Revision 15-3; Effective December 11, 2015

 

 

4100 Reserved for Future Use

Revision 12-1; Effective February 10, 2012

 

 

4200 Professional Therapies

Revision 14-1; Effective April 10, 2014

 

 

 

4210 General Description of Service Component

Revision 14-1; Effective April 10, 2014

 

The professional therapies service component consists of the following subcomponents:

  • Audiology Services — The provision of audiology as defined in Texas Occupations Code, Chapter 401.
  • Behavioral Support Services — Specialized interventions that assist an individual in increasing adaptive behaviors and replacing or modifying maladaptive or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in the community.
  • Dietary Services — The provision of nutrition services as defined in Texas Occupations Code, Chapter 701.
  • Occupational Therapy Services — The practice of occupational therapy as described in Texas Occupations Code, Chapter 454.
  • Physical Therapy Services — The provision of physical therapy as defined in Texas Occupations Code, Chapter 453.
  • Speech and Language Pathology Services — The provision of speech-language pathology as defined in Texas Occupations Code, Chapter 401.

 

4220 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the professional therapies service component are:

  • interacting face-to-face or by video conference or speaking by telephone with an individual, based on the professional therapies subcomponent provided, to conduct assessments or provide services within the scope of the service provider's practice;
  • interacting face-to-face or by video conference or speaking by telephone with a person regarding a professional therapies subcomponent provided to an individual, but not with:
    • a staff person who is not a service provider; or
    • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies;
  • writing an individualized treatment plan for an individual's professional therapies that, for behavioral support services, is a behavior support plan;
  • reviewing documents, except for a written narrative or written summary of a service component as described in Section 3820, Written Service Log and Written Summary Log, to evaluate the quality and effectiveness of an individual's professional therapies;
  • training the following persons on how to provide professional therapies treatment, including how to document the provision of treatment:
    • a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), transportation as a community support activity, day habilitation, respite, supported employment or employment assistance; or
    • a person other than a service provider who is involved in serving an individual;
  • reviewing documents in preparation for the training described in the bullet above;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan;
  • participating in the development of an IPC; and
  • for behavioral support services, in addition to the activities listed above:
    • assessing the targeted behavior so that a behavior support plan may be developed;
    • training and consulting an individual, family member or other persons involved in the individual's care regarding the implementation of the behavior support plan;
    • monitoring and evaluating the effectiveness of the behavior support plan;
    • modifying, as necessary, the behavior support plan based on the monitoring and evaluation of the plan's effectiveness; and
    • educating an individual, family members or other persons involved in the individual's care about the techniques to use in assisting the individual to control maladaptive or socially unacceptable behaviors exhibited by the individual.

 

4230 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the professional therapies service component.
  2. Activities Not Listed in Section 4220
    Any activity not described in Section 4220, Billable Activity, is not billable for the professional therapies service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the professional therapies service component:
    • providing services outside the scope of the service provider's practice;
    • providing services that are performed by a service coordinator or were performed by a former case manager;
    • scheduling an appointment;
    • transporting an individual;
    • traveling or waiting to provide a professional therapies subcomponent;
    • training or interacting about general topics unrelated to a specific individual, such as principles of behavior management, or general use and maintenance of an adaptive aid or equipment;
    • creating written documentation as described in Section 4260, Written Documentation;
    • reviewing a written narrative or written summary of a service component as described in Section 3820, Written Service Log and Written Summary Log; and
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan.

 

4240 Qualified Service Provider

Revision 14-2; Effective September 1, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the professional therapies subcomponents must be as follows:

  • for audiology services, an audiologist licensed in accordance with Chapter 401 of the Texas Occupations Code;
  • for behavioral support services:
    • a psychologist licensed in accordance with Chapter 501 of the Texas Occupations Code;
    • a provisional license holder licensed in accordance with Chapter 501 of the Texas Occupations Code;
    • a psychological associate licensed in accordance with Chapter 501 of the Texas Occupations Code;
    • a licensed clinical social worker in accordance with Chapter 505 of the Texas Occupations Code;
    • a licensed professional counselor in accordance with Chapter 503 of the Texas Occupations Code;
    • a person certified by DADS as described in 40 TAC §9.579; or
    • a behavior analyst certified by the Behavior Analyst Certification Board, Inc.;
  • for dietary services, a licensed dietitian licensed in accordance with Chapter 701 of the Texas Occupations Code;
  • for occupational therapy services, an occupational therapist or occupational therapy assistant licensed in accordance with Chapter 454 of the Texas Occupations Code;
  • for physical therapy services, a physical therapist or physical therapist assistant licensed in accordance with Chapter 453 of the Texas Occupations Code;
  • for social work services, a social worker licensed in accordance with Chapter 505 of the Texas Occupations Code; and
  • for speech and language pathology services, a speech-language pathologist or licensed assistant in speech-language pathology licensed in accordance with Chapter 401 of the Texas Occupations Code.

 

4250 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the professional therapies service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for professional therapies may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4260 Written Documentation

Revision 14-1; Effective April 10, 2014

 

Except as provided in Section 4270, Insurance Co-payment and Deductible (see No. 1, Item c and No. 2, Item c), a program provider must have written documentation to support a service claim for professional therapies that:

  • meets the requirements set forth in Section 3800, Written Documentation;
  • includes the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and
  • for any activity performed by multiple service providers at the same time for the same individual, includes a written justification in the individual's implementation plan for the use of multiple service providers.

 

4270 Insurance Co-payment and Deductible

Revision 14-1; Effective April 10, 2014

 

  1. Co-payment
    1. Number of Units on Service Claim
      If a program provider is aware that an individual is covered by an insurance policy that requires a co-payment for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the co-payment and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the lesser of the maximum number of units of service for which payment by the TxHmL Program will not exceed the amount of the co-payment paid by the policyholder.

      Example:
      An individual receives four units of service (one hour) of physical therapy and the insurance policy covering the individual requires a $20 co-payment, for which the policyholder requests to be reimbursed. If the TxHmL Program pays $19.35 per unit of service of physical therapy, the program provider must submit a service claim for one unit of service of physical therapy (the maximum number of units of service for which payment will not exceed the amount of the co-payment).
    2. Program Provider Must Pay Policyholder Amount of Service Claim
      A program provider that submits a service claim to obtain reimbursement for a co-payment must pay the policyholder the amount the program provider receives as payment for the service claim.

