4100, Eligibility for Habilitation Coordination Funded by Medicaid

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for habilitation coordination funded by Medicaid if he or she:

  • has an active PASRR Evaluation (PE) or resident review that is positive for intellectual disability (ID) or developmental disability (DD);
  • is a Medicaid recipient;
  • is 21 or older; and
  • is living in a nursing facility (NF)

Note: Receiving hospice services does not affect a person’s eligibility for habilitation coordination or other PASRR specialized services, if the interdisciplinary team (IDT) agrees the person would benefit from specialized services.

4200, Assignment of Habilitation Coordinator

Revision 22-1; Effective Nov. 28, 2022

A local intellectual and developmental disability authority (LIDDA) must assign a habilitation coordinator  to an eligible person within two business days after the PE is entered in the Long-Term Care (LTC) online portal. The habilitation coordinator must attend the person’s initial IDT meeting along with the LIDDA representative who is a required member of the IDT. See Section 2500, PASRR Initial IDT and SPT Meeting, and Section 4300, Initial IDT and SPT Meeting. If the assigned habilitation coordinator functions in another LIDDA capacity, the habilitation coordinator will indicate all represented functions on the sign-in sheet.

The habilitation coordinator must review the individual’s PE, Form 1054, Community Living Options, completed by the PE evaluator, and any other available supporting documentation (e.g., diagnostic information in the Client Assignment and Registration system (CARE), previous LIDDA services, previous service plans) before the initial IDT meeting.

4300, Initial IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator must attend the individual’s initial IDT meeting. The PE evaluator, or LIDDA representative, if the person who completed the PE is not in attendance, shares the results of the Community Living Options (CLO) presented during the PE (i.e., completed Form 1054, Community Living Options). If barriers are identified in Sections 6, 7 or 8 of Form 1054, then the habilitation coordinator and IDT members should determine if provision of any specialized service could help eliminate barriers. If so, the specialized service is considered recommended and must be identified as such on the PCSP form.

4310 Attendance at Initial IDT and SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

At the initial IDT and SPT meeting for an individual, the following LIDDA staff are in attendance:

  • the LIDDA staff representative who is a required member of the IDT (HHSC strongly encourages this LIDDA staff representative be the LIDDA staff who conducted the PE)*; and
  • the assigned habilitation coordinator**.

The assigned habilitation coordinator can be designated as the LIDDA required member of the initial IDT if the habilitation coordinator completed the PE.

*Attendance at the initial IDT and SPT meeting as a required IDT member is an activity that is included in the PE reimbursement rate.

**A habilitation coordinator's attendance at the initial IDT and SPT meeting is reimbursed through the habilitation coordination reimbursement rate if the habilitation coordinator and individual are face-to-face.

Note: Following an initial IDT and SPT meeting, a LIDDA must comply with Section 2520, Confirmation of IDT and SPT Meeting Information.

4400, Requesting Authorization for Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

4410 IDT Agrees to Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for an eligible person, the habilitation coordinator requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines.

4420 Refusal of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

If an eligible person or LAR does not want habilitation coordination, the HC:

  • requests authorization for habilitation coordination per the Habilitation Coordination Billing Guidelines to fund the habilitation coordinator’s attendance at the IDT meeting; and
  • uses Form 1044, Refusal of Habilitation Coordination, to document the refusal of habilitation coordination, gets necessary signatures, provides the person or LAR a copy of the completed form and maintains the original completed form in the person’s record.

Note: The habilitation coordinator must complete Form 1064, Habilitative Assessment for a person who has refused habilitation coordination.

4500, Developing Individual Profile and Habilitation Service Plan at First SPT Meeting

Revision 22-1; Effective Nov. 28, 2022

If the IDT agrees to the provision of habilitation coordination for a person, the habilitation coordinator convenes the first SPT meeting immediately after the initial IDT meeting.

At the first SPT meeting, the habilitation coordinator continues the discovery process and develops and uses Form 1063, Individual Profile – Nursing Facility, and Form 1057, Habilitation Service Plan (HSP). This section describes developing an individual profile and an HSP at the first SPT meeting. Although Section 5400, Develop and Revise Habilitation Service Plan and Individual Profile, describes the process for developing and revising an HSP and individual profile, a fully robust HSP and individual profile are not expected by the end of the first SPT meeting.

