2310 Criteria for Immediate or Expedited Responses to Service Requests

Revision 17-1; Effective March 15, 2017

An individual requires an immediate response to his service request if he has no available caregiver, he has personal care needs which are not now being met, and he is unable to do without personal care services for a full day.

The following examples of situations requiring immediate response are just that — examples. This list, and other lists within this section, are not intended to be all inclusive.

The individual:

• is totally bedridden or is unable to transfer from bed to chair without help,
• cannot manage toileting tasks without personal assistance, or
• is in danger of not receiving daily nourishment because of his need for total assistance in meal preparation or feeding.

An individual requires an expedited response to his service request if he needs personal care, he has no available caregiver, and his need for services has increased during the five days prior to the service request, or will increase during the five days following the service request. For example, the individual:

• is being or has been released from a hospital or nursing home within five calendar days of the request, and has no available caregiver to provide necessary care,
• is experiencing or recovering from a major illness and has no available caregiver, or
• loses his caregiver within five days of the request and has no available substitute.

All persons with AIDS or HIV infection requesting CCSE services should be carefully screened to determine if an immediate or expedited response is needed. CCSE regional nurses can provide consultation if needed. Persons with AIDS or HIV infection are often very ill and may need services initiated as soon as possible. It is essential that intake screeners and CCSE case workers follow the procedures for immediate or expedited responses, for all persons with AIDS or HIV infection who meet the criteria.

2320 Case Worker Response

Revision 18-1; Effective June 15, 2018

Respond to requests for Community Care Services Eligibility (CCSE) services according to the following program standards:

If the person with AIDS or HIV infection does not need an immediate or expedited response at intake, the case worker should closely monitor the situation during the routine referral process.

If the applicant's health condition suddenly deteriorates, make every effort to obtain services for the individual as quickly as possible.

After talking with the applicant or family, the case worker may alter the urgency of the request, as long as the change is made before the deadline for the intake priority. The case worker may contact the applicant after the period specified above if the:

• intake states that the applicant or family requests a delay in the visit and the visit is made on the date requested; or
• case worker makes two attempted contacts within the designated period. One attempted contact must be an attempted face-to-face contact (such as a home, hospital or nursing home visit) with the applicant or the authorized representative, referral source or other knowledgeable party if the applicant is unable to respond to the assessment questions. The second attempted contact must be either another attempted face-to-face contact or an attempted telephone contact with the applicant, his authorized representative, referral source or other knowledgeable party, if the intake does not identify an authorized representative for the applicant.

If the case worker contacts the applicant to schedule an appointment and the applicant refuses and states he does not want services, the case worker must close the intake in the Intake (NTK) system. The case worker may use the denial codes from the Community Services Interest List (CSIL) system in the comments in NTK. No entries in the Service Authorization System Online (SASO) are required and Form 2065-A, Notification of Community Care Services, is not sent.

The case worker should make every effort to ensure that the initial visit is conducted as close as possible to the date of the case assignment to the case worker. For service control purposes, this standard should be measured by comparing the date/time of the case assignment on Form 2110, Community Care Intake, to that on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Use the date of the initial assessment contact for Day Activity and Health Services (DAHS)-only cases. If the intake priority (for all except DAHS) is not checked (or information indicating priority level is not contained in case documentation), it is assumed to be immediate.

Although 14 days are allowed for a routine referral, timelines cannot be used as a justification to delay contact with the individual. If the two attempted contacts both occur near the end of the 14-day period, the case worker or supervisor may choose to call a timeliness error if a justifiable reason for delay is not documented in the case record.

Example: A case assignment for services is received March 1. The case worker makes the first attempted contact on March 11, and the second on March 14. In order to meet the program standard relating to timeliness of initial contact, the case worker must document why the delay could not have been avoided.

2330 Scheduling the Initial Interview

Revision 24-1; Effective March 1, 2024

The applicant is entitled to a face-to-face interview during the department's determination of their eligibility for Community Care Services Eligibility (CCSE) services.

Determining eligibility for CCSE services normally begins with a face-to-face assessment of the person, preferably in the home. Home visits are required for all CCSE applications, except for applications requesting Emergency Response Services, Home-Delivered Meals, or Day Activity and Health Services. Initial home visits for any one of these three services are required only at the applicant's request. A face-to-face home visit is required if, during the phone interview, it is determined attendant care is needed or requested, as indicated in Section 2431, Form 2060, Part A, Functional Assessment, and Section 4651, Assessing the Individual’s Needs.

Case workers must make at least two attempted contacts with a person before closing an intake. These two contacts should not be on the same day. The case worker may schedule the appointment by phone or by appointment letter using Form 2068, Application Redetermination, or Monitoring for Community Care Services. When feasible, ask the person's current caregiver to be present during the assessment. Schedule home visits for a time that is convenient to the applicant. If the appointment cannot be kept for any reason, the applicant or authorized representative must be notified in advance that the appointment will be rescheduled. Do not visit the applicant without informing the person in advance of the visit. If the person is not home for the scheduled appointment, the case worker should leave contact information such as a business card or letter, with relevant office and case worker contact information, for the person. The case worker should try to make a second attempt at contacting the person. The second attempt may be by phone or by home visit and if either is unsuccessful, the case worker may close the intake. The case worker cannot close out the intake until at least the second business day after the second contact attempt. The case worker needs to give the individual time to contact them back.

Example 1: Intake is assigned to the case worker Friday, March 2. On Monday, March 5, the case worker mails an appointment letter for an appointment on the following Monday, March 12. The case worker makes the home visit, but no one is home. The case worker leaves a letter with the office and case worker information on the door for the person. The case worker follows up by attempting to contact the person by phone on Wednesday, March 14, but is unsuccessful and is unable to reach the person or leave a message because the person’s number is not set up to accept voicemail. If the person does not respond, the case worker may close the intake since they made two attempts to contact the person. The case worker and may close the intake on the second business day after the second attempt or Friday, March 16.   

Example 2: Intake is assigned to the case worker Friday, March 2. On Monday, March 5, the case worker calls and reaches the person’s daughter whose phone number is the only number listed on the intake. The daughter states she is the power of attorney (POA) and lives with her mother who is the person who needs services. The daughter agrees to a home visit on Friday, March 9.  The case worker verifies the address and asks if there are any other phone numbers which need to be listed. The daughter verifies the address. The case worker makes the home visit, but no one is at home. The case worker leaves a business card with the case worker and office information on the door for the person and her daughter. The case worker has made two attempted contacts, the first by phone to set the appointment and the second with the home visit attempt. If the person has not responded, the case worker may close the intake Tuesday, March 13 which is the second business day after the second attempt to contact the person.

If a case worker contacts an applicant to schedule a home visit and the applicant states they have a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker should schedule a future date for the visit when the applicant thinks they will be better. If unable to schedule the visit for a future date, the case worker must contact the applicant at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation is considered an acceptable reason for delaying a required home visit.