      Example:
      Using the facts given in the example above, the program provider must pay the policyholder $19.35.
    3. Written Documentation
      A program provider must have written documentation to support a service claim submitted to obtain reimbursement for a co-payment made for a professional therapies subcomponent. The written documentation must include:
      • a copy of the insurance policy specifying the amount that must be paid by the policyholder as a co-payment;
      • a receipt that verifies payment of the co-payment by the policyholder;
      • an explanation of benefits (EOB) regarding the professional therapies subcomponent provided to the individual from the insurance company that issued the policy, showing that co-payments were required of the policyholder; and
      • proof that the policyholder was paid the service claim amount by the program provider.
  2. Deductible
    1. Number of Units on Service Claim
      If a program provider is aware that an individual is covered by an insurance policy that requires a deductible for a professional therapies subcomponent, and the policyholder requests to be reimbursed for the deductible and provides the documentation described in the first, second and third bullets of Item c below to the program provider, the program provider must submit a service claim for the professional therapies subcomponent for the maximum number of units of service for which payment by the TxHmL Program will not exceed the amount of the deductible paid by the policyholder for the professional therapies subcomponent.

      Example:
      An individual receives four units of service (one hour) of physical therapy services. The policyholder pays $100 for the services, which is applied toward a deductible, and requests to be reimbursed. If the TxHmL Program pays $19.35 per unit of service of physical therapy, the program provider must submit a service claim for the number of units of service the individual received, or four units of service of physical therapy.
    2. Program Provider Must Pay Policyholder Amount of Service Claim
      A program provider that submits a service claim to obtain reimbursement for payment made toward a deductible for a professional therapies subcomponent must pay the policyholder the amount the program provider receives as payment for the service claim.

      Example:
      Using the facts given in the example above, the program provider must pay the policyholder $77.43 ($19.35 x 4 units of service).
    3. Written Documentation
      A program provider must have written documentation to support a service claim to obtain reimbursement for a payment made toward a deductible for a professional therapies subcomponent. The written documentation must include:
      • a copy of the insurance policy specifying the amount that must be paid by the policyholder as a deductible;
      • an EOB regarding the professional therapies subcomponent provided to the individual from the insurance company that issued the policy, showing payments toward the deductible were required of the policyholder; and
      • proof of payment that verifies the policyholder was paid the service claim amount by the program provider.

 

4300 Day Habilitation

Revision 12-1; Effective February 10, 2012

 

 

4310 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The day habilitation service component is the provision of assistance to an individual that is necessary for the individual to acquire skills to reside, integrate and participate successfully in the community.

 

4320 Requirements of Setting

Revision 12-1; Effective February 10, 2012

 

Day habilitation may be provided to an individual only in a setting that is not the residence of the individual, unless the provision of day habilitation in a residence is justified because of the individual's medical condition or behavioral issues or because the individual is of retirement age, and such justification is documented in the individual's record.

 

4330 Billable Activity

Revision 14-2; Effective September 1, 2014

 

The only billable activities for the day habilitation service component are:

  • interacting face-to-face with an individual to assist the individual in achieving objectives to:
    • acquire, retain or improve self-help skills, socialization skills or adaptive skills that are necessary for the individual to successfully reside, integrate and participate in the community; and
    • reinforce a skill taught in school or professional therapies;
  • transporting an individual between settings at which day habilitation is provided to the individual;
  • assisting an individual with his or her personal care activities if the individual cannot perform such activities without assistance;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan; and
  • participating in the development of an IPC.

 

4340 Activity Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the day habilitation service component.
  2. Activities Not Listed in Section 4330
    Any activity not described in Section 4330, Billable Activity, is not billable for the day habilitation service component.
  3. Meeting Vocational Production Goal Not Billable Activity
    Assisting an individual for the sole purpose of meeting a vocational production goal is an example of an activity that is not billable for the day habilitation service component.

 

4350 Restrictions Regarding Submission of Claims for Day Habilitation

Revision 14-2; Effective September 1, 2014

 

A program provider may not submit a service claim for:

  • day habilitation for a day that the individual refuses to participate in day habilitation activities, unless the individual has refused to participate for 45 calendar days or less since the beginning of the preceding three-month period or since the implementation plan was amended to address the individual's refusal (whichever is later) and:
    • the service provider of day habilitation has made repeated attempts to engage the individual in the activity throughout the day; and
    • those attempts have been documented;
  • day habilitation provided to assist an individual in achieving objectives not documented in the individual's implementation plan;
  • day habilitation provided to an individual in excess of five units of service per calendar week;
  • day habilitation provided to an individual that is funded by a source other than the TxHmL Program (for example, the Department of Assistive and Rehabilitative Services);
  • day habilitation that is being provided by one service provider who is also the same service provider of a different service component or subcomponent to the same individual, at the same time, as referenced in Section 3710, One Service Provider; or
  • day habilitation in the individual’s residence without prior justification in the Person-DirectedPlan (PDP) and Implementation Plan (IP) and prior authorization by the Individual Plan of Care (IPC), as referenced in Section 4320, Requirements of Setting, and Section 3210, General Requirements, Bullets 1 and 2.

 

4360 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the day habilitation service component must have one of the following:

  • a high school diploma;
  • a high school equivalency certificate issued in accordance with the law of the issuing state; or
  • both of the following:
    • a successfully completed written competency-based assessment demonstrating the ability to provide day habilitation and the ability to document the provision of day habilitation in accordance with Section 3800, Written Documentation, and Section 4380, Written Documentation; and
    • written personal references which evidence the service provider's ability to provide a safe and healthy environment for the individual from at least three persons who are not relatives of the service provider (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these billing guidelines).

 

4370 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. One Day
    A unit of service for the day habilitation service component is one day.
  2. Service Claim for Unit of Service
    1. One-quarter Unit of Service
      A program provider may submit a service claim for day habilitation for one-quarter (0.25) unit of service if the program provider provides at least one and one-quarter hours of consecutive day habilitation on a calendar day.
    2. One-half Unit of Service
      A program provider may submit a service claim for day habilitation for one-half (0.5) unit of service if the program provider provides at least two and one-half hours of day habilitation on a calendar day. Two of the two and one-half hours must be consecutive.
    3. Three-quarters Unit of Service
      A program provider may submit a service claim for day habilitation for three-quarters (.75) unit of service if the program provider provides at least three and three-quarter hours of day habilitation on a calendar day. Two of the three and three-quarter hours must be consecutive.
    4. One Unit of Service
      A program provider may submit a service claim for day habilitation for one unit of service if the program provider provides at least five hours of day habilitation on a calendar day. Two of the five hours must be consecutive.

