Habilitation Coordination Billing Guidelines

Section 1000, Introduction

Revision 19-0; Effective July 7, 2019

 

Habilitation coordination is defined in 26 Texas Administrative Code (TAC) Chapter 303, §303.102 of rules governing Preadmission Screening and Resident Review (PASRR). Habilitation coordination funded by Medicaid provides assistance for an individual to access appropriate specialized services necessary to achieve a quality of life and level of community participation which is acceptable to the individual and legally authorized representative (LAR) on the individual’s behalf.

Section 2000, Definitions

Revision 19-0; Effective July 7, 2019

 

The following words and terms, when used in this manual, have the following meanings unless the context clearly indicates otherwise:

CLO or community living options — A process by which the LIDDA provides information to an individual and legally authorized representative (LAR) about the range of community living services, supports and programs the individual may be eligible for, and discusses services and supports the individual will need to live in the community, as well as individual preferences and barriers to community living.

Collateral contact — A person who is knowledgeable about the individual seeking admission to an NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.

Habilitation coordination — Assistance for an individual residing in a nursing facility to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the individual and LAR on the individual’s behalf.

Habilitation Coordinator — An employee of a local intellectual and developmental disability authority (LIDDA) who provides habilitation coordination.

HHSC — The Texas Health and Human Services Commission.

HSP or Habilitation Service Plan — A plan developed by the service planning team (SPT) while an individual is residing in an NF that:

  1. is individualized and developed through a person-centered approach;
  2. identifies the individual’s:
    1. strengths;
    2. preferences;
    3. desired outcomes; and
    4. psychiatric, behavioral, nutritional management, and support needs as described in the comprehensive care plan or Minimum Date Set (MDS) assessment; and
  3. identifies the specialized services that will accomplish the desired outcomes of the individual, or the LAR’s on behalf of the individual, including amount, frequency and duration for each service.

ID or intellectual disability — Defined in 42 Code of Federal Regulations (CFR) §483.102(b)(3)(i).

IDD habilitative specialized services — The following specialized services that are available to an individual:

  1. habilitation coordination;
  2. day habilitation;
  3. independent living skills training;
  4. behavioral support;
  5. employment assistance; and
  6. supported employment.

IDT or interdisciplinary team — A team consisting of:

  1. a resident with MI, ID or DD;
  2. the resident's LAR, if any;
  3. a registered nurse from the NF with responsibility for the resident;
  4. a representative of:
    1. the LIDDA, if the resident has ID or DD;
    2. the LMHA or LBHA, if the resident has MI; or
    3. the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and
  5. others as follows:
    1. a concerned person whose inclusion is requested by the resident or LAR;
    2. a person specified by the resident, LAR, NF, LIDDA, LMHA or LBHA, as applicable, who is professionally qualified, certified, or licensed with special training and experience in the diagnosis, management, needs, and treatment of people with MI, ID or DD; and
    3. a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.

Individual — A person:

  1. whose active PASRR evaluation (PE) or resident review is positive for ID or DD;
  2. who is 21 years of age or older; and
  3. who is a Medicaid recipient.

LAR or legally authorized representative — A person authorized by law to act on behalf of an individual seeking admission to an NF or resident about a matter described by this chapter, and who may be the parent of a minor child, the legal guardian or the surrogate decision maker. (See limitations on authority of surrogate decision maker in the definition of “surrogate decision maker.”

LIDDA or local intellectual and developmental disability authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.

LMHA or local mental health authority — An entity designated to provide mental health services in accordance with Texas Health and Safety Code §533.035(a).

LBHA or local behavioral health authority — An entity designated to provide mental health and chemical dependency services in accordance with Texas Health and Safety Code §533.0356(a).

Nursing facility (NF) — A Medicaid-certified facility that is licensed in accordance with Texas Health and Safety Code, Chapter 242.

Nursing facility specialized services — The following NF specialized services that are available to an individual:

  1. therapy services;
  2. customized manual wheelchair; and
  3. durable medical equipment.

PASRR or Preadmission Screening and Resident Review — required by 42 CFR 483.100-138.