Although a face-to-face visit with a person in a nursing home, hospital, prison or jail facility is acceptable, this visit does not allow the case worker to assess the person in the home environment or to assess family resources and how they function at home. If the initial visit and eligibility determination must be done in a location other than the person's home and in-home services are subsequently initiated, conduct a home visit within 30 days after service initiation and make any necessary revisions to the service plan per Section 2663, Reassessment of Functional Need. Document the home visit on Form 2059, Summary of Client's Need for Service (Item 4 or 8), or in the case narrative.

A person is not required to submit an application form, if they already receive services from the Texas Health and Human Services Commission (HHSC), or for whom Social Security Administration has already verified that the person is financially eligible for Supplemental Security Income (SSI).

A person who is not receiving services from HHSC, not receiving SSI, or who needs a financial eligibility determination from Medicaid for the Elderly and People with Disabilities (MEPD) must complete Form H1200 , Application for Assistance-Your Texas Benefits. 

The form may be mailed if the applicant can complete the form or has help available. If the applicant is not capable of completing the form, it is the case worker's responsibility to provide the form and help the applicant complete the form at the first interview. If the form has been mailed to the applicant, it is the case worker's responsibility at the first interview to review the form for completion and if necessary, help the applicant in completing the form.

The official date of application is the date HHSC staff receive a completed, signed and dated Application for Assistance. The application date on the Service Authorization System screen is the date of:

• receipt of the application, as defined above; or
• the initial home visit, for categorically eligible applicants for whom an application form is not required.

Related Policy

26 Texas Administrative Code Section 271 .151(b) 
Categorical Eligibility, 2341.3 
Income and Income Eligibles, 3310

2331 Information and Referral (I&R)

Revision 17-1; Effective March 15, 2017

If, during the initial interview it is determined that the individual could use services from other agencies in the community, refer him to the appropriate agency or community resource. Fully discuss the referral with him and his family, if they are present. Give complete information about Community Care Services Eligibility (CCSE)  services and about any other Texas Health and Human Services Commission (HHSC) services (for example, the Supplemental Nutrition Assistance Program (SNAP) or the Qualified Medicare Beneficiary program) that might be helpful. See Appendix XV, Services Available from Other State Agencies.

Always refer an applicant or individual to the Social Security Administration if the individual appears eligible for Supplemental Security Income (SSI) but does not receive SSI. Consult with Medicaid for the Elderly and People with Disabilities (MEPD) staff if there are questions about SSI eligibility.

When referring an individual to other agencies or other HHSC services, fully inform him about where he must go to apply. Help set up his appointment, if necessary. Provide the office address, telephone number, name of the correct person to contact, and the appointment date and time (if known).

Provide I&R services to individuals without regard to their incomes. Do not register with the Service Authorization System Online (SASO) persons who receive only I&R services. Document I&R services as required by regional policy.

2332 Requests for Services from Individuals Under Age 21

Revision 17-1; Effective March 15, 2017

Children who have a medical need and meet other eligibility requirements may receive Community Attendant Services (CAS). The age requirements that apply to other community care programs do not apply to CAS. However, the applicant under age 21 must meet all other eligibility criteria, including medical, financial, functional and unmet need.

Upon receipt of a request for services from an individual under age 21, the case worker must contact the regional nurse and arrange for a joint visit for the initial home visit assessment. The regional nurse will assist in the screening of the individual for medical need, determine if there are skilled tasks that cannot be performed by a personal attendant, and determine whether the caregiver must be present in the home to perform skilled tasks or react to emergency medical situations while the personal attendant is in the home.

See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information.

2333 Applications

Revision 24-1; Effective March 1, 2024

An application for services was made if any one of the following occurs:

• a home visit in relation to an intake or interest list release has occurred;
• the case worker has completed or begun to complete any part of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; or
• Form H1200, Application for Assistance-Your Texas Benefits, was completed.

Once an application has begun, the case worker must record the disposition of the application in the Service Authorization System Online (SASO).

Examples:

Example 1 (Request for Services Only): A hospital social worker contacts HHSC on behalf of a person who is being discharged the following day. The social worker notes that the person lives alone and believes the person’s condition will result in a need for personal attendant services (PAS). In response to the social worker's call, an intake specialist contacts the person and he states that his daughter will be living with him during the weeks following release from the hospital and will be able to provide all his needs. He states that he will call HHSC if PAS is needed at a later time.

This is not an intake but is an example of a request for services that is appropriately screened and determined CCSE services are not needed at this time. Although the intake specialist contacted the person and some information may have been recorded, Form 2110, Community Care Intake, was not completed in the Intake (NTK) system and a case worker was not assigned to the case. There is no need to send Form 2065-A, Notification of Community Care Services. No entries in SASO are required.

Example 2 (Intake Only): A person contacts HHSC requesting Home-Delivered Meals (HDM). The intake specialist completes Form 2110 and assigns the intake to a case worker. When the case worker calls to set up an appointment, the person states that he has changed his mind and does not want HHSC services. The case worker records the correct denial code (from the Community Services Interest List (CSIL) denial codes) for voluntary withdrawal in the NTK system comments section. There is no need to send Form 2065-A. No entries in SASO are required.

Example 3 (Application): A person contacts HHSC and requests Primary Home Care. The case worker schedules the home visit and upon arriving at the person’s home, the person states he is moving out of state and does not need services. Because a home visit was made, this is considered an application and must be entered in SASO and Form 2065-A sent to the applicant.

2333.1 Required SASO Entries for Applications Withdrawn Early in the Process

Revision 17-1; Effective March 15, 2017

All applications must be entered in the Service Authorization System Online (SASO) within 30 calendar days of the home visit date or receipt of the application. See Section 2611, Processing Time Frames, for additional information. This includes situations such as the one described in Example 3 in Section 2333, Applications, where very little information has been gathered. The type of SASO entries required depends on the type and amount of information collected by the case worker.

2340 The Initial Interview and Application Process

Revision 17-1; Effective March 15, 2017

During the initial home visit interview, the case worker:

• explores the applicant's needs and which services can meet those needs, including services available from other agencies;
• assists the applicant in the completion of the Application for Assistance, if the applicant is not categorically eligible;
• screens the applicant for the Community Attendant Services (CAS) program, if requesting attendant services and not categorically eligible;
• completes the functional assessment, including assessing the applicant's functional eligibility relative to the performance of activities of daily living and assessing the applicant's home, social/environmental supports and resources;
• presents Appendix XXXV, Long Term Services and Supports;
• reviews and explains Form 2307, Rights and Responsibilities, including information on confidentiality, and have the applicant sign the acknowledgment;
• offers to assist the applicant in registering to vote;
• reviews and explains the available service delivery options and complete the required documentation as explained in Section 6000, Service Delivery Options; and
• reviews and explains the Medicaid Estate Recovery Program (MERP), if requesting CAS, and has the applicant sign Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement.

If the applicant is only able to sign documents with an "X," the case worker may make the required documentation and then date and initial the entry.

The case worker also must be alert for indications of abuse, neglect or exploitation when assessing CCSE individuals. Anyone who has reason to believe an elderly person or an individual with a disability is being abused, neglected or exploited must report this information to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS) (Title 2, §48.306 of the Texas Resources Code). Immediately notify APS of any reports received that indicate an elderly person or individual with a disability has been abused, neglected or exploited.

