2710 Monitoring Visits and Contacts

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must monitor the individual's situation, the service(s) the individual receives and the adequacy of the service plan, in accordance with the requirements of the specific service he receives. Monitoring of the service plan includes checking for the appropriate priority level, ensuring the individual has the appropriate Community Care Services Eligibility and ensuring the hours/units authorized meet the individual's needs.

2710.1 Monitoring Initiation of Services

Revision 18-1; Effective June 15, 2018

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care for Aged and Disabled (CCAD) cases. Telephone or face-to-face monitoring visits to ensure service initiation are required for two groups of individuals:

• those with priority status (three-day and 30-day); and
• those who are using the Consumer Directed Services (CDS) option for service delivery (30-day only). See Section 6332.3, Monitoring CDS Service Initiation.

For these two groups, the case worker must:

• contact the provider if they determine that services have not been initiated;
• determine the reason for the delay;
• determine when services will begin;
• monitor the progress of service initiation; and
• complete a service satisfaction monitoring contact within 30 days of the first monitoring contact.

Case workers should be aware of service initiation issues and complete optional three-day or 30-day contacts if it is deemed appropriate based on the:

• individual's medical condition to ensure his health and safety;
• dependability of the individual's family/friends resource system;
• impact of environmental circumstances (for example, unsafe or unsanitary conditions that could become a barrier to service delivery); or
• provider's ability to deliver services within the specified timelines.

Although not required, case workers should verify service initiation by:

• contacting the individual by telephone or home visit;
• contacting the provider contracted to deliver services;
• reviewing notifications of service initiations from providers, including Form 2067, Case Information, or Form 2101, Authorization for Community Care Services;
• considering other reliable verbal or written information received that verifies service initiation; or
• providing the individual with notice to contact the case worker if services are not initiated within a designated time frame.

2710.2 Monitoring Ongoing Services

Revision 22-3; Effective Sept. 1, 2022

In addition to the initial three-day or 30-day monitoring contact, the minimum requirements for additional recipient contacts are:

• For all recipients, except those receiving Community Attendant Services (CAS), monitor services every six months. Contact the recipient:
  • by the last day of the sixth month from the initial assessment date for the initial six-month monitor; and
  • by the last day of the sixth month from the previous monitoring contact for ongoing six-month monitors.
• For a priority recipient (other than CAS) and if required by the region, make a face-to-face visit within six months of the last monitoring contact date. Example: If the last monitoring contact was made on March 15, the next contact is due on or before Sept. 14.
  
  Note: There are other possible circumstances that may require a home visit.
   
• For CAS recipients, the required 90-day monitoring visit must be completed with a face-to-face home visit. The 90-day monitoring visit meets the requirement of the six-month monitor.
• For Adult Foster Care recipients, after the first three monthly monitoring contacts (30 days, 60 days and 90 days), regular six-month monitors must be completed. The first six-month contact is required three months after the 90-day contact. 

More contacts or home visits are required if recipient circumstances warrant. Some recipients may need additional monitoring or problems may arise that require additional contacts. Recipients with weak or informal support systems may need to be seen more frequently. Home visits may be required to ensure the recipient’s safety and well-being are not compromised.

Develop a monitoring plan that considers:

• the recipient’s functional needs;
• the capabilities of family or friends’ resource and support systems; and
• the impact of the recipient’s environmental circumstances.

If a home visit is required, inform recipients in advance by phone or in writing, using Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is indication of abuse, neglect or fraud.

Related Policy 

Determining When a Home Visit is Necessary for Other Services, 2663.2
Monitoring Community Attendant Services Individuals, 2711
Adult Foster Care, 4100

2710.3 Service Plan Changes at the Monitoring Contact

Revision 17-1; Effective March 15, 2017

Reduce hours or terminate services at annual reassessment or any other time the individual:

• requests a reduction or termination;
• gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
• is performing all or some activities of daily living due to long-term improvement in functional condition.

The case worker uses his judgment to determine if the individual's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. See Section 2721.6, Long-term Versus Short-term Changes in the Individual's Condition, for additional details in making that determination.

The individual and provider may agree to change the number of personal attendant service (PAS) hours to be provided based on the individual's needs without prior approval from the case worker. The amount of service provided should be sufficient to meet the individual's needs depending on the loss or gain in the individual's functional ability to perform activities of daily living.

Case worker approval or denial is required for all requests to increase PAS service hours previously authorized or to add or delete priority status.

2710.4 Monitoring Documentation Requirements

Revision 20-2; Effective June 1, 2020

The primary purpose of each monitoring contact, whether a home visit or a phone call, is to determine the adequacy of the current service plan and actual service delivery.

Form 2314, Satisfaction and Service Monitoring, must be used for all required monitoring contacts, including three-day, 30-day, 60-day, 90-day, six months, and annual.

Note: All other contacts must be documented on Form 2058, Case Activity Record or other case narratives as determined by the region.

During each monitoring visit, assess the quality of services and whether the services continue to meet the needs of the recipient by determining that:

• services are delivered according to the service plan and as agreed to by the recipient and the provider agency;
• the attendant comes and leaves as negotiated by the recipient, attendant and provider agency;
• the recipient is satisfied with each of the services being delivered; or
• there is a need to change the priority status, increase hours or change other services.

