Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) designates staff to complete enrollments for persons into specified Medicaid programs.

 

13100 LIDDA Required Training

Revision 19-4; Effective September 9, 2019

 

All designated staff at a local intellectual and developmental disability authority (LIDDA) must complete all Texas Health and Human Services Commission (HHSC) online enrollment training before performing enrollment activities, and at least annually thereafter, for as long as the staff performs enrollment activities for the LIDDA. The training includes:

  • Authority Waiver Enrollment Training
    • Persons moving out of a large community intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
    • Persons authorized to enroll in the Texas Home Living (TxHmL) Program from the interest list; and
    • Persons authorized to enroll from the HCS interest list.
  • Community First Choice (CFC) in Medicaid Managed Care Organizations (MCO) Web-based Training
  • Community First Choice in the Home and Community based Services (HCS) and TxHmL Programs Web-based Training
  • Community First Choice Personal Assistant Services/Habilitation (PAS/HAB) Assessment for HCS and TxHmL Service Coordinators

The trainings are found at LIDDA Training Opportunities.

 

13200 Enrollment into the HCS and TxHmL Programs

Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) will complete the enrollment process for each authorized person into the Home and Community based Services (HCS) and Texas Home Living (TxHmL) Programs in accordance with Texas Health and Human Services Commission (HHSC) rules and within the time frames stated in this section. The enrollment process is complete when the person’s status in the Client Assignment and Registration (CARE) System screen C61, Consumer Demographics Inquiry, reads “active” or “denied.”

The LIDDA must request an extension for the enrollment if the time frames listed below cannot be met. HHSC will grant an extension for good cause for a person:

  • residing in a nursing facility: 90 calendar days after the LIDDA was notified of the program vacancy;
  • residing in a community intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or being discharged from a state mental health facility: 90 calendar days after the LIDDA was notified of the program vacancy; and
  • residing in his or her own or family's home: 75 calendar days after the LIDDA was notified of the program vacancy.

Prior to enrollment, the LIDDA must:

  • access the Service Authorization System Online (SASO) to determine if the person is currently enrolled in an HHSC program or a Medicaid waiver program;
  • review the HHSC Mutually Exclusive Services chart to determine if a service the person is receiving is mutually exclusive to the program that the LIDDA is offering;
  • ensure the person and legally authorized representative (LAR) are provided information about the Medicaid Estate Recovery Program, as described in Section 14000, Medicaid Estate Recovery Program (MERP) Overview; and
  • determine whether the person is a Medicare beneficiary.

If the person is enrolled in a Medicaid waiver program or a service that is mutually exclusive to the program that the LIDDA is offering, the LIDDA must:

  • contact the person’s case manager or service coordinator for the services or program the person is currently enrolled in to coordinate an explanation to the person and LAR about the similarities and differences between the services the person is receiving, and the program that the LIDDA is offering using the Long-term Services and Supports (LTSS) Program comparison information;
  • inform the person or LAR, following the explanation as described above, of the requirement to choose either the program the person is currently enrolled in, or the program that the LIDDA is offering;
  • use Form 8665, Person-Directed Plan, as well as the form’s instructions and the information contained in the discovery tool and discovery guide in the Home and Community-based Services Handbook Appendices when conducting person-directed planning for a person enrolling in the HCS or TxHmL Program; and
  • enter the person’s enrollment information into CARE screen L01, Consumer Enrollment: Add/Change/Delete; screen L23, Waiver ID/RC Assessment: Add/Chg/Del (if applicable); screen L02, Individual Plan of Care; screen L03, Enrollment Packet Checklist: Add/Chg/Del; screen L09, Register Client Update; and screen L05, Provider Choice: Add/Del.

If the person being offered a program vacancy in HCS or TxHmL is enrolled in the STAR+PLUS Waiver Program (SPW), the LIDDA must:

  • inform the person that disenrollment in SPW is required to enroll in HCS or TxHmL;
  • ensure the person’s Individual Plan of Care (IPC) begins on the first day of a month;
  • ensure the person’s enrollment data has been entered in CARE within seven days prior to the end of the month before the person’s scheduled enrollment date; and
  • comply with the instructions in this section when offering an HCS or TxHmL Program vacancy for a person whose enrollment process is not complete within the time frames listed in this section.