If a CCSE individual has been referred to APS in the past and it is possible another referral may be needed now for the same problems, contact APS to discuss the situation before a formal referral is made. Document the APS response in the CCSE case record. See Appendix XV-E, Department of Family and Protective Services (DFPS), for more information.

2341 Financial Application Process

Revision 24-1; Effective March 1, 2024

Applicants or their representatives applying for services provided regarding income must sign an application for assistance form. Non-Medicaid applicants or their representatives applying for retroactive reimbursement for Medicaid-covered attendant services must also sign an application for assistance form. The date of application is the date the department receives the signed application. Applicants must provide correct information about income and resources.

Non-Medicaid applicants or their representatives applying for Medicaid-covered attendant services may be reimbursed for services provided up to three months before the month of receipt of a completed, signed and dated application.

If an application is denied for any reason, the previously completed application form is valid for 90 days after the date of denial. A written, dated and signed statement of request to reapply must be obtained from the applicant or authorized representative. The statement must be sent to Medicaid for the Elderly and People with Disabilities by the close of business the second business day. Documentation in the case record must indicate if any changes have occurred since the original application date.

The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked application. The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for Community Attendant Services. The case worker includes all identifying information on Form H1746-A, and any other information that will help identify the original application, and faxes Form H1746-A and documentation to the Austin Document Processing Center.

The case worker will also be able to use Form H1200, Application for Assistance – Your Texas Benefits, on file for up to 90 days following the denial date of Form 2065-A, Notification of Community Care Services. The case worker may also use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the other forms signed at the initial home visit, and verifications on file. The case worker does not need to make an additional home visit but must review Form H1200 and Form 2060 with the applicant and document any changes occurring since the first visit. The case worker needs to follow appropriate time frames for annual reassessments as the annual reassessment will still be due within 12 months of the initial home visit.

Related Policy

26 Texas Administrative Code (TAC) Section 271 .151(c) 
26 TAC Section 271.151(e) 

2341.1 Application for Assistance Form

Revision 24-1; Effective March 1, 2024

People applying for services without categorical eligibility status apply for Community Care Services Eligibility (CCSE) services by completing Form H1200, Application for Assistance – Your Texas Benefits.

Use Form H1200 for people who are:

• not Medicaid recipients and apply or appear to be eligible for community Attendant Services (CAS); or
• non-Medicaid applicants who are not categorically eligible and who apply or appear to be eligible for:
  • Title XX CCSE services; or
  • Qualified Medicare Beneficiaries (QMB) or Specified Low-Income Medicare Beneficiaries (SLMB).

An application is incomplete until it contains the person’s signature. If unable to sign, it is acceptable to allow the person to make an "X," along with two witnesses' signatures. Unless no other option is available, the case worker should not be one of the witnesses.

If Form H1200 is being sent to Medicaid for the Elderly and People with Disabilities (MEPD), the signature must be on the form. Unsigned applications will be returned to the sender. HHSC staff must ensure applications are signed before referring to MEPD. If MEPD receives an unsigned application from HHSC with either Form H1746-A, MEPD Referral Cover Sheet, or Form 2067, Case Information, MEPD returns the application to HHSC with an annotation on the cover form (Form 2067 or Form H1746-A) that the application is unsigned and must be signed before HHSC can establish a file date. Once HHSC staff receive an unsigned application from MEPD, they must coordinate with the person to get the application signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to people.

2341.2 Application for Assistance Form Completion and Receipt Date

Revision 24-1; Effective March 1, 2024

Form H1200, Application for Assistance-Your Texas Benefits, may be mailed if the applicant can complete the form or has help available. If the applicant is cannot complete the form, it is the case worker's responsibility to provide the form and help the applicant with completing the form at the initial interview.

If Form H1200, Application for Assistance-Your Texas Benefits, has been mailed to the applicant, it is the case worker's responsibility at the initial interview to review the form for completion and help the applicant complete the form, if necessary.

Ensure that the person completes the entire application, signs and dates it, and understands the penalties for fraud in the event the person deliberately gives false information. Do not make any changes to Form H1200, Application for Assistance-Your Texas Benefits, after the applicant has signed it. Document any changed or additional information on Form 2064, Eligibility Worksheet.

For applicants or people requiring a Medical Assistance Only (MAO) determination to be sent to Medicaid for the Elderly and People with Disabilities (MEPD), the case worker must assist the applicant or person with completion of the application form and provide the most complete packet possible to MEPD. The case worker should ensure the following items are included to facilitate the financial eligibility process:

• bank accounts for community attendant services – bank name, account number and balance;
• award letters showing amount and frequency of income payments;
• life insurance policy – company name, policy number, face value or copy of the policy;
• a signed and dated Form H0003, Agreement to Release Your Facts;
• confirmation that Medicaid Estate Recovery Program and Appendix XXXV, Long Term Services and Supports, were shared with the applicant by checking the appropriate boxes on Form H1746-A, MEPD Referral Cover Sheet or Form 2067, Case Information;
• preneed funeral plans – name of company, policy or plan number, and copy of preneed agreement;
• correct up-to-date phone numbers; and
• power of attorney or guardianship – copy of the legal document.
   

While it may not be possible to obtain everything on the list, the case worker should gather all available information to prevent the applicant from a delay in certification. The case worker should explain to the applicant that failure to submit the required documentation to MEPD could delay completion of the application or cause the application to be denied.

When a signed and dated Form H1200, Application for Assistance-Your Texas Benefits , is received by the case worker at the home visit, or is mailed or hand delivered to a Texas Health and Human Services Commission (HHSC) office, the date of receipt becomes the official date of application.

If Form H1200, Application for Assistance – Your Texas Benefits, has not been returned by the 30th day from the initial home visit, the case worker may deny the application. The case worker sends Form 2065-A, Notification of Community Care Services, with Rule Reference 26 Texas Administrative Code Section 271.151(c): “Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form.” In the comments section, the case worker enters: “HHSC is unable to make an eligibility decision within 30 days due to your failure to furnish information.” The case worker must document all contact in the case record.

When an income eligible person is receiving services and their spouse applies  after the eligible person, the eligible person’s form, if it is less than one year old, may be used for the spouse. Review Form H1200, Application for Assistance-Your Texas Benefits, to ensure the information is still valid, have the spouse sign and date it for the current application, and complete a new eligibility determination. 
 

2341.3 Categorical Eligibility

Revision 17-1; Effective March 15, 2017

If a financial determination has already been made for the applicant by Social Security or another program within the Texas Health and Human Services Commission (HHSC), then the applicant may be considered categorically eligible. The applicant is categorically eligible if receiving:

• Supplemental Security Income,
• Temporary Assistance for Needy Families,
• Supplemental Nutrition Assistance Program,
• Medicaid,
• Medicaid Buy-In (MBI) benefits*,
• Qualifying Individual (QI) benefits,
• Specified Low-Income Medicare Beneficiary (SLMB) benefits,
• Qualified Medicare Beneficiary (QMB) benefits, or
• other Community Care Services Eligibility (CCSE) services.

