Revision 17-2; Effective March 31, 2017

 

Terminology

A contract termination occurs when a provider (business entity) will no longer have a contract with the Texas Health and Human Services Commission (HHSC). A contract termination requires that the individual receiving services from HHSC be transferred to a different provider before the effective date of the contract termination. For Community Care for Aged and Disabled (CCAD), the term contract termination replaces contract cancellation.

A contract assignment occurs when a contract is transferred from one business entity to another business entity. In this situation, there is an exchange between two business entities and the receiving business entity is assigned a new provider number. When a contract assignment occurs, the affected individual’s service authorization record is transferred to the new provider through an automated mass transfer process in the Service Authorization System (SAS).

Not all changes in the provider’s operation will require a provider change action. A contracted provider may have a change in ownership in which part of the business ownership changes, a complete change in ownership or a name change in the provider’s license. Not all of these provider operations result in the change in provider number. For CCAD, the term contract assignment replaces contract conversion.

 

Contract Termination Transfer Determination Procedures

When a contracted provider decides to terminate its contract with HHSC or when a contract assignment is needed, the contractor must notify HHSC contract staff. Notification of a contract termination may be received by contract or regional management staff. The contract termination end date negotiated with the provider must be 60 calendar days or less after the date the written notice of contract termination is received. If contract termination is due to license revocation, the end date is 30 calendar days or less. Expedited transfer procedures must be used if the contract termination or assignment occurs with less than 10 calendar days notification to HHSC.

Upon notification of a contract termination or contract assignment, the regional director will determine whether transfers will be handled as either routine or expedited transfers. The regional director must immediately report to the Community Care Services Eligibility (CCSE) director when a decision to apply expedited transfer procedures is made. A decision to apply routine procedures does not require notification to state office staff. The regional director will advise the case worker whether the transfer will be accomplished using routine or expedited transfer procedures.

The case worker must not initiate transfer procedures due to a contract termination until contract or regional management staff issues an official written notice to the provider.
If there is adequate time to refer the individual to a new provider without disrupting services or adversely impacting the individual, the regional director will advise the case worker to use routine transfer procedures.

If there is not adequate time to refer the individual to a new provider without disrupting services or if implementing routine procedures may adversely impact the individual, the regional director will advise the case worker to use expedited transfer procedures. An adverse impact is likely to occur when the individual:

  • requires total care;
  • is unable to transfer from a bed to a chair without help;
  • is unable to manage toileting tasks without help;
  • is in danger of not receiving daily nourishment because he is unable to prepare or eat his meals without help;
  • requires nursing services; or
  • has no caregiver available to provide the tasks necessary to maintain the individual’s health or welfare.

In some instances, services may be disrupted for a short time; however, if there is no adverse impact to the individual, the regional director may advise the case worker to use routine transfer procedures.

 

CCAD Routine Transfer Procedures for Contract Terminations

If the regional director directs staff to apply routine transfer procedures, the CCAD case worker completes the following activities:

  • Contacts the individual to advise of the contract termination and to request the individual’s choice of a new provider. If the individual does not select a provider agency from the list of contracted agencies in the service area, an agency may be selected for the individual as a last resort. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date. The regional director may designate a time frame for provider selection depending on the contract termination date.
  • Reviews the individual’s service plan for accuracy and if any changes are needed, revises the service plan. If the CCAD case worker is unable to determine the individual’s needs by telephone, or if an annual assessment is due within 30 days, the CCAD case worker makes a home visit to complete a reassessment of the individual. If there are changes in the service plan, the CCAD case worker sends Form 2101, Authorization for Community Care Services, to the current provider agency. The required time frame for conducting an annual reassessment is no longer three months.
  • Negotiates the transfer date with both provider agencies avoiding any service disruption to the individual whenever possible.
  • Sends an initial referral packet to the new provider agency within five calendar days of the contact and sends the losing provider a copy of Form 2101.

For a routine transfer referral, the receiving provider follows procedures and requirements for initial referrals except for Primary Home Care (PHC) and Community Attendant Services (CAS). For PHC and CAS, a new practitioner’s statement is not required for the transfer.

 

Expedited Transfer Procedures for CCAD Contract Terminations

An expedited transfer must be used when there is not adequate time to use the routine referral process to refer the individual to a new provider without disrupting services. In an expedited transfer, special procedures are used to quickly transfer the individual to a provider that can promptly begin service delivery. The regional director determines when an expedited transfer should be used. Generally, an expedited transfer is used when the contract termination occurs with less than 10 calendar days notification to HHSC, a large number of individuals are involved in the transfer, or both.

The regional director designates a coordinator to work with contract staff and providers to establish transfer dates. The coordinator or case worker identifies individuals whose annual reassessments are due or in process and negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for individuals with the new provider.

Using the expedited transfer process, the individual is offered a choice of providers. If the individual does not select a provider agency from the list of contracted agencies in the service area at the point of contact, the case worker assigns a provider from the regional agency rotation log. The rotation log must be maintained and kept up to date.

 

CCAD Expedited Transfer Procedures for Contract Terminations

If the regional director determines to apply expedited transfer procedures, the CCAD case worker completes the following activities:

  • Contacts the individual to advise of the contract termination and to request the individual’s choice of a new provider. If the individual does not select a provider agency from the list of contracted agencies in the service area within the designated time frame, the individual will be assigned to a provider agency by rotation. The selection is assigned from a regional agency rotation log. The rotation log must be maintained and kept up to date.
  • Reviews the individual’s service plan for accuracy and if any changes are needed, revises the service plan. If the CCAD case worker is unable to determine the individual’s needs by telephone or if an annual assessment is due within 30 days, the CCAD case worker makes a home visit to complete a reassessment of the individual. If there are changes in the service plan, the CCAD case worker sends Form 2101 to the current provider agency. The required time frame for conducting an annual reassessment is no longer three months.
  • Negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for each individual with the new provider and documents on Form 2065-A, Notification of Community Care Services, the negotiated effective date is due to expedited contract termination.
  • Sends a referral packet to the new provider agency and notes “Expedited Transfer” on Form 2101 within five calendar days of the provider agency selection and sends the losing provider a copy of Form 2101.