Within the same time frames, the LIDDA must have:

  • submitted to HHSC Form 8601, Verification of Freedom of Choice, with the person’s or LAR’s signature and date, declining the HCS or TxHmL Program, as appropriate;
  • submitted to HHSC documentation that the LIDDA sent a letter of withdrawal in accordance with HHSC rules; or
  • submitted a request to extend the time allowed for the enrollment, using Form 1045, HCS/TxHmL Request for Enrollment Extension.

Note: A request for extension received by HHSC after the 15th day of the last month of a quarter will not be approved for that quarter.

If the LIDDA that is authorized to offer an HCS or TxHmL Program vacancy to a person anticipates the person’s HCS or TxHmL enrollment will not be completed by the required date, the LIDDA must:

  • Request that HHSC grant an extension, using Form 1045, to the time allowed for the enrollment and provide a reason for the delay.
    • For HCS only: If the reason for the delay is related to determination of Medicaid eligibility, the LIDDA must proceed with enrollment activities and data entry of all the enrollment screens in CARE, as required by this section, prior to submitting a request for extension.
    • For TxHmL only: If the reason for the delay is related to determination of Medicaid eligibility, the LIDDA must proceed with enrollment activities and data entry of all the enrollment screens in CARE, as required by this section, prior to submitting a request for extension, unless the LIDDA determines the person is likely to be denied Medicaid. In which case, the LIDDA must provide a reason for such determination.
  • For all HCS and TxHmL slots: If the authorized LIDDA attempts to contact the person or LAR and learns that the person or LAR has relocated to another LIDDA’s local service area (LSA), the authorized LIDDA must determine the person’s designated LIDDA. See Section 5000, Guidelines for Determining and Changing Designated LIDDA.
    • If the authorized LIDDA is the designated LIDDA, then the authorized LIDDA will continue with all enrollment activities.
    • If the authorized LIDDA determines that another LIDDA is the designated LIDDA, then the authorized LIDDA must notify the appropriate staff at HHSC of the transfer and forward to the designated LIDDA:
      • a copy of the authorization letter;
      • Form 1049, Initial Documentation of Provider Choice; and
      • a copy of any extensions already obtained.
    • Once the designated LIDDA receives the information from the authorized LIDDA, then the designated LIDDA becomes the authorized LIDDA and is responsible for meeting required time frames for enrollment or requesting an extension.
  • For all HCS and TxHmL slots: If the authorized LIDDA contacts the person or LAR and begins the enrollment process and the person or LAR selects a provider in a different LIDDA’s LSA, then the authorized LIDDA must:
    • Conduct all pre-enrollment activities, such as providing the explanation of services and obtaining a signature on Form 8601.
    • Conduct diagnostic activities and Intellectual Disability/Related Condition (ID/RC);
    • Collect Medicaid eligibility information.
    • Complete the initial person-directed plan (PDP) and proposed Individual Plan of Care (IPC).
    • Request an extension on the enrollment if the enrollment will not be competed in the originally assigned or extended time frame.
    • Transfer the person to the LIDDA in which the selected provider operates.
    • Provide the initial PDP to the provider and complete the IPC negotiations with the provider.
    • Send hard copies of all enrollment documents to the receiving LIDDA, including Form 1049 and any enrollment extensions already obtained.

Once the receiving LIDDA receives the information from the authorized LIDDA, then the receiving LIDDA is responsible for meeting required time frames for enrollment.

  • For HCS only: The receiving LIDDA must complete the data entry of all enrollment screens in a timely manner and request an extension if enrollment is not expected to be approved by the required time frame.
  • For TxHmL only: The receiving LIDDA must complete the data entry of all enrollment screens in a timely manner and request an extension if enrollment is not expected to be approved by the required time frame. An exception to the requirement to complete data entry of all enrollment screens prior to requesting an extension is when the LIDDA determines the person is likely to be denied Medicaid. In which case, the LIDDA must provide a reason for such determination on Form 1045.