Ask enough questions during each contact to ensure the recipient’s current responses, together with the written case record, address each of the criteria listed above. See Appendix XVI, Monitoring Questions, for examples of specific questions that may be appropriate.

At every contact, document each of the following:

• Eligibility — Does the recipient continue to meet all eligibility requirements for the authorized services?
• Condition or Status — Has there been any change in the recipient's condition or situation that affects service delivery or adequacy of the service plan, such as priority status or the need for more hours or other services?
• Quality of Services — Have services been delivered according to the service plan? Does the attendant perform the required tasks and arrive and leave as scheduled? Is the recipient satisfied with the services that have been delivered?
• Adequacy of Service Plan — Does the service plan need to be changed?

Changes in services may be requested by the recipient or the provider agency. Document all requests for changes on Form 2067, Case Information, or Form 2058, Case Activity Record and include the date the request was received. If the recipient requests a change during the monitoring contact, document the request, and the action to be taken, on Form 2314.

Enter all required monitoring contacts in the Service Authorization System Online (SASO) Monitoring Wizard. A copy of the SASO automated Form 2314 must be filed in the case record.

Related Policy

Service Authorization System Online (SASO) Wizards and Use Requirements, Section 7300

2710.5 Actions Required After Monitoring

Revision 17-9; Effective September 15, 2017

Case workers report and discuss with the provider any problems or deficiencies in service provision and strive to resolve the problems. See Section 2736.1, Reporting Service Delivery Issues, for detailed instructions for handling service delivery issues.

2711 Monitoring Community Attendant Services Individuals

Revision 17-1; Effective March 15, 2017

Individuals receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of §1929(b) of the Social Security Act. The act requires the case worker to monitor the home and community care provided under the State plan and specified in the “ICCP” (Individual Community Care Plan). This monitoring must involve visiting each individual’s home or community setting where care is being provided not less often than once every 90 days.

An HHSC case worker must meet this requirement by conducting a face-to-face  visit with the individual receiving CAS in the individual’s home or community setting where CAS services or State Plan services included in the individual’s Individual Service Plan (ISP) are being provided. This face-to-face visit must occur not less often than once every 90 days. The 90 day visit will be for the purpose of monitoring the individual’s satisfaction of services.  

The Texas Health and Human Services Commission (HHSC) is required to make every reasonable attempt to complete the CAS monitoring, as the Social Security Act requires. In order to meet the reasonable attempt requirement, case workers must adhere to the following guidelines:

• The 90-day monitoring must be completed at least every 90 days with the individual or primary caregiver in the location where services are delivered.
• All attempts to contact the individual must be documented in the case record to support the efforts to meet the federal requirement. A 90-day monitoring contact may not be made with an employee of the provider serving the individual.
• If the 90-day monitoring visit becomes delinquent, it must still be completed at the earliest possible opportunity. The case record must contain ongoing documentation of attempts to contact the individual until the monitoring is actually completed.
• In cases where the individual is in a nursing facility, hospital or out of the service area, the 90-day monitor must be conducted within 14 calendar days of learning the individual has returned to the home. Documentation of the individual's inaccessibility must be contained in the case record.

Federal law specifically requires visits every 90 days, not every three months. This 90-day deadline will usually be one or two days short of three calendar months. Example: If a CAS case is monitored March 15, the next monitoring visit must be on or before June 13 (the 90th day after March 15). See Appendix XVIII, Time Calculation.

For CAS cases, the case worker sets the initial 90-day home visit schedule from the date within 90 days of the initial start of care (SOC), as determined by the regional nurse and documented on Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO). The case worker is not required to conduct a 90-day monitor home visit prior to the SOC date determined by the regional nurse. Once the initial SOC has been determined, the case worker sets subsequent 90-day monitors using the Deadline Calculation Chart within Appendix XVIII to calculate when the next 90-day monitoring visit is due. It is recommended that case workers conduct the annual reassessment simultaneously with the 90-day monitor due prior to the first annual reassessment to align future 90-day monitors due at the annual reassessment.

All 90-day monitors must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System Online (SASO) Monitoring Wizard. Use the coding for entry into the SAS Monitoring Wizard. See Section 7300, Service Authorization System (SAS) Wizards and Use Requirements, or the SASO Help File for assistance in completing the SASO monitoring visit.

Inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of any changes that may affect the eligibility of a CAS individual.

2712 Six-Month Monitoring Contacts

Revision 17-1; Effective March 15, 2017

When a six-month monitoring contact is required but a home visit is not required by the region, the contact may be completed by telephone. If the individual does not have a telephone or cannot communicate by telephone, and a caregiver or relative can tell the case worker about the individual's condition, service needs and the adequacy of service delivery, the contact may be with a caregiver or responsible relative. If contact cannot be made by telephone with the individual, caregiver or responsible relative, a face-to-face visit is required. The first attempted contact should be at least seven days before the contact due date. All attempts to contact the individual must be documented in the case record.

Before a face-to-face or telephone contact is made with someone other than the individual, make at least two attempted contacts with the individual. Document all attempts in the case record. For a priority status individual, two attempted contacts are defined as:

• at least one attempted face-to-face contact with the individual, his caregiver or his authorized representative if circumstances require a home visit; and
• another attempted face-to-face contact with the individual or his authorized representative if the region requires a home visit or a telephone contact with the individual, caregiver or his authorized representative.

