumer Rights and Services (CRS) — A division within the Department of Aging and Disability Services (DADS) that receives and processes complaints from individuals, family members, providers and the general public about the care, treatment or services provided to an individual.

 

# A C D E F H I L M N P R S T U

 

Denial — An action taken by DADS that:

  • denies an individual's request for enrollment into the CLASS program;
  • disallows a CLASS program service requested on an IPC that was not authorized on the prior IPC; or
  • disallows a portion of the amount or level of a CLASS program service requested on an IPC that was not authorized on the prior IPC.

Department of Aging and Disability Services (DADS) — Texas state agency that provides long-term services and supports to older people and individuals with physical, intellectual and developmental disabilities. DADS also regulates providers of long-term services and supports, and administers the state's guardianship program.

Department of Assistive and Rehabilitative Services (DARS) — Texas state agency that administers programs that ensure Texas is a state where people with disabilities, and children who have developmental delays, enjoy the same opportunities as other Texans to live independent and productive lives.

Department of Family and Protective Services (DFPS) — Texas state agency that protects children, the elderly and people with disabilities from abuse, neglect and exploitation by involving clients, families and communities.

Department of State Health Services (DSHS) — Texas state agency that promotes optimal health for individuals and communities while providing effective health, mental health and substance abuse services to Texans.

Direct Services — CLASS program services other than case management, financial management services, support consultation or transition assistance services.

Direct Service Agency (DSA) — A program provider that is a licensed Home and Community Supports Service Agency (HCSSA) that contracts with DADS to provide direct services to the individual.

Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.

 

# A C D E F H I L M N P R S T U

 

Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of an individual by taking advantage of an individual's disability or impairment.

 

# A C D E F H I L M N P R S T U

 

Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by DADS.

Financial Management Services Agency (FMSA) — An entity that provides financial management services to the individual/LAR who serve as the employer of their service providers.

 

# A C D E F H I L M N P R S T U

 

Habilitation Attendant — A direct service provider who can be an employee of a DSA or a CDS employer who assists an individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADLs.

Health and Human Services Commission (HHSC) — Texas state agency that provides leadership and direction, and fosters the spirit of innovation needed to achieve an efficient and effective health and human services system for Texans. HHSC oversees the operations of the health and human services system, provides administrative oversight of Texas health and human services programs, and provides direct administration of some programs, which is composed of five agencies:

  • Health and Human Services Commission (HHSC)
  • Department of Aging and Disability Services (DADS)
  • Department of State Health Services (DSHS)
  • Department of Assistive and Rehabilitative Services (DARS)
  • Department of Family and Protective Services (DFPS)

 

# A C D E F H I L M N P R S T U

 

Individual — A person who is determined by DADS to be eligible for or who receives CLASS program services.

 

Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.

Individual Plan of Care (IPC) — A written plan developed by an individual's service planning team that describes the type and amount of each CLASS program service to be provided to the individual, and services and supports to be provided to the individual through non-CLASS program resources including natural supports, medical services and educational services.

IPC Period — The effective period of an enrollment IPC and a renewal IPC as follows:

  • for an enrollment IPC, the period of time from the effective date of an enrollment IPC, until the first calendar day of the same month of the effective date in the following year; and
  • for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC.

Individual Program Plan (IPP) — A written plan that describes the goals and objectives to be met by the provision of each CLASS program service on an individual's IPC that are supported by justifications, are measurable and have timelines.

Institutional Services — Medicaid-funded services provided in a nursing facility licensed in accordance with Texas Health and Safety Code, Chapter 242, or in an ICF/ID certified by DADS for a capacity of more than six people.

Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID) — A public or private facility that provides health and habilitation services to individuals with intellectual disabilities or related conditions.

Interest List (IL) — A list of people who have contacted DADS and expressed an interest in receiving waiver services, but who have not applied for or been determined eligible for services.

 

# A C D E F H I L M N P R S T U

 

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of an individual, which may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.

 

# A C D E F H I L M N P R S T U

 

Medicaid — A program administered by the federal Centers for Medicare and Medicaid Services (CMS), and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.

Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.

Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease.

Medicaid Eligibility Services Authorization Verification (MESAV) — The automated system used by DADS to notify providers of Medicaid eligibility and service authorizations.

Money Follows the Person (MFP) — A policy that allows residents of nursing facilities to enroll into certain Medicaid waiver programs without having to wait on a program interest list upon determination of program eligibility.

Mutually Exclusive — DADS waiver or Community Care for the Aged and Disabled (CCAD) services that an individual may not receive while enrolled in the CLASS program because services may be duplicative in addressing the individual's needs.

 

# A C D E F H I L M N P R S T U

 

Neglect — The failure to provide an individual the reasonable care required, including but not limited to:

  • food,
  • clothing,
  • shelter,
  • medical care,
  • personal hygiene, and
  • protection from harm.

Non-CLASS Services — Services that are not provided under CLASS waiver provisions of §1915(c) of the Social Security Act.

Notice — A written statement describing the intent of action the state will bring against an individual or the individual's LAR at least 10 days before the date of action.

Nursing Facility — A residential institution that primarily provides:

  • skilled nursing care and related services for residents who require medical or nursing care;
  • rehabilitation services for the rehabilitation of injured, disabled or sick people; or
  • health-related care and services, on a regular basis, to individuals who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through institutional facilities.

 

# A C D E F H I L M N P R S T U

 

Provider Agency — An entity that has a contract with DADS to deliver CLASS services. See DSA and CMA.

 

# A C D E F H I L M N P R S T U

 

Related Condition (RC) — A severe chronic disability attributed to a condition other than mental illness but found to be closely related to intellectual disability. The condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities and requires treatment or services similar to those required for people with intellectual disabilities. It is manifested before the person reaches age 22, is likely to continue indefinitely, and results in substantial functional limitations in at least three of the following areas of major life activity:

  • self care,
  • understanding and use of language,
  • learning,
  • mobility,
  • self-direction, and
  • capacity for independent living.

 

# A C D E F H I L M N P R S T U

 

Service Planning Team (SPT) — A planning team convened and facilitated by a CLASS program case manager consisting of:

  • individual/LAR,
  • case manager, and
  • DSA representative.

An SPT may also include:

  • other people as requested by the individual/LAR; and
  • a person selected by the DSA, with the approval of the individual or LAR, who is professionally qualified by certification or licensure and has special training and experience in the diagnosis and habilitation of people with the individual's related condition, or directly involved in the delivery of services and supports to the individual.

Support Family Service (SFS) Agency — Agency providing services to an individual under age 18 who resides with a support family that allows the individual to reside successfully in a community setting by supporting the individual to acquire, maintain and improve self-help, socialization and daily living skills or assisting the individual with ADLs. An SFS agency must maintain licensure as a Child-Placing Agency through DFPS.

Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.

 

# A C D E F H I L M N P R S T U

 

Transition Assistance Services (TAS) Agency — Agency that provides a one-time service to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community.

Termination — A term used when an individual no longer meets the program’s eligibility criteria and services are ended.

Texas Health Steps-Comprehensive Care Program — Texas Health Steps is also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. Texas Health Steps is dedicated to:

  • expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts, and;
  • recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.

Texas Medicaid & Healthcare Partnership (TMHP) — A coalition of contractors headed by ACS State Healthcare LLC, which administers claims processing for Texas Medicaid and other state health-care programs for the state of Texas, under contract with HHSC.

 

# A C D E F H I L M N P R S T U

 

Utilization Review — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.