2100, Case Management
2110 Description of Case Management
Revision 24-3; Effective July 1, 2024
26 Texas Administrative Code Section 271.79 says people must meet the eligibility criteria for CCSE services and can receive case management without receiving services. Ineligible applicants receiving only information and referral are not eligible for case management.
Case management is a set of actions taken by a Texas Health and Human Services Commission (HHSC) caseworker to determine:
- if a person requesting service is eligible for HHSC services;
- what services the person needs; and
- who will provide those services.
Case management also includes:
- referring eligibles to service providers and facilitating the referral;
- monitoring the referral to ensure that the services are initiated;
- monitoring the service provision to ensure that services are meeting the person's needs; and
- periodically reassessing the person's financial and functional eligibility.
2120 Case Management Process
Revision 24-3; Effective July 1, 2024
Case management involves six single functions.
- Intake — Requests for service or information are made by the person or someone on the person's behalf by phone, letter, or in-person. Texas Health and Human Services Commission (HHSC) intake staff:
- determine the precise request;
- record certain information from the requester;
- give the requester certain information;
- determine if an immediate, expedited, or routine response is necessary; and
- refer the request to the appropriate unit for further action.
Review 2200, Intake Procedures for detailed intake procedures.
- Assessment — HHSC caseworkers respond to intake by visiting the person at home or in another setting to assess eligibility and needs. The assessment process includes:
- determining financial eligibility;
- determining functional eligibility for the performance of activities of daily living;
- assessing the person's home, social, and environmental supports, and resources;
- determining services the person needs and if family or community resources are currently meeting those needs; and
- assessing the person's physical condition and determining if that condition and their environment pose any risk.
Review 2400, Assessment Process for detailed assessment procedures.
- Service planning — Caseworkers develop a service plan with each eligible person after completing the assessment. Service planning includes:
- determining what services and environmental adaptations are required to satisfy the person's personal unmet needs, health, and safety;
- determining and specifying what services will be secured from whom or from where, how much will be provided, and on what schedule;
- specifying how often the caseworker will monitor the provision of services and personal satisfaction; and
- getting the person's agreement with the service plan.
Review 2500, Service Planning for detailed service planning procedures.
- Service authorization
- Non-Medicaid services — If non-Medicaid HHSC services need purchasing as part of the service plan, the caseworker:
- authorizes the services per program policies and procedures;
- sends the service plan and person’s referral information to the provider selected by the person; and
- discusses the plan with the potential provider, as necessary.
- Medicaid services — If Medicaid services need purchasing as part of the service plan, the caseworker:
- designates the services per Medicaid program policies and procedures;
- if necessary, gets consultation from the regional nurse about medical need for services;
- sends the service plan and person’s referral information to the provider selected by the person;
- discusses the plan with the provider supervisor, if requested; and
- discusses the plan with the regional nurse, as necessary.
Review 2600, Authorizing and Reassessing Services for detailed service authorization procedures.
- Non-Medicaid services — If non-Medicaid HHSC services need purchasing as part of the service plan, the caseworker:
- Service monitoring and evaluation — The caseworker:
- contacts each person after service referral, per case management requirements, to ensure that services were initiated as scheduled and to determine the person's satisfaction with the service;
- contacts and visits each person per the individualized case management plan or upon request by the person or others;
- accompanies regional nurses on utilization review home visits when requested;
- evaluates the person's condition, needs, and service provision on an ongoing basis, per HHSC procedures and individual requirements;
- requests consultation and joint home visits with the regional nurse, provider nurse, or both when indicated because of the person's health condition or risk status;
- receives information from providers about the person's ongoing needs and conditions; and
- reassesses a person's needs and reviews and reauthorizes service plans per required schedules.
Review 2700, Service Monitoring, Changes, and Transfers, for detailed procedures concerning service monitoring.
- The caseworker is also responsible for helping people who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. Review 2130, Your Texas Benefits Medicaid Card and Replacement, for detailed procedures.
2130 Your Texas Benefits Medicaid Card and Replacement
Revision 17-1; Effective March 15, 2017
Form H3087, Medicaid Identification, is no longer issued and has been replaced by the Your Texas Benefits (YTB) Medicaid card.
The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services as the card is not proof of ongoing Medicaid eligibility. Medicaid recipients must take the card to doctor or dental appointments and to the pharmacy. This card is expected to be for permanent use and the Texas Health and Human Services Commission (HHSC) will only issue a new card if the card is lost or if the information printed on the card changes.
The individual may call 1-855-827-3748 if the card is lost and the individual needs a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line, so even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the individual later regains eligibility.
Requesting Form H1027-A, Medicaid Eligibility Verification
Form H1027-A, Medicaid Eligibility Verification, is a secure form, not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services Forms website for completion of the form. Designated HHSC staff may continue to assist individuals in the following situations:
- Ongoing Medicaid Recipients — HHSC staff may assist with a manual Form H1027-A upon request because the recipient either lost the YTB Medicaid card or did not receive it. HHSC staff issuing Form H1027-A should inform the recipient of the following:
- Call 1-855-827-3748 for a replacement card.
- The burden of verifying Medicaid eligibility is with the provider. An individual who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from his provider or to fill a prescription. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line or by using the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
- New Medicaid Recipients — Eligibility information is not immediately available for providers/pharmacies to verify after Medicaid is approved. HHSC staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time the eligibility is determined and the time the eligibility is available in the on-line system.
Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time services are requested. The recipient may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage if he is not sure of his eligibility status.
More information about the new card is available at: www.yourtexasbenefits.com.