Revision 15-3; Effective December 8, 2015

 

 

The following words and terms, when used in these billing guidelines, have the following meanings unless the context clearly indicates otherwise:

ADLs or activities of daily living — Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing and transferring.

Adult — A person who is 18 years of age or older.

Annual vendor — A vendor that provides to a program provider, for a calendar year, one or more adaptive aids costing less than $500.

Behavior support plan — A written plan prescribing the systematic application of behavioral techniques regarding an individual that contains specific objectives to decrease or eliminate targeted behavior.

Billable activity — An activity for which a service claim may be submitted for service components and subcomponents listed in Section 3100, Applicable Service Components.

Calendar day — Midnight through 11:59 p.m.

Calendar month — The first day of a month through the last day of that month.

Calendar week — Sunday through Saturday.

Calendar year — January through December.

CFC PAS/HAB or Community First Choice Personal Assistance Services/Habilitation — A state plan service that consists of:

(A) personal assistance services that provide assistance to an individual in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including:

(I) non-skilled assistance with the performance of the ADLs and IADLs;

(II) household chores necessary to maintain the home in a clean, sanitary and safe environment;

(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and

(IV) assistance with health-related tasks; and

(B) habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:

(I) self-care;

(II) personal hygiene;

(III) household tasks;

(IV) mobility;

(V) money management;

(VI) community integration, including how to get around in the community;

(VII) use of adaptive equipment;

(VIII) personal decision making;

(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and

(X) self-administration of medication.

Clean claim — In accordance with the Code of Federal Regulations, Title 42, §447.45(b), defined as a service claim submitted by a program provider for a service delivered to an individual that can be processed without obtaining additional information from the provider of the service or from a third party.

Competitive employment — Employment in the competitive labor market, performed on a full-time or part-time basis, that pays an individual:

(A) at or above the applicable minimum wage; and

(B) not less than the customary wage and level of benefits paid by an employer to individuals without disabilities performing the same or similar work.

Co-payment — A fixed fee an individual pays for a service at the time the service is provided.

DADS — The Department of Aging and Disability Services.

Deductible — Payment made by an individual in a specified amount for a service received before coverage begins for that service under the insurance policy.

DFPS — The Department of Family and Protective Services.

Extended shift — During a 24-hour period, a combined period of time of more than 16 hours.

Face-to-face — Within the physical presence of another person who is not asleep.

Focused assessment — An appraisal of an individual's current health status that:

(A) contributes to a comprehensive assessment conducted by a registered nurse;

(B) collects information regarding the individual's health status; and

(C) determines the appropriate health care professionals or other persons who need the information and when the information should be provided.

Four-person residence — A residence approved in accordance with 40 TAC §9.153:

(A) that a program provider leases or owns;

(B) in which at least one person but no more than four persons receive:

(I) residential support;

(II) supervised living;

(III) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person’s own resources); or

(IV) respite;

(C) that, if it is the residence of four persons, at least one of those persons receives residential support;

(D) that is not the residence of any persons other than a service provider, the service provider’s spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and

(E) that is not a dwelling described in §9.155(a)(5)(H) of this subchapter (relating to Eligibility Criteria and Suspension of HCS Program Services).

Guardian — A guardian of the person or estate appointed for a person in accordance with state law.

GRO —General Residential Operation. As defined in Texas Human Resources Code, §42.002, a child-care facility that provides care for more than 12 children for 24 hours a day, including facilities known as children's homes, halfway houses, residential treatment centers, emergency shelters and therapeutic camps.

Health-related tasks — Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under state law to be performed by a service provider of CFC PAS/HAB. These include tasks delegated by a registered nurse, health maintenance activities, as defined in 22 Texas Administrative Code (TAC) §225.4, Definitions, and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist or speech-language pathologist.

IADLs or instrumental activities of daily living — Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing and other essential items; performing essential household chores; communicating by phone or other media; traveling around and participating in the community.

ICF/IID —Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided and that is licensed in accordance with Texas Health and Safety Code Chapter 252 or certified by DADS.

ID/RC assessment — A form used by DADS for making an LOC determination and LON assignment.

Implementation plan — A written document developed by the program provider for an individual that, for each HCS program service on the individual’s IPC not provided through the CDS option, includes:

(A) a list of outcomes identified in the PDP that will be addressed using HCS Program services;

(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:

(I) observable, measurable, and outcome-oriented; and

(II) derived from assessments of the individual's strengths, personal goals, and needs;

(C) a target date for completion of each objective;

(D) the number of HCS Program units of service needed to complete each objective;

(E) the frequency and duration of HCS Program services needed to complete each objective; and

(F) the signature and date of the individual, LAR, and the program provider.

Individual — A person enrolled in the HCS Program.

Integrated employment — Employment at a work site at which an individual routinely interacts with people without disabilities other than the individual's work site supervisor or service providers. To the same extent that people without disabilities in comparable positions interact with other people without disabilities, integrated employment does not include:

  • groups of people with disabilities working in an area that is not part of the general workplace where people without disabilities work; or
  • a mobile crew of people with disabilities working in the community.

