Revision 18-2; Effective September 3, 2018

 

 

4010 Outline

 

This section outlines the delivery of STAR Kids community long term services and supports. Sections 4100-4520 describe Medicaid state plan long term services and supports, assessment and reassessment requirements, and provider requirements.

Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements and limitations, and provider requirements.

 

4100 Community First Choice

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) is a group of services delivered under the authority of §1915(k) of the Social Security Act. CFC is under federal regulations governing home and community based services. Therefore, the settings in which CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) §441.301(c)(4) and §441.710 respectively. Permissible home and community based settings include member homes, apartment buildings and non-residential settings. Community based settings exclude:

  • nursing facilities;
  • hospitals providing long term care services;
  • inpatient psychiatric facilities;
  • intermediate care facilities for individuals with an intellectual disability or a related conditions (ICF-IID); or
  • a setting on the grounds of, or with the characteristics of, an institution.

Provider owned and controlled settings are also excluded from CFC because those providers are paid for CFC-like services as part of the provider’s rates, and to provide CFC would be duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person-centered, per 42 CFR §441.665. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.

 

4110 Community First Choice Eligibility

Revision 17-1; Effective June 1, 2017

 

Eligibility for Community First Choice (CFC) requires a STAR Kids member to meet the following conditions:

  • be Medicaid eligible;
  • meet the level of care provided in a hospital or nursing facility (NF), intermediate care facility for individuals with an intellectual disability or a related conditions (ICF/IID) or an institution providing psychiatric services; and
  • have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose eligibility is established due to eligibility for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per § 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month, as these members meet eligibility for an institution providing psychiatric services and an NF, respectively.

A member may not be authorized to receive both Personal Care Services (PCS) and CFC services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver provider and are not eligible to receive CFC through the managed care organization:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)

 

4111 Determining Institutional Level of Care

Revision 17-1; Effective June 1, 2017

 

STAR Kids Screening and Assessment Instrument (SK-SAI)

For members with physical disabilities, the SK-SAI contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP), on behalf of the Texas Health and Human Services Commission (HHSC), to determine if a member meets medical necessity for the level of care provided in a hospital or nursing facility. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of medical necessity for Community First Choice (CFC) services, the MCO must indicate so before submitting the assessment. The MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires nursing facility services or alternative community based services under the supervision of a physician.

Further information about the medical necessity determination process for CFC may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.

Intellectual Disability or Related Condition Assessment (ID/RC)

Upon notification from the MCO, Local Intellectual or Development Disability Authorities (LIDDAs) conduct assessments to determine whether a member meets the level of care (LOC) provided by an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID). In addition to the ID/RC, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a member does not have one on file. The LIDDA submits this information to the state for a determination of ID/RC. The state notifies both the LIDDA and the member's MCO about the determination. If a member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment. If the member does not agree to the CFC service plan or refuses CFC services, the MCO must notify the LIDDA within 10 business days of the member ending CFC services.

 

Child and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA)

 

A comprehensive provider of mental health rehabilitative services or a Local Mental Health Authority (LMHA) conduct the CANS or ANSA and a licensed practitioner determines whether the member meets an inpatient psychiatric facility level of care. If the member meets that LOC, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.

 

4120 Community First Choice Services

Revision 17-1; Effective June 1, 2017

 

Community First Choice services are personal assistance services, habilitation, emergency response services and support management.

 

4121 Community First Choice Personal Assistance

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) personal assistance service (PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Such assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC PAS include:

  • Non-skilled assistance with the performance of ADLs and IADLs;
  • Household chores necessary to maintain the home in a clean, sanitary and safe environment;
  • Escort services, which consist of accompanying, but not transporting, and assisting a member to access services or activities in the community; and
  • Assistance with health-related tasks. Health-related tasks, in accordance with state law, include tasks delegated by a registered nurse, health maintenance activities and extension of therapy. An extension of therapy is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow-up to therapy sessions. If appropriate, the member's attendant can assist the member in accomplishing such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) model, the member or legally authorized representative determines health-related tasks without a nurse assessment, in accordance with state laws, §531.051(e), Texas Government Code, and 22 Texas Administrative Code, §225.4.

CFC PAS is the same service (i.e., attendant care) as Personal Care Services (PCS). The only difference is the member's level of care (LOC) and how the service is billed. Information used to build a plan of care for CFC PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by the appropriate items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC PAS if he meets CFC level of care criteria.

Members may choose to receive CFC PAS only if they do not need or want CFC habilitation.

 

4122 Community First Choice Habilitation

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) habilitation assists members with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is provided to allow a member to reside successfully in a community setting by assisting the member to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the member on ADLs and IADLs. Personal assistance may be a component of CFC habilitation for some members. CFC habilitation services include training, which is interacting face-to-face with a member to train the member in activities, such as:

  • self-care;
  • personal hygiene;
  • household tasks;
  • mobility;
  • money management;
  • community integration, including how to get around in the community;
  • use of adaptive equipment;
  • personal decision-making;
  • reduction of challenging behaviors to allow members to accomplish ADLs, IADLs and health-related tasks; and
  • self-administration of medication.