During each six-month monitoring contact, ask about the:

• current condition and situation of the individual; and
• appropriate delivery of services.

Determine if any changes are needed in the service plan. The case worker may have to make a face-to-face contact if the:

• telephone contact indicates a significant change and the case worker cannot adequately assess the situation without a home visit (see Section 2721, Functional Changes);
• contact indicates a need to add a service or increase hours (see Section 2663.2, Determining When a Home Visit is Necessary for Other Services); or
• individual indicates dissatisfaction with services and the case worker cannot adequately assess the situation without a home visit.

A face-to-face contact is not required if the individual requests a decrease in hours, unless eligibility could be affected.

2720 Interim Changes

Revision 17-1; Effective March 15, 2017

2721 Service Plan Changes

Revision 17-1; Effective March 15, 2017

Changes to the service plan may be necessitated by changes in the individual's functional abilities or personal circumstances, including:

• hospitalizations;
• severe acute illnesses or accidents, or recoveries from major illness or accidents;
• loss of or changes in caregivers; and
• moves or changes in living arrangements.

2721.1 Individual Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Discuss with the individual the importance of reporting changes and explain the consequences of failing to do so. If the individual receives Primary Home Care (PHC), Community Attendant Services (CAS), Family Care (FC) or Home-Delivered Meals (HDM), explain the need to notify the provider if the individual will not:

• be home when services are scheduled, or
• need services when scheduled. This is particularly important for personal attendant services individuals with priority status.

2721.2 Provider Responsibility to Report Changes

Revision 17-1; Effective March 15, 2017

Attendants are also responsible for reporting to supervisors any changes in the individual's status or environment that threaten the individual's health or safety or that may affect his service plan. The provider supervisor reports these changes to the case worker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, skin problems, bruises, mental instability that endangers the individual or others, onset of incontinence, unusual complaints of pain, unusual behaviors, or unusual changes in food intake.

The attendant also reports changes that may affect social resource systems, family relationships and assistance programs Examples include changes or problems in housing, household make-up, loss or change in caregiver arrangements or loss of benefits. If necessary, refer the individual to Adult Protective Services.

If a provider fails to report changes that affect an individual's service plan, the problem must be discussed with provider staff. If the problem continues, document the instances and discuss them with the Community Care Services Eligibility (CCSE) supervisor, who notifies the contract manager and program manager.

2721.3 Determining if a Home Visit is Necessary

Revision 17-1; Effective March 15, 2017

The case worker will use his judgment to decide if he has enough information to respond to the reported change without visiting the individual. If in doubt, a home visit should be made. Consider the following when making that determination:

• Is the case worker already very familiar with the individual's situation?
• Does the information available about the change and its impact seem clear and appear reliable?
• Is the reported change relatively simple or more complex? Examples: Several changes at once or sudden and severe deterioration.
• Is there disagreement between what others say the individual now needs and what the individual is saying he needs?

Make a home visit and complete a functional reassessment if the individual needs or requests a new service and his current Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, score is below the minimum score for that service.

Reduce hours or terminate services at annual reassessment, or any time before the annual review, when the individual:

• requests a reduction or termination,
• gains a resource resulting in few unmet needs and the need to reduce service hours, or
• performs all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.

2721.4 Revising the Service Plan

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must revise the service plan, which is priority level, need for more/less hours or tasks, within 14 calendar days of learning of a change in the individual's status/condition, or must document why no changes to the service plan are needed. If the case worker becomes aware of the need for a service plan change as a result of conducting an annual reassessment, the change must be completed as part of that reassessment. If the individual is released for another CCSE service, the case worker will refer to Section 2611, Processing Time Frames.

Contact the individual and determine whether a new assessment, a revised service plan or a revised monitoring plan is needed, based on the individual's new condition or situation. Assess the needs of the individual and develop or revise the individual's service plan, including:

• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide (update if not being completely recreated);
• personal assistance services tasks;
• priority level; and
• number of hours/units of service the individual is authorized to receive per week.

2721.5 Long-term Versus Short-term Changes in the Individual's Condition

Revision 17-1; Effective March 15, 2017

The case worker uses his judgment to determine if the change in the individual's condition is expected to last through the current authorization period or beyond before reducing or terminating services. Do not reduce or terminate services if it is determined the individual is experiencing temporary improvement in functional condition.

If it is determined the individual's condition has temporarily improved because the individual is performing tasks previously done by the attendant, the individual and provider may agree to fewer hours per week. Send the provider Form 2067, Case Information, to inform the provider that fewer service hours may be provided if the individual agrees to the reduction. In this situation, the case worker would not update the Service Authorization System Online (SASO) record or send Form 2065-A, Notification of Community Care Services, to the individual for a reduction of hours.

If a change in the individual's condition impedes his functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Case worker approval or denial is required for all requests to increase personal attendant services hours previously authorized or to add or delete priority status. The amount of service provided must be sufficient to meet the individual's needs.

2721.6 Authorizing and Documenting Changes

Revision 17-1; Effective March 15, 2017

All requests for changes in services, whether received from the individual or the provider, must be documented in the case record. Documentation may be on Form 2067, Case Information, or recorded in the case record narrative. Form 2058, Case Activity Record, may be used as well as other case narratives. Form 2314, Satisfaction and Service Monitoring, may also be used, but is not required for changes.

