Revision 14-1; Effective September 1, 2014

 

 

8100 Termination of Medicaid

Revision 14-1; September 1, 2014

 

In most situations, the DADS case manager must provide a 30-day 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.

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.

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.

 

8200 Service Reduction

Revision 14-1; September 1, 2014

 

Rule: 40 Texas Administrative Code (TAC) §51.243, Denials, Terminations and Service Reductions

 

8210 Service Reduction Notification

Revision 14-1; September 1, 2014

 

The DADS case manager completes and sends Form 2065-B, Notification of Waiver Services, and all of the following applicable service authorization forms to the individual and the provider within two working days of completing the Individual Plan of Care:

  • Form 2402, Consumer Directed Services Option – Services Authorization;
  • Form 2414, Flexible Family Support Services 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.

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

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

 

8220 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; or
  • cost of adaptive aids, minor home modifications or Transition Assistance Services delivered to the individual up to 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.

 

8300 Self-Reported Incidents

Revision 14-1; September 1, 2014

 

Rule: 40 TAC Chapter 97, §97.249, Self-Reported Incidents of Abuse, Neglect and Exploitation

This rule includes definitions of reportable incidents. A provider must report incidents to Consumer Rights and Services (CRS) at 800-458-9858. Additional information can be found on the CRS website.

 

8400 Service Suspensions

Revision 14-1; September 1, 2014

 

Rules:
40 TAC, Chapter 51, Subchapter B, Division 3, §51.419, Service Suspensions by Program Provider
40 TAC, Chapter 51, Subchapter D, Division 2, §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;
    • is admitted into a state supported living center;
    • is admitted into a state mental health facility;
    • is admitted into a rehabilitation hospital; or
    • 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 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; and
  • 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 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.

 

8410 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 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.

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.

 

8411 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 of the wish 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 include:

  • 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; and
    • 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/apartment; and
    • 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).

 

8412 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. 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 return home from:
    • a hospital;
    • a nursing facility;
    • 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.

 

8500 Temporary Nursing Facility Admissions

Revision 14-1; September 1, 2014

 

The first date of service after the temporary admission to the nursing facility is the date of the nursing facility 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.

 

8600 Service Denials and Case Termination

Revision 14-1; September 1, 2014

 

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

 

8610 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.