For an expedited transfer referral, the receiving provider follows procedures and requirements for initial referrals except for PHC and CAS. For PHC and CAS, a new practitioner’s statement is not required for the transfer.

 

Contract Termination – Residential Living Arrangements

 

The transfer process for an individual residing in an adult foster care (AFC) home, assisted living (AL) facility, host family setting or residential care (RC) facility is complicated by the necessity to find a new living arrangement for the individual. Use the following steps when handling a contract termination affecting an individual residing in an AFC, AL, host family or RC setting.

Step

Responsibility

Action

1

Regional Director

  • works with contract staff, the case worker and providers to negotiate the date the transfer must be completed; and
  • identifies resources available to regional staff in facilitating transfer activities (for example, HHSC ombudsman).

2

Contract Staff

  • surveys regional facilities to identify available residential settings; and
  • provides a list of available residential settings to the case worker and the individual.

3

Case Worker

  • meets with residents (individually or as a group) to present available options that may include:
    • remaining in the current residential setting as a private pay resident;
    • transferring to a residential setting contracted with HHSC;
    • receiving services in the individual’s own home; or
    • moving to a nursing facility;
  • negotiates, as instructed by the regional director or coordinator, an expedited service initiation date for each individual with the new residential setting contracted provider, if that option is selected;
  • documents on Form 2065-A or Form 2065-B the negotiated effective date is due to expedited contract termination; and
  • completes the same procedures noted for routine or expedited transfers, except for time frames provided by the regional director or coordinator based on the contract termination end date.

Depending on the option selected by the individual when a residential setting contract is terminated, the case worker completes the appropriate procedures to complete the action. For example, if an individual in a residential setting chooses to go to his daughter’s home in the community, the case worker follows normal procedures for authorizing services in the community. If an individual chooses to move or return to a nursing facility permanently, the case worker follows normal procedures to terminate program eligibility and services.


Contract Terminations When No Other Provider is Available

In some situations, a provider may request to terminate its contract and there is no other provider available in the service area to provide that service. For example, if a Home-Delivered Meals provider terminates its contract, there may not be another provider in the service area to deliver meals. In that case, the HHSC case worker must contact the individual and offer any other available resources to meet that need. In this example, the individual may elect to receive services by an attendant to prepare meals or locate a congregate meal location.

When a service is terminated rather than transferred to a new provider, the HHSC case worker must send Form 2065-A or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual noting the service is terminated due to the contract termination.


Contract Assignment

Residential and Non-Residential Settings

After HHSC contract staff have negotiated the contract assignment effective date, contract staff will notify the regional director that the provider plans to assign its contract, as well as the contract assignment effective date. A transfer due to a contract assignment must not occur before the contract assignment effective date.

On or within two working days after the contract assignment effective date, regional staff must send Form 2097, Provider Contract Assignment Notification Letter, to the individual informing him of the change in provider. The letter informs the individual of the change in contract and offers the option to change to a provider selected by the individual or remain with the new provider. The letter informs the individual of the change in contract and offers the option to change to a provider selected by the individual or remain with the new provider.


Individual Chooses to Remain With the New Provider

After receiving confirmation of the automated mass transfer, the case worker reviews the Texas Medicaid and Healthcare Partnership error page in the Service Authorization System (SAS) to identify an individual whose service authorization record transfer was not processed. It should not be necessary to check each service authorization record. However, for CCAD, the SAS wizard will not replicate the provider change until the case worker runs the wizard, selecting "Provider Transfer." To prevent billing problems, the CCAD case worker must complete a provider transfer in the SAS wizard immediately for an individual whose service authorization records were not automatically converted. For assistance with an individual whose service authorization records were not automatically converted, contact the coordinator or the regional Claims Management Services (CMS) coordinator.

The losing provider should provide the new provider with all applicable forms. If the losing provider does not provide the forms to the new provider, the case worker must provide copies of the current forms to the new provider. For CCAD, refer to Appendix XIII, Contents of Referral Packets, for the list of forms to be sent for provider transfers.

It is not necessary to obtain acceptance by the new provider or send Form 2065-A to the individual or new provider. The case worker must document in the case record the transfer was due to a contract assignment from the losing provider to the new provider. In a mass transfer completed through the automated transfer process, only the SAS service authorization records are automatically changed to end the losing provider and authorize all services to the gaining provider.

For CCAD, the SAS wizard does not automatically update all data. The provider transfer must be processed in the wizard so the history and Form 2101 data will match changes to the service authorization records.


Individual Chooses to Change to a Different Provider

If the individual chooses to change from the new provider that received the contract assignment to a provider selected by the individual, the case worker must complete two provider change actions. The CCAD case worker uses the SAS wizard to complete the provider change actions. The first provider change action is to change service authorizations from the losing provider to the new provider for services delivered after the contract assignment effective date. The second provider change action is to change service authorizations from the new provider to the provider selected by the individual for services.

Both CCAD provider change actions must be completed within the time frame in Section 4676, Change of Providers.

For all programs, the individual may change providers at any time, as described in current procedures regardless of any changes in the provider’s operation.

Questions may be directed to the Policy Development and Oversight mailbox at: pdo@hhsc.state.tx.us.