Revision 14-1; Effective September 1, 2014

 

 

Rules:

40 Texas Administrative Code (TAC) §51.217, Individual Plan of Care
40 TAC §51.413, Response to Service Authorization
40 TAC §51.415, Notification to the Individual

 

3100 Interest Lists

Revision 14-1; September 1, 2014

 

Rules:

40 TAC Chapter 48, Community Care for Aged and Disables, §48.1301, Interest Lists
40 TAC Chapter 51, Division 2, Enrollment, §51.221, Other Responsibilities

Individuals requesting Medically Dependent Children Program (MDCP) services must be placed on the MDCP interest list, regardless of the program's enrollment status, according to the date and time of their request. Individuals are released in order of that date. An individual is placed on the MDCP interest list at any time by:

  • calling the Community Services Interest List (CSIL) Unit toll-free at 877-438-5658; or
  • contacting the DADS local office in person or by telephone.

When the regional office receives a request for MDCP services, Department of Aging and Disability Services (DADS) staff inform the individual about DADS services and the MDCP interest list. DADS staff refer the individual directly to the CSIL Unit at 877-438-5658 for placement on the MDCP interest list.

DADS staff must assist individuals with placement on the MDCP interest list if they are unable to do so or do not wish to call themselves.

The DADS CSIL Unit:

  • identifies the individuals to be released from the MDCP interest list;
  • conducts a Texas Integrated Eligibility Redesign System (TIERS) inquiry to determine each individual's Medicaid enrollment status; and
  • sends a list by email of individuals released from the MDCP interest list to the appropriate regional MDCP supervisor for assignment to a case manager.

Within five calendar days of receipt of designated names from the CSIL Unit, the regional MDCP supervisor assigns case managers and returns the list of names and assigned case managers to the CSIL Unit.

Within three business days of receipt of the assigned case managers, the CSIL Unit:

  • mails an enrollment packet and letter notifying the individual of release from the MDCP interest list and provides the name of the assigned case manager; and
  • sends a memo notifying the assigned case manager of the individual's release from the MDCP interest list and current Medicaid enrollment status.

The enrollment packet sent to the individual contains:

  • an interest list release notification letter identifying the individual's assigned case manager and a request for a response to confirm interest in applying for MDCP services;
  • Form 2439, Selection Acknowledgement, to confirm interest in applying for MDCP services;
  • an MDCP frequently asked questions (FAQ) information sheet;
  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form 0003, Authorization to Furnish Information.

The information packet sent to the case manager contains:

  • a referral memorandum with available Medicaid numbers; and
  • copies of each individual's notification letter.

The individual has 30 days from the date of the MDCP interest list release notification letter to complete and return enrollment materials to the case manager. An individual may be placed on multiple interest lists, but may only be enrolled in one waiver program at a time. If the individual prefers not to apply for MDCP services, the individual may request to remain on the MDCP interest list, but will be placed at the bottom of the list.

DADS staff collect data on the state of the individual’s caregiver, and make a home visit as part of the eligibility determination process to complete medical and social assessments, develop the Individual Plan of Care and assist the individual’s family with completing an application for Medicaid, if necessary.

DADS send a letter with attached enrollment materials to the individual’s parent or guardian which must be completed and promptly returned to DADS. If the application packet is not returned to DADS by 30 days from the date of the MDCP interest list release notification letter, DADS will remove the individual’s name from the interest list.

 

3200 Limited Stay Nursing Facility for Medically Fragile Individuals

Revision 14-1; September 1, 2014

 

Individuals may request MDCP services through the Money Follows the Person (MFP) option, if they are too medically fragile to reside in a nursing facility (NF) for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care.