*Note: Medicaid Buy-In benefits provide categorical eligibility only for the following programs:

• all Long Term Services and Supports Title XX programs,
• Day Activity and Health Services Title XIX,
• Primary Home Care, and
• Texas Home Living waiver program.

Completion of the Application for Assistance form is not required for a categorically eligible applicant. The date of the initial home visit with the person is considered the date of application.

See Section 7110, TIERS Inquiries, for complete information on how existing coverage affects eligibility for CCSE services.

2341.3.1 Effect of QI Benefits on Eligibility for Community Care Services

Revision 17-1; Effective March 15, 2017

The Qualifying Individuals (QI) program was created by Public Law 105-33, as part of the Balanced Budget Act of 1997. The legislation specifies that QI recipients cannot be eligible under any other Title XIX-funded program and simultaneously receive QI benefits. Therefore, applicants and individuals receiving QI benefits are not eligible for Primary Home Care (PHC), Community Attendant Services (CAS) or Title XIX Day Activity and Health Services (DAHS). QI recipients are eligible to receive Title XX Family Care (FC) or Title XX DAHS, or both, provided all other eligibility criteria are met.

Identification of QI Coverage

At the time of application for Title XIX services and at each subsequent annual reassessment, case workers must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is receiving QI services. TIERS designates QI coverage as Type Program (TP) of Assistance TP-26.

Procedure for Applicants

If an applicant specifically requests PHC, CAS or DAHS, explain that individuals may not receive QI while receiving any other Title XIX-funded service. Inform the individual that there is no prohibition against receiving Title XX FC or DAHS at the same service levels. Applicants requesting DAHS must be certified for Title XX DAHS. Receipt of QI services does not preclude applicants from being placed on any existing interest list.

Procedure for Ongoing Individuals

When it is discovered that an individual receiving a Title XIX Community Care Services Eligibility (CCSE) service (CAS, PHC or Title XIX DAHS) has been certified for QI benefits, the case worker must first determine if enrollment in Title XX FC/ DAHS is open or if an interest list exists for the desired service. If no interest list exists, process the request for the desired service. If it is determined that the individual will have to be placed on a Title XX FC/ DAHS interest list, the case worker must contact the individual to give him the choice of service he wants to continue (QI or Title XIX CCSE service).

The case worker's next actions will depend on the individual's decision:

• If the individual elects to continue receiving the Title XIX CCSE service, explain that this will require that his QI benefits be denied. Send Form 2067,
• Case Information, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to let MEPD know the individual's decision.
• If the individual decides to transfer to a Title XX service in order to keep his QI benefits, grant that service (if regional budgetary conditions allow) without placing him on the interest list. Otherwise, the individual should be placed at the top of the interest list. Title XIX service cannot remain open while the individual waits for an available slot.
• Follow up with written notification using Form 2065-A, Notification of Community Care Services.

2341.4 Refusal to Cooperate with the Application Process

Revision 24-1; Effective March 1, 2024

If the applicant refuses to sign Form H1200, Application for Assistance – Your Texas Benefits,  or otherwise refuses to participate in the assessment process, do not proceed with the application process. Advise the applicant that they will receive a notice of ineligibility in the mail. Send the applicant Form 2065-A, Notification of Community Care Services. Use Code 17, "You failed to provide the necessary information."

2341.5 Retroactive Payment Process

Revision 17-1; Effective March 15, 2017

The retroactive payment process is an option that an individual and/or the provider may use if the individual has an immediate need for assistance with personal care task(s) pending the Texas Health and Human Services Commission's eligibility decision for Medicaid eligibility. See Section 2348, Retroactive Payments.

2342 Screening for Personal Attendant Services (PAS)

Revision 21-3; Effective September 1, 2021
 
Program Standard: Staff must screen all applicants and recipients for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC) or continuing with an authorization for FC. When appropriate, make a referral for PHC or CAS eligibility services.

Screening Initial Applicants

Determine if the applicant is currently receiving Medicaid before the initial interview.  If the person is active on Medicaid, explore eligibility for PHC using the additional screening criteria to determine if a referral to PHC is appropriate.

If the person is not on Medicaid, explore income and resources to determine if they are potentially eligible for CAS. If the person does not appear eligible for PHC or CAS, explore eligibility for FC.

If the person's income and resources appear to be within the Supplemental Security Income (SSI) limits and the person appears to have a medical need for assistance with personal care, refer them to the Social Security Administration (SSA) for an SSI application. However, staff should continue the referral for the PAS even if the applicant refuses to apply for SSI.

If the person is not receiving Medicaid and their income and resources are above SSI limits, complete Form H1200, Application for Assistance - Your Texas Benefits,  during the interview or review the application form mailed to the applicant for completion. Assist the applicant in the completion of the form and obtain all required verifications that are available.

If the person cannot complete the application form during the interview, explain that is important to return the form and any additional verification documents as soon as possible. Also, explain their eligibility for attendant services cannot be determined until the form is received.

Fax the completed application and verification documents with Form H1746-A, MEPD Referral Cover Sheet, to the Austin Document Processing Center (DPC) within two business days.

Screening Ongoing FC Cases for PHC or CAS

Apply the screening exception criteria at the next annual review if a person or provider reports interim changes between annual reassessments.

Review the screening exception criteria to see if the person’s circumstances have changed at each annual functional reassessment of FC.

Example: a person was placed on FC due to no personal care tasks, the annual reassessment is being completed over the phone, and the person now requires a personal care task. Staff must refer the person to CAS or PHC and complete the home visit within 14 days of the annual functional reassessment.

CAS – A referral to MEPD must be sent within two business days of the home visit for the annual functional reassessment.

PHC – If it is not mandatory to enroll the person in STAR+PLUS, the transfer to PHC must be completed within 14 calendar days. If it is mandatory to enroll the person in STAR+PLUS, leave the person on FC, but start the process for the person’s enrollment in STAR+PLUS.

Financial eligibility must be redetermined for FC within 24 months of the last eligibility determination.

Example: if MEPD previously determined the person was ineligible for CAS due to resources, staff must review the person’s financial status. If it appears the person would now meet CAS requirements, staff must assist the person in completing a new Form H1200, Application for Assistance – Your Texas Benefits, and obtain verification of income and resources to send to MEPD.

Related Policy

Timely Referral to MEPD, 2342.2
Exceptions to Verification Requirements, 3422
Transition Between HHSC and STAR+PLUS, 6430
Income and Resource Limits, Appendix XI

2342.1 Receipt Date of the Application Form

Revision 17-1; Effective March 15, 2017

The date of the official application is the day the application form is received by the case worker at a home visit, or received by mail or hand delivered to a Texas Health and Human Services Commission office.

See Section 2333, Applications, for a list of acceptable applications.

If the case worker receives the application form during the home visit, the case worker enters the date in the "Date Form Received" box at the top of the form.

2342.2 Timely Referral to MEPD

Revision 20-4; Effective December 1, 2020

Before the initial home visit, staff must check TIERS to determine if the applicant has an active record. If there is no active record, consider the person a "new" applicant. A new applicant is a person who is not currently authorized to receive services in TIERS.