Information used to build a plan of care for CFC habilitation may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. This section of the PCAM should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for CFC emergency response services (ERS).

CFC ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports and are available for members who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use ERS for ERS to be authorized.

Need for ERS is assessed using the SK-SAI, Section Z.

 

4123 Community First Choice Emergency Response Service

Revision 17-1; Effective June 1, 2017

 

Community First Choice emergency response services (ERS) is designed to assist individuals who do not require supervision during the day or are alone for large parts of the day, and are cognitively able to recognize an emergency. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, to a member's emergency. This service is not routinely authorized for members who are minors.

 

4124 Community First Choice Support Management

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.

 

Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Z.

 

4130 Community First Choice Assessment and Authorization

Revision 17-1; Effective June 1, 2017

 

 

4131 Assessment for a Nursing Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

Nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services is established using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member's eligibility for NF services according to the Texas Administrative Code §19.2401 definition of “medical necessity.”

To ensure the TMHP evaluates the submitted SK-SAI for the nursing facility LOC, the MCO must submit the SK-SAI with field Z5a=1 to indicate that an MN determination is needed. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. This does not preclude the member or MCO from seeking determination of a different institutional LOC. If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.

 

4131.1 Reassessment for a Nursing Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

For members requiring a reassessment of medical necessity (MN) for a nursing facility level of care for continued eligibility for Community First Choice services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

 

4132 Assessment for an Intermediate Care Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator and his contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability and ID/RC, the LIDDA submits the assessment for a determination of level of care to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility (ICF), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.

If a member meets an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

 

4132.1 Reassessment for an Intermediate Care Facility Level of Care

Revision 17-1; Effective June 1, 2017

 

Ninety days prior to the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility (ICF) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an Intermediate Care Facility Level of Care, for all reassessments.

If a member continues to meet an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

 

4133 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 17-1; Effective June 1, 2017

 

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider of mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A licensed practitioner must concur with the assessment or may deviate a member to a higher or lower LOC, based on his clinical judgement. A licensed practitioner must review the CANS or ANSA at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months.

Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their health plan for functional necessity of CFC services at any time while enrolled in YES.

 

4133.1 Reassessment for an Institution for Mental Disease Level of Care

Revision 17-1; Effective June 1, 2017

 

Assessment of a psychiatric institutional level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet a psychiatric institutional level of care, the MCO may conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or his representative of the denial for CFC services. The member may be eligible for personal care services, if functionally necessary.

 

4140 Functional Assessment for Community First Choice Services

Revision 17-1; Effective June 1, 2017

 

Functional need for Community First Choice (CFC) services is primarily established by Sections J, K, L, M, N, O, and P of the STAR Kids Screening and Assessment Instrument (SK-SAI) which form the Personal Care Assessment Module (PCAM). This module contains assessment questions for the attendant care (CFC PAS) and habilitation services available through CFC. The following questions/information in the SK-SAI core module are triggers for the PCAM and may indicate the member has functional need for CFC services:

  • A personal care aide is provided in a school or day program;
  • The caregiver, member or others are concerned about the member's developmental status or decline from baseline related to self-care (dressing, bathing, using toilet, self-care);
  • Decline in functional status as compared to 90 days ago or since the last assessment;
  • Instrumental activity of daily living (IDAL) self-performance;
  • Activity of daily living (ADL) self-performance;
  • The member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • The member requires diet modification to swallow solid food;
  • The member requires modifications to swallow liquids;
  • The member received personal care services, attendant care or a home health aide in the last 30 days; and/or
  • The member or his legally authorized representative requests an assessment for CFC or personal care services.

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should only be completed if the member is specifically seeking CFC services. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4140.1 Reassessment of Functional Need for Community First Choice

Revision 17-1; Effective June 1, 2017

 

The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested due to a change in the member's health condition or living situation.

 

4200 Personal Care Services

Revision 17-1; Effective June 1, 2017

 

Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through age 20. PCS is considered medically necessary when a member requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a physician statement of need. STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to assist the individual in performing a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

  • Assistance with ADLs and IADLs;
  • Nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and 22 Texas Administrative Code Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions); and
  • Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task.

The amount and duration of PCS is determined by the MCO and must take the following into account:

  • Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that inhibits the member's ability to accomplish ADLs or IADLs;
  • The member's caregiver's need to sleep, work, attend school and meet his own medical needs;
  • The member's caregiver's legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household;
  • The member's caregiver's physical ability to perform PCS;
  • Whether requiring the member's caregiver to perform PCS will put the member's health or safety in jeopardy;
  • The time periods during which PCS tasks are required by the member, as they occur over the course of a 24-hour day and a seven-day week;
  • Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability that is below that expected of a typically developing child of the same chronological age; and
  • Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows.