The DADS regional nurse and the DADS state office physician will review the medical fragility of an individual requesting a limited NF stay. Medical judgment of the DADS state office physician will be applied on a case-by-case basis when the criteria below do not capture the severity or fragility of the individual's medical condition. An individual must meet two or more of the following criteria to be considered medically fragile:

  • Ventilator dependent with a tracheostomy
  • Renal dialysis
  • 24 hour/day oxygen dependence
  • Total parenteral nutrition (TPN)
  • Tracheostomy
  • Daily recurrent seizures within the past six months requiring medical intervention during the seizure activity (e.g., medication administration, oxygen)
  • Documented immune deficiency confirmed by lab findings (i.e., IgA or IgG deficiency) or on immunosuppressive drug therapy
  • Total nutrition via enteral tube feeding
  • Congestive heart failure requiring hospitalization within the past six months
  • Hospice

Individuals determined medically fragile by the DADS state office physician and approved for a limited NF stay must stay at least part of two days in the NF. Admission and discharge from the facility must occur on different days.

 

3210 MFP Procedures for Requesting a Limited Nursing Facility Stay

Revision 14-1; September 1, 2014

 

Individuals who wish to request MDCP services through the Money Follows the Person (MFP) option must contact the Community Services Interest List (CSIL) Unit at 877-438-5658. The CSIL Unit will forward the name of the individual, or the individual's parent or guardian, interested in the MFP option to the appropriate regional MDCP supervisor or regionally-designated representative.

The regional MDCP case manager must contact the individual, or the individual's parent or guardian, by phone to explain the individual must:

  • complete a limited nursing facility (NF) stay if the individual is determined to be too medically fragile to complete an extended NF stay;
  • obtain documentation from the individual's physician on Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, regarding the recommendation for the length of stay the individual can complete in a NF; and
  • obtain admission and discharge documentation from the NF.

If the individual's physician recommends a limited stay, the DADS regional nurse and DADS state office physician will review the documentation and approve the limited stay request if the physician documentation clearly supports that the individual meets two or more of the criteria on Form 2406.

The DADS case manager informs the individual, or the individual's parent or guardian, that Form 2406 must be completed by the individual's physician and returned to the case manager within 30 calendar days of the initial contact with the individual, or the individual's parent or guardian. The individual cannot access MDCP services through the limited NF stay until the physician completes and signs Form 2406 and DADS approves the limited NF stay.

 

3300 Case Management Process

Revision 14-1; September 1, 2014

 

The provider, DADS case manager and individual work together to develop the Individual Plan of Care (IPC), as required by 40 Texas Administrative Code (TAC) §51.217, Individual Plan of Care. Refer to the Case Manager Medically Dependent Children Program Handbook for information about these activities. The DADS case manager then sets up the IPC and submits it to the Home and Community Support Services Agency (HCSSA) or Financial Management Services Agency (FMSA) of choice.

  1. The DADS case manager and DADS regional nurse work with the individual during a home visit to set up the draft IPC.
  2. The DADS case manager shares (by either email or fax) the draft IPC with the HCSSA or FMSA provider that the individual previously chose.
  3. The provider reviews and decides whether to accept the individual for services. The provider may choose to conduct a home visit prior to accepting the individual for services. If the provider decides to accept the individual for services, the provider must follow the steps in TAC §51.413, Response to Service Authorization.
  4. Within 14 calendar days of receiving the service authorization, the provider must follow the rules at TAC §51.415, Notification to the Individual.
  5. Once the provider decides to accept the individual, the provider contacts the DADS case manager by phone or using Form 2067, Case Information.
  6. The provider then begins home visits to deliver services according to the IPC.

The provider may request time to review the draft Form 2410, Medical-Social Assessment and Individual Plan of Care; therefore, the discussion between the DADS case manager and the provider must occur in time to meet the 30-day time frame for authorizing services from the initial home visit. After all parties (the case manager, individual, provider and primary caregiver) agree with the draft IPC, the service initiation date is negotiated according to §51.217(b).

 

3310 Initiating the Individual Plan of Care (IPC)

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.217, Individual Plan of Care

The service initiation date is negotiated during the development of the IPC and prior to the provider receiving a service authorization form. The provider must ensure the service delivery record contains a copy of the IPC and appropriate documentation supporting the claim for the services delivered. The provider must maintain an in-home record and notify the DADS case manager if a significant change in the individual’s health occurs during the IPC period.