 

4380 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for day habilitation that:

  • meets the requirements set forth in Section 3800, Written Documentation;
  • includes a description of the location of the day habilitation site;
  • includes, for each calendar day, the exact time the day habilitation began and the exact time it ended documented by a staff person who is present at the day habilitation site during those times;
  • includes:
    • a written service log, as described in Section 3820, Written Service Log and Written Summary Log, of the calendar day for which the service claim is submitted; or
    • a written summary log as described in Section 3820; and
  • includes a description in the individual's implementation plan of objectives the program provider is assisting the individual to achieve, as described in the first bullet of Section 4330, Billable Activity.

 

4400 Registered Nursing

Revision 12-1; Effective February 10, 2012

 

4410 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301, provided to an individual with a medical need.

 

4420 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the registered nursing service component are:

  • interacting face-to-face with an individual who has a medical need for registered nursing, including:
    • preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;
    • assisting or observing administration of medication; and
    • assessing the individual's health status, including conducting a nursing assessment or an RN nursing assessment;
  • speaking by telephone with an individual who has a medical need for registered nursing, including assessing the individual's health status;
  • interacting by video conference with an individual who has a medical need for registered nursing, including:
    • observing administration of medication; and
    • assessing the individual's health status, including conducting a nursing assessment or an RN nursing assessment;
  • at the time an individual receives medication from a pharmacy, ensuring the accuracy of:
    • the type and amount of medication;
    • the dosage instructions; and
    • checking medications at the time they are received from the pharmacy for matching labels with the doctor’s order and medication administration record sheet (MARS) for correct type and amount of medication, or additional times when there are documented medication errors or labs that show the individual’s therapeutic levels are abnormal;
  • researching medical information for an individual who has a medical need for registered nursing, including:
    • reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and
    • completing an RN nursing assessment;
  • training the following persons how to perform nursing tasks:
    • a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), transportation as a community support activity, day habilitation, respite, supported employment or employment assistance; or
    • a person other than a service provider who is involved in serving an individual; and
    • reviewing documents in preparation for the training described in the bullet above;
  • interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with:
    • a staff person who is not a service provider; or
    • a service provider of:
      • registered nursing;
      • licensed vocational nursing unless supervised by the registered nurse;
      • specialized registered nursing;
      • specialized licensed vocational nursing unless supervised by the registered nurse; or
      • professional therapies;
  • interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity;
  • instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic that is specific to an individual such as choking risks for an individual who has cerebral palsy;
  • supervising a licensed vocational nurse regarding an individual's nursing services or health status;
  • instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC, 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) or the Human Resources Code, §§161.091-.093, as applicable;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan;
  • participating in the development of an IPC; and
  • developing one annual nursing report.

 

4430 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the registered nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the registered nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the registered nursing service component, regardless of whether they constitute the practice of registered nursing:
    • performing or supervising an activity that does not constitute the practice of registered nursing, including:
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4420;
    • creating written documentation as described in Section 4470, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing unless supervising the licensed vocational nurse, specialized registered nursing or specialized licensed vocational nursing unless supervising the licensed vocational nurse) or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4440 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the registered nursing service component must be a registered nurse.

 

4450 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the registered nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for registered nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4460 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for registered nursing provided to one individual on a single calendar month. The service times of more than one registered nurse may be accumulated on the last day of the month. The service time of more than one registered nurse may be accumulated on the last day of the month.

Example:

A registered nurse provides registered nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 25, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for registered nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for registered nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of registered nursing to an individual. During the same month, Nurse B provides 7 minutes of licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4470 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4471 Licensed Vocational Nursing

Revision 12-1; Effective February 10, 2012

 

 

4471.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The licensed vocational nursing service component is the provision of licensed vocational nursing to an individual, as defined in Texas Occupations Code, Chapter 301.

 

4471.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the licensed vocational nursing service component are:

  • interacting face-to-face with an individual who has a medical need for licensed vocational nursing, including:
    • preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;
    • assisting or observing administration of medication; and
    • conducting a focused assessment of the individual's health status;
  • speaking by telephone with an individual who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if:
    • the assessment is conducted using protocol approved by DADS; and
    • the licensed vocational nurse has been trained by a registered nurse on using the protocol;
  • interacting by video conference with an individual who has a medical need for licensed vocational nursing, including:
    • observing administration of medication; and
    • conducting a focused assessment of the individual's health status;
  • at the time an individual receives medication from a pharmacy, ensuring the accuracy of:
    • the type and amount of medication;
    • the dosage instructions; and
    • checking medications at the time they are received from the pharmacy for matching labels with the doctor’s order and medication administration record sheet (MARS) for correct type and amount of medication, or additional times when there are documented medication errors or labs that show the individual’s therapeutic levels are abnormal;
  • researching medical information for an individual who has a medical need for licensed vocational nursing, including:
    • reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and
    • completing a focused assessment;
  • training a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), transportation as a community support activity, day habilitation, respite, supported employment, or employment assistance, or a person other than a service provider who is involved in serving an individual, regarding how to perform nursing tasks;
  • reviewing documents in preparation for the training described in the bullet above;
  • interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual, but not with:
    • a staff person who is not a service provider; or
    • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies;
  • interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;
  • instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan;
  • participating in the development of an IPC; and
  • developing one annual nursing report.

 

4471.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the licensed vocational nursing service component.
  2. Activities Not Listed in Section 4471.2
    Any activity not described in Section 4471.2, Billable Activity, is not billable for the licensed vocational nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:
  • performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:
    • performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse;
    • transporting an individual;
    • waiting to perform a billable activity; and
    • waiting with an individual at a medical appointment;
  • making a medical appointment;
  • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
  • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
  • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4471.2;
  • creating written documentation as described in Section 4471.7, Written Documentation;
  • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
  • interacting with:
    • a staff person who is not a service provider; or
    • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
  • performing an activity for which there is no medical need.

 

4471.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the licensed vocational nursing service component must be a licensed vocational nurse.

 

4471.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the licensed vocational nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for licensed vocational nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4471.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one licensed vocational nurse may be accumulated on the last day of the month.

Example:

A nurse provides licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for licensed vocational nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month July 31, 2012, three units of service for licensed vocational nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of licensed vocational nursing to an individual. During the same month, Nurse B provides 7 minutes of registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4471.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4472 Specialized Registered Nursing

Revision 12-1; Effective February 10, 2012

 

 

4472.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The specialized registered nursing service component is the provision of professional nursing, as defined in Texas Occupations Code, Chapter 301, to an individual who has a tracheostomy or is dependent on a ventilator.