Consider the application complete with a name, address and signature. A person does not have to fill out the application in its entirety to be considered valid. The date of receipt of the application form with the name, address and signature is considered day zero.

New Applications

No later than the close of business on the second business day after receipt of a completed application form, staff must:

• Fax the completed application and verification documents with Form H1746-A to the Austin Document Processing Center (DPC); and
• Retain the original Form H1200, Application for Assistance – Your Texas Benefits, and a copy of the successful fax transmittal confirmation in the case record. The original application form must be retained in the case record for three years after the case is denied or closed.

Prior Applications

If an active record of the applicant is found in TIERS, including current recipients requesting a program transfer, then no later than close of business on the second business day after receipt of the completed application form, CCSE staff must:

• fax the completed application and verification documents to the Austin DPC, using Form H1746-A as a cover sheet; and
• retain the original Form H1200, Application for Assistance – Your Texas Benefits in the case file. The original form must be kept for three years after the case is denied or closed. CCSE staff must also retain a copy of the successful fax transmittal confirmation in the case record.

Transmittal

All communication to MEPD must include Form H1746-A, MEPD Referral Cover Sheet.

Note: Form 2067, Case Information, is not an acceptable means of communication to MEPD staff.

If Form H1746-A is not completed correctly, an incorrect assignment to MEPD staff could result.

CCSE staff must follow the guidelines listed in the H1746-A form instructions or in Appendix V, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, to ensure correct assignment is made.

Related Policy

Application for Assistance Form, 2341.1
Medicaid Program Actions, Appendix XXXII
Program Transfer Guide with Form H1200, Appendix XLV
Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, Appendix V

2342.3 Exception Criteria for Referrals to PHC or CAS

Revision 24-1; Effective March 1, 2024

The case worker must screen all applicants for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring to Family Care (FC). The case worker applies the following exception criteria to determine if the applicant has a reason not to be referred for CAS, or if on Medicaid, would not be eligible for PHC.

To determine if the applicant is not appropriate for a referral to PHC or CAS, screen the applicant for the following criteria:

• Does the applicant specifically state that they will accept care only from their spouse as the paid attendant, and unmet need policy does not preclude this arrangement?
  • If yes, the applicant is referred for FC or placed on the Family Care interest list and is not referred for CAS. If no, then continue the screening process.
• Does the applicant receive Qualifying Individual (QI) benefits?
  • If yes, explain the choices of benefits per Section 2341.3.1, Effects of QI Benefits on Eligibility for Community Care Services. If the applicant elects to keep the QI benefits, they may be referred for FC or placed on the FC interest list. If the person elects to be referred to CAS, continue the screening process.

Other Criteria:

• Does the applicant meet the citizenship requirements needed to establish eligibility for Medicaid-funded programs?
• Does the applicant have a need for at least one personal care task?
• Does the applicant have a medical condition causing a functional impairment in performing personal care tasks?
• Does the applicant have a medical diagnosis other than mental illness, intellectual disability or both?
• Does the applicant have a practitioner who will sign a statement that the applicant has a medical need for help with personal care tasks and other activities of daily living?
• Does the applicant require at least six hours of service per week or meet exemptions listed in Section 4633, Functional Eligibility?

If the applicant answers “Yes” to all other criteria, then a referral for PHC or CAS is made. If the applicant answers “No” to any one of the other criteria, then the person is referred for FC or placed on the FC interest list and is not referred for PHC or CAS.

Placement on the FC Interest List

Within five workdays of screening for CAS or PHC, using the original date of the request for services, assigned staff must enter all relevant data into the Community Services Interest List (CSIL) if FC enrollment is:

• open and the applicant does not meet the screening criteria for CAS or PHC, or the case worker will authorize FC while CAS financial eligibility is pending; or
• not open and the applicant does not meet the screening criteria for CAS or PHC.

The original date of the request for services is the date the applicant called in requesting services, listed on Form 2110, Community Services Intake.

FC Services Pending the CAS Eligibility Decision

If FC enrollment is open in a region, the case worker assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending from Medicaid for the Elderly and People with Disabilities (MEPD). If a person placed on the FC interest list is released from the interest list, the case worker must screen the person for CAS and refer to MEPD, if screening criteria are met. The case worker also assesses the applicant for FC and, if eligible, authorizes services while the CAS eligibility decision is pending.

If the person is determined eligible for CAS, the case worker follows the policy in Section 4652.3, Initial Referrals for Community Attendant Services, and negotiates a transfer from FC to CAS. The case worker sends Form 2065-A, Notification of Community Care Services, noting the transfer of services. If the person is not eligible for CAS, the case worker continues FC services, unless the person was denied CAS for refusal to cooperate.

Refusal to Cooperate with MEPD

If the person is denied for refusal to cooperate with the financial eligibility determination process, including refusal to furnish information or withdrawing the CAS application, the case worker must follow up with the person to explore why they did not cooperate. If the person states they are unwilling to cooperate with the financial eligibility determination process, then the case worker must advise the person their application for services is denied and will be referred for CAS again if they reapply later. The case worker documents all contacts in the case record and sends Form 2065-A to the person citing rule reference 26 Texas Administrative Code Section 271.69(a)(3).  In the comments section, the case worker includes the following statement. “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. Medicaid for the Elderly and People with Disabilities has notified HHSC you failed to provide the necessary information to determine eligibility for Medicaid-funded services.” If the person requests to be placed on the FC interest list, they may be placed on the list, but must be informed that they will be referred to CAS when their name is released from the list.

If the person is receiving FC services pending the MEPD eligibility decision and they refuse to cooperate with the financial eligibility determination process as described above, the case worker must deny FC services. The case worker documents all contacts in the case record and sends Form 2065-A to the person citing rule reference 26 Texas Administrative Code Section 271.69(a)(3). In the Comments section, the case worker includes the following statement, “To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. You failed to provide the necessary information to determine eligibility for Medicaid-funded services.”

If the individual states that he cooperated and thought he submitted all requested information, the case worker may check the Comments section in the Texas Integrated Eligibility Redesign System (TIERS). The case worker may need to assist the individual in obtaining any missing requested documentation.

The individual can reapply for CAS for up to 90 days from the date of the MEPD denial without completing a new Form H1200, Application for Assistance – Your Texas Benefits. The case worker must obtain a written, dated and signed statement of request to reapply from the applicant or authorized representative to establish the date of application. The case worker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked “Application.” The case worker must clearly note on Form H1746-A that the applicant is requesting to reapply for CAS. The case worker includes all identifying information on Form H1746-A, and any other information that will help identify the original application. Fax Form H1746-A and documentation to the Austin Document Processing Center.

Applications Denied by MEPD

If a referral is sent to MEPD and the person is denied CAS eligibility for reasons other than refusal to cooperate with the financial eligibility determination process, then the person remains eligible for FC or is placed on the FC interest list. The assigned staff enter the information into the CSIL using the original request date for services when placing the person on the interest list.