Make all necessary changes in the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. To authorize changes in priority level and/or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the individual if the:

• Primary Home Care, Community Attendant Services, Family Care hours increase or decrease;
• individual gains or loses priority status;
• number of home delivered meals per week changes; or
• authorized units of Day Activity and Health Services change.

Document the outcome of the request for the change in the case record. If it is determined that no revision is needed in the service plan, document the decision and the reasons in the case record. If the provider or regional nurse requested the change, use Form 2067.

2722 Individual Moves and Case Transfers

Revision 17-1; Effective March 15, 2017

At times, an individual's move requires transferring the individual's case to a new case worker within the same region or a different region.

When an individual moves to an area served by a different case worker within the same region or outside the region, the case remains open and the existing service plan stays in effect until a new plan is implemented. Every effort should be made to minimize gaps in coverage for the individual. Although the old plan remains in effect until amended, actual services may in some cases have to be temporarily suspended. For example, the new area/region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility. The case worker who is notified of the move should initiate the action for the transfer.

2722.1 Procedures If the Losing Case Worker Initiates Action

Revision 17-8; Effective September 1, 2017

If the current case worker (losing case worker) is contacted by the individual (or individual's representatives) and the individual has not already moved, it is that case worker's responsibility to:

• contact the office in the new location and get the name, address and telephone number of the gaining case worker to give to the individual.
• contact the gaining case worker by telephone and discuss the case. Provide the gaining case worker with the individual number so the case worker can access the Service Authorization System Services (SASO) for current individual information.
• have the gaining case worker fax a provider choice list, if the current provider does not provide services in the new area. If the same provider will be serving the individual in the new location, the losing case worker keeps Form 2101, Authorization for Community Care Services, open and the gaining case worker makes any needed changes. If moving to another region, the provider number will be different even if the individual is staying with the same agency.
• provide the individual with the case worker and provider information. Have the individual select a new provider and relay that information to the gaining case worker with a projected date of transfer.
• forward the case record to the gaining case worker within three workdays of confirming the move.
• send Form H1746-A, MEPD Referral Cover Sheet, if applicable, advising of the transfer and the new address so that the MEPD case can also be updated. Advise staff for any other services the individual is receiving that the individual has moved (for example, Supplemental Nutrition Assistance Program).

2722.2 Procedures If the Gaining Case Worker Initiates Action

Revision 17-3; Effective May 15, 2017

It is the gaining case worker's responsibility to:

• update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case. Include the negotiated start date and the losing provider's end date.
• mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency.
• advise the losing case worker that Form 2101 has been updated. He must print a copy of Form 2101 and send it to the losing provider.
• update any current Community Care Interest List entries for the individual for the new area.
• send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) individuals to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist advising that the individual has moved to the service area and has a continued need for service. The old and new addresses should be provided, so the CAS case can be requested from the current MEPD worker.
• contact the individual within 14 days to assess the individual's new living arrangements and need for service plan changes. If needed, schedule a home visit. (See Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary.)

2722.3 Additional Procedures

Revision 17-1; Effective March 15, 2017

The regional nurse does not need to give prior approval unless a reassessment is being conducted at the same time the transfer is being done, and then a copy of Form 2101, Authorization for Community Care Services, needs to be forwarded to the regional nurse with the transfer agency information.

The provider does not have to obtain new physician's orders for prior approval from the regional nurse for a transferring case.

2723 Freedom of Choice

Revision 17-3; Effective May 15, 2017

In areas where there is more than one provider for a specific service, allow the individual the freedom to choose/change providers without restriction.

When an individual requests to change providers, the case worker must first determine the individual's reason for dissatisfaction and whether the individual's satisfaction can be met without the provider change. The case worker completes the following steps within fourteen days of the individual's request:

1. Ask the individual or his representative to select a new provider, and document the choice.
2. Contact the gaining provider before the transfer occurs to determine when services can begin.
3. Update the information on Form 2059, Summary of Client's Need for Service.
4. Update Form 2101, Authorization for Community Care Services, by entering:
   • the nine-digit vendor provider number; and
   • a statement in the comments section that this is an individual-requested change of providers and the effective date of the change.
5. Send the new provider Form 2110, Form 2059 and Form 2101.
6. For non-Community Attendant Services (CAS) cases, send the current (losing) provider a copy of Form 2101 that reflects the effective date of the transfer.
7. On CAS cases where the change is being made in conjunction with an annual reassessment, the regional nurse will:
   • update Form 2101 upon receipt; and
   • send the updated form that shows the effective date of the transfer to the new provider.

The case worker will send the current (losing) provider a copy of the updated form that reflects the effective date of the transfer.

In situations in which the individual has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC case worker must determine how much information to share with the new provider regarding the previous actions. See Section 2840.1, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for Individuals Denied SSI

Revision 17-1; Effective March 15, 2017

In almost all instances, receipt of Supplemental Security Income (SSI) entitles an individual to Medicaid. In most instances, loss of SSI eligibility also means loss of Medicaid benefits. There are several exceptions to this, however, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCSE individual receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the individual to apply to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for an eligibility determination. Send a referral to the MEPD specialist if the individual is interested.

2725 Certificates of Insurance Coverage

Revision 17-1; Effective March 15, 2017

Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health insurers, including Medicaid, furnish certificates of creditable coverage whenever an individual ceases coverage under a plan or policy. The purpose of the certificate is to provide evidence that the individual had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the individual may obtain.