Information from the following sources is discussed with the SPT and included in the HSP and individual profile where appropriate:

  • the PE or resident review;
  • the CLO that was conducted during the PE;
  • CARE (e.g., diagnostic data, previous LIDDA services);
  • previous service plans; and
  • other available supporting documentation, including previous assessments such as those listed in Section 5210, Reviewing Assessments.

Also included in the HSP are all specialized services, including habilitation coordination, agreed upon during the IDT meeting. At a minimum, for each specialized service agreed upon during the IDT meeting, the HSP must indicate either:

  • an assessment will be conducted; or
  • the amount, frequency and duration of the specialized service to be provided.

The habilitation coordinator must complete the HSP and individual profile, and send them to the members of the SPT, within 10 calendar days following the first SPT meeting.

The habilitation coordinator should ask the NF to include all PASRR specialized services identified on the HSP in the NF baseline care plan or NF comprehensive care plan, whichever is most current. The habilitation coordinator must request a copy of the NF baseline care plan or comprehensive care plan from the NF.

4510 Specialized Services Requiring an Assessment

Revision 22-1; Effective Nov. 28, 2022

An assessment is required for:

  • all NF specialized services; and
  • the following intellectual and developmental disability (IDD) habilitative specialized services:
    • behavioral support;
    • employment assistance; and
    • supported employment.

The HSP must state an outcome that supports starting an assessment.

When there is lack of consensus among all IDT members about whether a person should receive a NF specialized service or an IDD habilitative specialized service (IHSS), then obtaining an assessment for the specialized service is required. The assessment will indicate whether the person can benefit from the specific NF specialized service or IHSS.

An assessment is not completed for a person who refuses specialized services or in cases in which there is no funding for specialized services.

4520 Specialized Services that Do Not Require an Assessment

Revision 22-1; Effective Nov. 28, 2022

For independent living skills training and day habilitation, the SPT identifies for inclusion in Section 5 of Form 1057, Habilitation Service Plan (HSP):

  • the outcome(s); and
  • the amount, frequency and duration based on the person's identified needs, interests and desired outcomes.

4530 Frequency and Duration of Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The duration of habilitation coordination is “while the person is living in the nursing facility,” which is pre-printed on Form 1057, Habilitation Service Plan (HSP). The frequency of habilitation coordination is determined by the SPT per the requirements in rule and Section 5100, Required Face-to-Face Visits.

4700, Providing Habilitation Coordination

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator provides ongoing habilitation coordination per Section 5000, Habilitation Coordination. They continue  the discovery process and revising Form 1057, Habilitation Service Plan (HSP), with the SPT as assessments become available and as the individual’s needs change or are more fully realized.

4800, Additional LIDDA Responsibilities

Revision 22-1; Effective Nov. 28, 2022

4810 Determining Guardianship

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator determines if a person  has a legal guardian and verifies that letters of guardianship are current by requesting a copy of the letters of guardianship or by contacting the court. If the person has a current legal guardian, then all forms must be signed by the guardian. If the person does not have a legal guardian, then all forms must be signed by the him or her.

If the guardianship information is not current, the habilitation coordinator should obtain signatures of both the individual and the person listed as guardian, until appropriate steps can be taken to verify current guardianship.

For more information, see Section 5920, Activities Related to Guardianship.

4820 Communication of Complaint Process

Revision 22-1; Effective Nov. 28, 2022

The habilitation coordinator ensures that the person or LAR is informed orally and in writing of the processes for:

  1. filing complaints about services delivered by the LIDDA, such as habilitation coordination, service coordination, and IHSS, with:
    • the LIDDA; and 
    • the IDD Ombudsman at 800-252-8154; 
  2. filing complaints about the provision of NF specialized services with:
    • the LIDDA; and
    • HHSC Complaint and Incident Intake at 800-458-9858; and
  3. reporting an allegation of abuse, neglect, or exploitation to DFPS at 800-647-7418.

Each LIDDA must develop a process for receiving and resolving complaints about a provider of NF specialized services, MI specialized services, or the LIDDA’s provision of IHSS, habilitation coordination or service coordination. This process must include the LIDDA's phone number and the toll-free number to the IDD Ombudsman.