 

3311 Service Initiation Date

Revision 14-1; September 1, 2014

 

Rules:

40 TAC §51.217(b), Individual Plan of Care
40 TAC §51.413, Response to Service Authorization
40 TAC §51.417, Notification to the Case Manager

During the development of the Individual Plan of Care (IPC), the service initiation date is negotiated prior to the provider receiving a service authorization form.

After the initial service initiation date has been agreed upon by all parties, the DADS case manager sends the provider the appropriate service authorization form, any or all of the following:

  • Form 2414, Flexible Family Support Service Authorization;
  • Form 2430, Employment Assistance and Supported Employment Service Authorization; or
  • Form 2415, Respite Service Authorization.

The provider must sign the service authorization form and send the original and a signed copy of the practitioner’s orders back either by U.S. mail or fax transmission to the DADS case manager within 14 days of receipt of the service authorization form. (See §51.413.)

If the provider is unable to provide services as indicated on the service authorization form, the provider must contact the DADS case manager by telephone and fax or mail Form 2067, Case Information, and notify the individual or primary caregiver within one work day of awareness prior to the service initiation date. (See §51.417.)

 

3312 Documentation of the IPC

Revision 14-1; September 1, 2014

 

Rule: 40 TAC, §51.509, Claims and Service Delivery Records

The provider must ensure the service delivery record contains a copy of the Individual Plan of Care (IPC) and documentation supporting the claim for the services delivered. This includes the following forms, as applicable:

  • Form 2065-B, Notification of Waiver Services
  • Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services
  • Form 2401, Qualified Income Trust (QIT) Co-Payment Agreement
  • Form 2410, Medical-Social Assessment and Individual Plan of Care
  • Form 2411, Interim Plan of Care
  • Form 2412, Budget Revision
  • Form 2414, Flexible Family Support Services Authorization
  • Form 2415, Respite Service Authorization
  • Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization
  • Form 2430, Employment Assistance and Supported Employment Service Authorization

The DADS case manager will send copies of the IPC, which could include Form 2410, Form 2411, Form 2412, Form 2414, Form 2415 and/or Form 2430, to the provider at the time of the initial assessment, annual reassessment or whenever an interim IPC is completed. The provider must ensure these documents are included in the service delivery record.

 

3320 Changes to the IPC

Revision 14-1; September 1, 2014

 

The provider must notify the DADS case manager if an individual has a significant change in health during the Individual Plan of Care (IPC) period and requests to make a change to the IPC. The individual or primary caregiver may also request to change providers (typically the Home and Community Support Services Agency) at any time during the IPC year.

 

3321 Interim IPC

Revision 14-1; September 1, 2014

 

Rules:

40 TAC §51.415, Notification to the Individual
40 TAC §51.417, Notification to the Case Manager

The provider must notify the DADS case manager upon awareness if an individual has a significant change in health during the Individual Plan of Care (IPC) period and requests to make a change to the IPC. The change can be requested by the Home and Community Support Services Agency (HCSSA), individual or primary caregiver. If the DADS case manager determines that an IPC change is needed, the DADS case manager sends the provider Form 2065-B, Notification of Waiver Services, along with all applicable service authorization forms. The effective date of the IPC change is the date the DADS case manager entered the request into the Service Authorization System (SAS), or the date negotiated with:

  • the individual;
  • the individual's primary caregiver; and
  • any other person who participates in the individual's care.

The date negotiated cannot be a date prior to the date the request was processed. The DADS case manager sends a copy of the service authorization to the HCSSA.

The provider must immediately, upon awareness, notify the DADS case manager by telephone and send Form 2067, Case Information, if it is determined that the provider cannot deliver the services as authorized on the revised IPC. See §51.417 for further detail. In addition, the provider must notify the individual or primary caregiver and give both parties the reason why services cannot be delivered. See §51.415 for further details and the time frame for notification to the individual or primary caregiver.