This legislation will affect community care individuals who are Medicaid recipients. Information regarding certificates of coverage is provided to CCSE applicants and individuals on Page 2 of Form 2065-A, Notification of Community Care Services.

Texas Medicaid & Healthcare Partnership (TMHP) is the contractor that produces these certificates for denied Medicaid individuals. If an individual has questions about the certificate or needs a replacement certificate, he should write or call TMHP.

2730 Special Procedures for Helping Individuals Enter or Leave a Nursing Facility, Institution, or Hospice

Revision 17-1; Effective March 15, 2017

2731 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

Some individuals living in their own homes may need counseling about the available options for receiving long-term care, including nursing facility placement. Caregivers of individuals who have heavy care needs may experience severe stress or be unable to continue the duty for weeks and months without reprieve. Individuals may be at risk if they remain in their current environments. Assess these situations from the standpoints of both the individual's safety and the caregiver's ability to withstand the stress of constant care. Offer them the opportunity to consider nursing facility care.

If an individual wants to enter a nursing facility, help him make his plans. If the individual is not a Medicaid recipient, refer him to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as quickly as possible.

If an individual lacks family or a responsible person to help him with all the final activities involved in moving into a nursing facility, help him by involving his friends and other volunteers.

Nursing Facility Care for Individuals Under Age 22

State Law (Chapter 242, Health and Safety Code) requires that the Community Resource Coordination Group (CRCG) be notified no later than the third day after the date a Community Care for the Aged and Disabled child under age 22 with a developmental disability is initially placed in an institution.

The name and telephone number of the CRCG contact person may be obtained by calling the CRCG State Office at 512-206-4564. A CRCG list is also available via the Internet at https://crcg.hhs.texas.gov/faq.html.

If notice is received of an initial placement of a child in an institution, contact the person making the placement to ensure that family members of the family are aware of:

• service and support that could provide alternative to placement of the child in the institution, and
• available placement options.

2732 Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

2732.1 Individuals Entering a Nursing Facility

Revision 17-1; Effective March 15, 2017

A batch process is in place that closes the service authorization records for Community Care individuals who have entered a nursing facility. When Form 3618, Resident Transaction Notice, is submitted by the nursing facility, all Service Authorization System Online (SASO) authorization records, except Service Code 20-Emergency Response Services, are closed by an automated batch process that occurs five times a week.

The batch process uses the date in Item 11 (Date of Above Transaction) on Form 3618 as the end date of the service authorization. A daily report is generated and posted to the Claims Management Project Documents website.

Regional Claims Management System (CMS) coordinators must access the reports and notify case workers when they have individuals whose service authorization records are closed by the batch process. Case workers must monitor these cases for 30 days until it is determined whether the individual's nursing facility stay will be long term. If the individual will be remaining in the facility, the case worker closes the remaining Service Code 20 record, if applicable.

2732.2 Individuals Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

For individuals being discharged from a nursing facility who are to begin receiving Community Care services, Provider Claims Services has established a hotline number to call to close the nursing facility authorization. The hotline number is 512-438-2200. Select Option 1.

The case worker should call the hotline directly to request the nursing facility record in the Service Authorization System Online(SASO) be closed so Community Care services can be authorized. The case worker will no longer contact the regional Claims Management Services (CMS) coordinator for this action. The case worker must confirm the individual has been discharged from the facility and Community Care services are negotiated to begin on or after the date of discharge.

When calling the hotline, the case worker must identify himself as a Texas Health and Human Services Commission (HHSC) employee and report that the individual has discharged from the nursing facility and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SASO, including the Service Code 60. The case worker documents the contact in the case record.

2732.3 Individuals Denied a Determination of Medical Necessity

Revision 17-1; Effective March 15, 2017

When a Medicaid nursing facility resident is denied a determination of medical necessity, Texas Medicaid & Healthcare Partnership (TMHP) sends a denial letter to the individual and the individual's physician. The facility and the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are notified via TMHP's weekly status report.

If the individual requests CCSE services, respond to this request by following the usual intake procedures, including interviewing and assessing needs. If the individual is determined eligible to receive CCSE services but prefers to receive services outside the intake unit's geographical area, the intake unit staff refers the case to the appropriate case worker or region. When CCSE staff receive an out-of-town referral or inquiry, they help with alternate placement activities.

2732.4 Promoting Independence Initiative

Revision 17-1; Effective March 15, 2017

Promoting Independence (PI) Initiative, enacted by House Bill 1867 of the 79th Session of the Texas Legislature, is intended to ensure a system of services and supports that fosters independence and productivity, and provides meaningful opportunities for the elderly and people with disabilities to live in their home communities.

Money Follows the Person (MFP) is available for persons requiring waiver services. It allows Medicaid funds that are being used to pay for the individual's care in a nursing facility to be transferred to pay for Medicaid waiver services in the community. Individuals identified as using MFP-funded services do not use regional interest list allocations.

MFP does not apply to non-waiver community care services.

For additional information, see the appropriate program handbook for the desired community care or waiver service.