PCS may be authorized to support a member's primary caregiver(s) but may not be authorized to supplant a member's natural support, nor to provide a member's total care. PCS may be authorized in an individual or group setting including, but is not limited to the:

  • member's home;
  • home of the primary or other caregiver;
  • member's school;
  • member's day care facility; or
  • community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, is required to meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation may be submitted to the MCO with documentation of medical necessity.

PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities.

PCS may not be used as respite, child care, or for the purposes of restraining a member. PCS may be authorized in a group setting.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver program and are not eligible to receive PCS through the MCO:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); and
  • Texas Home Living (TxHmL) Program.

 

4210 Assessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

Sections J, K, L, and M of the STAR Kids Screening and Assessment Instrument (SK-SAI) form the Personal Care Assessment Module (PCAM). This module contains assessment questions for personal care services (PCS). The following questions in the SK-SAI core module are triggers for the PCAM and may indicate the member requires PCS:

  • A personal care aide is provided in a school or day program;
  • The caregiver, member or others are concerned about the member's developmental status or decline from baseline related to self-care (dressing, bathing, using toilet self-care);
  • Decline in functional status as compared to 90 days ago or since the last assessment;
  • Instrumental activity of daily living (IADL) self-performance;
  • Activity of daily living (ADL) self-performance;
  • The member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • The member requires diet modifications to swallow solid food;
  • The member requires modifications to swallow liquids;
  • The member received PCS, attendant care or a home health aide in the last 30 days; and/or
  • The member or his legally authorized representative requests an assessment for Community First Choice (CFC) or PCS.

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4211 Reassessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new physician statement of need to substantiate the member's continued need for PCS upon each annual reassessment.

 

4220 Personal Care Services Providers

Revision 17-1; Effective June 1, 2017

 

Personal care services must be provided by an individual who:

  • is 18 years of age or older;
  • is an attendant who:
    • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services; or
    • is employed by the member or his legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.
  • has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
  • is not the responsible adult of the member if the member is under the age of 18; and
  • is not the spouse of the member.

 

4300 Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Private duty nursing (PDN) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PDN is available to STAR Kids members from birth through age 20. PDN services must be available when the services are medically necessary to correct or ameliorate a member's disability, physical or mental illness, or condition. The services correct or ameliorate when the services improve, maintain or slow the deterioration of the member's health status.

Nursing services are medically necessary under the following conditions:

  • The services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations;
  • The services correct or ameliorate the member's disability, physical or mental illness, or condition. Nursing services correct or ameliorate the member's disability, physical or mental illness, or condition when the services improve, maintain or slow the deterioration of the member's heath status.
  • There is no third party resource financially responsible for the services.

PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize member health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options.

PDN is considered only when the services are consistent with the definition of "nursing" as described in the Texas Nursing Practice Act or its implementing regulations. PDN must not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the member's nursing needs.

The managed care organization (MCO) may deny or reduce PDN hours if the member's PDN needs decrease. The MCO may not:

  • deny or reduce PDN when the member's nursing needs have not decreased;
  • require a member's responsible adult(s) to provide PDN services to the member;
  • require a member or a member's responsible adult(s) to designate an alternate caregiver to provide PDN services; or
  • deny or reduce the amount of authorized PDN services because the member's responsible adult(s) is trained and capable of performing such services, but chooses not to do so.

 

4310 Assessment for Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for private duty nursing (PDN). The following questions/information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires PDN:

  • A skilled nursing visit or PDN is provided in a school or day program;
  • The member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
  • The member requires enteral or parenteral feeding;
  • The member received any of the following treatments in the last 30 days:
    • Chemotherapy;
    • Dialysis;
    • Intravenous (IV) medication;
    • Oxygen therapy;
    • Radiation;
    • Suctioning;
    • Tracheotomy care;
    • Transfusion;
    • Ventilator;
    • Wound care;
    • Nebulizer;
    • Urinary catheter care insertion or maintenance;
    • Comatose or persistent vegetative state managed care;
    • Continuous positive airway pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP);
    • Chest percussive therapy;
    • Active medication adjustment;
    • Intermittent positive pressure breathing (IPPB); and/or
    • Seizure management;
  • The member is being assessed for Community First Choice services or the Medically Dependent Children Program.

If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PDN. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

4311 Reassessment and Reauthorization

Revision 17-1; Effective June 1, 2017

 

At a minimum, the need for and the amount and duration of private duty nursing must be reassessed 90 days following initial authorization and every six months, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.

 

4320 Providers of Private Duty Nursing

Revision 17-1; Effective June 1, 2017

 

Private duty nursing (PDN) may be provided by a licensed Home and Community Support Services Agency (HCSSA), an independently enrolled registered nurse (RN) or a licensed vocational nurse (LVN) under the supervision of an RN, contracted with the STAR Kids managed care organization.