 

3322 Provider Transfers During the IPC Period

Revision 14-1; September 1, 2014

 

The individual or primary caregiver may request to change providers, typically the Home and Community Support Services Agency (HCSSA), at any time during the Individual Plan of Care (IPC) year. The provider must notify the DADS case manager verbally and in writing, using Form 2067, Case Information, within five working days if the individual notifies the provider that he wishes to be transferred to another provider. The DADS case manager negotiates the effective date of the change with the individual/primary caregiver and the providers. The DADS case manager completes the transfer within 14 days of when the case manager received the request from the individual or primary caregiver to change providers.

The DADS case manager sends the gaining provider Form 2065-B, Notification of Waiver Services, authorizing the transfer to the gaining provider. The losing provider will receive an authorization termination notice from the DADS case manager on one of the following forms:

  • Form 2414, Flexible Family Support Services Authorization;
  • Form 2415, Respite Service Authorization;
  • Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization; or
  • Form 2430, Employment Assistance and Supported Employment Service Authorization.

The DADS case manager terminates the service authorization and adds the end date, which must be the day before services begin with the gaining provider. The DADS case manager sends this form to the losing provider and the individual. The losing provider's authorization will be terminated within the same 14-day time frame to complete the provider transfer.

When an individual transfers from one provider to another, the DADS case manager will send the losing provider Form 2067, requesting the:

  • total number of units for respite and/or flexible family support services and/or employment assistance and/or supported employment delivered by the HCSSA from the authorized start date through the day before the IPC change effective date; or
  • total cost of adaptive aids, minor home modifications or Transition Assistance Services delivered to the individual up to the IPC change effective date.

The losing provider must respond to the DADS case manager before the 14th day after the date written on Form 2067.

 

3400 Reporting Issues to the DADS Case Manager

Revision 14-1; September 1, 2014

 

A provider reports verbally to the DADS case manager by the next working day that it will no longer serve the individual due to health and safety concerns. The provider must follow up the verbal report within five working days with Form 2067, Case Information, which must include the reasons why the provider cannot serve the individual.

If the individual has chosen and is assigned a new provider, the case manager provides the new provider with sufficient information to avoid putting the provider at risk. With this information, the provider can adequately plan for safely delivering services to the individual, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise.

 

3410 Service Delivery Issues Reported to the DADS Case Manager

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.417, Notification to the Case Manager

The provider is required to report service delivery issues to the DADS case manager, as described in §51.417. DADS requires a provider to notify the DADS case manager of issues that impact service delivery. The provider may notify the DADS case manager of any issues either verbally or by fax using Form 2067, Case Information, within one working day. If the provider notifies the DADS case manager orally, the provider must follow up with written documentation on Form 2067 within five working days of the verbal notification unless otherwise stated in the rule.

 

3411 Primary Caregiver Refuses to Comply with IPC

Revision 14-1; September 1, 2014

 

The provider must notify the DADS case manager verbally and must send the DADS case manager Form 2067, Case Information, if the primary caregiver does not follow the Individual Plan of Care (IPC). The DADS case manager will contact the primary caregiver to discuss the situation within 14 days of receiving a report of service delivery issues from the provider. If the issue continues after the initial contact, the DADS case manager convenes a service planning team meeting to address the issue.

 

3412 Provider Unable to Verify Medicaid Status

Revision 14-1; September 1, 2014

 

The provider is required to verify the individual’s Medicaid eligibility each month. The provider may verify the individual's eligibility status by using the Medicaid Eligibility Service Authorization Verification (MESAV) system available through the Texas Medicaid & Healthcare Partnership (TMHP) login website. If the provider is unable to verify the individual's Medicaid eligibility status after checking MESAV, the provider may contact the DADS case manager by phone or by faxing a copy of Form 2067, Case Information, to verify the individual's Medicaid eligibility status via the Texas Integrated Eligibility Redesign System (TIERS). The DADS case manager will verify the individual’s Medicaid eligibility status and notify the provider.