If the person being offered a program vacancy is currently receiving general revenue-funded services from the LIDDA, the LIDDA must inform the person and LAR that if they decline the offer of waiver services identified by HHSC (i.e., HCS or TxHmL), the LIDDA will terminate the general revenue-funded services in accordance with rules governing the HCS or TxHmL Program.

The information below pertains to a person with Medicare and Medicaid (referred to as “full-dual eligible”). A person with only Medicaid is not affected by the Medicare Prescription Drug Program and will continue to receive his or her drugs through Medicaid.

If the person is a Medicare beneficiary, the LIDDA must verify that the person:

  • is enrolled in a Medicare-sponsored prescription drug plan, which can be a stand-alone drugs-only insurance plan or a Medicare Advantage Prescription Drug (MA-PD) plan; and
  • has been deemed eligible for extra help and if not, refer the person in applying for extra help to the Social Security Administration.

If the person is not already enrolled in a drug plan, the LIDDA must explain to the person and LAR that the person must enroll in a drug plan in order to receive prescription medications and that upon enrollment in the waiver program, he or she will be auto-enrolled in a drug plan, which may or may not be the drug plan that is most beneficial. The LIDDA must:

  • encourage the person to enroll in a drug plan before enrollment if possible; and
  • offer help, if requested, to the person and LAR with evaluating the drug plans to identify the plan that is most beneficial to the person.

The LIDDA must explain to the person and LAR that:

  • The person will now get his or her prescription medications through a drug plan. Note: As a Medicaid wrap-around service, Medicaid will pay for a limited list of drugs that Medicare will not pay for, including benzodiazepines, barbiturates, and prescribed over-the-counter drugs.
  • The person will be automatically deemed eligible for the extra help, which will assist with his or her drug costs.
  • The person is not responsible for any cost sharing for his or her prescription medications.
  • The person will pay little or no premiums and no deductible.
  • The person will be responsible for paying for any prescription medications that are not covered by his or her drug plan or the Medicaid wrap-around service (as noted above).
  • If the person is enrolling in TxHmL, the LIDDA service coordinator can assist him or her with changing drug plans and filing an exception, appeal or grievance with the drug plan.
  • If the person is enrolling in HCS, the program provider can assist him or her with changing drug plans and filing an exception, appeal or grievance with the drug plan.

The LIDDA must explain to the person and LAR the following information, and then document on Form 8601, Verification of Freedom of Choice, that:

  • He or she chooses the TxHmL or HCS Program rather than the ICF/IID Program or other services (or program); or
  • He or she declines the TxHmL or HCS Program and chooses instead the ICF/IID Program or Other. If the person or LAR chooses Other, then the LIDDA must ensure the reason for declining is explicitly stated.

For a person who has declined to participate in the HCS or TxHmL Program, the LIDDA must:

  • submit to HHSC a copy of the completed Form 8601; and
  • enter the decline status code in CARE if the person’s name is on the HCS or TxHmL Interest List.

For a person who has chosen to participate in the HCS or TxHmL Program, the LIDDA must:

  • submit to HHSC a copy of the completed Form 8601;
  • explain to the person or LAR that he or she may choose any contracted HCS or TxHmL Program provider, as appropriate to the program being offered, in the LSA that has not reached its service capacity, as identified in CARE;
  • be objective in assisting the person or LAR in selecting an HCS or TxHmL Program provider, and not influence the person or LAR’s decision;
  • provide the person or LAR with a current list (i.e., dated within seven days) from CARE (XPTR HC062096 for HCS and HC062097 for TxHmL) of all contracted TxHmL or HCS Program providers, as appropriate to the program being offered, in the LIDDA’s LSA. The list will also include local “applicant contact” information, if available, for use by the person or LAR.
    • If the LIDDA operates an HCS or TxHmL Program and the program’s enrollment is at or above capacity (identified in CARE Screen C70 as “CAP”), the LIDDA must redact its provider name from the list of providers given to the person or LAR and document the selection of the program provider on Form 1049, Initial Documentation of Provider Choice, and submit a copy of the form.