An RN must develop a plan of care that accounts for the following items, at a minimum:

  • A clinical summary that documents active diagnoses and current clinical condition;
  • Member's mental or cognitive status;
  • Types of treatments and services, including amount, duration and frequency;
  • A description of any required equipment and/or supplies;
  • Member's prognosis;
  • Member's rehabilitation potential;
  • Member's current functional limitations;
  • Activities permitted;
  • Member's nutritional requirements;
  • Member's medications, including dose, route and frequency;
  • Safety measures to protect against injury;
  • Instructions for timely discharge or referral;
  • Date the member was last seen by the treating physician;
  • Identification of activities of daily living and health maintenance activities with which the member needs assistance. The plan of care must indicate whether the tasks must be performed by a licensed nurse or a qualified aide, or may be performed by a personal care attendant;
  • A certification statement that an identified contingency plan exists; and
  • All other medical orders.

PDN must not be provided by a member's legally responsible adult if the member is under age 18 or the spouse of the member.

 

4330 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 17-1; Effective June 1, 2017

 

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.

 

4400 Prescribed Pediatric Extended Care Centers

Revision 17-1; Effective June 1, 2017

 

Prescribed Pediatric Extended Care Center (PPECC) services may be a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP) for STAR Kids members who meet the following medical necessity criteria for admission:

  • Eligible for THSteps-CCP;
  • Age 20 years or younger;
  • Have an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
  • Considered to be a medically dependent or technologically dependent member;
  • Stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
  • Requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
    • deterioration of a chronic condition;
    • loss of function;
    • imminent risk to health status due to medical fragility; or
    • risk of death;
  • Has a prescription for PPECC services signed and dated by an ordering physician who has personally examined the member within 30 calendar days prior to admission and reviewed all appropriate medical records;
  • Has consent for the member's admission to the PPECC signed and dated by the member or the member's responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of PDN by the member or member's responsible adult in both managed care and non-managed care service delivery systems; and
  • Resides with the responsible adult and does not reside in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility, intermediate care facility or special care facility.

PPECC services require prior authorization and are intended as an alternative to private duty nursing (PDN). However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, Personal Care Services (PCS), Home Health Skilled Nursing (HHSN), Home Health Aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and Early Childhood Intervention services rendered in the member's residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but PPECC services must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

  • The development, implementation and monitoring of a comprehensive plan of care that:
    • is provided to a medically dependent or technologically dependent member;
    • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
    • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the member and the training needs of the member’s caregiver(s);
    • specifies if transportation to and from the PPECC is needed; and
    • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
  • Direct skilled nursing care and caregiver training and education intended to:
    • optimize the member’s health status and outcomes; and
    • promote and support family-centered, community-based care as a component of an array of service options by:
      • preventing prolonged or frequent hospitalizations or institutionalization;
      • providing cost-effective, quality care in the most appropriate environment; and
      • providing training and education of caregivers;
  • Nutritional counseling and dietary services as specified in a member’s plan of care;
  • Assistance with activities of daily living while the member is in the PPECC;
  • Psychosocial and functional development services; and
  • Transportation services to and from a PPECC. Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC. When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle. The member must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance. Transportation is billed separately by the PPECC when utilized by a member. A non-emergency ambulance may not be utilized for transport to and from a PPECC.

Note: A member or the member's responsible adult may decline a PPECC's transportation and choose to be transported by other means, including his or her responsible adult. A member’s legally authorized representative is not required to accompany a member when the member receives services in a PPECC, including transportation services to and from the center and therapy services that are billed separately. Fee-for-service Medicaid does not require prior authorization for the transportation billing code. Rather, authorization for PPECC services implies authorization for transportation.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

  • baby food or formula;
  • services to members that are related to the PPECC owner by blood, marriage or adoption; and
  • services covered separately by Texas Medicaid, such as therapies or durable medical equipment, or individualized comprehensive case management beyond that required for service coordination.

 

4410 Assessment for Prescribed Pediatric Extended Care

Revision 17-1; Effective June 1, 2017

 

Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

  • A current authorization for private duty nursing (PDN);
  • A skilled nursing visit or PDN is provided in a school or day program;
  • Member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
  • Member requires enteral or parenteral feeding;
  • Member received any of the following treatments in the last 30 days:
    • Chemotherapy;
    • Dialysis;
    • Intravenous (IV) medication;
    • Oxygen therapy;
    • Radiation;
    • Suctioning;
    • Tracheotomy care;
    • Transfusion;
    • Ventilator;
    • Wound care;
    • Nebulizer;
    • Urinary catheter care –insertion or maintenance;
    • Comatose or persistent vegetative state – manage care'
    • Continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
    • Chest percussive therapy;
    • Active medication adjustment;
    • Intermittent positive pressure breathing (IPPB); and/or
    • Seizure management; and
  • The member is being assessed for Community First Choice services or the Medically Dependent Children Program.

If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

 

4411 Reassessment and Reauthorization

Revision 17-1; Effective June 1, 2017

 

At a minimum, the need for and the amount and duration of services from a Prescribed Pediatric Extended Care Center must be reassessed 90 days following initial authorization and every 180 days following, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.