If the person who was denied CAS eligibility for reasons other than refusal to cooperate is released from the FC interest list within 90 days of the application date, the case worker may use:

• Form H1200, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide,
• the additional forms signed at the initial home visit; and 
• verifications on file to determine eligibility for FC.  

The case worker:

• must review all the information provided and note any changes on Form 2064, Eligibility Worksheet;
• must establish that the person meets all financial eligibility requirements for Title XX services; 
• does not need to do another home visit, but must review Form H1200 and Form 2060 with the applicant and document any changes occurring since the first visit; and
• will need to follow appropriate time frames for annual reassessments as the annual reassessment are still due within 12 months of the initial home visit. 

FC Annual Reassessments

Refer to Section 4447, Reassessment, for FC reassessment procedures.

2342.4 Spouse Attendant in Family Care Services

Revision 17-1; Effective March 15, 2017

If an individual states he will accept care only from his spouse, then the individual may be assessed for Family Care services or placed on the Family Care interest list and not referred to Primary Home Care (PHC) or Community Attendant Services (CAS).

Individuals on Medicaid may elect to receive Family Care services to have a spouse attendant. The policy that states, “"To be eligible for Family Care, the individual must not be eligible to receive attendant care services funded through Medicaid",” does not apply if the individual elects to have a spouse attendant. Even though these individuals meet the criteria to be referred to CAS, they may elect to receive Family Care services and not be screened or referred to Medicaid for the Elderly and People with Disabilities (MEPD) for a financial determination.

Unmet need policy applies and the case worker must carefully evaluate tasks provided and tasks not currently provided by the spouse to determine the service plan purchased through Family Care services. See Section 2513, Caregiver as the Paid Attendant, and Section 2514, Who Cannot Be Hired as the Paid Attendant, for additional information. The policy must be followed and the spouse assessed as any other caregiver. One exception to the policy is that on Form 2101, Authorization for Community Care Services, the case worker must note the individual is requesting the spouse as the paid attendant.

If the arrangement for the spouse as the attendant ends, then the individual must be referred for the appropriate Medicaid funded service.

2342.5 Disability Determination for People Under 65 Applying for CAS

Revision 24-1; Effective March 1, 2024

The Texas Health and Human Services Commission (HHSC) case worker must help certain people under 65 complete the forms required by HHSC for a disability determination. People 65 or over may qualify for Medicaid or Medicaid-funded programs, such as Community Attendant Services (CAS), without a disability determination.

The case worker must review a person’s disability status by using the State On-Line Query (SOLQ) or Wire Third Party Query (WTPY) systems. A person has a disability established by Social Security if there is a disability onset date on the SOLQ or WTPY systems. If the person under 65 does not have a Social Security established disability, the case worker must help the person complete Form H1200, Application for Assistance – Your Texas Benefits, Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact when assessing eligibility.

To determine a disability, HHSC must review evidence, signed by the person’s treating physician, including medical reports, detailing the degree and history of the individual's diagnosis. The case worker must inform the person when scheduling the initial face-to-face contact that the case worker will need the required evidence at their initial contact. If the case worker schedules the face-to-face contact at least seven calendar days in advance, the case worker must send Form 2423, Request for Medical Evidence, to the person on the same day of the phone contact to advise the person of the evidence requirement. If the case worker schedules the face-to-face contact less than seven calendar days in advance, the case worker must present Form 2423 at the face-to-face contact. The case worker must not delay the face-to-face contact to allow the person time to get the medical evidence.

The case worker includes the completed Form H3034, Form H3035 and any evidence obtained at the initial face-to-face contact with Form H1200 following current transmittal procedures to Medicaid for the Elderly and People with Disabilities (MEPD). If evidence was not available at the initial face-to-face contact, the case worker documents "No evidence was obtained" in the Section I, Comments about your disability, on Form H3034 before submitting to HHSC for a disability determination.
 

2343 Confidentiality

Revision 24-1; Effective March 1, 2024

Information for Texas Health and Human Services Commission (HHSC) applicants and other people is confidential and can only be used for purposes directly connected to administration of HHSC services. HHSC routinely shares confidential information with providers because the information shared is directly connected with service administration.

Information can also be shared with other entities if the purpose is directly tied to the administration of services. Consult the unit supervisor before making the decision to share information with people other than the providers.

Code of Federal Regulations, Title 42, Part 431, Subpart F – Safeguarding Information of Applicants and Recipients – (a) Section 1902(a) (7) of the Act requires that a state plan must provide safeguards that restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan.

Refer to Section 1140, Disclosure of Information, regarding national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

Related Policy

26 Texas Administrative Code Section 271 .151(a) 
 

2344 Individual Rights and Responsibilities

Revision 18-2; Effective November 19, 2018

During the initial visit with the applicant and, as appropriate, the responsible person (RP), discuss the information contained in Form 2307, Rights and Responsibilities. Ensure the applicant understands the significance of his rights and responsibilities.

If the applicant appears unable to understand this information or the complaint process, it is important to give the RP a copy of Form 2307. Sharing the applicant's rights and responsibilities with the RP is particularly important if it appears the applicant may not be able to fully understand his rights and responsibilities. An RP may be a guardian, family member or other individual who assists in the development of the care plan and/or who maintains regular communication with the applicant or department regarding the applicant's well-being.

The applicant must:

• provide all information needed to establish eligibility and develop a service plan. Falsifying information is illegal and may result in criminal charges filed against the applicant.
• promptly report changes in income, living arrangements, family size, loss of assistance grants or Medicaid benefits, or other changes that affect eligibility. If the applicant willfully fails to report changes that affect eligibility and receives services for which he/she is not eligible, the applicant may be prosecuted for fraud.

Rights and Responsibilities Documentation Requirements

At Application

At the initial home visit, the case worker must clearly and fully explain the information in the following forms with the applicant. Maintain copies in the case record and review with the applicant/RP as indicated in the instructions for each form.

Individuals must receive the following forms and attachments:

• Form 2307, Rights and Responsibilities;
• Attachment 2307-EVV, Electronic Visit Verification Rights and Responsibilities, if applying for Community Attendant Services, Primary Home Care or Family Care Services;
• Form 1581, Consumer Directed Services Option Overview; and
• Form 1584, Consumer Participation Choice, if applying for personal attendant services (PAS).

If the applicant selects the Consumer Directed Services (CDS) option on Form 1584, he/she must also receive:

• Form 1582, Consumer Directed Services Responsibilities; and
• Form 1583, Employee Qualification Requirements; and
• Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option.

If the applicant selected the Service Responsibility Option on Form 1584, he/she must also receive:

• Form 1581-SRO, Service Responsibility Option (SRO) Overview; and
• Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

See Section 6000, Service Delivery Options, for complete information and requirements on CDS and SRO.

Individuals applying for Family Care, Community Attendant Services or Primary Home Care, Emergency Response Services (ERS) and Adult Foster Care (AFC) services must be given the following forms for the requested service:

• Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities;
• Attachment 2307-B, ERS Eligibility Criteria and Responsibilities; or
• Attachment 2307-F, AFC Rights and Responsibilities.

All applicants must receive Form 2065-A, Notification of Community Care Services, notifying them of the eligibility decision.