2733 Individuals Receiving Services through Local Authorities

Revision 17-1; Effective March 15, 2017

Local Authorities (LAs) specialize in working with persons who have intellectual developmental disabilities (IDDs), intellectual disabilities (IDs) or persons with mental illness, especially those who are in crisis situations. Close coordination with LA is vital to ensure the safety and well-being of the individual and others. Contact the local LA agency to determine what procedures to follow to obtain permission from the individual to discuss his case with LA staff.

The liaison case workers at the LA community center are responsible for helping individuals with IDD/ID with the process of admission to or discharge from state supported living centers or intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID). Refer to the appropriate liaison worker any persons requesting or requiring entry into these facilities. Liaison case workers also have primary case management responsibility for individuals with IDD/ID who return to the community from state supported living centers. Contact liaison workers for specific information about their responsibilities and about the availability of LA resources for individuals with IDD/ID.

Persons discharged from state hospitals are referred to the appropriate LA community center or outreach program for follow-up. LA case management services are available to them if they meet eligibility and priority criteria. Contact the liaison worker for specific eligibility information. These individuals may also apply personally for CCSE services.

If there is no LA case worker assigned to the individual's case, contact the local LA agency to discuss the individual's condition. Refer the individual to them for services, assistance and/or case management, if appropriate. Include the LA case worker in the development of the individual's CCSE service plan and clearly define the case worker's roles and responsibilities in managing the case. Encourage the LA case worker to offer support counseling and training to the:

• individual;
• the individual's caregiver; and
• provider of services.

Keep the LA case worker informed of changes in:

• the individual's environment (such as hospitalizations, residence, household composition);
• the individual's physical/mental condition;
• medications or lack of medication; and
• the service plan.

Document in the case record contacts with LA staff, including any agreements reached.

Refer to Appendix XV, Services Available from Other State Agencies, for a list of the services that may be available through the LA agency.

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

2734 TDC Individuals Leaving TDC

Revision 17-1; Effective March 15, 2017

Texas Department of Corrections (TDC) staff are responsible for discharge planning for elderly or disabled persons being released from TDC. TDC tries to make a referral at least 30 days before the inmate is to be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the individual in the community and provides or arranges for other services he may need. Follow the usual case management procedures to certify the individual eligible for services, to refer his case for service, and to monitor or evaluate any services authorized.

2735 Individuals Who Need Hospice Services

Revision 17-1; Effective March 15, 2017

Medicare and Medicaid hospice services are available to terminally ill Medicare/Medicaid eligibles who file an election statement with a particular hospice. Hospice applicants must be certified as terminally ill (six months or less to live) by a physician. For dually eligible individuals who elect hospice care, coverage is concurrent for the Medicare and Medicaid programs. Hospice care is also available on a private-pay basis.

Hospice staff contact the case worker by telephone concerning the start and cancel dates for hospice care. Hospice staff will no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. Individuals may elect or cancel hospice care at any time.

Individuals electing hospice may be eligible for services through HHSC as long as there is no duplication in the services delivered. A Medicaid recipient, age 21 and older, who elects Medicaid hospice, waives his rights to other programs with Medicaid services related to the treatment of the terminal illness. The Medicaid recipient does not waive his rights to services offered by HHSC that are unrelated to the treatment of the terminal illness. Individuals under 21 years of age who elect hospice do not waive rights to Medicaid services related or unrelated to the terminal illness.

HHSC case workers must follow up with the individual receiving services to determine what hospice will provide and adjust the individual’s service plan to assure no duplication of services. Case workers must respond to a notification of hospice election within the time frames of a change request.

The unmet need policy in Section 2433, Determining Unmet Need in the Service Arrangement Column, does apply to hospice individuals. Coordinate any CCSE service plan with the hospice provider to prevent duplication and to assure adequate services to the individual. If an individual's need for help with a particular task is adequately met by the hospice provider, do not authorize purchased services for that task.

If the need for help will not be met by the hospice provider, or if the need will be only partly met, authorize services on the same basis used for any other individual.

Case workers may receive a request to initiate a CCSE service for an individual who is already receiving that service from a hospice. In this case, it must be determined whether the hospice will continue to provide the needed care. Authorize the CCSE service if the hospice service will end on a particular date, or if the hospice provider will provide the service only until the CCSE service can begin. Coordinate service initiation and ending dates with the hospice provider in order to prevent a break in services. When a CCSE individual enters a nursing home under hospice, terminate CCSE services effective the date the individual entered the facility. If the individual receives hospice care at home, making reduction or termination of CCSE services necessary, give the individual the usual 12-day advance notice before the effective date of the reduction or termination.

If an HHSC individual with Medicaid for the Elderly and People with Disabilities (MEPD) eligibility determination (Community Attendant Medicaid Hospice Program Services) enters a nursing facility under Medicaid hospice, the HHSC case worker notifies the MEPD staff of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In relevant situations, consider hospice services as a resource available to CCSE applicants and individuals. Monitor CCSE individuals on an ongoing basis to determine whether they need or are receiving hospice services.

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

2736 Complaints, Grievances or Suggestions

Revision 17-1; Effective March 15, 2017

The applicant or individual has the right to lodge a complaint, voice a grievance or recommend changes in policy or service without restraint, interference, coercion, discrimination or reprisal. Staff must:

• acknowledge the complaint, grievance or recommendation within 14 days of the date the Texas Health and Human Services Commission (HHSC) receives it; and
• resolve it within 60 days of that date.