 

4472.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the specialized registered nursing service component are:

  • interacting face-to-face with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for registered nursing, including:
    • preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;
    • assisting or observing administration of medication; and
    • assessing the individual's health status, including conducting a nursing assessment or an RN nursing assessment;
  • speaking by telephone with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for registered nursing, including assessing the individual's health status;
  • interacting by video conference with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for registered nursing, including:
    • observing self-administration of medication; and
    • assessing the individual's health status, including conducting a nursing assessment or a comprehensive assessment;
  • at the time an individual receives medication from a pharmacy, ensuring the accuracy of:
    • the type and amount of medication;
    • the dosage instructions; and
    • checking medications at the time they are received from the pharmacy for matching labels with the doctor’s order and medication administration record sheet (MARS) for correct type and amount of medication, or additional times when there are documented medication errors or labs that show the individual’s therapeutic levels are abnormal;
  • researching medical information for an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for registered nursing, including:
    • reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and
    • completing an RN nursing assessment;
  • training the following persons on how to perform nursing tasks for an individual who has a tracheostomy or is dependent on a ventilator:
    • a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), transportation as a community support activity, day habilitation, respite, supported employment or employment assistance; or
    • a person other than a service provider who is involved in serving the individual;
  • reviewing documents in preparation for the training described in the bullet above;
  • interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual who has a tracheostomy or is dependent on a ventilator, but not with:
    • a staff person who is not a service provider; or
    • a service provider of:
      • registered nursing;
      • licensed vocational nursing unless supervised by the registered nurse;
      • specialized registered nursing;
      • specialized licensed vocational nursing unless supervised by the registered nurse; or
      • professional therapies;
  • interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the registered nurse justifies, in writing, the need for the registered nurse to perform the activity;
  • instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;
  • supervising a licensed vocational nurse regarding an individual's nursing services or health status;
  • instructing, supervising or verifying the competency of an unlicensed person in the performance of a task delegated in accordance with rules of the Texas Board of Nursing at 22 TAC 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) or the Human Resources Code, §§161.091-.093, as applicable;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan;
  • participating in the development of an IPC; and
  • developing one annual nursing report.

 

4472.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized professional nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized registered nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the specialized registered nursing service component, regardless of whether they constitute the practice of registered nursing:
    • performing or supervising an activity that does not constitute the practice of registered nursing, including:
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4472.2, Billable Activity;
    • creating written documentation as described in Section 4472.7, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing unless supervising the licensed vocational nurse, specialized registered nursing, or specialized licensed vocational nursing unless supervising the licensed vocational nurse), or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4472.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized registered nursing service component must be a registered nurse.

 

4472.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the specialized registered nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for specialized registered nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4472.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized registered nursing provided to one individual during a single calendar month. The service times of more than one specialized registered nurse may be accumulated on the last day of the month.

Example:

A nurse provides specialized registered nursing services to one individual three times in a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for specialized registered nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized registered nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized registered nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of specialized registered nursing to an individual. On the same calendar day, Nurse B provides 7 minutes of specialized licensed vocational nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4472.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for specialized registered nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4473 Specialized Licensed Vocational Nursing

Revision 12-1; Effective February 10, 2012

 

 

4473.1 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

The specialized licensed vocational nursing service component is the provision of licensed vocational nursing, as defined in Texas Occupations Code, Chapter 301, to an individual who has a tracheostomy or is dependent on a ventilator.

 

4473.2 Billable Activity

Revision 15-2; Effective October 30, 2015

 

The only billable activities for the specialized licensed vocational nursing service component are:

  • interacting face-to-face with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for licensed vocational nursing, including:
    • preparing and administering medication or treatment ordered by a physician, podiatrist or dentist;
    • assisting or observing administration of medication; and
    • conducting a focused assessment of the individual's health status;
  • speaking by telephone with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for licensed vocational nursing, which may include conducting an assessment of an individual if:
    • the assessment is conducted using protocol approved by DADS; and
    • the licensed vocational nurse has been trained by a registered nurse on using the protocol;
  • interacting by video conference with an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for licensed vocational nursing, including:
    • observing administration of medication; and
    • conducting a focused assessment of the individual's health status;
  • at the time an individual receives medication from a pharmacy, ensuring the accuracy of:
    • the type and amount of medication;
    • the dosage instructions; and
    • checking medications at the time they are received from the pharmacy for matching labels with the doctor’s order and medication administration record sheet (MARS) for correct type and amount of medication, or additional times when there are documented medication errors or labs that show the individual’s therapeutic levels are abnormal;
  • researching medical information for an individual who has a tracheostomy or is dependent on a ventilator and who has a medical need for licensed vocational nursing, including:
    • reviewing documents, except for a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log, to evaluate the quality and effectiveness of the medical treatment the individual is receiving; and
    • completing a focused assessment;
  • training a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), transportation as a community support activity, day habilitation, respite, employment assistance or supported employment, or a person other than a service provider who is involved in serving an individual on how to perform nursing tasks for an individual who has a tracheostomy or is dependent on a ventilator;
  • reviewing documents in preparation for the training described in the bullet above;
  • interacting face-to-face or by video conference or speaking by telephone with a person regarding the health status of an individual who has a tracheostomy or is dependent on a ventilator, but not with:
    • a staff person who is not a service provider; or
    • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing) or professional therapies;
  • interacting face-to-face or speaking by telephone with a pharmacist or representative of a health insurance provider, including the Social Security Administration, about an individual's insurance benefits for medication if the licensed vocational nurse justifies, in writing, the need for the licensed vocational nurse to perform the activity;
  • instructing a service provider, except a service provider of registered nursing or specialized registered nursing, on a topic specific to an individual such as choking risks for an individual who has cerebral palsy;
  • participating in a service planning team meeting;
  • participating in the development of an implementation plan;
  • participating in the development of an IPC; and
  • developing one annual nursing report.