If the HCS or TxHmL Program operated by the LIDDA is selected by the person or the LAR to be the person’s program provider, the LIDDA must complete Form 1052, Public Provider Choice Request. The LIDDA must then determine whether the requested LIDDA program is operating at, or over, its capacity as identified in CARE.  
 

  • If the LIDDA operated program is at, or over, its capacity as identified in CARE, the LIDDA may request its provider capacity be temporarily increased to accommodate a family-specific or person specific circumstance and choice. See Texas Health and Safety Code, §533A.0355 (d)(2) (D) (iii).
  • Form 1052 must contain:
    • In Section I and II, an explanation from the person or LAR who selected the LIDDA’s HCS or TxHmL Program to be his/her program provider describing why he/she selected the LIDDA’s program and why other program providers in the service area were not adequate or desirable; and
    • In Section III, information from the LIDDA program representative requesting a temporary increase in its capacity to accommodate the named person or LAR’s choice.
  • If the LIDDA program is below its capacity, as identified in CARE, the LIDDA omits Sections I, II and III on Form 1052 and submits Form 1052 to HHSC for approval in accordance with the form’s instructions.

For a person who is being enrolled in the TxHmL Program, the LIDDA service coordinator must facilitate the completion of Form 8586, TxHmL Program Service Coordination Notification.

The LIDDA must maintain the following completed forms in the person’s records:

  • Form 8601, Verification of Freedom or Choice;
  • Form 1049, Initial Documentation of Provider Choice;
  • Form 8586, TxHmL Program Service Coordination Notification, if applicable; and
  • Form 8511, Understanding Program Eligibility and Services.

 

13300 Enrollment into the ICF/IID Program

Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) must:

  • complete enrollment of a person into the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) program in accordance with HHSC rules;
  • prior to enrollment, ensure the person and legally authorized representative (LAR) are provided information about the Medicaid Estate Recovery Program, as described in Section 14000, Medicaid Estate Recovery Program (MERP) Overview; and
  • prior to enrollment, determine whether the person is a Medicare beneficiary. Note: A person with Medicaid only is not affected by the Medicare Prescription Drug Program and will continue to receive his or her drugs through Medicaid.

If the person is a Medicare beneficiary, the LIDDA must do the following:

  • Verify that the person:
    • is enrolled in a Medicare-sponsored prescription drug plan, which can be a stand-alone drugs-only insurance plan or a Medicare Advantage Prescription Drug (MA-PD) plan; and
    • has been deemed eligible for extra help and if not, refer the person in applying for extra help to the Social Security Administration.
  • If the person is not already enrolled in a drug plan, explain to the person and LAR that the person must enroll in a drug plan to receive prescription medications and upon enrollment in the ICF/IID program, he or she will be auto-enrolled in a drug plan which may or may not be the most beneficial drug plan.
    • Encourage the person to enroll in a drug plan before enrollment if possible; and
    • Offer help, if requested, to the person and LAR with evaluating the drug plans to identify the plan that is most beneficial to the person.

If the person is enrolled in both Medicaid and Medicare, the LIDDA must explain to the person and LAR that the person will:

  • get his or her prescription medications through a drug plan. Note: As a Medicaid wrap-around service, Medicaid will pay for a limited list of drugs that Medicare will not pay for, including benzodiazepines, barbiturates, and prescribed over-the-counter drugs;
  • be automatically deemed eligible for the extra help, which will assist with his or her drug costs; and
  • not have any cost-sharing responsibilities, such as premiums, deductibles, co-payments or co-insurance for drugs covered by the plan. The ICF/IID program provider can assist the person or LAR with changing drug plans and filing an exception, appeal or grievance with the drug plan.