Annual Reassessments and Changes

• Clearly document in the case record that the individual's rights and responsibilities were reviewed at the annual reassessment.
• Keep the current Form 2307 on file at the annual reassessment if nothing has changed affecting the individual's services. Telephone numbers and staff names do not constitute a change for completing a new Form 2307, although it is important that the individual knows how to reach the case worker (business cards are suggested).
• If the individual's services have changed, the individual/RP must complete and sign a new Form 2307.
• As appropriate, review the information on Attachment 2307-A, Attachment 2307-B, Attachment 2307-F and Attachment 2307-EVV with the individual/RP. Complete new forms if PAS, ERS or AFC are being added as new services.
• With the exception of ERS, Home-Delivered Meals (HDM), and Day Activity and Health Services (DAHS), a home visit is required to add a service to the individual's service plan.
• Review and offer the choice of service delivery options at the annual reassessment and obtain a new signed and dated Form 1581.
• Clearly document in the case record that the choice of service delivery options was reviewed at the annual reassessment.
• Obtain a new signed and dated Form 1584 at any time the individual changes his service delivery option. The case worker will also need to complete Form 1581, (or Form 1581-SRO), Form 1582, (or Form 1582-SRO) and Form 1583, as appropriate.
• Send Form 2065-A if the case action includes:
  • the addition of a new service;
  • a change in the amount of service;
  • a change in the amount of the individual's copayment;
  • a change in priority status; or
  • termination of the case or service.

See Appendix IX, Notification/Effective Date of Decision, for additional details or exceptions.

2345 Registering to Vote

Revision 24-1; Effective March 1, 2024

The National Voter Registration Act (NVRA) of 1993 requires that the Texas Health and Human Services Commission (HHSC) offer each person applying for HHSC services the opportunity to register to vote, to record the person’s decision on Form 1019, Opportunity to Register to Vote/Declination, and to file it in the case record. Additionally, HHSC case workers must also offer the person an opportunity to register to vote at annual reassessments, when notified of a change of address and name change.

The HHSC case worker must provide the same degree of help, including bilingual assistance, to help the person complete the voter registration forms provided with the completion of any HHSC forms.

The case worker may not make a determination about a person’s eligibility for voter registration other than a determination of if the person is voting age, which is 18 years old, or is a U.S. citizen. A person’s age or citizenship may be verified by the case worker if the age or citizenship can be readily determined from information filed with HHSC for purposes other than voter registration. A person must be offered voter registration help as provided by the NVRA if the person’s age or citizenship cannot be determined.

At the time a person applies for services, at annual reassessments or when changing addresses, they must be given the opportunity to:

• complete Form H0025, HHSC Application for Voter Registration, and mail it to the voter registrar; or
• complete Form H0025 and provide it to HHSC staff to mail to the voter registrar.

If the person wants to complete Form H0025 during the interview, the case worker must review the form for completeness in the presence of the person. If the form does not contain all the required information, including the required signature, the case worker returns it to the person for completion. If the person requests the case worker mail the form, Form H0025 must be sent to the appropriate county voter registrar within five working days of signature by the person.

When HHSC staff offer people the opportunity to register to vote, as required by the National Voter Registration Act, they must also inform people of the option of requesting a ballot by mail. People may request a ballot by mail if they are:

• out of the county during early voting and on Election Day;
• 65 or older;
• sick or disabled; or
• confined to jail.

He or she can print an application for a ballot by mail (PDF) from the Texas Secretary of State website and mail it to the Early Voting Clerk. HHSC staff must also assist in completing any form while an person is registering to vote as prescribed in current voter registration policy.

Declining to Register

If the person does not wish to complete Form H0025, they must complete and sign Form 1019. If the person refuses to sign Form 1019, the case worker must document the refusal on the form. The case worker must keep each declination form in the case record for at least 22 months after the date of signing.

Annual Reassessments Conducted by Phone

If the person receiving services wishes to register to vote during an annual reassessment conducted by phone, the case worker must mail Form H0025 to the person within three working days after the date of the phone call. If the person does not wish to register to vote, the case worker must ask the person to complete and sign Form 1019. The case worker must mail them Form 1019 within three working days after the date of the phone call. The case worker must inform the person that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the person refuses to sign the declination form, or the case worker does not receive the form within 30 calendar days after the date of the phone call with the person, the case worker must enter on Form 1019 that the person refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the person’s case record for at least 22 months after the date of signing.  

Change of Address or Name Change

The case worker must contact the person by phone within five working days after receiving notification of a change of address or a name change and offer the opportunity to register to vote. If the person does not have a phone, the case worker must mail Form H0025 and Form 1019 within five working days after being notified of a change in address. If the case worker does not receive either Form H0025 or Form 1019 within 30 days of mailing the forms to the person, the case worker must complete Form 1019 indicating that the person failed to return Form 1019.

If the person wants to register to vote, the case worker must mail Form H0025 to them within three working days after the date of the phone call. If the person does not wish to register to vote, the case worker must ask them to complete and sign Form 1019. The case worker must mail the person Form 1019 within three working days after the date of the phone call. The case worker informs the person that Form 1019 must be returned within 30 calendar days after the date of the phone call with the case worker. If the person refuses to sign the declination form, or the case worker does not receive the form within 30 days after the date of the phone call with the person, the case worker must enter on Form 1019 that the person refused to sign or failed to return the declination form. HHSC staff must retain each declination form in the person’s case record for at least 22 months after the date of signing.

Additional Guidelines

The case worker must not:

• influence a person's political party preference;
• display any political party preference or allegiance; or
• make any statement or take any action for the purpose or effect of:
  • discouraging the person from registering to vote; or
  • leading the person to believe that a decision of whether to register has any bearing on the availability of or eligibility for HHSC services or benefits.

If the person has any questions about the voter registration process that the case worker cannot answer, the case worker must:

• advise the person to call the Office of the Texas Secretary of State toll-free at 800-252-8683; or
• give the person the phone number of the local county voter registrar.

2346 Service Delivery Options

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) offers applicants and individuals three options for the delivery of personal attendant services (PAS). It is the case worker's responsibility to present information on all available service delivery options to the applicant at the initial interview and to ongoing individuals at the annual review, or whenever requested.

The service delivery options include the:

• Consumer Directed Services (CDS) service delivery option, managed by the individual;
• Service Responsibility Option (SRO), co-managed by the individual and the agency in the specific pilot area; and
• Agency Option (AO), managed by the agency.

If the applicant/individual chooses an option other than the AO, the case worker will conduct special casework procedures including, but not limited to:

• providing an overview of the option(s) the applicant/individual is interested in by using Form 1581, Consumer Directed Services Option Overview, for CDS; and/or Form 1581-SRO, Service Responsibility Option (SRO) Overview, for SRO; and
• reviewing the individual's roles and responsibilities under the chosen option by using Form 1582, Consumer Directed Services Responsibilities, for CDS; and/or Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, for SRO.

Once the applicant/individual has made a choice, the case worker asks the applicant/individual to sign Form 1584, Consumer Participation Choice, to document the choice of option. Additional casework procedures are detailed in:

• Section 6100, Agency Option (AO);
• Section 6200, Service Responsibility Option (SRO); and
• Section 6300, Consumer Directed Services (CDS).