2736.1 Reporting Service Delivery Issues

Revision 17-9; Effective September 15, 2017

Program provider service delivery issues may be reported to the Health and Human Services (HHS) Office of the Ombudsman. These reports may be generated by:

• the individual/individual's representative;
• Texas Health and Human Services Commission (HHSC) staff, including issues discovered by the case worker, or reports received during monitoring contacts; and
• other individuals, including the individual's family/friends.

Service delivery issues include any dissatisfaction expressed by the individual regarding a service delivery provider. The individual may express dissatisfaction about:

• the quality of a service provided (care, treatment or services received);
• aspects of interpersonal relationships, such as rudeness; or
• the service provider's failure to:
  • respect the individual's rights;
  • follow terms of the contract or applicable rules; or
  • provide services which may or may not have had an adverse effect on the individual.

This list is not all inclusive.

Complaints of a regulatory nature about nursing facilities, home and community support service agencies, intermediate care facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, and Home and Community-based Services and Texas Home Living providers should be reported to Consumer Rights and Services at 1-800-458-9858 or crscomplaints@hhsc.state.tx.us to generate an investigation by Regulatory Services.

Within five working days of receiving a report or becoming aware of service delivery issues, the case worker must respond to the individual and the provider either by phone or face-to-face contact to discuss the issues. The case worker must inform the provider of the service delivery issues and discuss resolutions. The case worker convenes an interdisciplinary team (IDT) meeting, if appropriate. The case worker coordinates with the individual and provider to implement actions required to resolve the issues. The case worker must document the receipt of the report and contacts with the individual and the provider in the case record. The case worker must document any barriers or hindrance by either party that interferes with resolution of the issues. The resolution of the issues and/or attempts to resolve the issue must be documented.

If service delivery issues cannot be resolved within 10 working days of the initial receipt of a report or becoming aware of service delivery issues, the case worker must:

• report the service delivery issues to the HHS Office of the Ombudsman at 1-877-787-8999;
• inform the individual of his right to call the HHS Office of the Ombudsman to register a complaint regarding the provider, including a Consumer Directed Services agency (CDSA); and
• inform the individual of his right to choose another provider.

The case worker must make the report to the HHS Office of the Ombudsman within three working days after the 10-working-day resolution period ends.

In situations where service delivery issues may compromise the individual's health and safety, the case worker must report as soon as possible but no later than 24 hours of receiving the report or becoming aware of service delivery issues. The case worker must also contact Adult Protective Services (APS) or Child Protective Services (CPS) within 24 hours if there is an immediate or imminent threat to the health and safety of the individual. The case worker must continue to work with the individual and provider to resolve the issues within the 10-working-day time frame.

The case worker must identify the specific service the provider is delivering when calling to report a complaint. For example, the case worker identifies the provider as a "Primary Home Care provider" when making a referral that involves Primary Home Care service delivery issues. The case worker must provide specific information related to the service delivery issue, including actions taken to resolve the issues and why the actions did not resolve the issues.

2740 Fraud Detection and Documentation

Revision 17-1; Effective March 15, 2017

2741 Provider Fraud

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, when there is an indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

• Intentional misstatement or concealment by the provider created a false impression.
• HHSC paid the provider based on the false impression, when the payment would not have been made if the truth had been known.

Examples of provider fraud include (list is not all-inclusive):

• billing for services which were not provided,
• provision of services which are not medically necessary,
• filing false claims,
• continuing inappropriate billing after provider education visits,
• billing for services provided by inappropriate persons,
• practicing without a proper license or obtaining a license under false pretenses,
• using improper billing practices, and
• violating the contract or provider agreement.

2742 Responding to Allegations of Provider Fraud

Revision 17-1; Effective March 15, 2017

When an allegation of provider fraud is received, staff should follow these procedures:

• During the first contact, staff receiving the complaint should obtain facts relating to the specific case in as much detail as possible. This includes:
  • who engaged or participated in the alleged fraudulent conduct,
  • what the suspected violation was,
  • when the conduct occurred (dates or time periods),
  • where the conduct occurred,
  • how the fraudulent action was performed, and
  • the names of witnesses and how they can be contacted.
• Staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
• Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

2743 Individual Fraud

Revision 17-1; Effective March 15, 2017

Individuals receiving Long Term Care Services are perceived honest and entitled to the same protection under the law as all other individuals. However, when there is indication of potential fraud, the allegations must be investigated.

To determine the existence of fraud, the following must be established:

• Intentional misstatement or concealment by the individual or authorized representative created a false impression.
• The Texas Health and Human Services Commission or contracted provider delivered services based on the false impression, when the services would not have been provided if the truth had been known.

Examples of individual fraud include (list is not all-inclusive):

• knowingly providing false information regarding an applicant's financial, medical or functional status in order to be determined eligible for assistance;
• withholding or concealing information pertaining to the applicant's financial, medical or functional status which may cause the applicant to be ineligible for services;
• receiving services which the individual knows to be medically unnecessary; and/or
• knowingly receiving services from individuals who do not have a proper license or who obtained a license under false pretenses.