IPC or individual plan of care — A written plan that:

  • states the type and amount of each HCS Program service to be provided to the individual during an IPC year;
  • states the services and supports to be provided to the individual through non-HCS Program resources, including natural supports, medical services, and educational services; and
  • is authorized by DADS.

IPC year — A 12-month period of time starting on the date an authorized initial or renewal IPC begins.

Legally authorized representative — A person authorized by law to act on behalf of an individual and may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.

Licensed vocational nurse — A person licensed to practice vocational nursing in accordance with Texas Occupations Code, Chapter 301.

Local Authority — An entity to which the Health and Human Services Commission's authority and responsibility, as described in Texas Health and Safety Code, §531.002(11), has been delegated.

LOC or level of care — A determination given to an individual by DADS as part of the eligibility determination process based on data submitted on the ID/RC Assessment.

LON or level of need — An assignment given to an individual by DADS upon which reimbursement for day habilitation, host home/companion care, residential support and supervised living is based. The LON assignment is derived from the service level score obtained from the administration of the Inventory for Client and Agency Planning (ICAP) to the individual and from selected items on the ID/RC Assessment.

Managing conservator — a managing conservator appointed for a minor in accordance with state law.

Minor — An individual under 18 years of age.

PDP or person-directed plan — A written plan, based on person-directed planning and developed with an applicant or individual in accordance with Form 8665, Person-Directed Plan, that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual (and LAR on the applicant’s or individual’s behalf) and ensure the applicant’s or individual’s health and safety.

Prior approval — Assurance from DADS, prior to a program provider purchasing a requested adaptive aid or minor home modification, that the program provider will be paid for the adaptive aid or minor home modification if the program provider complies with Section 5000, General Requirements for Service Components Not Based on Billable Activity, and Section 6170, Authorization for Payment.

Pre-enrollment minor home modifications —Minor home modifications completed before an applicant is discharged from a nursing facility, an ICF/IID or a GRO and before the effective date of the applicant's enrollment in the HCS Program.

Pre-enrollment minor home modifications assessment —An assessment performed by a licensed professional as required by Appendix X, Billable Minor Home Modifications, to determine the need for pre-enrollment minor home modifications.

Preselection visit — An individual’s temporary stay in a residence in which the individual receives the residential assistance subcomponent of host home/companion care, residential support or supervised living and such subcomponent is different than the residential assistance subcomponent authorized by the individual’s IPC.

Program provider — An entity that provides HCS Program services under a Medicaid Provider Agreement for the Provision of HCS Program Services with DADS.

Registered nurse — A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301.

Residence — A place of bona fide and continuous habitation that is a structure with a common roof and common walls, except if the structure contains more than one dwelling such as an apartment complex or duplex, “residence" means a dwelling within the structure. A person may have only one residence.

RN clinical supervision — The monitoring for changes in health needs of the individual, overseeing the nursing care provided and offering clinical guidance as indicated, to ensure that nursing care is safe and effective and provided in accordance with the nursing service plan for the individual.

RN nursing assessment — An extensive evaluation of an individual's health status that:

(A) addresses anticipated changes in the conditions of the individual as well as emergent changes in the individual's health status;

(B) recognizes changes to previous conditions of the individual;

(C) synthesizes the biological, psychological, spiritual and social aspects of the individual's condition;

(D) collects information regarding the individual's health status;

(E) analyzes information collected about the individual's health status to make nursing diagnoses and independent decisions regarding nursing services provided to the individual;

(F) plans nursing interventions and evaluates the need for different interventions; and

(G) determines the need to communicate and consult with other service providers or other persons who provide supports to the individual.

Self-employment Work in which the individual solely owns, manages and operates a business, is not an employee of another person, entity or business, and actively markets a service or product to potential customers.

Service claim — A request submitted by a program provider to be paid by DADS for a service component or subcomponent.

Service coordination — A service as defined in Chapter 2, Subchapter L of this title.

Service coordinator — An employee of a local authority who provides service coordination to an individual.

Service planning team — As defined in 40 TAC §9.153, a planning team consisting of an applicant or individual, LAR, service coordinator and other persons chosen by the applicant or individual or LAR on behalf of the applicant or individual (for example, a program provider representative, family member, friend or teacher).

Service provider — A staff member or contractor of the program provider who performs billable activity.

Staff member — A full-time or part-time employee of the program provider.

Supervision — The process of directing, guiding and influencing the outcome of an unlicensed staff's performance.

TAC — Texas Administrative Code.

Three-person residence — A residence:

(A) that a program provider leases or owns;

(B) in which at least one person but no more than three persons receive:

(I) residential support;

(II) supervised living;

(III) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person’s own resources); or

(IV) respite; and

(C) that is not the residence of any person other than an HCS service provider, the service provider's spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and

(D) that is not a dwelling described in 40 TAC §9.155(a)(5)(H).

Transportation plan — A written plan, based on person-directed planning and developed with an applicant or individual using Form 3598, Individual Transportation Plan. An individual transportation plan is used to document how transportation will be delivered to support an individual’s desired outcomes and purposes for transportation as identified in the PDP.

Volunteer work — Work performed by an individual without compensation that is for the benefit of an entity or person other than the individual and is performed in a location other than the individual’s residence.