2347 Texas Medicaid Estate Recovery Program (MERP)

Revision 20-4; Effective December 1, 2020

Under the Medicaid Estate Recovery Program (MERP), the state may file a claim against the estate of a deceased Medicaid recipient, age 55 and older, who received certain long-term care services.

The following services and programs are subject to MERP claims:

• nursing facility (NF) care;
• intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID), which include state supported living centers;
• Medicaid waiver programs:
  • STAR+PLUS Home and Community Based Services (HCBS);
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS);
  • Texas Home Living (TxHmL); and
• Community Attendant Services (CAS).

Additional information on the MERP is available on the MERP website.

Community Attendant Services

Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, provides written information regarding the MERP.  

Provide Form 8001 to a person applying for CAS at the initial home visit or face to face contact. Do not provide MERP information over the phone.

During the home visit or face to face contact, staff must:

• complete page 2 of Form 8001 by entering the name of the applicant, the applicant’s responsible person or their authorized representative (AR), if applicable, and the name of the case manager on page two;
• provide the Form 8001 to the applicant, the responsible person or the AR and request they read and acknowledge the information by signing page 2;
• provide a copy of the signed Form 8001 to the applicant; and
• retain a copy of the signed Form 8001 in the case file.

An applicant, a responsible person or an AR may sign page 2 of the Form 8001 to indicate that they received and understand the MERP information. If the applicant, the responsible person or the AR, refuses to sign the Form 8001, staff must check the box on the bottom of page 2 to document the refusal and sign the Form 8001 to indicate that the MERP information was shared with the applicant.

When providing the written MERP information during the home visit or face to face contact, staff must clearly explain the following:

• the Form 8001 is only an informational notice;
• the applicant does not have to sign the form to receive services; and
• refusal to sign the form does not exempt their estate from recovery, if it is determined that MERP is applicable at the time of death.

Staff may explain program requirements to share MERP information but must not make recommendations about the MERP or speculate if MERP will be applicable upon the applicant's death. Only the MERP unit staff can determine if an applicant meets the “grandfathered” or exempt status.

If the applicant, the responsible person or the AR has additional questions about the MERP, direct them to the contact information on page 2 of the Form 8001.

2348 Retroactive Payments

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §47.85 (c)(1) — The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS's Application for Assistance – Aged and Disabled form is received:

(A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and

(B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

If an application is received for retroactive attendant care services, the following actions apply. Upon receipt of a completed, signed and dated application or request for services, send Form H1236, Notification of Receipt of Application, to the provider currently serving the applicant. The notice advises the provider that its individual:

• has applied with the Health and Human Services Commission (HHSC) for services, and
• is interested in applying for retroactive payments.

The case worker must send the completed application to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) or Community Care Services Eligibility (CCSE) regional staff so that a decision can be made regarding the applicant's financial eligibility.

Note: An individual who may complete or sign an application for an applicant or individual may not be on the list of people to whom HHSC can release the applicant's individually identifiable health information. See Section 1150, Personal Representatives, for individuals who may receive or authorize the release of individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

A Medicaid-eligible or categorically eligible individual does not have to complete an application when requesting services. Also, an individual who requests facility-initiated Day Activity and Health Services (DAHS) does not have to complete an application if he has stopped receiving services by the time he is contacted. The DAHS facility can be reimbursed for facility-initiated DAHS provided to an individual who was Medicaid eligible when service was received, even if the individual does not complete an application.

The following applies to individuals receiving Primary Home Care (PHC) or DAHS through provider or facility-initiated services.

If a request for DAHS is received from a Medicaid-eligible individual who is not required to complete a written application and is receiving DAHS services, then the individual must allow staff to process the initial paperwork if the individual plans to continue receiving services.

If the individual refuses to participate or allow staff to process the initial paperwork:

• for DAHS, send Form 2065-A, Notification of Community Care Services, for facility-initiated DAHS individuals with a denial date that is 12 days from the form date.
• for PHC, follow procedures in Section 4644, Applicant Approved for Retroactive Payment and Denied Continued Services by the Case Worker, to deny individuals who are receiving PHC and are applying for retroactive reimbursement.

For situations listed above, deny DAHS or PHC individuals on Form 2101, Authorization for Community Care Services, with a reason for withdrawal of services.

See Section 4640, Retroactive Payments, for complete procedures relating to retroactive payments.

2349 Procedures for Applicants Aging Out of PCS to PHC

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) has an agreement with the Texas Department of State Health Services (DSHS) for individuals receiving Personal Care Services (PCS) to be referred for Primary Home Care (PHC) two months prior to the individual's 21st birthday. See Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for additional information and a listing of DSHS offices.

This time frame has been set to ensure there will not be a gap in services. The DSHS case worker will make the referral for intake 60 days prior to the individual's 21st birthday. Referrals from DSHS must be accepted, Form 2110, Community Care Intake, must be completed and the intake assigned to a case worker. Regional staff must also check the quarterly Age Out list, in case the referral from DSHS is not timely.

Since there are differences in PCS and PHC services, the HHSC case worker will thoroughly explain the allowable PHC services at the time of the initial PHC assessment. PHC may not offer some of the services provided through the PCS program.

The applicant must meet all PHC eligibility criteria, including medical, functional and unmet need. If the applicant is eligible, PHC services are negotiated to begin on the individual's 21st birthday. PCS services should end at midnight on the day before the individual's birthday. Coordinate the transition with the PCS case worker and applicant to ensure there are no gaps in services.

All time frames are applicable and processing of the intake must not be delayed. The case worker must make the home visit within 14 calendar days and send a referral Form 2101, Authorization for Community Care Services, to the selected provider within five business days. Currently, the Service Authorization System Online (SASO) will not allow the processing of referral Form 2101 due to the age edit in the system. Therefore, Form 2101 must be completed manually. This edit will be modified in the future to allow completion of the case prior to the individual's 21st birthday.

Upon receipt of Form 3052, Practitioner's Statement of Medical Need, and final eligibility determination, the case worker negotiates the start of care date for the individual's 21st birthday, completes a manual authorization Form 2101, and sends it to the provider. Form 2065-A, Notification of Community Care Services, is sent within two business days of sending authorization Form 2101. Since SAS entry cannot be completed until the individual's 21st birthday, the case worker is allowed up to five business days after the 21st birthday to complete the data entry.

If the PCS Individual Is Ineligible for PHC

If the individual is not eligible for PHC due to a low score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, requests voluntary withdrawal or has no unmet need, the denial code must be entered in SASO. These cases are tracked for reporting purposes.

PCS Caregiver as the Paid Attendant

Refer to Section 2422.5, Attendant Policy for Individuals Transferring from Another Personal Attendant Services (PAS) Program, for special procedures regarding caregivers as paid attendants in PCS cases. If a parent or other caregiver has been the paid attendant through PCS, he may meet the criteria to continue to be the paid attendant and would not be listed as "Do Not Hire." Caregiver support may also be appropriate in some cases.