 

4420 Providers of Prescribed Pediatric Extended Care

Revision 17-1; Effective June 1, 2017

 

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 40 Texas Administrative Code Chapter 15 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services may not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual and PPECC medical policy. These components include:

  • Member's name, date of birth and Medicaid number;
  • PPECC's name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, phone and fax numbers;
  • Ordering physician's name, phone number, TPI and NPI;
  • Date the PPECC nursing assessment was completed and name, title and credentials of the RN who completed the POC and his/her dated signature;
  • Name, title and credentials of the team member who completed the POC and his/her dated signature;
  • Date the member was last seen by the ordering physician;
  • Requested start of care date for PPECC services;
  • All pertinent diagnoses and known allergies;
  • Nursing services to be provided, including amount, duration and frequency;
  • Member's prognosis;
  • Member's mental status;
  • Rehabilitation potential;
  • Equipment and/or supplies required;
  • Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
  • Other prescribed services, including amount, duration and frequency;
  • Nutritional requirements, including type, method of administration and frequency;
  • Medications, including the dose, route, frequency and any medication-related allergies if known;
  • Treatments, including amount and frequency;
  • Wound care orders and measurements;
  • Safety measures to protect against injury;
  • Functional developmental services and psychosocial services, including amount, duration and frequency;
  • Name, phone number and signature of the responsible adult;
  • Member’s emergency contact name and phone number;
  • Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
  • List of services the member receives in the home and school settings. (e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), personal care services, private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)). Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
  • Member-specific measureable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
  • Responsible adult training needs;
  • Prior and current functional or medical limitations;
  • Permitted activities;
  • Member's scheduled days and hours of attendance;
  • Confirmation of a discharge plan, including instructions for timely discharge or referral;
  • Method of transportation;
  • PDN provider name, TPI, NPI, phone, address and fax number, if known;
  • Ordering physician signature and date of signature;
  • Transportation services needed by a member to access PPECC service (a non-emergency ambulance may not be used for transport to and from a PPECC); and
  • Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 636 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), Rule §363.211 (Benefits and Limitations).

A face-to-face evaluation must be performed annually by the ordering physician. A physician order is required for each initial and recertification authorization, and revisions. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician's order, unless the physician is the member’s treating physician and has examined the member outside of the PPECC setting. The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

  • Speech, physical, and occupational therapies (including therapies rendered by a home health agency);
  • Certified respiratory care services;
  • Early intervention services provided through the ECI program, which are subject to ECI policies.

Authorization Requirements

Per Rule §363.211, initial, recertification and revision requests for PPECC services must include the following documentation, which adheres to requirements in the Texas Medicaid Provider Procedures Manual:

(1) physician order for services (a physician signature on the PPECC plan of care serves as a physician order for authorization purposes);

(2) a plan of care developed by the PPECC;

(3) all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual, or MCO forms if they contain comparable content; and

(4) signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include an acknowledgement by the participant or the participant's responsible adult that he or she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care, must also be obtained.

Forms available online for PPECC include:

  • CCP Prior Authorization Request (requires ordering physician signature).
  • PPECC POC (requires ordering physician, PPECC RN and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
  • Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN, and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms, and are subject to approval by HHSC.

 

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 17-1; Effective June 1, 2017

 

See Section 4330, Private Duty Nursing and Prescribed Pediatric Extended Care Center Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services, and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC, or a combination of both services.

 

4500 Day Activity and Health Services

Revision 17-1; Effective June 1, 2017

 

Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations may not require DAHS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for DAHS.

 

4510 Assessment for Day Activity and Health Services

Revision 17-1; Effective June 1, 2017

 

The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse or licensed vocational nurse, based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member's home. Health assessments must be conducted, at minimum, when:

  • members need initial assessment for prior authorization by a STAR Kids managed care organization;
  • members transfer to a new facility (conducted by the new facility);
  • at reauthorization; and
  • the DAHS nurse determines a member needs to be reassessed.

The member or his legally authorized representative must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member's functioning.

 

4511 Reassessment for Day Activity and Health Services

Revision 17-1; Effective June 1, 2017

 

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may be no older than 90 days from the date at which an authorization is requested.

A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation, and nutritional services when:

  • a member first enters the facility;
  • transferring from another Day Activity and Health Services facility; and
  • a member's condition changes. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.

 

4520 Day Activity and Health Services Providers

Revision 17-1; Effective June 1, 2017

 

To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Care and Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

  • Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services.
  • Physical rehabilitative services, which include restorative nursing and group/individual exercises with range of motion exercises.
  • Nutrition services, which include:
    • one hot noon meal a day;
    • a mid-morning and mid-afternoon snack;
    • preparation of foods required for special diets; and
    • dietary counseling and nutrition education for the individual and his family.
  • Transportation, including to and from the facility, as well as to and from the facility on an activity outing, and to and from a facility approved to provide therapies if the member requires specialized services on days of attendance at the DAHS facility. The provider must:
    • coordinate the use of other transportation resources within the community;
    • make every effort to have families transport individuals;
    • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and
    • have sufficient staff to ensure the safety of members being transported to and from their homes.
  • Activities and other supportive services:
    • Activities offered at the facility must be meaningful, fun, therapeutic and educational.
    • A provider must offer at least three different scheduled activities in at least one or more of the following activities:
      • Exercise;
      • Games;
      • Educational or reality orientation; and/or
      • Crafts.
    • A provider must offer at least one of the following activities, at cost to the provider, monthly:
      • Trips or special events; or
      • Cultural enrichment.