 

3413 Provider Unable to Begin on Service Initiation Date

Revision 14-1; September 1, 2014

 

If the provider determines that service will not begin on the authorized service initiation date, the provider must notify the DADS case manager verbally and follow up by faxing Form 2067, Case Information, to the DADS case manager with the reason for the delay and the new service initiation date. This action must occur within five working days of oral notification.

 

3414 Provider Initiated Changes to Delivery of Services

Revision 14-1; September 1, 2014

 

The provider may notify the DADS case manager verbally, but must fax the DADS case manager Form 2067, Case Information, of any changes in service delivery within one working day of becoming aware of the need for a change. The DADS case manager determines if the change in service delivery requires a change to the individual's Individual Plan of Care (IPC). The DADS case manager contacts the individual by phone or home visit if the change in service delivery requires a change to the IPC. If the individual agrees with the change, the DADS case manager will complete the change to the IPC following DADS case management procedures. If the individual does not agree with the change, the DADS case manager must contact the provider and resolve the provider's change in service delivery. The provider may not exceed the amount of services already authorized on the IPC.

 

3500 Loss of Medicaid Eligibility

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.405(b), Monitoring Medicaid Eligibility

If the provider becomes aware the individual has lost Medicaid eligibility, the provider must immediately inform the DADS case manager verbally and must send the case manager Form 2067, Case Information, within one working day of awareness. If Medicaid eligibility is no longer in effect, the provider stops providing services immediately and the DADS case manager will follow this action with a formal notice to the individual and provider that services were suspended. The provider must notify the individual or primary caregiver by phone or home visit regarding the need to suspend services and the reason why.

MDCP services cannot continue past the last date of Medicaid eligibility. The provider will receive Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, from the DADS case manager cancelling the authorization. DADS will not reimburse providers for services delivered when the individual does not have Medicaid eligibility, even if the individual files a timely appeal.

The DADS case manager will notify the provider of the loss of Medicaid via Form 2067.

 

3510 Service Reduction, Service Denial or Case Termination

Revision 14-1; September 1, 2014

 

In most situations, the DADS case manager must provide 30 days notification to the individual for any case action that is a service reduction, service termination or case termination. The intent of the 30-day notification time frame is to allow the individual and primary caregiver sufficient time to adjust to DADS decision.

The DADS case manager does not have to give 30 days notice for service or case denials as the individual has not yet received services.

In some instances, delaying termination or reduction of services for 30 days may have an adverse effect on the individual. In these instances, DADS may provide less than 30 days notification for any case action. These instances may include:

  • a service reduction in order to add or increase a waiver service to the Individual Plan of Care (IPC); or
  • a case termination for an individual’s voluntary withdrawal or enrolling into another waiver program. This exception does not apply to an individual aging out since the MDCP termination date is known.

If the individual or primary caregiver requests the case action occur before the 30-day notification time frame, the DADS case manager must inform the individual and primary caregiver that the individual:

  • has a right to a 30-day notification period before the case action may occur; and
  • may waive the 30-day notification period by completing Form 1574, Exception to the 30-Day Notification.

Within two working days of receiving a request to waive the 30-day notification for any case action, the DADS case manager must send the individual or primary caregiver Form 1574. The form must be completed and returned to the DADS case manager before the date of the required 30-day notification of any case action.

If Form 1574 is not returned to the DADS case manager before the date of the required 30-day notification of any case action, the DADS case manager sends the notification to the individual, primary caregiver and provider for the case action 30 days in advance of the effective date. The effective date for the case action will be negotiated between the DADS case manager, the individual or primary caregiver, and the provider.

 

3511 Service Reduction Notification

Revision 14-1; September 1, 2014

 

Approved

The DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and the following service authorization forms, as applicable, to the individual and the provider within two working days of completing the IPC.

  • Form 2402, Consumer Directed Services Option – Services Authorization;
  • Form 2414, Flexible Family Support Service Authorization;
  • Form 2415, Respite Service Authorization;
  • Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization; and
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

Denial

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to:

  • notify the applicant/individual of denied service;
  • suspend the individual's waiver services; and
  • notify providers of DADS decision.