The processes for people and LARs to request a review of their concerns or dissatisfaction must be easily understood. The policy must explain how the person or LAR may receive assistance to request the review, the time frames for the review, and the method that the person or LAR is informed of the outcome of the review. The LIDDA must present this policy in the languages that the person and LAR are most comfortable.

4900, Medicaid and Medicare

Revision 22-1; Effective Nov. 28, 2022

4910 Medicaid Eligibility Guidelines

Revision 22-1; Effective Nov. 28, 2022

HHSC requires all people to meet Medicaid eligibility for PASRR. Eligibility must be attained and maintained for the person to continue receiving PASRR specialized services. People eligible for certain types of Medicaid coverage are eligible for PASRR. However, not all types of Medicaid coverage ensure eligibility.

Every person certified for Medicaid benefits has a "TOA code" and a "program code" assigned to their Medicaid record. See the table below for the appropriate coverage codes for participation in PASRR. CARE Screen C63 (Medicaid Eligibility Search), Screen 192 and Screen 193 (Medicaid Eligibility Information) can be used to verify a person’s current and past Medicaid records.

Required Medicaid Codes

TOA CodeProgram CodeTOA CodeProgram CodeTOA CodeProgram Code

Contact your local HHSC office by calling 211, or visiting the HHSC website for specific questions about Medicaid coverage. 

4920 Responsibility to Reestablish Medicaid Eligibility

Revision 22-1; Effective Nov. 28, 2022

If a person loses Medicaid eligibility or is delayed in having Medicaid eligibility determined or re-determined, a NF and LIDDA may be unable to receive authorizations or bill for PASRR specialized services, including habilitation coordination. It is the responsibility of the representative payee to contact the appropriate entity to determine the necessary action to reinstate benefits.

If the individual or family is the representative payee, the habilitation coordinator must assist, if requested.

If the NF is the representative payee, the NF is responsible for ensuring action is taken to reestablish Medicaid eligibility. In most circumstances, assisting people with Medicaid eligibility determinations, re-determinations, and MCO selection is allowable as a medically related social service, which is a service provided by the NF that help the individual in attaining the highest practicable physical, mental, or psychosocial well-being.

If needed, the LIDDA is expected to work with the NF to help a person reestablish Medicaid eligibility. Failure of a representative payee to help reestablish Medicaid eligibility may be reported to HHSC Complaint and Incident Intake.

To minimize billing issues about habilitation coordination, LIDDAs should review the service authorization in Medicaid Eligibility Service Authorization Verification (MESAV) to verify that the person is admitted into the correct Medicaid program.

4930 MCO Selection

Revision 22-1; Effective Nov. 28, 2022

STAR+PLUS is the Texas Medicaid managed care program for people who live in NFs. A NF resident must select a STAR+PLUS managed care organization (MCO). If a NF resident fails to select an MCO, the resident will be assigned an MCO.  

A person enrolled with an MCO is assigned a service coordinator. The MCO service coordinator has responsibility for coordinating and ensuring the delivery of NF add-on services and acute care services. An MCO service coordinator must conduct quarterly visits with the individual. MCO service coordinators also work with the individual, families, habilitation coordinators, and other service coordinators or case managers to ensure a smooth transition to the community, when appropriate. The individual’s MCO service coordinator should be a part of the care planning process and is a member of the IDT and SPT, if the individual does not object. The habilitation coordinator should ask the individual or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at IDT and SPT meetings and must document evidence of this discussion in the individual’s record. 

4930.1 Individual Does Not Have an MCO

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA becomes aware that a person is not assigned an MCO, the LIDDA must contact the NF and request the NF give information and guidance to the person or LAR on how to select and enroll in an MCO. The LIDDA must not delay transition planning activities if the person does not have an MCO and is ready to transition to the community.

Note: As part of medically related social services, a NF may provide information to a person or the person’s LAR about available MCOs and guidance on how to enroll in the preferred MCO. A NF may not choose an MCO on behalf of the individual.

4940 Individual is Dual Eligible

Revision 22-1; Effective Nov. 28, 2022

Many people who live in NFs are eligible for both Medicaid and Medicare. A NF stay for a person admitting from an acute care hospital may initially be funded by Medicare. However, the person’s Medicaid eligibility, and therefore their eligibility for PASRR, does not change. If the person is Medicaid-eligible and meets the other criteria for habilitation coordination, he or she must not be refused access to those services whether or not the current stay is paid for by Medicare or Medicaid.