 

4600 Medically Dependent Children Program Services

Revision 18-2; Effective September 3, 2018

 

The Medically Dependent Children Program (MDCP) provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, supported employment, and employment assistance to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.

Only members who are assessed as meeting medical necessity (MN) and who have a slot in the MDCP waiver are eligible for MDCP services. Federal guidelines require that members must need and use one or more waiver services to qualify and maintain eligibility for MDCP. The minimum utilization of MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they utilize Community First Choice (CFC), as described in Section 1530, Unmet Need for at Least One Waiver Service.

The managed care organization service coordinator must inform all members receiving MDCP services of the requirements outlined in Section 1530 and the following:

  • If the member’s eligibility is Medical Assistance Only (MAO) and:
    • CFC has been authorized, at a minimum, one MDCP service must be utilized at least once a month to qualify and maintain enrollment in MDCP.
    • CFC has not been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
  • If the member’s eligibility is not MAO and CFC has been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.

If a member is offered enrollment in MDCP or at an MDCP member's reassessment, during the STAR Kids assessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the service coordinator may discuss the member's needs as they relate to the available MDCP services. The service coordinator may develop a recommended individual service plan (ISP) if the member's Resource Utilization Group (RUG) is not known, as the RUG determines the member's budget.

Example: The service coordinator could ask the member and/or his caregiver if they would like respite or have a desire for employment services. The service coordinator could ask if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services. The service coordinator could inquire which services the member/caregiver would like more of, should the member's budget be unknown during the assessment. Based on the discussion, the service coordinator could develop a recommended ISP for that member and work with the member/caregiver in person or telephonically to develop a final service plan once the member's budget is known.

 

4700 Medically Dependent Children Program Respite and Flexible Family Support Services

Revision 17-1; Effective June 1, 2017

 

 

4710 Medically Dependent Children Program Respite

Revision 17-1; Effective June 1, 2017

 

Respite is a service that provides temporary relief from caregiving to the applicant/member or his primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/member's parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the CDS option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-Home Respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or Private Duty Nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite is a service to provide relief to the primary caregiver, if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member and/or legally authorized representative's preferences and the member's approved cost limit. MCOs must develop internal processes related to respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP. The MCO must document banked hours using Form 2605, Respite Tracking Tool.

 

4711 In-Home Respite

Revision 17-1; Effective June 1, 2017

 

In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or his legally authorized representative under the Consumer Directed Services (CDS) option.

A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by his available budget. Managed care organizations may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan.

 

4711.1 Attendant with Delegated Tasks

Revision 18-2; Effective September 3, 2018

 

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may to use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of respite, he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the Home and Community Support Services Agency provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

4712 Out-of-Home Respite

Revision 17-1; Effective June 1, 2017

 

Respite may be provided out of the home if indicated in a physician's order or if the member and/or his legally authorized representative prefer. Out-of-home respite providers are:

  • special care facilities licensed by the Texas Department of State Health Services (DSHS);
  • day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
  • hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • nursing facilities licensed by the Texas Health and Human Services or Department of Aging and Disability Services;
  • camps licensed by DSHS and accredited by the American Camping Association; and
  • foster families approved by a DFPS child placing agency.

Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.

 

4720 Respite Limits

Revision 17-1; Effective June 1, 2017

 

Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

  • primary caregiver;
  • member's spouse; or
  • member's parent, representative, guardian or managing conservator, if the individual is under age 18.

 

4730 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

 

4740 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

 

4750 Flexible Family Support Services

Revision 17-1; Effective June 1, 2017

 

Flexible family support services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

  • child care;
  • independent living; and
  • post-secondary education.

FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.

 

4751 Flexible Family Support Services in Child Care

Revision 17-1; Effective June 1, 2017

 

The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the amount of hours needed to support the member's needs within the Medically Dependent Children Program cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.

FFSS does not replace personal care services provided through Texas Health Steps or Community First Choice. FFSS are provided when a member regularly participates in child care in the home or out of the home, or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.

 

4752 Flexible Family Support Services for Independent Living

Revision 17-1; Effective June 1, 2017

 

A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with his or her goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.

To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.

 

4753 Flexible Family Support Services in Post-Secondary Education

Revision 17-1; Effective June 1, 2017

 

A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.

 

4754 Flexible Family Support Services Requiring Delegated Tasks

Revision 17-1; Effective June 1, 2017

 

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or his legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

4760 Flexible Family Support Services Limits

Revision 17-1; Effective June 1, 2017

 

Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services or Community First Choice.

42 Code of Federal Regulations §446.301(b)(1)(ii) requires that Medically Dependent Children Program services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions.