PASRR Level II Evaluation (PE) — A face-to-face evaluation:

  1. of an individual seeking admission to an NF who is suspected of having MI, ID or DD; and
  2. performed by a LIDDA, LHMA or LBHA to determine if the individual has MI, ID or DD and, if so, to:
    1. assess the individual's need for care in a nursing facility;
    2. assess the individual's need for specialized services; and
    3. identify alternate placement options.

PASRR Level 1 (PL1) — The process of screening an individual seeking admission to an NF to identify whether the person is suspected of having MI, ID or DD.

QIDP or qualified intellectual disability professional — A person who meets the qualifications described in 42 CFR §483.430(a).

Service coordination — Assistance in accessing medical, social, educational and other appropriate services and supports, including alternate placement assistance that will help a person achieve a quality of life and community participation acceptable to the person and LAR on the person's behalf.

Service coordinator — An employee of a LIDDA who provides service coordination.

Specialized services — The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID or DD: a. NF specialized services; b. IDD habilitative specialized services; and c. MI specialized services.

SPT or service planning team — A team convened by a LIDDA staff member that develops, reviews and revises the HSP and the Transition Plan for an individual.

  1. The team must include:
    1. the individual;
    2. the individual’s LAR, if any;
    3. the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the individual is transitioning to the community;
    4. the managed care organization (MCO) service coordinator, if the individual does not object;
    5. while the individual is in a nursing facility:
      1. a nursing facility staff member familiar with the individual’s needs; and
      2. a person providing a specialized service to the individual or a representative of a provider agency that is providing specialized services for the individual;
    6. if the individual is transitioning to the community:
      1. a representative from the community program provider, if one has been selected; and
      2. a relocation specialist; and (vii) a representative from the LMHA/LBHA, if the individual has MI.
  2. Other participants on the SPT may include:
    1. a concerned person whose inclusion is requested by the individual or the LAR; and
    2. at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.

Transition Plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in assisting an individual to transition from residing in a nursing facility to living in the community.

Section 3000, References in Law, Rule and Policy

Revision 19-0; Effective July 7, 2019

 

The provision of habilitation coordination is also governed by the following:

Section 4000, Qualified Service Provider of Habilitation Coordination

Revision 19-1; Effective September 19, 2019

 

In order to provide and bill for habilitation coordination, a habilitation coordinator must be a LIDDA employee who meets the qualification requirement described in 26 TAC §303.501.

 

4100 Habilitation Coordination Service Authorization Revision

19-0; Effective July 7, 2019

 

The habilitation coordinator must send a request for habilitation coordination service units from HHSC. To be paid for participating in the initial IDT meeting, a request must be sent using designated Form 2358, Habilitation Coordination Authorization Request, and faxed to the HHSC Provider Claims section at 512-438-2301 within three business days of the initial IDT for processing. If the IDT agrees to the provision of habilitation coordination for the individual, the LIDDA requests habilitation coordination for 12 months effective the date of the IDT meeting.

Service authorizations may take five to seven business days to appear on Medicaid Eligibility and Service Authorization Verification (MESAV).

 

4110 Habilitation Coordination Service Authorization Requests

Revision 19-0; Effective July 7, 2019

 

There are six habilitation coordination authorization requests that the habilitation coordinator will identify on Form 2358, Habilitation Coordination Authorization Request, that will be processed by HHSC staff:

 

4120 Termination Codes

Revision 19-0; Effective July 7, 2019

 

For all terminations submitted by the habilitation coordinator, an accompanying code will need to be used to reflect what type of termination is being submitted. Below are the codes:

Code Description
1 Client Leaves the LIDDA’s catchment area
2 Death of Client
5 Client Requests Service Termination
23 Transferred to Another Service
29 Discharged from Facility (Assumed to Home)
32 Hospitalized over 30 days
39 Other

 

4200 Units of Service

Revision 19-1; Effective September 19, 2019

 

A billable unit of service is the method for calculating the amount the habilitation coordinator may bill HHSC. HHSC established the habilitation coordination rate based on an assumption of a caseload of 26 individuals served within any given calendar month. For the first year of implementation, HHSC will not be imposing a contractual requirement that LIDDAs maintain a caseload of 26 individuals. HHSC encourages and expects that LIDDAs will maintain manageable caseloads that continue to support the integrity and quality of habilitation coordination that PASRR residents receive. Rate information is published by procedure code in the applicable Texas Medicaid Fee Schedule located on the Texas Medicaid website (see Fee Schedules).