 

4473.3 Activity Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the specialized licensed vocational nursing service component.
  2. Activities Not Listed in Section 4420
    Any activity not described in Section 4420, Billable Activity, is not billable for the specialized licensed vocational nursing service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the specialized licensed vocational nursing service component, regardless of whether they constitute the practice of licensed vocational nursing:
    • performing or supervising an activity that does not constitute the practice of licensed vocational nursing, including:
      • performing an activity that constitutes the practice of professional nursing and must be performed by a registered nurse;
      • transporting an individual;
      • waiting to perform a billable activity; and
      • waiting with an individual at a medical appointment;
    • making a medical appointment;
    • instructing on general topics unrelated to a specific individual, such as cardiopulmonary resuscitation or infection control;
    • preparing a treatment or medication for administration and not interacting face-to-face with an individual;
    • storing, counting, reordering, refilling or delivering medication except as allowed in the fourth bullet of Section 4473.2, Billable Activity;
    • creating written documentation as described in Section 4473.7, Written Documentation;
    • reviewing a written service log or written summary log of a service component as described in Section 3820, Written Service Log and Written Summary Log;
    • interacting with:
      • a staff person who is not a service provider; or
      • a service provider of any nursing service component (registered nursing, licensed vocational nursing, specialized registered nursing or specialized licensed vocational nursing), or professional therapies, if not during a service planning team meeting or during the development of an IPC or an implementation plan; and
    • performing an activity for which there is no medical need.

 

4473.4 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the specialized licensed vocational nursing service component must be a licensed vocational nurse.

 

4473.5 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the specialized licensed vocational nursing service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for specialized licensed vocational nursing may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4473.6 Accumulation of Service Times

Revision 12-3; Effective October 1, 2012

 

A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for specialized licensed vocational nursing provided to one individual during a single calendar month. The service times of more than one specialized licensed vocational nurse may be accumulated.

Example:

A nurse provides specialized licensed vocational nursing services to one individual three times during a single calendar month: July 1, 2012, 8:30-8:55 a.m. (25 minutes); July 6, 2012, 4:15-4:20 p.m. (5 minutes); and July 28, 2012, 8:00-8:05 p.m. (5 minutes).

Without accumulating service times, two units of service for specialized licensed vocational nursing are billable for the service time of 25 minutes. The service times of five minutes are not billable because they are less than eight minutes each.

If all three service times are accumulated into one service time of 35 minutes (25 + 5 + 5), two units of service for specialized licensed vocational nursing are billable.

If the first service time of 25 minutes is billed as two units of service on the day it was provided, and the second and third service times are accumulated into one service time of 10 minutes (5 + 5), which is billable as one unit of service on the last day of the month, July 31, 2012, three units of service for specialized licensed vocational nursing are billable (2 + 1).

Example:

Nurse A provides 7 minutes of specialized licensed vocational nursing to an individual. During the same month, Nurse B provides 7 minutes of registered nursing to the same individual. You could not accumulate the time and neither service would meet the minimum requirements for billing a unit of their respective nursing component.

 

4473.7 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for specialized licensed vocational nursing. The written documentation must meet the requirements set forth in Section 3800, Written Documentation.

 

4500 Community Support (Transportation)

Revision 15-2; Effective October 30, 2015

 

4510 General Description of Service Component

Revision 15-2; Effective October 30, 2015

 

The community support service component is transportation provided to an individual.

 

4520 Community Support Billing Requirements

Revision 15-2; Effective October 30, 2015

 

  1. Billable Activity
    The only billable activity for the community support subcomponent is transporting the individual, except from one day habilitation, employment assistance or supported employment site to another.
  2. Activity Not Billable
    1. Activities in Section 3300
      The activities listed in Section 3300, Activity Not Billable, are not billable for transportation as a community support activity.
    2. Activities Not Listed in No. 1 Above
      Any activity not described in No. 1 above is not billable for transportation as a community support activity.
  3. Restrictions Regarding Submission of Claims for Transportation as a Community Support Activity
    A program provider may not submit a service claim for transporting an individual from one habilitation or supported employment site to another.
  4. Qualified Service Provider
    In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of transportation as a community support activity:
    • may not have the same residence as the individual; and
    • must have one of the following:
      • a high school diploma;
      • a high school equivalency certificate issued in accordance with the law of the issuing state; or
      • both of the following:
        • a successfully completed written competency-based assessment demonstrating the ability to provide transportation as a community support activity and the ability to document the provision of transportation as a community support activity in accordance with Section 3800, Written Documentation, and No. 8 below; and
        • written personal references which evidence the service provider's ability to provide a safe and healthy environment for the individual from at least three persons who are not relatives of the service provider (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these billing guidelines).
  5. Unit of Service
    1. 15 Minutes
      A unit of service for transportation as a community support activity is 15 minutes.
    2. Fraction of a Unit of Service
      A service claim for transportation as a community support activity may not include a fraction of a unit of service.
    3. Service Time
      Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.
  6. Written Documentation

    Transportation as a Community Support Activity Specific Information
    A program provider must have written documentation to support a service claim for transportation as a community support activity. The written documentation must include:
    • the name of the individual who was being transported;
    • the day, month and year the transportation was provided;
    • the place of departure and destination for the individual being transported;
    • a notation of whether the program provider is using Method A or Method B to calculate transportation time, as required by (7)(b)(II);
    • a begin and end time for each transportation time, as described in (7)(b);
    • the total minutes of each transportation time;
    • for each "trip" if using Method A (see (7)(a)(III) and (IV)) or, for each "segment" if using Method B (see (7)(a)(V)):
      • the number of passengers;
      • the number of service providers;
      • the resulting service time; and
      • the signature of the service provider transporting the individual;
    • the unit of service for a service claim resulting from each service time; and
    • any service times accumulated to make a unit of service for a service claim.

    Example Form
    Form 2124, Community Support Transportation Log, may be used to document transportation as a community support activity. This log is only an example, however. A program provider may document such activity in any way that meets requirements.