The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.

 

4800 Adaptive Aids, Minor Home Modifications, and Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

 

4810 Adaptive Aids

Revision 17-1; Effective June 1, 2017

 

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

  • perform activities of daily living; or
  • control the environment in which they live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

 

4811 Service Limits on Adaptive Aids

Revision 17-1; Effective June 1, 2017

 

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. After any applicable state plan benefits (e.g., durable medical equipment) are exhausted, adaptive aids covered in the Medically Dependent Children Program include:

  • van lifts;
  • vehicle modifications;
  • jump seats;
  • tumble form chairs;
  • feeder seats;
  • medically appropriate strollers;
  • barrier-free lifts;
  • stair lifts;
  • environmental control units;
  • alarm systems;
  • support rails;
  • electrical work related to use of authorized adaptive aids;
  • installation of authorized adaptive aids; and
  • repairs to adaptive aids.

The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

 

4820 Minor Home Modifications

Revision 17-1; Effective June 1, 2017

 

A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in his or her home. If a home modification is requested and the member or his legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.

 

4821 Service Limits on Minor Home Modifications

Revision 17-1; Effective June 1, 2017

 

The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.

The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.

Minor home modifications are limited to:

  • purchase and installation of permanent and portable ramps not covered by other sources;
  • widening of doorways;
  • modification of bathroom facilities; and
  • modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

  • adhere to Americans with Disabilities Act (ADA) requirements;
  • meet Texas Accessibility Standards;
  • meet all applicable state and/or local building codes; and
  • have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or his legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

 

4830 Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

The service coordinator must advise applicants or members who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or member needs assistance in setting up a household when relocating into the community from the NF. STAR Kids managed care organizations (MCOs) may not require TAS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for TAS. The applicant or member may access TAS if they:

  • plan to rent an apartment;
  • plan to rent a house;
  • have a home, but the utilities have been off while in the NF;
  • have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for applicants/members transitioning from NFs into MDCP and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant's or member's transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

  • security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
  • essential furnishings for the apartment or house;
  • moving expenses required to move into the house or apartment; and
  • site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, or legally authorized representative to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP waiver services, and notified in writing that he or she is eligible. The service coordinator must contact the applicant/member or applicant's/member's representative before certification to verify the applicant or member has made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.

 

4831 Deposits

Revision 17-1; Effective June 1, 2017

 

The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or member's name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the applicant's or member's service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant's or member's name or to pay for arrears on previous utilities if the account is in the applicant's or member's name and he or she will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the applicant's or member's transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the applicant's or member's place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or member identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the applicant or member not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.

 

4832 Moving Expenses

Revision 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant's or member's belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or member from the nursing facility to his or her residence in the community.

 

4833 Site Preparation

Revision 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for preparing the applicant's or member's place of residence for occupancy if the current condition of the residence prevents the applicant's or member's transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and is in need of some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the applicant or individual is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the applicant's or member's residence has been unattended or the applicant or member is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.

 

4834 Limits on Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per applicant or member. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. The service coordinator must be as specific as possible when describing the items purchased. A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to nursing facility placement may receive a one-time TAS authorization if the service coordinator determines that no other resources are available to pay for the basic services or items needed by the applicant or member. TAS may not be used for:

  • monthly rent or mortgage expenses;
  • current or future use of utilities;
  • service upgrades;
  • food items; or
  • any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to applicants or members who are discharged from a nursing facility and require TAS to set up a household.

 

4835 Transition Assistance Services Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member or his legally authorized representative, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member or member's authorized representative, if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.

 

4836 Three-Day Monitor Requirement

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.

 

4837 Failure to Leave the Facility

Revision 17-1; Effective June 1, 2017

 

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes his mind or has a change in health making it impossible for him to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.

  • If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
  • If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
  • If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.

If the member is only in the community for a few days and returns to the nursing facility, the member keeps the item(s) purchased through TAS.

 

4900 Supported Employment and Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Senate Bill 45, 83rd Legislature, Regular Session, 2013, required all Medicaid waivers offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program are EA and SE. STAR Kids managed care organizations may not require SE or EA providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for SE or EA services.

 

4910 Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) waiver services to help the individual locate paid employment in the community and includes:

  • identifying a member's employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with a member's identified preferences, skills and requirements; and
  • contacting a prospective employer on behalf of a member and negotiating the member's employment.

For any MDCP member, the service coordinator must ensure and document that employment services are not available to the member from the member's school district or other available community resource before authorizing waiver EA services.

The service coordinator refers the member to the Texas Workforce Commission (TWC) within 30 days of meeting with a member and identifying an interest in obtaining employment. The service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.

A member who has been referred for TWC or contacted TWC himself is not eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed it, or until the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive waiver-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.

If the member has exhausted TWC services or been determined ineligible for TWC services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). Employment assistance can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member's MDCP budget.