2744 Responding to Allegations of Individual Fraud

Revision 17-1; Effective March 15, 2017

When potential individual fraud is discovered, staff should follow these procedures:

1. Record all pertinent facts relating to the specific case in as much detail as possible. This includes:
   • who engaged or participated in the alleged fraudulent conduct,
   • what the suspected violation was,
   • when the conduct occurred (dates or time periods),
   • where the conduct occurred,
   • how the fraudulent action was performed, and
   • the names of individuals with knowledge of the situation and how they can be contacted.
2. If fraud is alleged by a third party, staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
3. Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

Restitution must not be requested in cases where fraud is being pursued. Restitution is securing payment from an individual when fraud is not indicated. Once restitution is requested, you cannot refer the case for fraud.

2745 Reporting Suspected Fraud in the Consumer Directed Services Option

Revision 17-1; Effective March 15, 2017

Following are established procedures for reporting suspected fraud in the Consumer Directed Services (CDS) option to the Office of Inspector General (OIG). This applies when there is suspected fraud committed by the individual receiving services, the CDS employer or the CDS employee. This does not apply to provider fraud.

When the HHSC case worker suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, or is made aware of suspected fraud from an entity other than the Financial Management Services Agency (FMSA), the case worker must report the suspected fraud to the OIG. The case worker can submit the referral using the OIG website, https://oig.hhsc.state.tx.us/wafrep/, or by calling 1-800-436-6184. The case worker must inform the OIG the individual is using the CDS option.

If the case worker does not receive a referral number after submitting the information on the OIG website, it means the referral may not have transmitted successfully. The case worker must call 1-800-436-6184 to confirm the OIG received the referral and ask for the referral tracking number. The case worker must document the suspected fraud and referral information on Form 2058, Case Activity Record.

Once the case worker submits the fraud referral to the OIG, the case worker must inform the FMSA about the suspected fraud and that a referral was made to the OIG using Form 2067, Case Information. The case worker must also send a secure email to CDS Operations staff, cds@hhs.texas.gov, at state office containing the following information for tracking purposes:

• Name of the FMSA;
• Name of the person(s) suspected of committing fraud (include as much identifying information as possible, such as Social Security number, Medicaid number, date of birth, address and phone number);
• Brief summary of the fraud allegation, including dates and estimated cost as a result of the violation;
• Date the fraud allegation was reported to the OIG and the OIG referral tracking number;
• Program or service impacted; and 
• Contact information for the HHSC case worker who submitted the referral and the HHSC office where the case worker is located.

When an FMSA suspects fraud was committed by the individual receiving services, the CDS employer or the CDS employee, the FMSA will make a referral to the OIG. The FMSA will inform HHSC CDS Operations staff at state office that the FMSA submitted a fraud referral to the OIG for tracking purposes.

The FMSA will also inform the HHSC case worker that a fraud referral was submitted to the OIG using Form 2067. The case worker must file Form 2067 received from the FMSA in the individual’s case file. No further action is needed by the case worker regarding the fraud referral once the FMSA notifies HHSC the referral was made to the OIG.

2750 Fraud Referral

Revision 17-1; Effective March 15, 2017

2751 Development of the Fraud Referral Packet

Revision 17-1; Effective March 15, 2017

Consult the unit supervisor for guidance in determining the appropriateness of the referral and the information being provided. If it is decided that a referral is to be submitted, complete the online reporting document, Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, available at oig.hhsc.state.tx.us/wafrep. The online reporting system will prompt the user to enter:

• the name of the person providing information;
• additional contact person information, if available;
• the name of the person completing the form, if different from the person providing the information;
• law enforcement information, if available (indicate if law enforcement was notified);
• witness information, if available;
• the name of the person or facility being reported; and
• detailed information about the waste, abuse or fraud concern, including:
  • provider identification. Include the name, provider type and specialty, business address, residence address and provider numbers.
  • identification of the alleged illegal act. Include specific data regarding potential witnesses, addresses, work and home telephone numbers. Also include names, mail codes and telephone numbers of all staff who can provide information.
  • identification of policy, regulation or procedural violations. Cite the appropriate numerical reference and manual title, the department rule or policy clearance letter. The reference should include the specific chapter, subchapter, page number and effective date of the manual or publication.
  • source. Indicate who or what initiated the allegation.
  • other pertinent documentation related to the case.

Once all of the information has been entered, the system will allow users to print the information to be included in the referral packet.

2752 Expedited Referrals

Revision 17-1; Effective March 15, 2017

If staff have reason to believe that the conduct of the suspected provider, individual or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the unit supervisor must first be consulted. An expedited referral should be made when a delay would:

• probably result in the loss, destruction or altering of valuable evidence;
• probably result in harm to an individual;
• probably result in significant monetary loss to the Texas Health and Human Services Commission (HHSC) that would probably not be recoverable; or
• hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit at 512-436-6184 before the referral packet is produced. The HHSC representative will instruct staff as to what portions of the required information should be completed and sent.

2753 Referral of Potential Fraud

Revision 17-1; Effective March 15, 2017

If the unit supervisor determines that the criteria for fraud exists, a fraud referral to the Texas Health and Human Services Commission (HHSC) Medicaid Program Integrity Unit is initiated (even if the potential fraud does not affect Title XIX funds). Mail the referral packet to:

Office of Inspector General
Mail Code 1361
P.O. Box 13247
Austin, TX 78708-5200

HHSC is responsible for ensuring that all pertinent information is obtained and may subsequently request additional information. Providing requested material to the HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. Continue to maintain the case as usual. HHSC staff should preserve a professional working relationship with the provider, individual or authorized representative while the fraud referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.