  7. Determining Unit of Service for Transportation as a Community Support Activity

    General Process
    The unit of service for a service claim for transportation as a community support activity is determined by:
    • calculating transportation time, number of passengers and number of service providers using Method A or Method B, as described in Item b. below;
    • determining service time using the formula set forth in Item c below; and
    • converting service time to units of service for a service claim using Appendix III, Conversion Table, as described in Item d. below.
    1. Calculating Transportation Time, Passengers, Service Providers
      1. How to Calculate
        Transportation time, number of passengers and number of service providers must be calculated using Method A or Method B as described below.
      2. Use of Only One Method on a Single Calendar Day
        A program provider may not use Method A and Method B on the same calendar day.
      3. Definitions Applicable for Method A and Method B
        The following definitions apply to Method A and Method B:
        • A "passenger" is a person who receives a service funded by DADS, including a person enrolled in the intermediate care facilities for persons with intellectual disability (ICF/ID) program or a waiver program other than HCS.
        • A "trip" is a discrete period of continuous time during which one or more individuals are being transported in the same vehicle.
      4. Method A
        Using Method A, the transportation time, number of passengers and number of service providers are the same for all individuals transported in a single trip:
        • Transportation time begins when the first individual gets on the vehicle and ends when the last individual gets off the vehicle.
        • The number of passengers is the total number of passengers transported during the trip.
        • The number of service providers is the total number of service providers who provide services during the trip, including the driver of the vehicle.
      5. Method B
        Using Method B, the transportation time, number of passengers and number of service providers are determined separately for each individual transported in a single trip in segments that begin and end when the number of passengers or the number of service providers changes during the trip.
    2. Determining Service Time
      1. How to Determine
        Service time must be determined using the transportation time, number of passengers and number of service providers for an entire trip (if using Method A) or for each segment of a trip (if using Method B).
      2. Formula
        The formula for calculating the service time is:
        Service Time = [# of Service Providers x Transportation Time] ÷ # of Passengers
    3. Converting Service Time to Units of Service
      Service time must be converted to units of service for a service claim as set forth in Appendix III.
    4. Examples of Determining Unit of Service for Transportation as a Community Support Activity
      See Appendix II, Determining Units of Service for the Community Support Activity of Transporting an Individual, for examples of determining the units of service for a service claim for transportation as a community support activity.
    5. Accumulation of Service Times
      1. For Single Calendar Day
        A program provider may accumulate service times, as described in Section 3610, 15-Minute Unit of Service (see No. 2), for transporting one individual on a single calendar day. The service times of more than one service provider may be accumulated.
      2. Example of Accumulating Service Time
        See Appendix II for an example of accumulating service time for transportation as a community support activity.

 

4600 Respite

Revision 12-1; Effective February 10, 2012

 

 

4610 General Description of Service Component

Revision 15-2; Effective October 30, 2015

 

  1. Temporary Provision of Assistance
    The respite service component:
    • is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills; and
    • provides relief for a caregiver of the individual who:
        • is the temporary provision of assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills;
        • provides relief for a caregiver of the individual who:
          • has the same residence as the individual;
          • routinely provides assistance and support necessary for an individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills;
          • is temporarily unavailable to provide such assistance and support; and
          • is not a service provider of Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) unless:
            • the service provider of CFC PAS/HAB routinely provides unpaid assistance and support to the individual; and
            • is used to provide temporary support to the primary caregiver.
  2. Room and Board
    If respite is provided in a setting other than the individual's residence, the program provider must provide room and board to the individual free of charge.

 

4620 Billable Activity

Revision 14-2; Effective September 1, 2014

 

The only billable activities for the respite service component are:

  • interacting face-to-face with an individual to:
    • assist the individual with activities of daily living, including:
      • bathing, dressing and personal hygiene;
      • eating;
      • meal planning and preparation; and
      • housekeeping;
    • assist the individual with ambulation and mobility;
    • reinforce any professional therapies subcomponent provided to the individual;
    • assist with the administration of the individual's medication or to perform a task delegated by a registered nurse in accordance with rules of the Texas Board of Nursing at 22 TAC, 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) or the Human Resources Code, §161.091-.093, as applicable;
    • conduct habilitation activities that teach the individual to:
      • develop or improve skills that allow the individual to live more independently;
      • develop socially valued behaviors;
      • integrate into community activities;
      • use natural supports and typical community services available to the public; and
      • participate in leisure activities;
    • secure transportation for the individual;
    • supervise the individual's safety and security; and
    • transport the individual, except from one day habilitation site to another;
  • interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and
  • performing one of the following activities that does not involve interacting face-to-face with an individual:
    • shopping for the individual;
    • planning or preparing meals for the individual;
    • housekeeping for the individual;
    • procuring or preparing the individual's medication;
    • securing transportation for the individual; and
    • any billable activity referenced in this section that occurs at a camp that is accredited by the American Camp Association.

 

4630 Respite in Residence or During Overnight Stay in Non-residence

Revision 12-1; Effective February 10, 2012

 

  1. Residence
    If an individual receives respite in a residence, the residence must be:
    • the individual's residence;
    • a three-person residence;
    • a four-person residence; or
    • the residence of another person (other than a three-person residence or a four-person residence) in which no more than three persons are receiving TxHmL or HCS Program services or a non-TxHmL/HCS program service similar to TxHmL or HCS Program services.
  2. Non-residence
    If an individual is receiving respite during an overnight stay in a setting that is not the residence of any person, no more than six persons receiving TxHmL or HCS Program services or a non-TxHmL/HCS Program service similar to TxHmL or HCS Program services may be in the setting.

 

4631 Residential Location

Revision 12-1; Effective February 10, 2012

 

A program provider may provide respite to an individual only if the program provider has documented a residential location of "own/family home" on the individual's IPC.

 

4640 Activity Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the respite service component.
  2. Activities Not Listed in Section 4620
    Any activity not described in Section 4620, Billable Activity, is not billable for the respite service component.

 

4650 Submitting a Service Claim for Respite

Revision 12-1; Effective February 10, 2012

 

  1. Respite Provided in an Individual's Residence
    If a program provider provides respite in an individual's residence, the program provider may submit a service claim for no more than 96 units of service (24 hours) in one calendar day.
  2. Respite Provided in Location Other Than the Individual's Residence
    If a program provider provides 10 hours or more of respite to an individual in one calendar day in a location other than the individual's residence, the program provider may submit a service claim for no more than 40 units of service.

 

4651 Restrictions Regarding Submission of Claims for Respite

Revision 15-2; Effective October 30, 2015

 

A program provider may not submit a service claim for:

  • respite provided to an individual whose IPC does not have a residential location of "own/family home;"
  • respite provided to an individual who does not have the same residence as a caregiver who routinely provides assistance and support necessary for the individual to perform personal care, health maintenance and independent living tasks; participate in community activities; and develop, retain and improve community living skills;
  • respite provided to an individual that is not for relief of a caregiver who routinely provides assistance and support described in the bullet directly above;
  • respite provided to an individual that is relief of a caregiver who is a service provider of foster/companion care, residential support or supervised living to the individual;
  • respite provided to an individual who lives independently (that is, does not have a caregiver who routinely provides the assistance and support described in the second bullet above); or
  • more than 40 units of respite if more than 10 hours of respite are provided to an individual in one calendar day in a location other than the individual's residence.