 

3512 Case Termination Notification

Revision 14-1; September 1, 2014

 

In a case termination due to voluntary withdrawal from the program, the termination date is the last date the individual or primary caregiver requests MDCP services.

The DADS case manager must contact the provider at least two working days before the case termination effective date to prevent the provider from delivering services to the individual after the case termination date. The contact may be by telephone or on Form 2067, Case Information, sent by the DADS case manager using fax, email or U.S. mail.

The DADS case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for case terminations. The effective date of Form 2065-C is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver program or the last day of MDCP services requested by the individual or primary caregiver. The DADS case manager completes and sends Form 2065-C and applicable service authorization forms to the individual and the provider within two working days of determining program ineligibility.

 

3513 Service Reduction Information

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.243, Denials, Terminations and Service Reductions

 

3514 Provider Information for Completing Service Reductions

Revision 14-1; September 1, 2014

 

When the DADS case manager plans a change to the Individual Plan of Care (IPC) for a service reduction, it may be necessary to obtain service delivery information from the provider to complete the change. When this occurs, the DADS case manager verifies with the provider the number of units or the cost of services delivered from the authorized start date through the day before the IPC change is effective.

The provider will receive from the DADS case manager Form 2067, Case Information, which will request the:

  • number of units for Respite and/or Flexible Family Support Services delivered by the Home and Community Support Services Agency (HCSSA), delivered from the authorized start date through the day before the IPC change effective date;
  • cost of services from the Financial Management Services Agency (FMSA), for Respite or Flexible Family Support Services delivered from the authorized start date through the day before the IPC change effective date; or
  • cost of adaptive aids, minor home modifications, or Transition Assistance Services (TAS) delivered to the individual from the authorized start date through the day before the IPC change effective date.

After the DADS case manager receives the completed Form 2067 from the provider, the DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and applicable service authorization forms to the individual and the provider within two working days of completing the service reduction to the IPC. The effective date of Form 2065-B and applicable service authorization forms for a service reduction is 30 days after the date on the individual's notification letter.

 

3520 Service Suspensions

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.241, Service Suspensions by DADS

The DADS case manager or a provider may suspend an individual's MDCP services during the Individual Plan of Care (IPC) period. The DADS case manager or the provider must suspend MDCP services when:

  • the individual:
    • is admitted into a hospital;
    • is admitted into a nursing facility (NF);
    • is admitted into a state supported living center;
    • is admitted into a state mental health facility;
    • is admitted into a rehabilitation hospital;
    • is admitted into an intermediate care facility for persons with intellectual disability or related conditions; or
  • someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider's staff, DADS staff or another person in the residence; or
  • someone in the individual's residence discriminates against the provider's staff or DADS staff.

If an individual or caregiver or someone else in the residence exhibits behavior that constitutes imminent danger or a threat to the health or safety of the individual or another person, the provider must take action. Examples include, but are not limited to:

  • exhibiting weapons;
  • making direct or indirect threats of physical harm, force or death;
  • physically attacking a person with or without a weapon;
  • threatening use of force by self or someone else; or
  • sexual harassment or sexual assault.

If the individual's safety may be at risk, the provider must contact the Department of Family and Protective Services (DFPS) at 1-800-252-5400 and the police, if appropriate, the same day the provider is aware of the suspension. The provider must also notify the DADS case manager of the risk to an individual’s health and safety the same day the provider is reporting that information to DFPS and the police.

An individual who threatens his own health or safety or that of others should be considered for referral to the Local Authority and the police, if appropriate.

 

3521 Notification of Service Suspensions

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419, Service Suspensions by Program Provider

The provider is required to notify the DADS case manager verbally or by fax no later than one working day after services are suspended giving the reason for the suspension, the effective date of the suspension and the duration, if known, for service suspensions initiated by the provider. The provider must include an explanation of the attempts to resolve the issues that initiated the suspension. If the program provider's notification is verbal, the program provider must send written notification using Form 2067, Case Information, to the DADS case manager within five working days after the verbal notification.