Service Procedure Code Modifier Rate Unit Effective
Habilitation Coordination S0311 96 $208.23 Monthly 7/7/2019

 

The number of habilitation coordination units needed by the individual are determined by the IT or SPT and documented on the HSP. The monthly habilitation coordination fee may only be billed during a month when a billable activity has occurred. Habilitation coordination progress notes must include the following elements:

Elements noted above do not necessarily have to be contained within the narrative describing the encounter as long as they are contained within the progress note that also contains the narrative (e.g., billing strip).

 

4210 SASO Codes

Revision 19-0; Effective July 7, 2019

 

A service authorization for habilitation coordination is created in the Service Authorization System Online (SASO) by designated HHSC staff for one unit per month requested, for up to 12 months, with effective the date of the IDT or the date that the habilitation coordinator meets with the individual. The service authorization is identified as a Service Group (SG) 14 or “SG 14,” which means the LIDDA is the provider. The service code for which is associated with “habilitation coordination” is 10H provided by a LIDDA.

 

4300 Service Claim Requirements

Revision 19-0; Effective July 7, 2019

 

For habilitation coordination services to be reimbursed, there must be at least one face-to-face meeting with an individual delivered by a qualified provider employed by the LIDDA. A LIDDA must submit an electronic service claim for habilitation coordination that meets the requirements specified by Texas Medicaid & Healthcare Partnership (TMHP).

Section 5000, Billable Activities

Revision 19-0; Effective July 7, 2019

 

The monthly rate for habilitation coordination covers all habilitation coordination activities provided to the individual in one month. One contact must be face-to-face, and include one or more of the following activities:

Section 6000, Non-Claimable Activities

Revision 19-0; Effective July 7, 2019

 

HHSC does not authorize the monthly habilitation coordination fee for activities that are not one of the habilitation coordination activities defined in Section 5000 of the IDD PASRR Handbook.

 

6100 Non-Claimable Activities Related to Habilitation Coordination

Revision 19-0; Effective July 7, 2019

 

The following are activities that are included in the rate of habilitation coordination, but can’t be billed exclusively without a face-to-face meeting and an activity discussed in Section 5000:

 

6200 Non-Claimable Activities Related to Administration

Revision 19-0; Effective July 7, 2019

 

The following are examples of non-billable administrative activities and not required for habilitation coordination but maybe required by a LIDDA:

Section 7000, Data Reporting Requirements

Revision 19-0; Effective July 7, 2019

 

The following reporting requirements for the Mental Health and ID Business Objects Warehouse (MBOW) must be followed:

Section 8000, Billing and Payment Reviews

Revision 19-0; Effective July 7, 2019

 

A LIDDA must provide any documentation related to habilitation coordination that is requested by HHSC in the time frame specified by HHSC.

Section 9000, Billing Guidelines Technical Assistance

Revision 19-0; Effective July 7, 2019

 

Forms

ES = Spanish version available.

Form Title  
2358 Habilitation Coordination Authorization Request  

Revisions

19-1, Section 4200 Changes and Appendix Deleted

Effective September 19, 2019

 

The following change(s) were made:

Section Title Change
4200 Units of Service Revises the requirement to have a 26-person cap on a habilitation coordinator's caseload.
Appendix I LIDDA Habilitation Coordinator (HC) Maximum Caseload Size Deletes the appendix.

19-0, New Handbook

Effective July 7, 2019

 

The Habilitation Coordination Billing Guidelines informs local intellectual and developmental disability authorities about billing and system reporting requirements regarding habilitation coordination provided through the Preadmission Screening and Resident Review program.

Contact Us

For questions about the Habilitation Coordination Billing Guidelines, email: idd-bh_pasrrspa@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us