 

4660 Qualified Service Provider

Revision 12-1; Effective February 10, 2012

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the respite service component:

  • may not have the same residence as the individual; and
  • must have one of the following:
    • a high school diploma;
    • a high school equivalency certificate issued in accordance with the law of the issuing state; or
    • both of the following:
      • a successfully completed written competency-based assessment demonstrating the ability to provide respite and the ability to document the provision of respite in accordance with Section 3800, Written Documentation, and Section 4690, Written Documentation; and
      • written personal references which evidence the service provider's ability to provide a safe and healthy environment for the individual from at least three persons who are not relatives of the service provider (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these billing guidelines).

 

4670 Unit of Service

Revision 12-1; Effective February 10, 2012

 

  1. 15 Minutes
    A unit of service for the respite service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for respite may not include a fraction of a unit of service.

 

4680 Payment Limit

Revision 12-1; Effective February 10, 2012

 

The maximum amount DADS will pay a program provider for respite provided to an individual is based on the dollar cap for services per IPC year.

 

4690 Written Documentation

Revision 12-1; Effective February 10, 2012

 

A program provider must have written documentation to support a service claim for respite. The written documentation must:

  • meet the requirements set forth in Section 3800, Written Service Log and Written Summary Log;
  • include the exact time the service event began and the exact time the service event ended documented by the service provider making the written service log; and
  • include a written justification in the individual's PDP for the use of more than one service provider for any activity simultaneously performed by more than one service provider.

 

4700 Supported Employment

Revision 12-1; Effective February 10, 2012

 

 

4710 General Description of Service Component

 

Revision 14-2; Effective September 1, 2014

Supported employment means assistance provided in order to sustain competitive employment or self-employment to an individual 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. Supported employment includes employment adaptations, supervision, training related to an individual’s assessed needs, and earning at least a minimum wage (if not self-employed).

4720 Billable Activity

 

Revision 15-3; Effective December 11, 2015

The only billable activities for the supported employment service component are:

  • employment adaptations, supervision and training related to an individual's disability;
  • participating in a service planning team meeting;
  • assisting the individual with transportation needs which include:
    • determining how the individual will travel to and from a job;
    • training the individual on how to travel to and from a job; and
    • securing transportation for or transporting an individual, as necessary, to assist self-employment, work from home or perform in a work setting;
  • orienting and training the individual in work-related tasks;
  • training or consulting with employers, coworkers or advocates to maximize natural supports;
  • monitoring job performance;
  • communicating with managers and supervisors to gather input and plan training;
  • communicating with company personnel or support systems to ensure job retention;
  • training in work-related tasks or behaviors to ensure job retention (for example, grooming or behavior management);
  • setting up compensatory strategies;
  • assisting the individual to report earned income to the Social Security Administration and the Texas Health and Human Services Commission;
  • assisting the individual to develop a method for ongoing income reporting and for staying informed about the impact of the individual’s earnings on cash, Medicaid and other benefits;
  • assisting the individual to utilize work incentives to maintain needed benefits and continue to access needed supports and services;
  • assisting the individual with career advancement;
  • assisting the individual to develop assets and obtain self-sufficiency through work;
  • training or consulting in work-related tasks or behaviors such as support for advertising, marketing and sales;
  • training or consulting with paid or natural supports (accountants, employees, etc.) who are supporting the individual either short-term or long-term in managing the business;
  • problem-solving related to company personnel or support systems necessary to run the business effectively and efficiently; and
  • assistance with bookkeeping, marketing and managing data or inventories.

 

4730 Activity Not Billable

Revision 15-2; Effective October 30, 2015

 

  1. Activities in Section 3300
    The activities listed in Section 3300, Activity Not Billable, are not billable for the supported employment service component.
  2. Activities Not Listed in Section 4720
    Any activity not described in Section 4720, Billable Activity, is not billable for the supported employment service component.
  3. Examples of Non-billable Activities
    The following are examples of activities that are not billable for the supported employment service component:
    • interacting with an individual prior to the individual's employment;
    • face-to-face contact with an individual to provide Supported Employment services simultaneously with Day Habilitation services, Employment Assistance, Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB) or Respite;
    • habilitation activities provided and billed as part of the Day Habilitation or CFC PAS/HAB service component;
    • time spent waiting to provide a service;
    • any activity taking place in a sheltered work environment or other similar types of vocational services furnished in specialized facilities, or using Medicaid funds paid by DADS to the provider for incentive payments, subsidies or unrelated vocational training expenses;
    • any activity that occurs before or after employment which is gained as a result of paying an employer to encourage the employer to hire an individual;
    • any activity that occurs before or after employment which is gained as a result of paying an employer for supervision, training, support and adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business;
    • paying the individual as an incentive to participate in Supported Employment activities; and
    • paying the individual for expenses associated with the start-up costs or operating expenses of an individual’s business.

 

4740 Qualified Service Provider

Revision 14-1; Effective April 10, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the supported employment service component:

  • is at least 18 years of age, is not the individual’s legally responsible person and must have one of the following:
    • a bachelor's degree in rehabilitation, business, marketing or a related human services field, and at least six months of paid or unpaid experience providing services to people with disabilities;
    • an associate's degree in rehabilitation, business, marketing or a related human services field, and at least one year of paid or unpaid experience providing services to people with disabilities; or
    • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, and at least two years of paid or unpaid experience providing services to people with disabilities.
  • has experience evidenced by:
    • for paid experience, a written statement from a person who paid for the service or supervised the provision of the service; and
    • for unpaid experience, a written statement from a person who has personal knowledge of the experience.

 

4750 Restrictions Regarding Submission of Claims for Supported Employment

Revision 14-1; Effective April 10, 2014

 

A program provider may not submit a service claim for supported employment provided to an individual if supported employment is available to the individual through the public school system.

 

4760 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the supported employment service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for supported employment may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4770 Written Documentation

Revision 14-1; Effective April 10, 2014

 

A program provider must have written documentation to support a service claim for supported employment. The written documentation must:

  • meet the requirements set forth in Section 3800, Written Documentation;
  • include the exact time the service event began and the exact time each service event ended documented by the service provider making the written service log;
  • for an individual under age 22, include evidence that supported employment services are not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.); and
  • for any activity simultaneously performed by more than one service provider, include a written justification in the individual's PDP for the use of more than one service provider.