 

4911 Coordination with Texas Workforce Commission for Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Upon request and with proper authorization for disclosure, the service coordinator will assist the member to provide the Texas Workforce Commission (TWC) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

  • Photo identification;
  • An original Social Security card;
  • Member's home address and mailing address;
  • Names and addresses of any doctors the member has seen recently;
  • Names and addresses of any schools the member has attended;
  • Information about the member's medical insurance;
  • A list of places the member has worked, including type of job, dates, the reason for leaving and salary;
  • Proof of income for the member and his or her spouse, or parents (if the parents claim the member as a dependent on their income tax);
  • Proof of expenses related to monthly mortgage/rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
  • Names, addresses and phone numbers of two people who will always know how to contact the member;
  • Any reports of recent medical exams, school records or other information that may help the VRC understand the member's disability;
  • Member's most recent service plan;
  • Any current vocational assessments or person-directed plans that focus on employment opportunities;
  • Any other available records pertaining to the member's disabilities, including but not limited to medical, psychological and psychiatric reports;
  • A copy of the member's court-ordered guardianship documents, if any guardian has been appointed; and
  • Contact information for the member's service coordinator.

If the VRC determines that TWC is not the appropriate resource to meet the member's needs and does not take an application for services, documentation of this decision in the member's record serves as sufficient evidence that TWC is not available and the member is eligible to receive waiver-funded employment assistance.

TWC will:

  • Notify a member in writing if the member is determined to be eligible, ineligible or if TWC is unavailable;
  • Notify a member in writing when TWC is completed;
  • Develop with the eligible member an Individualized Plan for Employment (IPE) within 90 days of determination of eligibility for services;
  • After the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
  • Upon request and with proper authorization for disclosure, provide copies of any of the member's records to the service coordinator, including the following documents:
    • A completed copy of the member's application statement;
    • A member's completed IPE;
    • Written documentation specifying a member's eligibility status; and
    • The notification letter indicating TWC is completed.

If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member's service coordinator will attempt to contact the assigned TWC VRC to determine the status of the application and document the contact in the narrative notes.

The member's service coordinator will ensure that communication is maintained with the assigned TWC VRC regarding waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWC, as defined in the individual's TWC VR IPE.

At the request of a member determined eligible for TWC, the service coordinator, if possible, will assist the member and:

  • participate in TWC planning meetings related to the member's employment, or ensure other individuals important to the member attend, as appropriate;
  • take an active role in providing input to the TWC IPE, or ensure other individuals important to the member provide input, as appropriate; and
  • review the long term services and supports listed on the TWC IPE and if any of those services and supports are available through the waiver, incorporate them in a revision to the member's service plan prior to the end of TWC services.

The member's provider must begin providing or subcontracting for those services and supports approved in the member's service plan without a gap between the provision of TWC and waiver services.

 

4912 Employment Assistance Providers

Revision 17-1; Effective June 1, 2017

 

Employment assistance providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or his legally authorized representative (LAR) under the Consumer Directed Services (CDS) option. At a minimum, the employment assistance provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and satisfy one of these options:

Option 1:

  • A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
  • Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

  • An associate's degree in rehabilitation, business, marketing, or a related human services field; and
  • One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • A high school diploma or Certificate of High School Equivalency (GED credentials); and
  • Two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

 

4920 Supported Employment

Revision 17-1; Effective June 1, 2017

 

Supported employment (SE) services provide assistance to help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

SE services include:

  • assistance provided to a member to sustain competitive employment and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed;
  • employment adaptations, supervision and training related to a member's assessed need; and
  • ensuring members earn at least minimum wage, if not self-employed.

Competitive employment is work:

  • in the competitive labor market in which anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
  • for which a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community in which members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

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

An MDCP member may seek SE to provide assistance to the member in maintaining self-employment. Self-employment is work in which the member:

  • 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.

SE may only be authorized through the MDCP waiver if documentation is maintained in the member's record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.) or the Texas Workforce Commission.

 

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 17-1; Effective June 1, 2017

 

The service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third party resources before using Medically Dependent Children Program employment services, including school districts.

Activities include:

  • devoting time during a member's initial service planning meeting to discuss employment with the member and family and the process to obtain employment services and supports;
  • making a referral to TWC, assisting with completing the application form, and documenting the referral and outcome of the referral in the member's case record;
  • continuing to explore the possibility of employment at subsequent service planning meetings for a member who is not employed in the community;
  • affirming or explaining how a member can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
  • explaining rights to appeal if services are denied, reduced or terminated; and
  • monitoring whether the member and family are satisfied with the employment supports.

 

4922 Supported Employment Providers

Revision 17-1; Effective June 1, 2017

 

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency, also called a home health agency, or are employed by a member or his legally authorized representative under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting individual, and satisfy one of these options:

Option 1:

  • A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
  • Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

  • An associate's degree in rehabilitation, business, marketing, or a related human services field; and
  • One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • A high school diploma or Certificate of High School Equivalency (GED credentials), and
  • Two years of paid or unpaid experience providing services to people with disabilities.

Under CDS, the provider cannot be the member's legal guardian or the spouse of the legal guardian.