The DADS case manager contacts the individual and tries to resolve the problem within 12 days from the date on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. If the problem cannot be resolved, the provider may report to DADS that it will no longer serve the individual due to health and safety concerns.

For any situation requiring waiver service suspension, the DADS case manager notifies the individual and provider by completing Form 2065-C. If the individual or provider has informed the DADS case manager of the return date from an institution, the DADS case manager notes the duration of the suspension on the comments section of Form 2065-C.

 

3522 Extension of Suspension

Revision 14-1; September 1, 2014

 

DADS may extend a suspension for an additional 30 days if the reason for the individual's suspension will exceed 180 days.

If the individual or primary caregiver notifies DADS with a request for MDCP services to resume, the DADS case manager reviews the reasons for the request to determine if an exception will be permitted. Examples of reasons for extending the suspension period for individuals:

  • residing in an institution:
    • documentation or verbal communication from a treating professional that demonstrates the individual will be able to return to his home in the community within 30 days of exceeding the 180 suspension period.
    • proof of having a home in the community to live in upon discharge from the institution.
    • resources in the community (for example, involved family) that will be available to help support the individual when he moves back into the community.
  • living or traveling out of state:
    • confirmation of having made a rental deposit for a home or apartment in the state of Texas.
    • evidence that the barriers previously preventing the individual from returning to Texas now have been eliminated (for example, individual has identified a residence in Texas; individual will soon be discharged from an out-of-state institution).

 

3523 Resuming Services

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.419(d), Service Suspensions by Program Provider, Resuming Services After a Suspension

The duration of the suspension may depend on the reason for the suspension, such as the individual requiring an extended stay in a hospital or nursing facility (NF). The DADS case manager will communicate with the provider or individual to obtain a date to resume services.

DADS requires providers resume services after a suspension:

  • upon the individual's discharge and return home from:
    • a hospital;
    • an NF;
    • a state supported living center;
    • a state mental health facility;
    • a rehabilitation hospital; or
    • an intermediate care facility for persons with intellectual disability or related conditions;
  • on the date the provider becomes aware of the individual's return home; or
  • on a date specified in writing by the DADS case manager.

The DADS case manager completes Form 2065-B, Notification of Waiver Services, to notify the individual and provider to resume services. The DADS case manager completes and sends Form 2065-B to the individual and provider within two working days:

  • of becoming aware of the individual's return to his residence with the effective date being the same date as the individual's return; or
  • after resolving the reckless behavior or discrimination issues that led to the suspension with the effective date being the date the DADS case manager completes the form.

 

3524 Temporary Nursing Facility Admissions

Revision 14-1; September 1, 2014

 

The first date of service after the temporary admission to the nursing facility (NF) is the date of the NF discharge and the service end date is the same as the Individual Plan of Care period. The DADS case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan.

 

3525 Service Denials and Case Closure

Revision 14-1; September 1, 2014

 

Rule: 40 TAC §51.243, Denials, Terminations, and Service Reductions

 

3600 Appeals and Hearings

Revision 14-1; September 1, 2014

 

Rule: 1 TAC, Chapter 357, Subchapter A, Uniform Fair Hearing Rules

An individual may appeal a DADS action. A DADS action means a service suspension, service reduction, denial or termination. To appeal a DADS action, an individual must make a request for a fair hearing verbally or in writing to the case manager within 90 days from the date on the notice of the DADS action.

If an individual who is currently receiving services requests a fair hearing before the effective date of the DADS action on the notice, the program provider will be notified by the DADS case manager to continue services; however, if a suspension occurs because of reckless behavior, then services will not continue during the appeal process.

If an individual who is currently receiving services does not submit a request for a fair hearing before the effective date of DADS action on the notice, the program provider must, unless otherwise directed by the DADS case manager, discontinue services on the effective date of the DADS action on the notice.