 

4800 Employment Assistance

Revision 14-1; Effective April 10, 2014

 

 

4810 General Description of Service Component

Revision 14-1; Effective April 10, 2014

 

Employment Assistance means assistance provided to an individual to help the individual locate paid employment in the community.

 

4820 Employment Assistance Billable Time/Activities

Revision 15-2; Effective October 30, 2015

 

Employment Assistance services consist of developing and implementing strategies for achieving the individual’s desired employment outcome, including more suitable employment for individuals who are employed. Services are individualized, person-directed and may include:

  • Identifying an individual's employment preferences, job skills and requirements for a work setting and work conditions;
  • Locating prospective employers offering employment compatible with an individual's identified preferences, skills and requirements;
  • Contacting a prospective employer on behalf of an individual and negotiating the individual's employment;
  • Assisting the individual with transportation needs, which include:
    • determining how the individual will travel to and from a job;
    • training the individual on how to travel to and from a job;
    • securing transportation for or transporting an individual, as necessary, to assist the individual to obtain a job; and
    • transporting the individual to help the individual locate paid employment in the community;
  • Participating in service planning team meetings, including those with the Department of Assistive and Rehabilitative Services or, for individuals under age 22, with the individual’s school district;
  • Exploring options related to wages and employment outcomes (including self-employment outcomes);
  • Exploring the individual’s interests, capabilities, preferences and ongoing support needs;
  • Exploring the extended services and supports required at and away from the job site that will be necessary for employment success;
  • Observing the individual's work skills and behaviors at home and in the community;
  • Touring current or potential work environments with the individual;
  • Assisting the individual to understand the impact of work activity on his/her services and financial supports;
  • Assisting the individual to utilize work incentives to maintain needed benefits;
  • Collecting personal and professional reference information;
  • Assessing the individual's learning style and needs for adaptive technology, accommodations and on-site supports;
  • Assessing the individual's strengths, challenges and transferable skills from previous job placements;
  • Identifying the individual's assets, strengths and abilities;
  • Identifying negotiable and non-negotiable employment conditions;
  • Identifying targeted job tasks the individual can perform or potentially perform;
  • Identifying potential employers or self-employment options;
  • Training related to an individual’s assessed needs specific to his/her employment preferences, job skills and requirements for a work setting and work conditions;
  • Writing resumes and proposals to assist in placement;
  • Contacting employers and developing individual jobs;
  • Performing a job analysis to determine if a potential job meets the individual’s interests, capabilities, preferences and ongoing support needs;
  • Assisting the individual with job applications, pre-employment forms, practice interviews, and pre-employment testing or physicals;
  • Accompanying the individual to interviews;
  • Negotiating aspects of the individual’s employment with prospective employers; and
  • Educating the employer about the Work Opportunity Tax Credit and other employer benefits.

For self-employment, services may additionally include:

  • Supporting the individual in work-related tasks or behaviors such as advertising, marketing, sales, accounting and obtaining licenses and registrations;
  • Training or consulting with paid or natural supports (accountants, employees, etc.) who will be supporting the individual either short-term or long-term in managing the business; and
  • Setting up services to address long-term supports that will be necessary to sustain the business.

 

4830 Employment Assistance Non-Billable Time/Activities

Revision 15-2; Effective October 30, 2015

 

  • Employment Assistance provided when an individual is independently employed in the community, unless the person-directed plan (PDP) has identified outcomes for the individual to find additional or more suitable employment.
  • Habilitation activities provided and billed as part of the Day Habilitation or Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB).
  • Time spent waiting to provide a service.
  • Face-to-face contact with an individual to provide Employment Assistance services simultaneously with Day Habilitation services, Supported Employment, CFC PAS/HAB or Respite.
  • Employment Assistance services accessed and/or funded through other sources at no cost to the Texas Home Living provider. Examples include, but are not limited to, services provided to an individual through the Texas Department of Assistive and Rehabilitative Services, the public school system, Medicaid Rehabilitative Services for Persons with Chronic Mental Illness, senior citizen centers, volunteer programs or other community-based sources.
  • The use of Medicaid funds paid by DADS to the provider for incentive payments, subsidies or unrelated vocational training expenses, such as paying an employer:
    • to encourage the employer to hire an individual; or
    • for supervision, training, support and adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business.
  • The use of Medicaid funds paid by DADS to the provider for incentive payments, subsidies or unrelated vocational training expenses, such as paying the individual:
    • as an incentive to participate in Employment Assistance activities; or
    • for expenses associated with the start-up costs or operating expenses of an individual’s business.

Unit of Service: 15 minutes

 

4840 Employment Assistance Qualified Service Provider

Revision 14-1; Effective April 10, 2014

 

In addition to meeting the requirements in Section 3400, Qualified Service Provider, a qualified service provider of the employment services component:

  • is at least 18 years of age, is not the individual’s legally responsible person and must have one of the following:
    • a bachelor's degree in rehabilitation, business, marketing or a related human services field, and at least six months of paid or unpaid experience providing services to people with disabilities;
    • an associate's degree in rehabilitation, business, marketing or a related human services field, and at least one year of paid or unpaid experience providing services to people with disabilities; or
    • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, and at least two years of paid or unpaid experience providing services to people with disabilities.
  • has experience evidenced by:
    • for paid experience, a written statement from a person who paid for the service or supervised the provision of the service; and
    • for unpaid experience, a written statement from a person who has personal knowledge of the experience.

 

4850 Unit of Service

Revision 14-1; Effective April 10, 2014

 

  1. 15 Minutes
    A unit of service for the supported employment service component is 15 minutes.
  2. Fraction of a Unit of Service
    A service claim for supported employment may not include a fraction of a unit of service.
  3. Service Time
    Service time is calculated in accordance with Section 3610, 15-Minute Unit of Service (see No. 2), including when multiple persons are being served.

 

4860 Employment Assistance Documentation Requirements

Revision 14-1; Effective April 10, 2014

 

Documentation will be maintained in the file of each participant receiving employment assistance verifying that such assistance is not otherwise available to the participant under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142. See the DADS/DARS MOA for more detail on coordination and documentation processes: Standards for Manual Consumer Services Contract Providers.

A service log for each service event that describes the service and, when appropriate, includes information pertaining to the individual's progress toward goals and objectives.

The service log must include:

  • Name of the individual
  • Type of service
  • Date of service (month, day, year)
  • Place of service
  • Actual begin and end time of each billable service event
  • Description of the service event
  • Name and title of the service provider
  • Signature of the service provider